HELENA — The new version of the Senate’s plan to repeal and replace the Affordable Care Act doesn’t make broad changes from the previous rendition’s wiping out of Medicaid expansion and hasn’t won over the support of Montana lawmakers and those in the health care industry who opposed it before.

U.S. Sen. Steve Daines, a Republican who has not taken a public position on any iteration of the bill, did not have a stance yet Thursday.

"Sen. Daines is currently reviewing the bill while waiting for additional analysis on the bill and listening to Montanans," a spokeswoman said.

Daines previously has said he needs to see a Congressional Budget Office markup, which would estimate the impacts of the bill, before he decides. With the previous version of the bill, he said he wanted to hear from Montanans during a town hall conducted by telephone before making up his mind.

Daines has said in the past he wants a bill that improves access to care and lowers costs while preserving Medicaid for the disabled and children and not ripping the rug out from those covered by Medicaid expansion.

U.S. Sen. Jon Tester, a Democrat, sent out a news release Thursday that conveyed his continuing opposition.

“This plan rips away coverage from thousands of Montanans, allows insurers to deny Montanans coverage if they have pre-existing conditions like high blood pressure, and imposes an age tax on folks in their 50s and 60s,” Tester wrote. “This pig got more lipstick, but it still smells like a pigpen. Congress needs to work together to address rising premiums and deductibles, and when they are ready to work in a bipartisan manner, I’ll be waiting at the table.”

Much of the focus on the effects of the bill in Montana has centered around changes to Medicaid and Medicaid expansion. More than 216,000 Montanans are covered by Medicaid, 96,846 of whom are children and 19,085 are adults who have disabilities. Nearly 80,000 people earning up to 138 percent of the federal poverty level, or $16,400 a year, gained coverage under expansion starting in 2016.

The state gets an enhanced federal match for money it spends on expansion coverage. But the Senate plan lowers the match severely and eliminates it entirely by 2024. The state could not afford to keep the program running without the enhanced match. Language in state law also calls for the expansion to be shut down if the federal match rate drops below what was set in the Affordable Care Act.

Aaron Wernham, CEO of the Montana Healthcare Foundation, said Thursday he doesn’t see any improvements to the Medicaid situation.

The foundation enlisted Manatt Health earlier this month to estimate the impacts of the previous bill on Medicaid and found it would cost the state $5.3 billion in federal funding between 2020-2026. Cuts would be so severe the state would struggle to pay for other priorities like education and infrastructure.

While the bill does put more money, $45 billion over 10 years, into addressing the opioid epidemic, Wernham said that likely wouldn’t be enough to offset the losses in Medicaid funding that covers behavioral health, mental illness and substance abuse.

“That’s one of the most important tools Medicaid has offered us is a way to stably reimburse practices that want to take care of those patients,” he said. “We recognize this bill has some funding added to take care of those problems but it doesn’t really appear to make up in any way for the funding that’s in Medicaid itself.”

He also said that funding through grant programs that may or may not be reauthorized don’t encourage hospitals to hire staff or take on additional areas of service.

John Doran, the divisional vice president of external affairs at Blue Cross and Blue Shield of Montana, said Thursday he was still reviewing the specifics of the new version of the bill, but from the insurer’s standpoint the No. 1 need is still to stabilize the insurance marketplace.

“Currently there’s a lot of uncertainty on the rules and regulations, which is adding to the instability of the marketplace,” he said.

The new bill offers the option for insurance companies to sell plans that don't meet some of the requirements laid out in Obamacare, such as covering preventive care, something critics have said would create a separate pool for healthy young people who don’t want to pay for full coverage and drive up costs for older people. Doran said that choice in plans is a good thing, but it’s important to not create two different pools of customers.

He also emphasized Blue Cross and Blue Shield of Montana wants to see a bill that has some sort of mechanism to encourage broad and continuous coverage and ways to help offset the cost of purchasing coverage.

The new version of the bill does not have a requirement for individuals to have insurance or employers to provide it. It does increase the subsidies to defray the cost of buying insurance for those who qualify.

“There needs to be some incentive for people to buy a health insurance and keep it throughout the year,” Doran said.

Heather O’Loughlin, co-director of the Montana Budget and Policy Center, said the new bill doesn't make any changes that sway her organization’s opinion that the bill is bad for Montana.

“It is clear that this bill cannot be fixed, and the Senate should scrap this plan and find ways to make health insurance more affordable and stabilize the markets. The Senate continues to make minor changes to the legislation, but the facts remain the same: it will end Medicaid expansion and make health care unaffordable for many of those with pre-existing conditions and older Montanans."

Democratic Gov. Steve Bullock, who championed Medicaid expansion, echoed Tester’s makeup-on-a-farm-animal comments when assessing Tuesday’s version of the Senate bill.

"They tried to put lipstick on a pig — and failed,” Bullock said in a statement. “The bill still slashes Medicaid, still threatens coverage for Americans with pre-existing conditions, and still means higher costs for less care for millions of Americans. It's certainly no improvement."

Also on Tuesday, U.S. Sens. Lindsey Graham, R-South Carolina, and Bill Cassidy, R-Louisiana, announced on CNN they are working on their own health care bill that would send money to states in the form of block grants. Graham said on CNN the bill would keep taxes in place on the wealthy, repeal the individual and employer mandate and medical device tax and let states have more control.

"Rather than try to run health care from Washington, we're going to block grant it to the states and here’s what will happen: If you like Obamacare, you can re-impose the mandates at the state level. You can repair Obamacare if you think it needs to be repaired. You can replace it if you think it needs to be replaced. It will be up the governor. They have a better handle on this than any bureaucrat in Washington,” Graham said.

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