Montana State Senator Ed Buttrey is a no-nonsense businessman from Great Falls. Like a lot of Republicans, he's not a fan of the Affordable Care Act, nor its expansion of Medicaid, the health insurance for the poor and disabled.
"We didn't want to implement a plan that was another entitlement that just had a bunch of people signing up to get free or cheap or subsidized health care," Buttrey said. "We wanted a plan that said, 'We're going to get you on. We're going to get you healthy. We're going to identify your barriers to employment or better employment, and then we're going to move you off the plan.'"
So Buttrey wrote a Medicaid expansion bill for Montana that linked the health coverage to a job training program. He wanted everyone getting benefits to have to meet with a labor specialist who would help them figure out how to get a job or to get a better paying job.
The goal is to "make them healthier, get them off social programs, get them off dependence on government, get them into higher wage jobs that have a future that possibly pay benefits. That's a great benefit for the state," he said.
But so far, federal officials said states can't make participation in a work program mandatory for Medicaid recipients. Montana, instead, had to make its job training component voluntary.
Republican leaders across the country have long angled for more state control over Medicaid. The program's funding comes from both states and the federal government, with the U.S. Department of Health and Human Services scrutinizing states' use of the money. In Montana and many other states, the bulk of Medicaid funding comes from the federal government. HHS in a Trump administration may let states have more leeway -- in fact, Seema Verma, Trump's pick to run that division of HHS, advocated for more state control when she helped Indiana expand Medicaid. So the door could open to more Medicaid experiments like the one Buttrey has been pushing for.
The feds' rejection of mandatory job training meant Buttrey was barely able to win enough votes in Montana's Republican majority legislature to pass Medicaid expansion in 2015 last April. How's it working?
"I think it's a success story. I love this. I'm the poster child," says Ruth McCafferty. She is a 53-year-old single mom from Kalispell, with three kids at home. She lost her job with a lending company last spring, and she had no idea there was a new job training program available when she signed up for Medicaid. She was just focused on finding a way to afford the drugs she needs to control her diabetes and asthma.
"One inhaler that I do is $647," she says, bringing her medication costs to about $1,000 a month. "My plan was not to get them, only, like, a couple of them that were affordable, like $60, and the rest of them I was like, I guess I'll just be called 'Wheezy' from now on!"
McCafferty instead got Medicaid, filled her prescriptions, and she got free online training to become a mortgage broker. The state even paid for her 400-mile roundtrip to Helena to take the certification exam. And now they're paying part of her salary at a local business as part of an apprenticeship to make her easier to hire.
"It's awesome!" she said.
Of the 53,000 Montanans who've signed up for expanded Medicaid, only about 3,000 have signed up for help getting a job. That's in part because the federal government won't allow states to use Medicaid money for it. To set it up here, Buttrey had to cobble together funding from other jobs programs and squeeze $1 million out of a reluctant state legislature.
Giving states the flexibility to tie their Medicaid programs to work requirements is an idea that's likely to be popular with the new Congress and Trump administration. But health policy researcher Joan Alker, who runs the Center for Children and Families at Georgetown University, warns that it could backfire.
"I think it's great and well worth doing to link people who might not be aware of existing job training programs or other kinds of work supports that can help them work. What I think is problematic is when this becomes a stick and not a support," she said.
Alker said many people on Medicaid already have jobs, often low-paying ones that don't offer health insurance, and they have little time for new training. In Montana, about two-thirds of those on Medicaid are already working. She said if people fail to meet a work requirement and then lose health benefits as a result, they'll likely just get sicker and become less able to work.
This story is part of a partnership that includes Montana Public Radio, NPR and Kaiser Health News.