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This paper analyzes the politics and early outcomes of the 2023 68th legislative session that set budgetary and other policy for the 2025 biennium. Montana, whose political complexation was purple 2004-2020 moved unambiguously red in the elections of November 2020. This trend continued in the 2022 elections in which the GOP gained a legislative supermajority, with significant state fiscal implications for the most recent state budget. The first half of the paper focuses on spending and tax bills. The second half focuses on what attracted the most attention in Montana’s media and citizenry- the culture wars. Budgetary decisions often interacted with culture war issues and the paper makes note of this. The battle continues in the courts after a major climate change case challenged the state’s way of doing business.

BackgroundHigh alcohol intake is associated with increased mortality. We aimed to identify factors affecting mortality in people drinking extreme amounts of alcohol.MethodsWe obtained information from the UK Biobank on approximately 500,000 participants aged 40-70 years at baseline assessment in 2006-2010. Habitual alcohol intake, lifestyle and physiological data, laboratory test results, and hospital diagnoses and death certificate data (to June 2020) for 5136 men (2.20% of male participants) and 1504 women (0.60%) who reported consuming ≥80 or ≥50 g/day, respectively, were used in survival analysis.ResultsMortality hazard ratios for these excessive drinkers, compared to all other participants, were 2.02 (95% CI 1.89-2.17) for all causes, 1.89 (1.69-2.12) for any cancer, 1.87 (1.61-2.17) for any circulatory disease, and 9.40 (7.00-12.64) for any liver disease. Liver disease diagnosis or abnormal liver function tests predicted not only deaths attributed to liver disease but also those from cancers or circulatory diseases. Mortality among excessive drinkers was also associated with quantitative alcohol intake; diagnosed alcohol dependence, harmful use, or withdrawal syndrome; and current smoking at assessment.ConclusionsPeople with chronic excessive alcohol intake experience decreased average survival, but there is substantial variation in their mortality, with liver abnormality and alcohol dependence or other alcohol use disorders associated with a worse prognosis. Clinically, patients with these risk factors and high alcohol intake should be considered for early or intensive management. Research can usefully focus on the factors predisposing to dependence or liver abnormality.

Background & aimsOnly a minority of excess alcohol drinkers develop cirrhosis. We developed and evaluated risk stratification scores to identify those at highest risk.MethodsThree cohorts (GenomALC-1: n = 1,690, GenomALC-2: n = 3,037, UK Biobank: relevant n = 6,898) with a history of heavy alcohol consumption (≥80 g/day (men), ≥50 g/day (women), for ≥10 years) were included. Cases were participants with alcohol-related cirrhosis. Controls had a history of similar alcohol consumption but no evidence of liver disease. Risk scores were computed from up to 8 genetic loci identified previously as associated with alcohol-related cirrhosis and 3 clinical risk factors. Score performance for the stratification of alcohol-related cirrhosis risk was assessed and compared across the alcohol-related liver disease spectrum, including hepatocellular carcinoma (HCC).ResultsA combination of 3 single nucleotide polymorphisms (SNPs) (PNPLA3:rs738409, SUGP1-TM6SF2:rs10401969, HSD17B13:rs6834314) and diabetes status best discriminated cirrhosis risk. The odds ratios (ORs) and (95% CIs) between the lowest (Q1) and highest (Q5) score quintiles of the 3-SNP score, based on independent allelic effect size estimates, were 5.99 (4.18-8.60) (GenomALC-1), 2.81 (2.03-3.89) (GenomALC-2), and 3.10 (2.32-4.14) (UK Biobank). Patients with diabetes and high risk scores had ORs of 14.7 (7.69-28.1) (GenomALC-1) and 17.1 (11.3-25.7) (UK Biobank) compared to those without diabetes and with low risk scores. Patients with cirrhosis and HCC had significantly higher mean risk scores than patients with cirrhosis alone (0.76 ± 0.06 vs. 0.61 ± 0.02, p = 0.007). Score performance was not significantly enhanced by information on additional genetic risk variants, body mass index or coffee consumption.ConclusionsA risk score based on 3 genetic risk variants and diabetes status enables the stratification of heavy drinkers based on their risk of cirrhosis, allowing for the provision of earlier preventative interventions.Lay summaryExcessive chronic drinking leads to cirrhosis in some people, but so far there is no way to identify those at high risk of developing this debilitating disease. We developed a genetic risk score that can identify patients at high risk. The risk of cirrhosis is increased >10-fold with just two risk factors - diabetes and a high genetic risk score. Risk assessment using this test could enable the early and personalised management of this disease in high-risk patients.

Budgets, combined with tax policy, provide rich evidence of the applied values of legislative bodies and executives. This paper evaluates budget and tax legislation in Montana that resulted from the 67th legislative session in 2021 that set policy for the 2023 biennium. Montana, whose political complexation has long been purple, moved unambiguously red in the elections of November 2020. This paper speaks to how this changed things in Montana's public policy, in the areas of budget and tax, and a series of other policy areas. One of the more notable findings is that while budget and tax certainly shifted right with the dominance of the Republican Party that itself has moved further right than where it was as recently as 2019, it did not move as far right as many observers had anticipated. The explanation provided here is that this was largely a result of the large infusion of federal COVID relief funds.

Montana uses a biennium budget; there was not a legislative session in 2018.The 65th Montana Legislature ended its constitutionally mandated 90-day biennium session with a $10.3 billion, two-year all funds budget in April 2017.  The Republican-controlled legislature returned to its contentious tradition. There were several big issues, but due to budget shortfalls, and few policy issues were resolved. Infrastructure bills generally failed, although the first gas tax in decades passed to help with infrastructure needs. Montana’s colleges and universities took significant cuts in their budgets and tuition increased roughly 13 percent. Except for K-12 programs, most state agencies’ budgets were cut. Overall, it was a grim legislative session that produced very few results and resolved few problems. The balanced budget lasted less than two months when revenue projections turned out to be wrong and the governor had to use his authority to further cut expenses, which included layoffs and additional cuts to state agencies and services. It was a session marked by lack of funds and budget cuts across most agencies. As the fall season began, the state budget appeared to be in shambles only months after the session adjourned. A special session was called in November 2017 to address Montana’s $227 million budget shortfall, largely a result of the most expensive state fire season in Montana’s history.  Bills were passed to address the shortfall.  Governor Steve Bullock allowed most of the bills to become law. Although some funding would later be partly restored after the special session for some agencies, most of the cuts remained.

Laboratory tests can play an important role in assessment of alcoholic patients, including for evaluation of liver damage and as markers of alcohol intake. Evidence on test performance should lead to better selection of appropriate tests and improved interpretation of results. We compared laboratory test results from 1578 patients between cases (with alcoholic cirrhosis; 753 men, 243 women) and controls (with equivalent lifetime alcohol intake but no liver disease; 439 men, 143 women). Comparisons were also made between 631 cases who had reportedly been abstinent from alcohol for over 60 days and 364 who had not. ROC curve analysis was used to estimate and compare tests ability to distinguish patients with and without cirrhosis, and abstinent and drinking cases. The best tests for presence of cirrhosis were INR and bilirubin, with areas under the ROC curve (AUCs) of 0.91 ± 0.01 and 0.88 ± 0.01, respectively. Confining analysis to patients with no current or previous ascites gave AUCs of 0.88 ± 0.01 for INR and 0.85 ± 0.01 for bilirubin. GGT and AST showed discrimination between abstinence and recent drinking in patients with cirrhosis, including those without ascites, when appropriate (and for GGT, sex-specific) limits were used. For AST, a cut-off limit of 85 units/L gave 90% specificity and 37% sensitivity. For GGT, cut-off limits of 288 units/L in men and 138 units/L in women gave 90% specificity for both and 40% sensitivity in men, 63% sensitivity in women. INR and bilirubin show the best separation between patients with alcoholic cirrhosis (with or without ascites) and control patients with similar lifetime alcohol exposure. Although AST and GGT are substantially increased by liver disease, they can give useful information on recent alcohol intake in patients with alcoholic cirrhosis when appropriate cut-off limits are used.