Access to affordable health care is one of the most critical issues facing Montana today. The Affordable Care Act needs reform. Costs keep rising, fewer healthy people are staying in the market, and coverage gets more expensive every year.
When I was Montana’s Insurance Commissioner, I oversaw the rate filings for the plans sold in our state, year after year. My job was to make sure premiums were actuarially sound. It is a delicate balance between what it costs to deliver care, reimbursement rates for providers, and premiums families can afford to pay. I worked hard to understand all sides of that equation.
You have probably heard some say that insurance premiums in Montana increased due to Congress not extending the enhanced premium tax credits and allowing them to expire. Those credits were a temporary fix passed during the COVID pandemic, aimed at a small set of the individual market and never meant to last beyond the COVID crisis. These insurance company credits expired, as designed.
In reality, extending these credits would not have affected most Montanans and would have moved the Montana premiums by only single digits, and only for a small part of our market. The increases we saw across the board this year came from a much larger and older problem.
That problem is adverse selection. In other words, premiums go up every year, and every year some people decide the coverage is no longer worth the cost.
Those who leave the market are often younger and healthier. When they leave, the concentration of higher-cost individuals gets larger, the costs to the insurer rise, and premiums rise for everyone still paying for the plan.
Young, healthy Montanans increasingly do not see value in the coverage they are being asked to buy at the prices available. We need to win them back with coverage that is worth the price.
We cannot subsidize ourselves out of this underlying problem.
Premiums also climb because of the rising cost of care. Prescription drugs alone now account for more than 25 percent of every premium dollar. That is a huge number. A prescription drug can pass through multiple layers of middlemen before it reaches the patient, with costs and rebates often hidden along the way.
In my first legislative session as Insurance Commissioner, my office sponsored the Pharmacy Benefit Managers (PBM) Transparency Act, carried by Senator Greg Hertz, to make those PBMs report their costs, rebates, and fees. There is more to do, and most of it has to happen at the federal level. Regarding PBMs, federal ERISA preemption, which governs employer health plans, is one area we need to look at closely, so states have more power to regulate the entire PBM market rather than just a subset.
One of the clearest places to start is the 340B program. It is a critical source of affordable medication for many of our rural hospitals and the patients they serve. We need to protect this program for the providers and patients who depend on it. We also need reforms that prevent abuse and ensure the program serves the patients and providers it was designed to help. It is a significant program, and taxpayers deserve accountability.
I make it a point to visit as many of our critical access hospitals and rural clinics as I can. Some of them get as much as 80 percent of their income from Medicare and Medicaid, which tells you how much those programs matter in rural Montana.
Two of the biggest challenges I hear about are workforce shortages and housing. Time and again, a facility gets good applicants who cannot find a place to live and withdraw their applications.
In many rural communities, there simply are not enough workers to fill critical health care jobs. Last year, Congress set aside $50 billion for rural health transformation, and Montana was one of the largest recipients in the country. That investment is good for Montana, but it also reflects the scale of the challenge facing rural health care.
There is no single fix here, but there are good ideas we need to put to work. First, we should expand Health Savings Accounts; let people put more into them, and let them use the money for premiums, deductibles, direct primary care, and healthy living, not just for high-deductible plans.
When patients have more control over their health care dollars, they become more engaged in what care costs and what value they are receiving. This helps re-establish traditional patient-provider relationships.
Second, we should allow people to buy the plans they actually want, including short-term and catastrophic coverage.
Third, we should create a dedicated way to cover the highest-cost patients instead of forcing the entire individual market to function like a high-risk pool.
There are real challenges ahead. We need to protect rural and critical access hospitals while making sure the system remains sustainable. We need to give young and healthy Montanans a reason to value their coverage, so we can spread the risk. We need to bring down prescription drug prices and add transparency to the prescription drug supply chain. We need reimbursement rates that keep our providers open for business.
This work requires a serious conversation focused on what actually lowers costs and improves access. That means listening to the people delivering care and the Montanans who depend on it. I have spent years working on these issues from both the state and federal level, and I will keep working with Montanans to get it right.
Rep. Troy Downing represents Montana’s 2nd District.
