“Elective abortions up to and including the moment of birth. Healthy, 9-month-year-old baby killed at the moment of birth. That’s what Jon Tester and the Democrats have voted for.”

Tim Sheehy, Montana GOP candidate for U.S. Senate, said in a June 8 debate

Tim Sheehy, the Republican candidate seeking to unseat Democratic Sen. Jon Tester of Montana and give U.S. Senate control to the GOP, is campaigning on what he calls Tester’s and Democrats’ “extreme” position on abortion. 

In a televised debate June 8, Sheehy accused Tester and Democrats of voting for “elective abortions up to and including the moment of birth.” That statement prompted Tester to respond: “To say we’re killing babies at 40 weeks is total BS.”

Sheehy has made this accusation on , which says, “Jon Tester supports elective abortion on demand up until the moment of birth. Think about that again: Jon Tester supports aborting a healthy, full-term baby the day before it’s due. That is the extreme position here.” Similar statements have been made in the campaign’s posts.

Painting the Democratic candidate with, in Sheehy’s words, an “extreme” position on abortion is a familiar conservative campaign strategy and campaign this . But how does it hold up? 

Some Recent History

Asked for evidence to support Sheehy’s accusations, Sheehy’s campaign spokesperson, Katie Martin, said the Republican candidate was referring to Tester’s vote for the , which failed to pass the Senate in 2022. She cited the bill’s provisions that said health providers and patients would have the right to perform and receive abortion services without certain limitations or requirements impeding access.

Anti-abortion advocates say the measure, which in the current Congress, would create a loophole eliminating any limits to aborting a fetus later in pregnancy. And, rather than define when a fetus is viable during pregnancy, the bill would leave the question of viability to the health provider, who is financially motivated to perform abortions, according to , a nonprofit group supporting anti-abortion candidates, .

“It would impose no-limits abortion on demand in all 50 states at any point in pregnancy,” said Marjorie Dannenfelser, president of SBA Pro-Life America.

In 2022, the legislation failed two votes in the Senate before the U.S. Supreme Court’s decision removed federal protections for abortion access and left the issue to the states to decide. Tester voted for the measure both times, but the bill failed to advance after votes of 46-48 and 49-51.

, director of the Women’s Health Policy Program at KFF, said nothing in the Women’s Health Protection Act supports an abortion up to the moment of birth. Rather, the legislation would allow a health provider to perform abortions without obstacles such as waiting periods, tests deemed medically unnecessary, unnecessary in-person visits, or other restrictions imposed by states.

The bill would explicitly allow an abortion after a fetus is viable when, according to the legislation, “in the good-faith medical judgment of the treating health care provider, continuation of the pregnancy would pose a risk to the pregnant patient’s life or health.”

“This is not abortion on demand until the moment of birth,” Salganicoff said. “Even if politicians and anti-abortion activists make this claim, there are no clinicians that provide ‘abortions’ moments before birth.”

Besides the Women’s Health Protection Act, the Sheehy campaign cited Tester’s opposition to “born-alive” legislation meant to protect babies who survive botched abortions.

“At what week does he think it’s inappropriate for medical providers to perform an abortion?” Martin said of Tester. “That would clear up his stance on the issue. Based on his voting record, it suggests he does, in fact, support abortion on demand up until the moment of birth.”

In 2002, Congress passed a that gave legal protections to infants who survive abortions. A to expand that law to add criminal penalties to health professionals who do not take steps to preserve the life of any child born. Montana voters rejected a similar ballot question in 2022.

Tester was elected to the Senate four years after the first bill passed and a vote was not taken on the 2022 measure.

Looking at the Data

Instances of fetuses surviving abortions . So are abortions performed later in pregnancy: in the U.S. happen at or after 21 weeks of gestation. (The percentage of abortions that occur when the fetus is presumed to be viable, 24 weeks or later, is presumably lower, but the Centers for Disease Control and Prevention does not break out abortion rates for that period.)

An analysis by SBA Pro-Life America’s , concluded that 6% of abortions performed in 2020, or an estimated 55,800 abortions, happened at or after .

“Most late-term abortions are elective, performed on healthy women with healthy babies for the same reasons given for first-trimester abortions,” Dannenfelser said.

SBA Pro-Life cites abortions at 15 weeks and later because that is the stage of development at which , according to the group. That is the same rationale behind Republican Sen. Lindsay Graham’s introduced in 2022.

But the says “the science conclusively establishes” that a fetus does not have the capacity to feel pain until 24 or 25 weeks.

“Every medical organization that has examined this issue and peer-reviewed studies on the matter have consistently reached the conclusion that abortion before this point does not result in the perception of pain in a fetus,” according to the OB-GYN medical group.

, a professor in the University of California-San Francisco’s Department of Obstetrics, Gynecology & Reproductive Sciences, said “born-alive” laws are trying to regulate something that doesn’t happen.

Kimport, whose research involved interviewing 30 people in 2018 who had abortions after 24 weeks of pregnancy, and 10 more from 2021 to 2022, also criticized Sheehy’s use of “elective abortion.” In her view, that terminology reflects a political colloquialism that’s come to mean an abortion that is optional. That’s different from the medical definition, she said, in which an elective procedure is one that may be necessary but is not an emergency and can be scheduled for a particular date, such as knee surgery.

Women have abortions later in pregnancy either because they find out new information or because of economic or political barriers, Kimport said.

“I have never spoken to somebody whose abortion decision was not informed by deep thought and consideration,” she said.

Trying to Change the Debate

is a University of California-Davis law professor who specializes in the law, history, and politics of reproduction, health care, and conservatism. She said Sheehy’s argument reprises a Republican talking point that abortion opponents have made for decades.

Similar arguments are being heard nationwide as to constitutionally protect abortion this election cycle.

Republicans such as Sheehy are accusing Democrats of being extreme on abortion partly to steer the discussion away from their own uncertain position, Ziegler said. The anti-abortion bloc is a key part of the GOP base, but since the Dobbs ruling, , including Montana, have added or upheld abortion rights in elections.

“They can’t really disavow what pro-life groups want as extreme because many of their base voters would be horrified by that,” Ziegler said. “But they can’t embrace it because then many swing voters would be horrified by that.”

Kimport said Sheehy’s statement “reveals a blatant misunderstanding of pregnancy care.”

“What people don’t understand about third-trimester abortions is that there aren’t very many, but for the people who do need abortions later in pregnancy, the circumstances are often desperate and intense,” she said. “And these are the people who are being maligned in these political conversations.”

Our Ruling

Sheehy’s description of Tester’s “extreme” position that would allow abortion “up until the moment of birth” simply doesn’t hold up.

These statements are rooted in Tester’s support for the Women’s Health Protection Act. That bill, however, doesn’t open the door to abortion on demand later in pregnancy. Instead, it allows for the role of medical judgment. In addition, CDC data indicates that late-term pregnancies are rare. Also, the term “elective abortion” is a political rather than medical phrasing.

We rate this claim False.

sources:

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Both Republican and Democratic legislators on the voted Jan. 18 to renew their informal objection to the proposed child care licensing rules, which the committee has blocked since November. The vote prevents the state’s Department of Public Health and Human Services from adopting the rules until at least March, when committee members say they will debate a formal objection that could delay the rules’ adoption until spring 2025.

Committee members renewed their objection after complaining that health department officials had not contacted them to discuss revisions to the proposal.

“It’s really quite frustrating to see some necessary rule changes that providers in our communities are really asking for, along with other rule changes that are burdensome and unnecessary,” said Democratic Rep. , the vice chair of the committee, during the hearing. “I do hope we can find a path forward.”

Health department leaders have not decided on a course of action, spokesperson Jon Ebelt said in an email.

“We anticipated that the interim committee would extend its informal objection to our child care rules package and we continue to weigh options,” Ebelt said. “Increasing access to affordable, high-quality child care for hardworking Montana families remains of utmost importance to us.”

Child care providers are frustrated by the delay of what they say are much-needed changes to the child care licensing rules. The package would simplify the licensing process, reduce paperwork required from providers and parents, and create a new type of license for providers who operate outside of school hours, among other changes. Rachel Wanderscheid, the director of the , told the committee that the rules have been in the works for at least three years and that the panel should let them move forward.

“They are good for providers, they are good for families,” she said. “There are a couple of different areas of contention, but I would say overall — 95% — they’re great.”

The most contentious provision in the would require large child care facilities to enroll children who, for religious reasons, have not been vaccinated. Montana, , already allows religious exemptions from immunization requirements for school-age children. But this proposal would add a religious exemption to its immunization requirements for younger kids in the state.

Health care advocates worry that, if more parents claim vaccine exemptions, levels of community immunity to preventable infectious diseases, such as measles and pertussis, will drop and result in outbreaks.

The health department’s proposal also would eliminate a requirement that child care facilities send home infected and unvaccinated children and staffers when someone at the facility becomes sick with a vaccine-preventable disease.

Health department officials originally proposed the vaccine rules in 2022. The committee blocked the proposal then, too. In response, the department said it would not enforce the ban on religious exemptions.

In November, ºÚÁϳԹÏÍø News was the first to report that health department officials had tucked the exemption 45 pages into the draft licensure rules. Department officials said then that the rules package was needed to align with laws passed by the legislature in 2021 and 2023. One law, the , generally prohibits the state from infringing on a person’s right to the exercise of religion. Another based on vaccination status.

Mississippi began allowing similar exemptions for schools and child care centers in July following a court ruling that the state’s lack of a religious exemption violated the U.S. Constitution’s free exercise clause. But other states, including California, New York, Connecticut, and Maine, have removed religious exemption policies during the past decade.

The American Academy of Pediatrics has called for elimination of nonmedical vaccine exemptions, arguing they are “inappropriate for individual, public health, and ethical reasons,” according to .

The Montana health department has the option of waiting out the legislative committee’s objections and adopting the rule. An informal objection by the committee can be renewed for up to six months, after which the department can implement the rule. In this case, that renewal option would expire in April.

But if the committee votes to make a formal objection, the rule can be blocked until the end of the next legislative session, in spring 2025, said Maddie Krezowski, an attorney for the legislature. That would give lawmakers a chance to address the law underlying the rule during the session.

The committee also could file its formal objection with the secretary of state to be published with the adoption of the rule, creating implications for any legal challenges that follow. The burden of proof in court would shift from anyone potentially suing the health department to the department itself, said Krezowski.

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“These families came to me knowing we could offer them a safe and healthy environment,” Hutzenbiler said. Part of ensuring that healthy environment is having a strong vaccination policy, she said, especially for those who are immunocompromised or too young to receive the full slate of childhood vaccines.

So, when officials at Montana’s health department revived a proposal that would allow people to claim religious exemptions from immunization requirements at child care facilities, Hutzenbiler was both dismayed and relieved. Dismayed, because allowing more children to claim exemptions could compromise the community immunity levels necessary to defend against highly infectious diseases like measles and pertussis. Relieved, because as she scoured the proposed regulations, she found that her facility, which is licensed to care for up to 15 children, would be in a category of smaller providers that could choose whether to enroll unvaccinated kids.

“If it came down to where I had to, I had no choice, I would stop enrolling children today,” Hutzenbiler said. “In five years, I would be closed.”

Montana, , allows religious exemptions from immunization requirements for school-age children. If the state is successful in expanding its policy to child care facilities, it would become the second this year to add a religious exemption to its immunization requirements for younger kids. Mississippi for schools and child care centers in July following a court ruling that the state’s lack of a religious exemption violated the U.S. Constitution’s free exercise clause.

Until recently, the trend had been going the other way, with four states — California, New York, Connecticut, and Maine — removing religious exemption policies over the past decade. West Virginia has never had a religious exemption.

But religious exemptions, fueled by conservative backlash to covid-19 vaccinations, have become caught up in partisan politics, said , a University of California-Davis law professor who specializes in the law, history, and politics of reproduction, health care, and conservatism.

“It tends to be breaking down much more along red state-blue state lines, where progressive states are moving in the direction of mandating vaccines in more situations and conservative states are moving more in the direction of broadening exemptions,” Ziegler said. “So, as much as religious exemptions for vaccines are not a new issue, they’ve become polarized in a new way.”

The proposal in Montana the state Department of Public Health and Human Services floated last year, which a legislative committee temporarily blocked after public health advocates and child care providers objected. Afterward, in October 2022, health department officials said they would not enforce a religious exemption ban in child care centers.

“We are committed to ensuring that these families have viable child care options in accordance with state and federal law,” department spokesperson Jon Ebelt at the time.

However, in the state’s latest proposal, 45 pages into of child care licensure rules, the health department seeks to extend that exemption to child care facilities, where a family now can claim a vaccine exemption only for medical reasons. (There is an existing religious exemption for the vaccine against .)

ºÚÁϳԹÏÍø News sent the health department a list of questions about its decision to include a religious exemption in the rules proposal. Ebelt emailed a statement that did not address the exemption at all.

“The rules package cuts red tape to increase access to child care for hardworking Montana families, and ensures that related regulations align with statutory changes directed by the Legislature in 2021 and 2023,” his statement said.

The prohibits the state from infringing on a person’s right to the exercise of religion. Another based on vaccination status.

A religious exemption under Montana’s proposed rules would require a child’s parent or guardian to submit a form attesting that vaccination is contrary to their religious belief, observance, or practice. With no mechanism to check the validity of such claims, health professionals worry exemptions would spike, reducing community immunity levels.

“Exemptions lead to less people being vaccinated, which can lead to more outbreaks and more sick kids,” said Marian Kummer, a retired pediatrician who practiced in Billings for 36 years.

The risk of disease outbreaks would increase not only in those child care centers but in communities as well, said , an associate professor at the University of Montana School of Public and Community Health Sciences.

A community is from measles, for example, if 95% of the population is vaccinated against it, according to the World Health Organization. Montana’s vaccine exemption rate among kindergartners was 3.5% in the 2020-21 school year, according to , putting it within that range of protection.

The health department’s proposed changes also would eliminate a requirement that child care facilities keep out infected and unvaccinated children and staffers when someone becomes sick with a vaccine-preventable disease, said Kiely Lammers, director of the nonprofit advocacy group .

Some have questioned the legitimacy of religious exemptions. Most religions, including a majority of Christian denominations, have no theological objection to vaccination, according to a in the journal Vaccine. And the U.S. Supreme Court has ruled limits do exist on religious and parental rights: “The right to practice religion freely does not include liberty to expose the community or the child to communicable disease or the latter to ill health or death,” says the 1944 ruling in .

The American Academy of Pediatrics has called for the elimination of all nonmedical exemptions, including both religious exemptions and personal-belief exemptions, “as inappropriate for individual, public health, and ethical reasons,” according to .

In Connecticut, plaintiffs who challenged the state’s decision to remove religious exemptions said they objected to the use of fetal or animal cell lines in the research and development of vaccines. But a three-judge panel for the 2nd U.S. Circuit Court of Appeals that religious exemptions do not serve “to protect the health and safety of Connecticut students and the broader public” when it upheld Connecticut’s decision.

Yet even in California, which , efforts are underway to overturn the law. In a , several parents backed by a conservative law firm are challenging the law’s constitutionality. One plaintiff, Sarah Clark, said she believes vaccines run counter to her interpretation of the Bible “because they are a foreign substance and are harmful to the body.” Attorney General Rob Bonta’s office said Nov. 1 it hadn’t been served with the case yet but will review the complaint and respond as appropriate.

Montana’s proposed rule is scheduled for a public hearing Nov. 13. Some child care providers, like Hutzenbiler, expect it ultimately to take effect. She said she is already drafting language to submit to the state as required under the proposed rules, saying Munchkin Land Daycare will not accept unvaccinated children.

Lammers said state officials should be open to changes and give child care centers with 16 or more kids the same choice as smaller facilities not to enroll unvaccinated children.

“I’m hoping at the very least we can make it equal in all settings,” she said of the rule proposal.

Kummer, the retired pediatrician, said she hopes the proposal prompts enough opposition that the state removes the plans for the religious exemption. But she doubts that will happen, given the anti-vaccination sentiment of Montana policymakers.

“It’s going to take a tragedy in our state or somewhere else where people wake up to the fact that we need vaccinations,” Kummer said.

California news editor Judy Lin contributed to this report.

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The new states on the list include Montana, where lawmakers in the recently ended legislative session that contains $6.2 million in state and federal funds over the next two years to extend continuous postpartum eligibility from 60 days to 12 months after pregnancy. That would ensure coverage for between 1,000 and 2,000 additional parents in the state each year, according to federal and state estimates.

, the program director for Georgetown University’s Center for Children and Families, to expand postpartum coverage under Medicaid, the federal-state health insurance program for low-income people. What’s driving the wave is the recognition by policymakers of all political affiliations that the U.S. is in a maternal health crisis, she said. Maternal mortality rates , particularly among non-Hispanic Black women, according to the Centers for Disease Control and Prevention.

“Whether you’re conservative, liberal, or somewhere in between, people are really supportive of maternal health and helping moms and babies get a good start,” Clark said.

More than 4 in 10 births in the U.S. are covered under Medicaid. But the default postpartum coverage period is 60 days.

State by state, momentum has been building to ensure that new mothers’ medical care isn’t interrupted by loss of health care coverage. made it easier for states to extend postpartum Medicaid coverage by allowing them to simply amend their Medicaid plans instead of applying for a full waiver from the Centers for Medicare & Medicaid Services.

Besides Montana, legislators in Alaska, Mississippi, Missouri, Texas, Utah, and Wyoming passed measures this year to extend postpartum Medicaid coverage from 60 days to a year. States must submit amendments to their Medicaid plans to federal officials for approval. South Dakota officials to the state’s Medicaid plan in March.

That amendment is pending with CMS, which has approved 12-month postpartum coverage plans , as of May 30. New York and Vermont also have applications pending, and the states with newly passed measures are expected to submit theirs soon. It typically takes a couple of months for CMS to approve state Medicaid plan amendments to extend postpartum coverage, Clark said.

Lawmakers in Nebraska, Nevada, New Hampshire, and Wisconsin are considering measures to extend postpartum Medicaid coverage to 12 months.

Three other states considered but failed to pass legislation this year that would have authorized 12 months of postpartum Medicaid coverage: Idaho; Iowa; and Arkansas, which has the , according to the CDC.

Support in statehouses for such measures has been mostly bipartisan at a time of polarizing debate over reproductive health policy since the U.S. Supreme Court overturned Roe v. Wade last year.

Abortion has crept into the debate in some instances. The Texas House, for example, passed a 12-month postpartum coverage bill in April, only to see the measure amended in the state Senate to bar coverage for women after an abortion. After negotiations, said, “Medicaid coverage is extended for mothers whose pregnancies end in the delivery of the child or end in the natural loss of the child,” that federal officials won’t approve the amendment to the state plan.

The to Republican Gov. Greg Abbott, who has said he supports the measure.

Extended postpartum coverage allows new parents to establish a relationship with their health provider and manage their care and chronic illnesses without a disruption in insurance coverage. Continuous care is particularly important in the first year after birth, when patients face an increased risk of post-pregnancy complications and a significant number of maternal deaths occur from suicide and substance use, said , a senior research scientist at the University of Montana’s Rural Institute for Inclusive Communities.

“The year that follows the delivery is a very vulnerable year for the pregnant person,” Glover said. “They have a new infant in their family, and this is a time when they probably need health care more than ever.”

It’s particularly important to provide access to mental health and substance use treatment, said Stephanie Morton, the director of programs and impact for the nonprofit . “We know that suicide and overdose combined are a leading cause of death for new mothers,” she said.

Montana’s Republican governor, Greg Gianforte, included the postpartum coverage extension in his original budget proposal last fall. But a moment of confusion occurred on May 22 when Gianforte vetoed a bill that how certain provisions of the state budget are implemented, including the postpartum coverage extension. State health officials and the bill’s sponsor, Republican Rep. , said does not affect the ability of the state to extend postpartum Medicaid coverage.

“Supporting new mothers and infants by extending Medicaid coverage for up to 12 months postpartum was a top priority for the governor and his administration this session,” said state Department of Public Health and Human Services Director Charlie Brereton in an emailed statement. “We’re thankful for the Legislature’s support.”

States were not allowed to drop most beneficiaries from their programs during the covid-19 pandemic, so parents losing Medicaid coverage after the birth of a child wasn’t an issue. But states are reviewing their Medicaid rolls now that the public health emergency has ended. The Biden administration has estimated that 15 million people could lose Medicaid as a result.

That could include some people who would qualify for postpartum coverage in states whose approval of the extension is pending. But state agencies have a lot of discretion in how they redetermine Medicaid enrollment, and Clark said she expects they will do what they can to make sure new parents don’t lose coverage as part of what’s being called the Medicaid unwinding.

“We hope the state agencies would honor the wishes of the legislature,” she said.

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Medicaid beneficiaries nationwide are guaranteed continuous postpartum coverage during the ongoing covid-19 public health emergency. But momentum has been building for states to extend the default 60-day required coverage period ahead of the emergency’s eventual end. Approximately 42% of births nationwide are covered under Medicaid, the federal-state health insurance program for low-income people, and extending postpartum coverage aims to reduce the risk of pregnancy-related deaths and illnesses by ensuring that new mothers’ medical care isn’t interrupted.

The push comes as makes extending postpartum Medicaid coverage easier because states no longer need to apply for a waiver. A amid high U.S. maternal mortality rates also is driving the proposals, as is the expectation that more women will need postpartum care as state abortion bans proliferate in the wake of the U.S. Supreme Court’s decision to eliminate federal protections.

have already extended, or plan to extend, postpartum eligibility in their Medicaid programs. That number includes Texas and Wisconsin, which did not implement the ARPA provision but have proposed limited extensions of six months and 90 days, respectively.

The 15 states that limit postpartum Medicaid eligibility to 60 days are predominantly a swath of Republican-led states that stretch from the Mountain West to the South. But that could change when legislative sessions start in the new year.

In Montana, Republican Gov. Greg Gianforte and Department of Public Health and Human Services Director Charlie Brereton included 12-month postpartum eligibility in the governor’s proposed state budget. It would cost $9.2 million in federal and state funding over the next two years, , with the federal government covering nearly 70%.

A estimated about 2,000 women in Montana would benefit from the change. State health department spokesperson Jon Ebelt said state officials’ estimate is half that number. The reason for the disparity was not immediately clear.

Brereton considers the “extension of coverage for new mothers to be a pro-life, pro-family reform,” Ebelt said.

To become law, the proposal must be approved by state lawmakers once the legislative session begins in January. It has already received enthusiastic support from the senior Democrat on the committee that oversees the health department’s budget. “Continuous eligibility for women after they have a baby is really important,” said state Rep. during the Children’s Legislative Forum in Helena on Nov. 30.

The top Republican on the committee, state Rep.-elect , said he hasn’t dug in on the governor’s budget proposal but added that he plans to survey his fellow lawmakers and health care providers on the postpartum extension. “I wouldn’t dare venture a guess as to its acceptance,” he said.

Nationwide, more than 1 in 5 mothers whose pregnancies were covered by Medicaid lose their insurance within six months of giving birth, and 1 in 3 pregnancy-related deaths happen between a week and a year after a birth occurs, according to .

The U.S. had the highest overall maternal mortality rate, by far, among wealthy nations in 2020, at 23.8 deaths per 100,000 births, according to , a foundation that supports research focused on health care issues. The rate for Black women in the U.S. is even higher, 55.3 deaths.

“Many maternal deaths result from missed or delayed opportunities for treatment,” the report said.

The maternal mortality rate in Montana is not publicly available because the suppressed the state data in 2020 “due to reliability and confidentiality restrictions.” Ebelt, the state health department spokesperson, could not provide a rate before this article’s publication.

Annie Glover, a senior research scientist for the University of Montana’s Rural Institute for Inclusive Communities, said the governor’s proposal to extend postpartum Medicaid coverage could make a significant difference in improving overall maternal health in Montana. The university this year for such efforts, particularly to lower the mortality rate among Native Americans, and Glover said the state measure could further reduce rates.

“The reason really has to do with maintaining access to care during this very critical period,” Glover said. That goes for helping mothers with postpartum depression, as well as medical conditions like high blood pressure that require follow-ups with a physician well after delivery, she said.

In Wyoming, a legislative committee voted 6-5 in August to introduce a bill in the next session; the cost and their reluctance to further entangle the state in federal government programs.

About a third of Wyoming births are covered by Medicaid, and about 1,250 women would benefit from the change.

Postpartum eligibility bills are also expected to be taken up by legislators in and Mississippi, two states that have previously grappled with the issue. Both states have outlawed most abortions since the U.S. Supreme Court lifted federal protections in June, and Mississippi leaders have said additional postpartum care is needed because of the thousands of additional births expected as a result of the state’s ban.

A proposed coverage expansion died in the Mississippi House last session, but Lt. Gov. Delbert Hosemann said the Senate will revive the measure, .

Last year, federal officials approved a Medicaid waiver for Missouri that allows the state to extend postpartum eligibility. But to determine how enrollment would be affected by Missouri voters’ decision in August 2020 to expand Medicaid eligibility to more people. The delay prompted a bill to be filed last session that would have extended postpartum coverage by a year. That measure died, but a state lawmaker that will bring back the debate in the upcoming session.

In Idaho, a said it will press lawmakers to approve a postpartum eligibility extension, among other measures, after the state banned nearly all abortions this year.

KHN Montana correspondent Katheryn Houghton contributed to this report.

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Legislative Referendum 131 was approved for next month’s election by state lawmakers in 2021, more than a year before the U.S. Supreme Court removed federal protections for abortion in June.

Abortion remains legal in Montana because of a that protects it under the state constitution’s . Three laws passed by the Republican-led legislature in 2021 to restrict abortion while a legal challenge proceeds, arguing that they violate the constitutional provision.

But lawmakers sent LR-131 directly to voters to decide whether it should become law.

Here are five key things to know about the ballot measure:

1. What would the initiative do?

would impose criminal penalties of up to 20 years in prison and up to a $50,000 fine on any health care worker who doesn’t try to save a “born-alive infant.” That term is defined as a legal person who breathes, has a heartbeat, or has voluntary muscle movement after an abortion or delivery.

The measure would require health care providers to “take medically appropriate and reasonable actions” to keep the fetus or infant alive, but it doesn’t define or give examples of such actions. The health care workers liable under the initiative would be doctors and nurses but also any “individual who may be asked to participate in any way in a health care service or procedure.”

The initiative includes a mandatory reporting requirement, which means that any employee or volunteer at a medical facility who is aware of a violation must report it to authorities.

2. Where did the initiative come from?

, the 2021 legislation that authorized the referendum, was sponsored by state Rep. (R-Kalispell), chair of the panel that oversees the state Department of Public Health and Human Services’ budget.

“We need to make it abundantly clear that here in Montana, the protection of all life is available,” while introducing the bill in January 2021.

The bill is very similar to in 2018 as a template for state lawmakers nationwide. So far, 18 states have provisions along those lines, and more are considering them, according to the group. Its president and CEO, Catherine Glenn Foster, during the 2021 legislative session.

The Montana measure does not include a provision in the model legislation that gives an infant’s parents the right to refuse medical intervention if the treatment isn’t necessary to save the infant’s life, would only temporarily prolong the infant’s death, or carries risks that outweigh the potential benefits to the infant.

The Montana measure also excludes a clause in the model legislation that exempts parents and guardians from criminal and civil liability. The Montana initiative doesn’t address parental liability.

Bradley Kehr, Americans United for Life’s policy counsel, described the ballot initiative as “well tailored to the needs of Montana.”

3. What does the initiative have to do with abortion?

Regier’s bill says the purpose of the referendum is to protect infants who have survived abortions from being denied medical care and being left to die.

The measure’s passage would move the Family Research Council’s classification of Montana’s “born-alive” protections from compared with the rest of the nation, according to Connor Semelsberger, director of federal affairs for life and human dignity for the nonprofit organization, which advocates for anti-abortion measures.

Montana is not among the nine states that require health providers to report when an infant is born alive during an abortion. The Family Research Council lists the states that do as Arkansas, Arizona, Florida, Indiana, Michigan, Minnesota, Ohio, Oklahoma, and Texas.

Instances of fetuses surviving abortions . In Minnesota, which the Family Research Council points to as having the strongest protections in the U.S., five of the 10,136 abortions performed in 2021 resulted in a live birth, . None of the five survived.

The number of abortions in which a fetus could survive is small, too: The point at which a fetus can survive outside the womb is generally considered to be after 22 weeks of pregnancy, and about .

The leaders of two Montana clinics that provide abortions said the initiative’s passage would not affect their operations, as Montana law restricts performing abortions after a fetus is viable. The law does not define viability.

Nicole Smith, executive director of Blue Mountain Clinic in Missoula, said her clinic provides dilation-and-evacuation abortions that would not result in a live birth. “We do not provide obstetric or labor-and-delivery care,” she said, adding that she would refer a patient who needed that kind of care to someone who specializes in high-risk pregnancies.

Helen Weems, director of All Families Healthcare in Whitefish, said her clinic does not perform abortions after 12 weeks. LR-131 “is designed to look like an anti-abortion measure, but it has no relevance” to her clinic, she said. “There would never be an occasion in my practice where there would be an infant born alive,” Weems said.

4. If clinics that provide abortions won’t be affected, who will?

The initiative also covers any natural birth, induced labor, or cesarean section.

That could present obstetricians and gynecologists with an ethical dilemma of having to choose between their obligation to provide the best available medical care to their patients or the potential of facing legal penalties, according to a by the American College of Obstetricians and Gynecologists opposing the Montana measure.

The organization said LR-131 could require an aggressive course of treatment in extremely complex and often tragic medical situations. It opposes the measure as government interference in the patient-physician relationship that would impose additional trauma on families.

Smith said the initiative would apply to miscarriages and to hospital deliveries in cases when parents know their child won’t live but want to complete the birth for a chance to hold the baby and say goodbye.

Opponents of the ballot initiative use the example . They say that rather than allowing the family to hold, say goodbye to, or baptize the baby before it dies, the measure would require health care workers to remove it in an attempt to save its life.

found that all 129 infants who were born before 22 weeks and were included in the study died. Two received active medical treatment. Of those born in the 22nd week, 5% survived. Most of the 24 hospitals in the study provided treatment to all infants born at 25 or 26 weeks. Those born at week 26 had an overall survival rate of about 81%, and 59% survived without moderate or severe impairment.

5. What does existing federal and state law say?

, it’s already a felony to purposely, knowingly, or negligently cause the death of a viable, premature infant. passed in 2002 says a person includes “every infant member of the species homo sapiens who is born alive at any stage of development.” It defines “born alive” as evidence of a heartbeat, breathing, or voluntary muscle movements, but does not include any additional provisions.

Opponents of the Montana measure point to those laws as evidence that LR-131 is unnecessary and is instead meant to drive conservative voter turnout. “This cruelty is being forced on already grieving families for the cold, calculated political gain of extreme-right politicians,” Weems said.

Regier, the legislator whose bill authorized the referendum, said current Montana law does not go far enough to protect infants.

Semelsberger, of the Family Research Council, said the same about the federal law and that it has lacked enforcement. The organization supports (R-Neb.) that would add requirements to save the life of an infant, though with up to five years of maximum prison time, instead of the 20 years in Montana’s measure.

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But while Oregon voters in 2020 approved the supervised use of psychedelic mushrooms, the citizen initiative on the Colorado ballot in November goes further. Proposition 122 would allow the personal use of psilocybin mushrooms and certain plant-based psychedelic substances by adults 21 and over but would ban sales except in licensed “healing centers,” where people could ingest them under the supervision of trained facilitators.

The psychedelic substances, which can alter a person’s perception and cause hallucinations, are , which is the federal classification given to drugs deemed to have . However, a still-developing body of research has found that psychedelic mushrooms may have health benefits, such as treating depression.

As of June, 15 cities and other local U.S. jurisdictions have decriminalized possession of psilocybin or deprioritized the policing, prosecution, or arrest of users. Denver’s 2019 voter-approved initiative made the adult possession and use of psilocybin mushrooms the city’s lowest law enforcement priority, and it prohibited the spending of resources on enforcing related penalties.

Here are five key things to absorb about the initiative in Colorado:

1. What does the Colorado initiative do?

Proposition 122 is one of that Colorado voters will decide in the Nov. 8 general election. The measure would allow adults to grow, possess, and use mushrooms containing the chemicals psilocybin and psilocin, and decriminalize three plant-based psychedelics: mescaline (though it specifically excludes the peyote cactus), ibogaine (from the root bark of the iboga tree), and dimethyltryptamine (a compound in ayahuasca brew). It also would require the state to create regulations for facilities where adults 21 and older can buy and take the psychedelics under supervision. Selling the drugs outside of those facilities would remain illegal.

The measure sets a timeline for the regulatory process and facilities to be operational by late 2024 for psilocybin, and the state could expand the list of psychedelic substances to include mescaline, ibogaine, and dimethyltryptamine in those facilities starting in 2026. If voters approve the initiative, people who use those psychedelics would be protected from professional discipline or losing public benefits, and criminal records of past convictions for offenses made legal under the measure could be sealed.

The measure goes beyond the Oregon law voters approved in 2020 , called psilocybe cubensis, in supervised facilities. In Oregon, no facilities have opened yet and state health officials are still finalizing regulations.

2. What are the potential health benefits?

Supporters’ primary argument for the measure’s passage is that psychedelic mushrooms and plants have potential mental health benefits. Emerging research and clinical trials are studying the substances’ effectiveness as an alternative treatment for conditions such as depression, anxiety, and post-traumatic stress disorder. Proponents of the measure say regulation would increase access for people struggling to find effective mental health care. They also say psychedelic mushrooms are not addictive and pose no public safety risk.

3. What are the risks and unknowns?

Opponents caution that the measure is too far ahead of the science, and that the still-developing research should not be used to legitimize the legalization of psychedelic mushrooms and plants for medical or recreational use. They also point out that much of the research conducted has involved psychedelic mushrooms, and that relatively little is known about the effects of mescaline, ibogaine, and dimethyltryptamine.

According to officials at the , ingesting psilocybin can produce negative physical effects, such as vomiting, weakness, and lack of coordination, along with negative psychological effects, such as being unable to distinguish fantasy from reality. Psilocybin can trigger episodes of psychosis, so people with a personal or family history of psychosis are generally excluded from studies. Psilocybin can also exacerbate heart conditions.

Many people claim that because psilocybin is derived from plants (technically, fungi) it is safer than pharmaceutical drugs created in a lab. This distinction has no basis. Many plants are poisonous, and many pharmaceutical drugs are derived from natural substances.

4. What does the science say?

Initial studies have found that psilocybin can help depression or anxiety and . While the findings are promising, researchers caution that larger sample sizes and additional psilocybin’s neurobiological factors and . In 2019, the FDA called psilocybin a “,” a designation meant to speed up development of promising drugs. No psychedelics have been approved for medical use so far.

Of the drugs being considered in the Colorado initiative, psilocybin is the most studied. Clinical trials have tested psilocybin in combination with therapy. Unlike antidepressants, which must be taken regularly, psilocybin has been shown to have durable treatment effects after just one, two, or three doses. It is unclear whether psilocybin has any health benefits outside the psilocybin-assisted therapy protocols used in clinical studies.

Some research findings show that psilocybin-assisted therapy can be useful in treating substance use disorders, including nicotine and alcohol addiction. Clinical trials for mescaline, ibogaine, and dimethyltryptamine are still in preliminary stages.

5. Will this sprout another industry like marijuana?

Because psilocybin is naturally occurring, people tend to assume its path to legalization will follow that of cannabis. However, the compounds have key differences in the way they affect people. Psilocybin is unlikely to win approval as easily as marijuana, which is legal for medical use and the District of Columbia. Nineteen of those states and D.C. also allow recreational use.

The Colorado measure expressly forbids the sale of psychedelics outside of licensed facilities. However, the potential for legalization in the state and elsewhere in the U.S. has spurred the launch of dozens of companies eager to commercialize the sale and treatment of psilocybin. Some are organizing retreats to Jamaica, Peru, or Mexico, where they conduct ceremonies that reflect the traditional use of psilocybin and other natural psychedelics that date back centuries.

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Since 2016, has heard fewer than 20 cases a year, and very few of those are overturned, but preparing for those appeals and board meetings takes time from state Department of Public Health and Human Services’ staff members and attorneys, according to the

Getting rid of the appellate board also would help public assistance applicants who are rejected appeal their cases directly to district court, health department Director Charlie Brereton . Currently, rejected applicants can take their cases to court only after the board hears their appeals, though very few do so, according to a board member.

“I want to be very clear, with this proposal we are not seeking to eliminate an appeals pathway; rather, we’re streamlining the process and eliminating what we see as an unnecessary and underutilized step,” Brereton said.

The plan to get rid of the Board of Public Assistance is one of 14 bills that the state Department of Public Health and Human Services has asked legislators to draft for the . The proposal comes from a review of the state agencies under Republican Gov. Greg Gianforte’s , which seeks to improve efficiency and eliminate outdated or unnecessary regulations.

The three-person Board of Public Assistance presides over appeals of denials made by the health department’s Office of Administrative Hearings in nine programs: Temporary Assistance for Needy Families, which provides cash to low-income households with children; the Supplemental Nutrition Assistance Program, formerly known as food stamps; Medicaid, the federal-state program that pays for health care for low-income people; developmental disabilities services; the Low Income Energy Assistance Program; the Weatherization Assistance Program; refugee assistance; mental health services; and Healthy Montana Kids, which is the state’s Children’s Health Insurance Program.

The proposal to eliminate the board came as a surprise to at least one of its members, who learned about it from KHN. “I haven’t heard anything from the department,” said Sharon Bonogofsky-Parker, a Billings resident appointed by Gianforte in March 2021.

The board meets every other month, Bonogofsky-Parker said. She recalled one “really good case” during her tenure in which the board restored benefits to a disabled military veteran who had lost them because of documents forged by someone else.

But Bonogofsky-Parker estimated that the board sides with the department’s decisions about 90% of the time because most cases involve applicants who didn’t understand or follow the programs’ rules, whose income level changed, or who have some other clear disqualifying factor.

The board provides a service by hearing appeals that would otherwise clog the court system, she said. “By and large, these cases are pretty frivolous,” Bonogofsky-Parker said. “The board is useful in keeping a lot of these cases out of court.”

The view contrasts with Brereton’s, who described the ability of applicants to file court grievances expediently as a benefit of the proposed change.

District courts charge a $120 fee to start a proceeding of this type, according to the Lewis and Clark County District Court clerk’s office. That would create a potential obstacle for people trying to prove they qualify for public assistance. By contrast, Board of Public Assistance appeals are free.

State health department spokesperson Jon Ebelt said people with low incomes to request a court fee waiver. “This issue was considered during conceptual stages of the bill,” he said.

Bonogofsky-Parker said she doesn’t plan to oppose the department’s proposal, despite her view that the board acts as a bulwark against frivolous court cases. The other two board members, Gianforte appointee Danielle Shyne and Carolyn Pease-Lopez, a holdover from former Democratic Gov. Steve Bullock, did not respond to phone or email messages.

The Children, Families, Health, and Human Services Interim Committee will draft the bill for consideration by the full legislature in the 2023 session.

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Officials of another Montana hospital accused public officials of threatening and harassing their health care workers for refusing to treat a politically connected covid-19 patient with that antiparasitic drug or hydroxychloroquine, another drug unauthorized by the Food and Drug Administration to treat covid.

And in neighboring Idaho, a medical resident said police had to be called to a hospital after a covid patient’s relative verbally abused her and threatened physical violence because she would not prescribe ivermectin or hydroxychloroquine, “drugs that are not beneficial in the treatment of covid-19,” she wrote.

These three conflicts, which occurred from September to November, underline the pressure on health care workers to provide unauthorized covid treatments, particularly in parts of the country where vaccination rates are low, government skepticism is high, and conservative leaders have championed the treatments.

“You’re going to have this from time to time, but it’s not the norm,” said Rich Rasmussen, president and CEO of the Montana Hospital Association. “The vast majority of patients are completely compliant and have good, robust conversations with their medical care team. But you’re going to have these outliers.”

Even before the pandemic, the health care and social assistance industry — which includes residential care facilities and child day care, among other services — led all U.S. industries in nonfatal workplace violence, according to . Covid has made the problem worse, leading to hospital security upgrades, staff training and calls for increased federal regulation.

Ivermectin and other unauthorized covid treatments have become a major source of dispute in recent months. Lawsuits over hospitals’ refusals to provide ivermectin to patients have been filed in , , and elsewhere. The ivermectin harassment extends beyond U.S. borders to providers and public health officials worldwide, in such countries as . Even so, reports of threats of violence and harassment like those recently seen in the Northern Rocky Mountains region have been relatively rare.

Ivermectin is approved to treat parasites in animals, and low doses of the drug are approved to treat worms, head lice and certain skin conditions in humans. But has not authorized the drug to treat covid. The agency says that clinical trials are ongoing but that the current data does not show it is an effective covid treatment and taking higher-than-approved levels can lead to overdose.

Likewise, hydroxychloroquine can cause serious health problems and the drug does not help speed recovery or decrease the chance of dying of covid, .

In Missoula, Montana, the Community Medical Center was placed on lockdown and police were called on Nov. 17 after a woman reportedly threatened violence over how her relative was being treated, according to a Police Department statement. Nobody was arrested.

“The family member was upset the patient was not treated with ivermectin,” Lt. Eddie McLean said Tuesday.

Hospital spokesperson Megan Condra confirmed on Wednesday that the patient’s relative demanded ivermectin, but she said the patient was not there for covid, though she declined to disclose the patient’s medical issue. The main entrance of the hospital was locked to control who entered the building, Condra added, but the hospital’s formal lockdown procedures were not implemented.

The scare was reminiscent of one that happened in Idaho in September. Dr. Ashley Carvalho, who is completing her medical residency training in Boise, that she was verbally abused and threatened with both physical violence and a lawsuit by a patient’s relative after she refused to prescribe ivermectin or hydroxychloroquine.

“My patient was struggling to breathe, but the family refused to allow me to provide care,” Carvalho wrote. “A call to the police was the only solution.”

An 82-year-old woman who was active in Montana Republican politics was admitted to St. Peter’s Health, the hospital in Helena, with covid in October. According to a November report by a special counsel appointed by state lawmakers, a family friend contacted Chief Deputy Attorney General Kris Hansen, a former Republican state senator, with multiple complaints: Hospital officials had not delivered a power-of-attorney document left by relatives for the patient to sign, she was denied her preferred medical treatment, she was cut off from her family, and the family worried hospital officials might prevent her from leaving. The patient later died.

That complaint led to the involvement of Republican Attorney General Austin Knudsen, who texted a lobbyist for the Montana Hospital Association who is also on St. Peter’s board of directors. An image of the exchange was included in the report.

“I’m about to send law enforcement in and file unlawful restraint charges,” Knudsen wrote to Mark Taylor, who responded that he would make inquiries.

“This has been going on since yesterday and I was hoping the hospital would do the right thing. But my patience is wearing thin,” the attorney general added.

A Montana Highway Patrol trooper was sent to the hospital to take the statement of the patient’s family members. Hansen also participated in a conference call with multiple health care providers in which she talked about the “legal ramifications” of withholding documents and the patient’s preferred treatment, which included ivermectin and hydroxychloroquine.

Public Service Commissioner Jennifer Fielder, a former Republican state senator, left a three-minute voicemail on a hospital line saying the patient’s friends in the Senate would not be too happy to learn of the care St. Peter’s was providing, according to the special counsel’s report.

Fielder and the patient’s daughter also cited a “right to try” law that Montana legislators passed in 2015 that allows terminally ill patients to seek experimental treatments. But a legal analysis written for the Montana Medical Association says that while the law does not require a provider to prescribe a particular medication if a patient demands it, it could give a provider legal immunity if the provider decides to prescribe the treatment, .

The report did not offer any conclusions or allegations of wrongdoing.

Hospital officials said before and after the report’s release that their health care providers were threatened and harassed when they refused to administer certain treatments for covid.

“We stand by our assertion that the involvement of public officials in clinical care is inappropriate; that individuals leveraged their official positions in an attempt to influence clinical care; and that some of the exchanges that took place were threatening or harassing,” spokesperson Katie Gallagher said in a statement.

“Further, we reviewed all medical and legal records related to this patient’s care and verified that our teams provided care in accordance with clinical best practice, hospital policy and patient rights,” Gallagher added.

The attorney general’s office did not respond to a request for comment but told in a statement that nobody at the state agency threatened anyone.

Rasmussen, the head of the Montana Hospital Association, said St. Peter’s officials have not reached out to the group for assistance. He downplayed the attorney general’s intervention in Helena, saying it often happens that people who know medical leaders or trustees will advocate on behalf of a relative or friend.

“Is this situation different? Certainly, because it’s from the attorney general,” Rasmussen said. “But I think the AG was responding to a constituent. Others would reach out to whoever they know on the hospital board.”

He added that hospitals have procedures in place that allow family members of patients to take their complaints to a supervisor or other hospital leader without resorting to threats.

Hospitals in the region that have watched the allegations of threats and harassment unfold declined to comment on their procedures to handle such conflicts.

“We respect the independent medical judgment of our providers who practice medicine consistent with approved, authorized treatment and recognized clinical standards,” said Bozeman Health spokesperson Lauren Brendel.

Tanner Gooch, a spokesperson for SCL Health Montana, which operates hospitals in Billings, Butte and Miles City, said SCL does not endorse ivermectin or other covid treatments that haven’t been approved by the FDA but doesn’t ban them, either.

“Ultimately, the treatment decisions are at the discretion of the provider,” Gooch said. “To our knowledge, no covid-19 patients have been treated with ivermectin at our hospitals.”

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HELENA, Mont. — My unvaccinated 7-year-old son began hacking and sneezing in late September as the hospitals in our home state of Montana started buckling under the latest covid surge. I took him to get tested when his symptoms wouldn’t go away.

The cotton swab went up his nostrils and Thomas bucked out of my lap with a mighty snort, nearly ripping the 6-inch swab from the pediatrician assistant’s fingers. It came out bent, but the sample was usable, and as she put it away, I asked a question to which I already knew the answer.

“So we’re in quarantine?” She nodded. It would take about 72 hours to get the results, she said.

The next day, 4-year-old twins Anna and Karen started coughing and sneezing like their brother. They were already under orders to stay home after being exposed to a covid-positive classmate, but they, too, were slapped with a new quarantine while we waited for the test results.

We had already experienced two covid quarantines and summer camp closures in August. In September, our family accomplished a new feat in our pandemic journey: The twins entered a quarantine within a quarantine, running simultaneously to their brother’s quarantine.

For the parents of children too young to get vaccinated, the news that their vaccine safe and effective for children ages 5 to 11 is a light at the end of a seemingly never-ending quarantine tunnel. Remember those lockdowns that defined spring 2020 for everyone? We parents are still living them, in increments lasting up to 10 days. When we’re not in quarantine, we’re bracing for the next one.

My wife, Beagan, and I now flinch every time we see a school number on our phones’ caller ID. Are they closing again? Will our bosses be understanding this time? Can we find part-time care at the last minute? Are we even allowed to bring in that outside help if we’re in quarantine?

But the record hospitalizations and spike in covid deaths put the problems of our confined — yet healthy — family in perspective. The same day my son was tested, Montana was among the and the to help hospitals bursting with covid patients. The 1,326 new covid cases reported by the state included 118 kids under age 10.

Our pediatrician’s office is part of the St. Peter’s Health system, which was to ration medical services. Several hundred feet from us at the doctor’s office, all eight intensive care beds in the main wing of the hospital were filled, six by covid patients.

Here we were, just three weeks into the school year, and we were drained. Beagan and I spent much of August and September trying to manage the kids and our jobs. How bad might it get when the cold weather forced us all back indoors?

To top it off, we discovered that the two kittens we adopted from the local shelter had ringworm. The fungal infection spread to the entire family and the dog.

My wife summed it up neatly: “I feel like a crappy parent, a crappy employee, a crappy spouse, a crappy pet owner. I just feel crappy.”

Children are much less likely than adults to get seriously ill or die from covid-19. But they make up , and the highly transmissible delta variant has led to . Some children who get the disease may also develop “long covid” or the sometimes fatal .

Despite the surge, it seems a lot of people in Helena and around the state have put the pandemic behind them. Maskless faces in indoor spaces, crowded events and are the norm, aided by new state laws that stymie local health officials’ ability to implement common anti-covid measures.

I feel like an oddity when I’m one of the few masked patrons or employees at the grocery store, or my kids are the only ones masked at the children’s science museum. So I asked Dr. Lauren Wilson, vice president of the Montana chapter of the American Academy of Pediatrics, whether I was being too cautious.

Wilson said the parents of unvaccinated kids are right to be cautious, not just because their children might get covid, but because they could bring it home and spread it to vulnerable family members. It’s also important to balance protecting children with providing for their needs, particularly their mental health, she added.

That can be difficult when parents are experiencing “decision fatigue” from the scores of choices they face every day about their families’ safety, she said. It’s difficult to assess risks when so many people are ignoring public health recommendations.

Our wait for test results stretched from three days to five. On the last day, I wrote this essay between tea parties, breaking up fistfights, playing “Frozen” on the television for the umpteenth time and giving in to my son’s request to have potato chips for breakfast. The kids’ negative covid test results arrived near day’s end.

Then we found out 7-year-old son could soon join the ranks of the vaccinated if the Food and Drug Administration approves the Pfizer-BioNTech shot for his age group.

That will be a big day for us, along with the twins’ 5th birthdays in the spring. In the meantime, I’ve started to cough and sneeze. Considering the kids’ tests were negative, I think I’ll skip getting one myself — in hopes of breaking our quarantine streak.

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