In the five years that have passed since Montana expanded Medicaid, more than 65,000 residents have received preventative screenings, and 6,400 women have received a breast exam.

Nearly 90 of those tests came back positive for breast cancer.

“Thanks to Medicaid expansion, those women now can have treatment,” said state Rep. Kimberly Dudik. “Even though the Affordable Care Act is a federal policy issue, it became a state policy issue when we voted to expand Medicaid in 2013. Our state took action, and it's been a huge success since then. The health of Montanans has greatly improved.”

Dudik and state Sen. Diane Sands, both Missoula-area Democrats, are among a number of state lawmakers and health care officials looking to preserve the state's expanded Medicaid program.

At a recent panel discussion, they admitted that doing so won't be easy during the 2019 Legislature, the makeup of which will be decided this November. But failing to preserve the five-year-old program could have dire social and economic consequences, they believe, and lead to the closure of rural hospitals and the jobs they provide.

“We have our work cut out for us, because it impacts every aspect of the economy,” Sands said. “I hear about it every day on the doors, whether it's someone who got a job because of the expansion of services. I hear about it from people who are small business owners who didn't have health insurance before they were able to get this.”

According to Dudik, more than 96,000 Montana adults were able to access health care after Medicaid expansion, including 11,347 in Missoula County. They represent small business owners, low-income workers and those suffering from substance abuse and mental health disorders.

“One of the things I've focused on a lot is substance abuse problems, mental health issues and criminal justice reform, and all of these services are funded by ACA expansion,” said Dudik. “It we care about getting to the root cause of criminal behavior, we really need to keep the ACA expanded or people are going to be hurt.”

Health care has emerged as a central issue in this year's political races, extending from the state level all the way up to Montana's high-profile congressional races. But cut through the politics and most experts agree that one of the state's largest economic sectors – health care – could be riding on the outcome.

As the state considered budget cuts last year, several hospital executives said they'd face potential closure if revenues were lost, either through budget reductions or a retraction of Medicaid. At the critical access hospital summit this month, those fears had not diminished.

“It was a coming to Jesus kind of session for people from all over the state,” said Sands. “It's a fact. If we do not manage to reauthorize Medicaid, we'll lose hospitals in places like Glasgow and Plains. People won't get served. The hospitals will close. People will lose their jobs.”

Dudik, a staunch supporter of Medicaid expansion, points beyond the social benefits of improved health and access to care. The program also brings financial benefits, providing jobs while attracting precious federal funding.

Dudik said the state has received more than $36 million through enhanced federal matches for some existing Medicaid populations, and it gained access to federal funds that replaced state funding for other services.

Medicaid in Montana also has created 5,000 new jobs in the health care industry, she said. That created $280 million in new personal income, and $47 million in state tax revenues.

“What many people don't know is that people receiving Medicaid in Montana, 81 percent of those families are working,” said Dudik. “These aren't people who are just sitting around playing video games. They're hardworking Montanans who can't afford Medicaid now, or can't afford health care.”

Dudik also fears that losing Medicaid will result in the closure of rural hospitals. Since 2010, she said, 83 rural hospitals have closed, and 90 percent of them were in states that refused to expand Medicaid.

“I sit on the board of St. Patrick Hospital here in town, and without Medicaid expansion, we'd have a hard time staying in the black,” Dudik said. “That's true not only of large hospitals, but small ones in rural areas that would face closure if Medicaid expansion goes away. There's a proven correlation there. We're lucky that's not the case in Montana.”