UPDATE, November 7, 11:19 a.m.: The ballot initiative to tax tobacco products and use the funds to maintain Medicaid expansion in Montana failed on Tuesday.

One in ten people in Montana could lose their health coverage next year if Montana voters don’t pass a ballot measure in November to permanently expand Medicaid coverage.

The proposal to fund expansion includes raising taxes on tobacco products, leading tobacco companies to wage a $9 million war to thwart the effort.

Montana legislators, unlike many Republicans who have turned down billions in federal dollars to expand the program, passed Medicaid expansion under the Affordable Care Act (ACA) in 2015. But the expansion came with a sunset provision that would end it on June 30, 2019. Republican sponsor of the Medicaid expansion, state Sen. Ed Buttrey, said he would not vote to reauthorize the HELP Act, according to Montana Public Radio.

“Big tobacco is again telling lies that put lives at risk, spending millions to protect its profits at the cost of healthcare for nearly one-hundred-thousand people,” said Jonathan Schleifer, executive director of The Fairness Project, an advocacy group championing expansion. “There’s a clear choice in this election: Medicaid saves lives; tobacco companies kill.”

Health advocates and proponents of the ballot question, Initiative 185, supported by the Montana Hospital Association and the American Heart Association, point out that the initiative has been a resounding success and should be continued.

“Medicaid expansion has provided low-income adults with access to affordable preventive, mental health, substance use disorder treatment, and other services that promote individual and family health, as well as a healthy Montana workforce,” said Sheila Hogan, director of Montana’s Department of Public Health and Human Services. “More than 65,000 expansion adults have accessed preventive services to date.”

The program has expanded health-care coverage to more than 96,000 residents since 2016, driven down the rate of uninsured to a record 7.4 percent, created 5,000 jobs, and has saved the state millions by generating state savings and growing the economy, according to data from the health department.

The federal government has funded at least 90 percent of the cost of the Montana Medicaid expansion, saving more than $36 million in state funds. Medicaid expansion helped to generate more than $47 million in new tax revenues, according to an analysis. A report shows that Montana’s Medicaid program is already paying for itself. 

More than eight in ten adult Medicaid enrollees nationwide are in working families. The expansion in Montana has added $280 million in personal income in 2017 and has helped 6 percent to 9 percent more low-income adults join the workforce. Health care is now the main driver of private sector income and the second-largest source of jobs in Montana. One in five dollars earned there comes from health care jobs, according to an analysis by the Montana Healthcare Foundation.

The proposed initiative looks to increase taxes by $2 per pack of cigarettes for a total tax of $3.70 and by 33 percent of the wholesale price for all other tobacco products, including e-cigarettes and vaping products. This would help generate about $74 million per year by 2023.

Big tobacco is not having any of it. The industry has spent more than $9 million to persuade Montana residents to vote “no” on the ballot initiative, according to the Washington Post. A tobacco-funded group even sued but the Montana Supreme Court unanimously rejected Montanans Against Tax Hikes’ request to rewrite the ballot statement it claimed was “prejudicial,” according to the Associated Press.

Several health organization and hospital groups such as the Montana Hospital Association, the American Cancer Society, and Families USA, support the initiative. Advocates argue that the tobacco industry is once again pitting people’s health against company profits.

“For generations, Big Tobacco has saddled Montana taxpayers with an unfunded mandate from the huge health costs of their addictive products. Right now, every Montana taxpayer is paying close to $800 extra in taxes every year to help cover the costs of smoking. Yet, Big Tobacco is pouring millions into our state to protect their profits over the health of Montanans. The truth is, without I-185, one in ten Montanans will lose their current health care. And, if you don’t smoke—you don’t pay,” said Amanda Cahill, director of government relations at the American Heart Association in Montana.

The ACA, or Obamacare, now leaves Medicaid expansion up to individual states after a 2012 ruling by the Supreme Court, and the fight to expand the low-cost or free health care is gaining steam in Republican-controlled states like Utah, Idaho, and Nebraska, where voters will vote on Medicaid expansion in November.

If Medicaid extension ends, around 100,000 Montanans will lose coverage in a state that has a population of about 1 million. That sounds “frightening and devastating” to Erin Rumelhart, director of nursing at Providence St. Joseph Medical Center in East Polson, who learned firsthand what a lifesaver Medicaid can be.

She was 21 and in a nursing program when she found out she was pregnant and that she wasn’t covered for it under her parents’ insurance, she told Rewire.News. She wanted to complete her education and be a good mother, but she didn’t know how until she walked into the health department and found that she would be covered via Medicaid.

“It was an incredible gift at a time when I think I was very vulnerable,” said Rumelhart, now 38 with a 16-year-old daughter who is starting an internship in behavioral health. “I feel like the greatest thing I am is a mother and I did not have to compromise on care for myself or my unborn child. I was able to continue with a healthy pregnancy. It was a wonderful insurance for us, truly.”

As a nurse, Rumelhart said she sees a great number of patients who are covered by Medicaid because they don’t have other options. For her, this is “a real dignity issue” because health care is an essential part of everyday life and she can’t imagine how they will handle losing coverage if Medicaid expansion is not extended.

“There is a reason why [Medicaid] was created and I think the intention of it is so much related to dignity and justice and how we care for those who at times are unable to care for themselves.”