Despite importance to voters, little being said by candidates on health care

November 4, 2016

Health care is an important issue to Montana voters — but you wouldn’t necessarily know it from the current campaign.

Among registered voters surveyed Oct. 10-12, 13 percent named health care as the most important issue in this election, ranking behind the economy and national security, according to a Mason-Dixon poll commissioned by Lee Newspapers. Yet the issue has not been a prominent discussion in most statewide campaigns this fall.

U.S. House race

The contest for Montana’s U.S. House seat has the clearest potential to reshape the federal law and other aspects of the nation’s health care system.

Incumbent Republican Rep. Ryan Zinke argues the country should “repeal and replace” the Affordable Care Act.

He said he has “seen pieces” of a replacement plan that he could support, which should generally provide patients more options and ones that are “actually affordable.” Among promising ideas for improving the quality of care while reducing costs, he listed individual health care accounts, expanded telemedicine, increased Medicare reimbursement rates for frontier communities, more rural medical residencies, and expanded authority for some “frontline providers” like nurse practitioners and physician assistants.

“It’s going to take both sides. On the extremes, which we hear a lot, people argue the government has no part in medicine. I think we do. We deal with Medicaid and Medicare,” he said. “Obamacare will evolve and change no matter what.”

His Democrat challenger, Superintendent of Public Instruction Denise Juneau, said that repealing the law is “a waste of taxpayers’ time and taxpayers’ money.” She said targeted reforms are needed to drive down costs, primarily a tightening of regulations.

“It’s a mixed bag. The Affordable Care Act did some great things,” she said. “The problem is we left insurance companies in the driver’s seat. We need to fix that.”

She said the long-term solution should probably include a candid discussion about a single-payer system, but “that’s a long ways off. Especially in this Congress, it’s not going to happen.”

Governor’s race

Gov. Steve Bullock has touted his success building a bipartisan coalition that approved Medicaid expansion in the 2015 Legislature, noting that more than than 50,000 people have enrolled, and some hospitals have told him that the reduced level of charity care has helped their finances.

“That was a very important step that we took,” Bullock said.

He has made two health-related pitches while on the campaign trail this fall.

First, he has joined with state Sen. Diane Sands of Missoula, a Democrat, to propose a $1.6 million funding increase to state assistance programs for the elderly and the family members who care for them so the elderly can remain at home.

Bullock also has joined Jesse Laslovich, a Democrat running for state auditor, in proposing a price transparency measure that would make it easier for consumers to compare prices of procedures at major hospitals with a state-run website.

Republican candidate for governor Greg Gianforte agreed that price transparency is a step in the right direction.

Gianforte has toured several of the state’s hospitals and visited with industry leaders, but has said he does not have detailed health proposals in mind.

Asked about some Republican legislators who want to reverse at least part of the state’s Medicaid expansion during the 2017 session, Gianforte said he does not support changing the program “between now and 2019,” when the final, lowest level of federal support takes effect.

Generally, he said he thinks the state should look for ways to expand the use of telemedicine without incurring additional costs and review licensure requirements for ways to make it easier for physicians to move to Montana. He also would look to states like Texas for ideas about how best to drive down the cost of malpractice insurance by reforming tort law, a proposal that has drawn opposition from some who fear reducing physician liability could hurt consumers.

“There is no silver bullet in health care,” he said. “Anything that will bring costs down for the hospitals or doctors while maintaining the quality of care and preserving rural access, we ought to look at … Anytime you can take, just from a business perspective, take costs out of the delivery of a product, you’re going to ultimately lower the end cost to the consumer.”

Auditor’s race

In the auditor’s race, Republican Senate Majority Leader Matt Rosendale opposed Medicaid expansion, has widely criticized his opponent Laslovich for not fighting the implementation of the Affordable Care Act in Montana.

“There is a big difference between making sure everybody is covered with insurance and making sure people have access to good health care,” he said. “The legislation I worked on has not had any support from the auditor’s office or the governor’s office.”

He referenced bills to establish health care sharing ministries as an alternative to insurance in the state and a bill that would have allowed and outlined rules for primary care provider contracts. Rosendale supported these alternatives as good fee-for-service options for some Montanans.

Opponents of the measures, including some health care industry groups and his campaign opponent, argued the options do not offer the same level of patient care or protection under the law as insurance coverage. Rosendale has argued the choice should be left to Montanans.

He also has proposed changing the way some allegations of wrongdoing in regulated industries, including insurance, are investigated and sanctioned. He suggested forming panels to review “lesser violations” in a move to reduce “the power concentrated within the insurance commissioner.”

He said Laslovich “is a litigator and I’m not. And while that may be necessary at times, it shouldn’t be the first course of action.”

Laslovich, chief legal counsel to Montana state auditor Monica Lindeen, questioned Rosendale’s understanding of the office for which he is running and defended his record in the auditor’s office.

“If Matt wants to get rid of Obamacare, he should run for Congress. The state auditor can’t do anything about Obamacare. It is the law. The Supreme Court has upheld it,” Laslovich said, noting that recent state legislation, opposed for years by Republicans, did grant the auditor power to review insurance rate change proposals at a state level rather than relying on federal officials to do so. “My biggest criticism of Obamacare is the regulation of insurance is a state-based activity, always has been and for good reason.”

Laslovich has said it might make sense for the state to consider implementing a state-based health insurance exchange to replace the federally managed one so “we can control our own destiny.”

He also has suggested the nation might want to consider a single-payer system to control skyrocketing costs for patients, but said that is a federal, not state issue. Rosendale nonetheless has seized on the remark to cast Laslovich as a puppet of national Democrats seeking to expand the Affordable Care Act.

Laslovich has called the debate about the federal health care law a distraction from practical proposals a state auditor can make to actually protect Montana consumers and their pocketbooks. He cites his seven years in the office as having helped him prepare a list of specific health-related proposals for the 2017 Legislature.

One proposal stems out of a working group led by Laslovich last year. It reviewed high balance bills — frequently $20,000 or more — some Montanans must pay for air ambulance rides provided by out-of-network providers. Laslovich has suggested that air ambulance companies and other health providers should not send balance bills to families, instead going to direct arbitration or to court with insurance companies for additional payments.

The working group could not reach a consensus on draft legislation in large part because insurance companies opposed the proposal.

Laslovich said the reforms “won’t get done the way it needs to be done” unless he’s elected because he is the only person that has put so much time into working on the issue. In addition to leading the working group, he noted he has helped dozens of families negotiate their bills through his role as legal counsel and consumer advocate in the auditor’s office.

Among Laslovich’s priorities are reform bills previously advocated by the current State Auditor, Monica Lindeen, who is running for Secretary of State. One such proposal would grant firefighters and other emergency responders presumptive disease status under workers compensation law so they would not have to prove certain illnesses were caused by their job. It shifts the burden to the insurance company to prove it did not. The legislation passed in many other states is designed to recognize that firefighters are routinely exposed to hazardous chemicals.