Medicaid Expansion Doesn’t Raise Wages — And That Matters

I don’t experience Medicaid as a headline. I experience it in caseload numbers, crisis calls, documentation hours, and the quiet weight of knowing someone is depending on me to navigate a system they don’t understand.

I work in behavioral health and developmental disability services in Montana. Medicaid determines whether the person sitting across from me has coverage for home and community based services. It determines whether crisis stabilization is reimbursed. It determines whether most all agencies can continue operating in a rural community.

When Montana adopted Medicaid expansion in 2015, thousands of low-income adults gained insurance. The federal government covers 90% of the expansion population, and hundreds of millions of federal dollars flow into our state each year. Uninsured rates drop. Rural hospitals stabilize. From the outside, it looks like growth and progress.

But here is what expansion doesn’t change: my wage and many others.

Medicaid expansion changes who qualifies for coverage. It doesn’t automatically change the reimbursement rate attached to the work I do every day. In behavioral health and case management, wages are tied to reimbursement rates set through legislative appropriations and state budgeting decisions. If the rate per service doesn’t increase, or increase realistically, neither does the ceiling for compensation.

What expansion does change is demand. More insured adults means more people seeking therapy, more people needing medication management, more people entering substance use treatment, more people seeking case management services and more people needing help navigating complex systems. The front door widens, but the foundation underneath it — reimbursement structures, workforce supply, caseload sustainability — doesn’t automatically strengthen.

That reality shows up in higher caseloads, longer waiting lists, and burnout that isn’t theoretical. It’s lived.

From a fiscal standpoint, Medicaid is one of the largest components of Montana’s state budget discussions. Even with the 90% federal match, the overall size of the program affects how legislators approach rate increases. Raising reimbursement across a larger base carries real cost implications.

So, while expansion increases access, it doesn’t automatically increase sustainability.

Repealing expansion wouldn’t make mental illness or developmental disabilities disappear. It wouldn’t reduce the need for case management. It would shift costs — often into more expensive crisis systems, emergency rooms, or county resources. But keeping expansion without addressing reimbursement reform leaves the workforce carrying a growing load without structural reinforcement.

Coverage determines who can seek care, but reimbursement determines whether someone is still there to provide it. If we expand eligibility without reforming reimbursement (that's already lagging behind), we don’t build a stronger system — we stretch a fragile one. When the workforce burns out, the coverage card doesn’t matter. A system that grows without sustaining the people inside it isn’t reform; it’s math that eventually catches up with reality.