Twenty-four states and the District of Columbia said yes to Medicaid expansion when the law went into effect. Since then, just six more have signed on. States that do get billions of additional federal dollars, but many Republican lawmakers are loathe to say yes to the Obama administration.

The fight’s garnered many headlines in Florida recently as the Republican-led House and Senate are at odds on expansion and the legislative work—including setting a budget—came to a standstill. But the issue has also been hot out west this year where four Republican majority states took up Medicaid expansion. Wyoming , ’s governor is seeking to negotiate a compromise with Washington to offer legislators, and Alaska legislators are still wrestling with the issue. And after some legislative fireworks, Montana said yes.

Montana lawmakers have been stewing over Medicaid expansion since they said no to it in 2013 – the last time they met. When they reconvened in January, Americans for Prosperity, a conservative group supported by the billionaire brothers Charles and David Koch, staffed up in the state and targeted moderate Republicans, organizing anti-expansion “town hall” meetings in their districts.

But AFP didn’t invite targeted lawmakers themselves and that backfired. Many voters called AFP’s tactics meddling by outsiders, and some .

Tea Party lawmakers in the Montana House fought hard against Medicaid expansion. They killed a proposal by Democrats, and then nearly derailed a Republican-sponsored compromise. The House had to bend its rules to even bring the bill to the floor for a vote. But in the end, 20 Republicans felt politically safe enough to cross party lines and vote with all the Democrats to pass it.

Still, at the bill’s signing ceremony Republican Senator , who sponsored the bill, said, “This not Medicaid expansion.”

“I think everyone agrees that Medicaid is broken,” he says.  “To put more money into it, to bring more people into it, that’s certainly not going to help its brokenness.”

But surveys show favor Medicaid expansion. Supporters testified in large numbers at legislative committee hearings and attended rallies. In one, organized by an interfaith church group, Lutheran pastor Julia Seymour turned the crowd into a choir. She led them in singing, “Medicaid expansion, I’m going to let it shine” to the tune of “This Little Light Of Mine.”

Seymour’s determined to make sure all Alaskans have access to health insurance.

“The Bible tells us that faith, hope and love go on and do not end. And I’m keeping the faith and I am hopeful, but my love for some of the leaders is waning now and then,” she says.

As soon as the regular session ended,  Gov. Walker called lawmakers into .

The state is currently facing a massive because of the plunge in oil prices. And Walker says even in better financial times, Alaska doesn’t usually decline more than a billion federal dollars.

“If that was a road project or if that was some infrastructure project, we would be all over that,” he says.  “This is healthcare.”

Walker has proposed expanding on his own if lawmakers don’t act but it’s not clear he has this authority. About 40,000 people would if the state expands. About 30 percent of this group are Alaska Natives.

This story is part of a partnership with NPR, Montana Public Radio, Alaska Public Media and .

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Dillard found out she had uterine cancer a year ago. Her oncologist gave her a year to live. The 57-year-old has beaten those odds, but now her kidneys are failing. After the laughs are over, Smith sits down on the edge of Dillard’s bed, leans in, and starts talking about a surgical procedure to help her kidneys.

Smith is a palliative care doctor, a specialty that is in the U.S. The idea is to help patients cope with a terminal or life-altering illness. And unlike hospice care, it is not offered only in the final months of life. Smith works on pain management, coordinating care and even does some counseling. Dillard, who is now in chemotherapy again, really appreciates it.

“I can’t even say how much she’s helped me,” Dillard says. “Just little things. You know, showing me things like breathing techniques. Sort of like mediation, just ways to focus on things that are positive and happy rather than focusing on your sickness and how crappy you feel.”

Becoming A Better Listener

Two years ago, Linda Smith was a very different kind of doctor.

She worked in the emergency room at the busy Anchorage hospital, where the goal was to quickly stabilize a patient and move on. But two decades into her career, she started to question how she was caring for patients at the very end of their lives. She remembers putting patients on breathing tubes and hearing family members say things like, “I know Dad didn’t want this, but we’re just not ready to let him go.”

“I started to have a lot of regret about doing things to people that were painful and uncomfortable and were prolonging their suffering,” Smith says. She thought, “if I only had the time to sit down with the family, I probably wouldn’t be doing these things.”

In 2011, Smith enrolled in a one-year at Providence. She had a lot to learn. She found out she was a bad listener. And she was abrupt. As an ER doctor, sometimes she was so busy she didn’t even sit down to deliver devastating news.

“I can remember saying to families things like, ‘I’m sorry, there’s nothing more I can do.’ And I realize now that sounds like abandonment to many people when you say you can’t do anything more. And the reality is I may not be able to do anything more to the patient that will make them survive, but there’s a lot more that I can do. I always can do more.”

Treatment Tradeoffs

A lot of what Smith does is talk to people. She doesn’t advocate for or against treatment, but she wants patients and their families to understand their decisions.

If a doctor puts in a breathing tube, for example, that may extend a patient’s life, but they won’t be able to eat or talk. If they die with a tube in, the family will miss hearing their last words. So now Smith sits down for hard conversations and looks patients and their family members right in the eye. Earlier this year, she was called in to consult with the wife of a patient who was dying.

“When I entered the room,” Smith says, “The wife said to me, ‘I know who you are.’ And I said, ‘Oh. OK.’ And she said, ‘I don’t want to talk with you and I don’t want to like you because you’re here to talk about death and dying, aren’t you?'”

Smith had a short conversation with the woman, and left her a book on difficult end of life choices. She went back to visit her the next day.

“And she said, ‘You know, I so tried not to like you. And what you had to say. And I really realize that we need to have this discussion now, don’t we?’

“And I said, ‘When you’re ready, we’re ready to have that discussion.’ And she said, ‘I’m ready now,'” Smith recalls.

There’s a shortage of doctors who provide palliative care, and the as baby boomers slide towards old age.

Smith was planning to go back to the emergency room. But interactions like that one persuaded her to stay in palliative care. Now she works more and makes less money. Some days, she wonders if she’s crazy.

But then she gets to visit a patient like Dawn Dillard.

Back in her hospital room, Dillard and Smith talk about having a second procedure. Smith leaves and calls Dillard’s other doctors. They end up agreeing that the second procedure isn’t really necessary after all. So instead of staying another night in the hospital, Dillard is back home by the end of the day.

This story is part of a reporting partnership that includes ,  and Kaiser Health News.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).