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Accidents happen: How one mistaken vote killed Montana’s Medicaid expansion

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Some states have declined to expand Medicaid because they oppose Obamacare. Others worry about the financial burden of expanding the entitlement. But there appears to be only one state where the Medicaid expansion failed due to a Democratic legislator accidentally voting against it.

Congratulations, Montana.

“We’re tremendously sorry about what happened,” Minority Leader Chuck Hunter, a Democrat, said of the mistaken vote. “Montanans are the losers in this outcome.”

When I first read about this in a local Montana paper, it sounded unbelievable. How did a legislator get the vote wrong? And, if the vote was a mistake, was there some mechanism to change it? This was, after all, a vote deciding whether 70,000 Montanans would gain health coverage — and whether the state would massively expand an entitlement program.

So I started making some phone calls to Montana. Turns out everybody knew about this mistaken vote — and that the story was even more complex than I had thought.

In a lot of ways, the best place to start is with Liz Bangerter, a Republican legislator from Western Montana who opposes the health-care law.

“Obamacare is very negatively viewed here,” Bangerter told me when we spoke Tuesday. “It does have some good parts, but the general idea, I’m opposed to that.”

Still, Bangerter didn’t want her state to miss out on the chance to expand health insurance to some of Montana’s 176,000 uninsured residents. So she introduced House Bill 623, which would allow the state to give many low-income residents “income-enhancement” grants, which would get their income above the poverty line — and that would mean they qualify for tax subsidies on the health insurance exchange.

“The idea would be that, if we didn’t expand Medicaid, the exchanges are available to anyone above 100 percent,” Bangerter explains. “This could help the people who were short on earning 100 percent, but earned too much to be on traditional Medicaid. I got buy-in from hospitals and other charitable groups, that they would help with this.”

The proposal did not go over well in the House Health Services Committee. Hunter, the Democrat, says it “would cost the state a lot of money.” Bangerter claims it died because it was “too complicated.”

Either way, the Montana House struck the income enhancement language and bounced it over to the Montana Senate, which took a decidedly different approach to the Medicaid expansion.

“All of the complicated income stuff was struck out and they put in new language, based on Arkansas,” Hunter says, referring to Arkansas’ plan to use Medicaid dollars to buy private coverage for those eligible for the expansion.

And that is the legislation that was sent over to the Montana House on Thursday, April 18. The Montana legislature was within days of wrapping up its legislative session. To many, this seemed to be Montana’s last chance at expanding Medicaid in 2014.

“It was near the end of the session,” says Jacquie Helt, director of SEIU Healthcare 775 Northwest, who had lobbied hard for the expansion. “I can’t imagine the fatigue they’re all feeling at that point.”

This is when “the vote” — as many Montanans I spoke with described the mistaken ballot — occurred. When the Medicaid expansion bill came up, Republican House Speaker Mark Bladsel motioned for the legislation to be sent back to committee, where many observers expected that it would languish.

Here’s how Hunter describes what happened next. “It was tense,” he says. “I’m standing up, I’m appealing the speaker’s decision and he’s reading the rule [that says he can refer it to committee.].

“We had some procedural motions to challenge the speaker. One of our Democratic members pushed the wrong button. That procedural motion failed on a tied vote.”

That legislator was Tom Jacobson, a freshman from a central Montana town called Great Falls. Jacobson told local reporters that he got the vote wrong, although he did not respond to my phone calls and e-mail requesting comment.

Montana’s House rules do generally allow legislators to change their votes (Bangarter told me that these changes were generally accompanied by a $20 donation to charity, but I could not find anything about that in the statute). They do not, however, allow legislators to change their vote if “it would affect the outcome of legislation.” And in this case, it would change the outcome: One vote flipping would mean the Medicaid expansion would make it to the floor.

“We got very close to pulling this off,” Montana Hospital Association's John Flink says. “If the person who made the mistake had voted the correct way, the bill would have gone to the floor. We had the votes there.”

There was an attempt to remedy the situation: The House voted again that day, on the same procedural motion, after the mistake had been discovered. But by then, four Republicans had flipped to support sending the Medicaid bill back to committee, and not to the House floor. A vote failed 48 to 52.

Bangarter, the original sponsor of the legislation, is among those who changed her mind.

“It kind of all happened so fast,” she recalls. “The minority leader opposed it, and I was thinking wait a second, I haven’t read the rules. I did that before the second vote and agreed, it was totally legal what he was doing. Myself and a few others switched our votes because of that.”

As to what happens next, the Montana legislative session ends Saturday — and won’t meet again until 2015. There’s some talk of using a voter referendum to move forward, but even that can’t happen until the next election year.

Obamacare supporters do admit that the mistaken vote is a tough pill to swallow. “I can’t spend too much time dwelling on what a member of the house did,” the SEIU’s Helt says. “It just gives you that pit in your stomach.”

“Was it unfortunate? Absolutely,” Helt added, saying that she does not blame Jacobson, who got the vote wrong. “Do I think that one flawed vote single-handedly denied 70,000 Montanans [insurance]?  I don’t think that’s fair.”

“It’s hard,” Hunter says, “to lose that much on a single vote.”

Some prefer not to talk about it at all. When I asked Flink, whose hospitals arguably had the most to gain from a major insurance expansion, how it felt to lose so much on a single, mistaken vote, he would only say, “I don’t want to talk about that on the record.”

KLIFF NOTES: Top health policy reads from around the Web. 

In Chicago, a hospital sees success in keeping beds empty. "To help control costs, Advocate has hired scores of workers to coordinate care and keep an eye on the highest-cost patients, like those who are obese or have diabetes. It started providing doctors’ offices with report cards on their performance. Dozens of quality-control measures cover items as varied as blood pressure, rehospitalizations for asthma attacks or the use of expensive imaging machines." Annie Lowrey in the New York Times

Washington State is looking at moving public employees onto its exchange. "Washington state appears to be the first major government to seriously explore the possibility of pushing workers into the exchange — but it probably won’t be the last. Rick Johnson, who advises state and local governments on health care policy at the New York-based consulting firm Segal Co., said he expects it will be an option some governments will look at in the years to come." The Associated Press