Carly Graf - Helena Independent Record - Jun. 26, 2025
Though final negotiations for the federal “megabill” are still underway in Washington, D.C., it’s clear the measure could have seismic implications for health care and public assistance programs in Montana.
The U.S. House of Representatives last month narrowly passed its version of the mammoth budget reconciliation proposal, dubbed the “One Big Beautiful Bill Act.” Senators now come up with their own proposal before the two chambers angle to find a compromise ahead of the Trump administration’s requested July 4 deadline.
Provisions inside both would enact sweeping changes to the country’s social safety net in order to fund the massive tax cut that’s a banner priority for President Donald Trump.
All four members of Montana’s congressional delegation have expressed support for these cuts. Reps. Troy Downing and Ryan Zinke both voted for the bill in the House.
Nearly every path to the trillions of dollars the White House hopes to hand out in income tax breaks requires deep cuts to Medicaid.
Montanans. They are low-income adults, children, people with disabilities and more. An estimated 31,000 people could lose coverage if provisions in the draft budget bill go into effect, according to findings from the Montana Healthcare Foundation.
Plans from the House and Senate would institute an 80-hour-per-month work requirement for adults enrolled in Medicaid expansion, the Obama-era initiative that allows states to choose whether to extend coverage to low income earners.
Montana’s 2025 Legislature renewed Medicaid expansion with no sunset date. Though the state’s program requires people to work or participate in other community engagement activities, the mandate has yet to be approved by the federal government.
Not only has the Trump administration said it will greenlight work requirements state-by-state, the House and Senate hope to broaden them nationally.
The House’s proposal would exempt low-income adults with children from having to work, whereas the Senate’s would only spare parents with children under 14. American Indians would be exempted.
Both chambers would also require people to reapply for Medicaid at least twice per year and reduce a retroactive eligibility window if their coverage lapses while their application is evaluated. Right now, it’s 90 days. It could be as short as one month under the bill.
Supporters say the changes close loopholes and maintain the integrity of government programs as being only for the most needy.
“Republicans are trying to save Medicaid while Democrats are trying to drain Medicaid,” said Gabby Wiggins, the spokesperson for Montana U.S. Sen. Steve Daines, in an email. “It’s important to note that education, volunteer work and other forms of community engagement are all ways the work requirement can be met, and there are appropriate exceptions for individuals who are disabled, pregnant, and caretakers.”
Critics argue the changes would increase bureaucratic bungles for Medicaid enrollees and incorrectly boot people off the program, offering Montana’s redetermination process as a proof point. Thousands of people lost health insurance not because they were ineligible, but because of procedural or administrative errors.
With fewer people enrolled, there would come a decline in federal money that would otherwise flow into Montana’s health care system. Providers say Medicaid dollars have allowed them to offer more specialty and preventative health care.
For example, the Indian Family Health Clinic in Great Falls has quadrupled its primary care provider roster and added both urgent and walk-in services in the last decade since Medicaid expansion started bringing in more money from the feds.
Without the government dollars tied to Medicaid patients, executive director Rachel Arthur says the clinic would face “hugely detrimental” consequences.
The Big Beautiful Bill would also go after a tool that many states use to maximize how much money they draw down from the federal government in exchange for providing health care to Medicaid expansion enrollees.
Through provider taxes, states can charge hospitals a fee for inpatient and outpatient services provided to these patients. That fee is then added to the total cost hospitals bill to Medicaid. Because the feds cover 90% of services provided to a Medicaid enrollee — the reimbursement rate for the program — the state rakes in more money than it would without the additional fee.
Montana charges hospitals $70 for every inpatient bed day and 0.9% of outpatient revenue. These funds are pooled to help the state cover its share of Medicaid.
The House proposal would prohibit states from adding new provider taxes or increasing existing rates, while its Senate counterpart goes further by setting a limit on how high the fees can be.
Montana’s current provider tax would not exceed that threshold, so the state would continue to be able to capture the additional federal funding in most cases; however, it would be unable to increase the fees it collects in the future, which opponents caution could eventually hamstring the state in covering its own costs.
Still, limits on provider rate taxes are seen as one of the most vulnerable parts of the federal budget proposal. Republicans from rural states have voiced concern that it would disproportionately impact their hospitals and have threatened not to support the provision, while proponents say it simply right-sizes how much the feds pay into Medicaid based on the cost of care rather than an inflated price.
If states can’t cover their share, they could turn to premiums or copays so that Medicaid enrollees have to pay more out of pocket to make up the difference.
“That’s people losing their homes to pay for their medicines,” said Atty Moriarty, a Missoula-based pediatrician. “That’s people choosing between food and health care.”
Heather O’Loughlin from the Montana Budget and Policy Center said reinstituting these measures would be “ignoring what we already know,” which is that even small increases in out-of-pocket payments lead to fewer low-income adults enrolling in Medicaid.
Tucked into the more than 1,000-page budget bill is a section that would bar federal Medicaid dollars from going toward gender transition health care, including surgical procedures and hormone therapy, for transgender people.
Montana’s Medicaid program covers this same care for people diagnosed with gender dysphoria. In 2017, the state health department said excluding gender affirming care would violate nondiscrimination law.
Pulling federal Medicaid dollars for these treatments, though, could mean that health care providers can no longer afford the upfront costs required to offer them. Already, Community Medical Center in Missoula said it would stop offering gender-affirming care to minors, citing law changes.
The Republican-backed budget measure also takes aim at facilities that offer abortion.
Both Montana and federal law prohibit public funds from paying for abortions. The Big Beautiful Bill would halt the flow of Medicaid dollars to pay for preventative care, cancer screenings, sexually transmitted infection tests and other treatments at facilities that offer abortions for any reason other than rape, incest or the life of the mother.
It effectively singles out Planned Parenthood by saying that the ban applies to clinics that receive either themselves or as part of a network more than $1 million in government money per year. There are four Planned Parenthood clinics in Montana.
Democratic lawmakers in the state penned a letter to Montana’s congressional delegation asking them to oppose the efforts. They said slashing funding for Planned Parenthood would cut off vital health care services for the most vulnerable.
Rep. Troy Downing, a freshman Republican congressman, called the bill a “win for America and a win for Montana” in a statement. He highlighted the restrictions on Planned Parenthood as an important facet of the proposal.
The office of Rep. Ryan Zinke, western Montana’s GOP congressman, did not return a request for comment on the package as a whole as it currently stands.
Funds to help people pay for food could also be on the chopping block.
GOP plans in the House would have required states to take on a significant share of the Supplemental Nutrition Assistance Program (SNAP) expenditures, the country’s largest anti-hunger effort.
More than 80,500 people receive food stamps in Montana. The average household receives $361 each month to pay for groceries. SNAP is almost entirely funded by the feds at roughly $345 million every two years.
But unique Senate rules require tweaks to this approach. Final details have yet to be released, but the chamber has said it intends to maintain at least some of the cuts so the proposal could still potentially pass with a simple majority of votes.
In a statement, the Montana Food Bank Network said it is “deeply concerned.”.
“The proposals in both the House and Senate budget reconciliation legislation represent a stark step backward in the fight to end hunger,” it read. “By permanently altering the structure of SNAP and slashing billions from the program over the next decade, this legislation would cause direct harm to children, seniors, veterans, working families and people with disabilities.”
Expelling fraud, waste and abuse has become the calling card of Republicans who back the Big Beautiful Bill and the cuts it includes.
“We must strengthen Medicaid, with commonsense policies like removing illegal aliens and dead people from the program, ending the taxpayer-funded sex changes and implementing common sense work requirements, and SNAP by rooting out fraud, waste and abuse,” freshman GOP U.S. Sen. Tim Sheehy said in an emailed statement. “That’s exactly what this bill does, all while permanently securing the border, deporting illegal aliens, unleashing American energy, upgrading critical infrastructure, preventing the largest tax increase in American history and ensuring the critical resources Montanans rely on are protected.”
The Senate is expected to vote on the bill sometime in the next two weeks.
MBPC is a nonprofit organization focused on providing credible and timely research and analysis on budget, tax, and economic issues that impact low- and moderate-income Montana families.