Tribal leaders tell Montana budget panel Medicaid expansion must be preserved to sustain tribal health services

Tribal leaders, tribal health directors and urban Indian health providers told the Health and Human Services Joint Appropriations Subcommittee, Section B, on Jan. 20 in Helena that Montana’s Medicaid expansion is central to delivering preventive care, behavioral health and specialty services across reservations and in urban Indian clinics.

“For some, this absolutely is about life or death,” said Jennifer Finley, a member of the Confederated Salish and Kootenai Tribes’ (CSKT) Tribal Council, during testimony to the committee.

The testimony outlined financial and clinical impacts that tribes say have flowed from Medicaid expansion and warned of sharp reversals if the Legislature lets the expansion sunset. Speakers asked the committee to lift the sunset in the governor’s HB 2 (Schedule B), restore a DPHHS tribal-relations coordinator position and direct the Department of Public Health and Human Services (DPHHS) to evaluate the effects of Medicaid redetermination on tribal communities.

Tribal health leaders and urban Indian organizations gave multiple examples of services supported or expanded by third‑party revenue and Medicaid reimbursement. Joel Rosette, CEO of Rocky Boy Health Center, and others described growth in primary care, integrated behavioral health, dental and transportation services that they attribute to Medicaid expansion and third‑party billing. Dr. Natalie Weekes O’Neil, director of Fort Peck’s Health Promotion and Disease Prevention program, said Medicaid reimbursements for her program’s services in Q1 FY25 totaled about $2.1 million — a 100% federal match — and that school‑based clinics and a wellness center rely on those funds.

Speakers provided quantitative examples the committee can evaluate:

- CSKT/Flathead reservation: tribal health serves nearly 10,000 registered users across seven clinics, and Medicaid reimbursements have allowed clinic expansion and staffing increases (testimony: Jennifer Finley; Martin Charlo). - Lake County: testimony cited 5,852 American Indians covered by Medicaid prior to redetermination; enrollment declined by 1,773 people (about a 30% reduction) after redetermination (testimony: Jennifer Finley). - Fort Peck: multiple witnesses said loss of expanded Medicaid would translate to an estimated $4,300,000 annual reduction in tribal health funding for the reservation; Fort Peck’s Thundering Buffalo Wellness Center, school clinics and related programs were repeatedly cited as dependent on Medicaid revenue (testimony: Stacey Summers; Dennis Forebear; Dr. Natalie Weekes O’Neil). - Fort Belknap: testimony estimated a $1,672,200 loss to tribal health funding if expansion is not continued and credited Medicaid expansion with enabling a 3,100% increase in behavioral‑health encounters and a 92% decline in crisis responses (testimony: Cher Old Elk, representing Fort Belknap). - Crow service unit: presenters said IHS and tribal facilities received roughly $24.9 million in 100% federal reimbursements over the last two state fiscal years and that referrals and specialty care increased by about 140% since expansion (testimony: Joe Durglo; testimony entered for Chairman Frank White Clay). - Fort Peck health promotion: 21,567 health and fitness visits were reported in 2024 at reservation facilities supported by Medicaid‑linked programs (testimony: Dr. Natalie Weekes O’Neil).

Witnesses described operational and policy concerns that the committee can address: restore the DPHHS tribal‑relations manager (testified as a critical liaison that ensured tribal voice in agency decisions); require DPHHS to evaluate and report on coverage losses tied to redetermination; and consider directing DPHHS and the state budget office to develop mechanisms for tribes to contract with non‑tribal providers while preserving the 100% federal reimbursement for services delivered through tribal or IHS channels (testimony: Anna Whiting Sorrell). Several tribal leaders urged the committee to include funding for implementation of the Montana Indian Child Welfare initiative (MICWA) and to ensure HEART Initiative (marijuana tax) allocations reach tribal treatment efforts.

Committee members asked for follow‑up materials and coordination. The committee requested the recorded training session on IHS, tribal and urban health roles that DPHHS and regional IHS staff presented last September; Stephanie Ironshooter, director of the Office of American Indian Health at DPHHS, volunteered to provide a short framework diagram showing how IHS, tribal health programs, urban Indian organizations and state Medicaid interact; and the committee discussed inviting an IHS regional representative to testify in a future meeting to clarify federal program mechanics and funding flows.

Speakers stressed the practical consequences of funding changes: reductions in preventive screening, delayed specialty referrals, fewer local jobs and diminished workforce development programs used to train local providers. Multiple presenters noted that purchase‑referred care (PRC) and tribal contracts are complicated and vary by tribe and by whether a tribe is a self‑governance/638 contractor or a direct‑service area for IHS; that complexity drives the committee’s request for a clear mapping of payer flows and contractual options.

The session did not include a formal vote; presenters and committee members signaled intent to continue the conversation. Committee staff said the Subcommittee will continue hearings on behavioral health and developmental‑disabilities budget items the next day, and members indicated they would pursue follow‑up briefings on IHS coordination, transportation supports and options for preserving or replacing lost third‑party revenue.

The committee accepted written materials and resolutions offered by tribal delegations for the record.