Idaho and the ACA’s Medicaid expansion

Idaho voters have approved Medicaid expansion via a ballot initiative that won by a wide margin and had the support of the state's GOP governor

idaho Medicaid guide

Medicaid expansion in Idaho

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It’s harder to qualify for Medicaid in Idaho than in many other states: non-elderly adults without children aren’t eligible at all, and the eligibility limits for groups that are covered are relatively low. But that’s about to change, thanks to Proposition 2, which Idaho voters approved by a wide margin in the 2018 election, and whigh garnered the support of Republican Governor Butch Otter. The text of the ballot initiative (see page 10 of the voter guide) calls for the state to submit an expansion plan to the federal government within 90 days, and to implement to provisions of the proposition “as soon as practicable.”

Because Idaho has thus-far rejected federal funding to expand Medicaid under the Affordable Care Act (ACA), an estimated 78,000 residents are in the coverage gap — ineligible for subsidies in the exchange and also ineligible for Medicaid.

Governor Butch Otter supports a modified version of Medicaid expansion but opposes the ACA overall, and had said previously that he would not act unilaterally to expand Medicaid, as he feels it’s important for the legislature to be involved in the process. He also expressed optimism about how the Trump Administration would handle health care reform, in the days prior to Trump’s inauguration.

But the people of Idaho overwhelmingly favor Medicaid expansion, with more than three-quarters agreeing that the governor and legislature should take action to ensure that people in the coverage gap have access to affordable, quality health coverage. The Idaho Hospital Association and the Idaho Medical Association support the expansion of Medicaid, noting that Medicaid expansion helps rural hospitals remain open, and ensures that low-income residents have realistic access to medical care.

Medicaid expansion legislation was introduced once again in the Idaho legislature in 2018, but it died in committee and never reached a vote. But expansion advocates are bypassing the legislature altogether and taking the issue to the state’s voters. Supporters had to gather 56,192 signatures by April 30 in order to get the measure on the ballot in Idaho in November 2018. The ballot initiative calls for “straight” Medicaid expansion, with no waiver proposal needed.

The measure calls for the state to submit a Medicaid expansion plan to the federal government within 90 days (Maine’s experience is a cautionary tale here — voters there approved Medicaid expansion in the 2017 election, but the governor, who is adamantly opposed to Medicaid expansion, has been delaying the process ever since, and advocates have had to file a lawsuit in an effort to get the process moving. But in Idaho, both candidates for governor have said they’ll respect the outcome of the ballot initiative).

In early July, Medicaid expansion advocates delivered their petition signatures to the Idaho Secretary of State’s office. They had 70,000 signatures — well in excess of the number that was needed. The Secretary of State had to verify that enough signatures were collected from at least 18 of the state’s 35 legislative districts in order to approve the measure for the 2018 ballot, and that happened in July. So Proposition 2 was on the ballot in Idaho in November 2018, allowing voters in the state to decide whether to expand Medicaid. And voters approved it by a wide margin.

House promised to come up with a solution in 2017, but failed to do so

The Idaho House of Representatives voted overwhelmingly — and along party lines — not to expand Medicaid during the 2016 legislative session. But House Majority Leader Scott Bedke announced that he would appoint a bipartisan committee to address the issue, and committed to addressing the Medicaid coverage gap during the 2017 legislative session.

Proponents of Medicaid expansion have been critical of lawmakers’ failure to act on this issue, and viewed the legislative work group as a stall tactic that’s unlikely to make much progress anytime soon, especially given that there was a bill on the table already in 2016 (which had been approved by the Senate) and the House defeated it.

The ten-member committee began meeting during the summer of 2016, and although they have received overwhelming public support for Medicaid expansion, at least four of the members were still expressing opposition to the ACA’s Medicaid expansion as of August 2016.

The committee held a public forum in late September to solicit public comment on the issue, and heard from people both opposed to and in support of Medicaid expansion.

In February 2017, lawmakers introduced H.160, which would have created the Health Care Assistance Program. A similar bill, S.1142, was introduced in the Senate. Neither bill advanced out of committee, however, and the legislative session ended on March 29. The Health Care Assistance Program would have relied primarily on tobacco settlement funding, but only to the tune of $10.5 million annually — as opposed to $30 million that had been proposed for the Idaho Primary Care Access Program (a somewhat similar measure that failed to pass during the 2016 legislative session; details below).

Had H.160 passed, the money would have been used to fund primary care and limited prescription coverage for some of the people who are currently in the coverage gap in Idaho. But the low funding would have meant that only a limited number of people would have been helped (on a “first come, first serve” basis), and the coverage they would have been provided would not have been comprehensive.

In short, H.160/S.1142 was a Band-Aid for a bullet wound, and even that did not pass during the 2017 session.

In the 2018 session, H.B.1224, which called for Medicaid expansion, did not reach a vote.

After five years, still no expansion of Medicaid

More than 75 percent of Idaho residents want Governor Otter and the legislature to come up with a solution that allows the people currently in the coverage gap to gain access to comprehensive health insurance. And by not expanded Medicaid, Idaho is missing out on $3.3 billion in federal funding over ten years (assuming the ACA remains in place), and federal tax revenue collected in Idaho is being used to expand Medicaid in other states.

Medical providers, the Idaho Association of Counties, consumer advocates, and some lawmakers have been pushing for years for Medicaid expansion in Idaho. The state has long been considering the Healthy Idaho Plan, which would eliminate the coverage gap in the state, albeit via a waiver from CMS that would allow for an Idaho-specific approach., and during the 2016 legislative session, lawmakers also considered Governor Otter’s new proposal to expand access to primary care for people in the coverage gap.

Lawmakers have also considered much less robust solutions in 2016 (the Idaho Primary Care Access Program) and in 2017 (the Health Care Assistance Program), but neither solution was enacted.

In February 2016, the Senate Health and Welfare Committee heard public testimony for the first time regarding Medicaid expansion. But no agreements have been reached in Idaho regarding health coverage for the state’s lowest-income residents.

During the 2016 legislative session, lawmakers considered three bills related to Medicaid expansion and care for people in the coverage gap, but none made it out of committee:

  • S1204 would have expanded Medicaid as called for in the ACA, providing coverage to everyone with household incomes up to 138 percent of the poverty level.
  • S1205 would have implemented a modified version of Medicaid expansion (Healthy Idaho – see details below), which was recommended by Otter’s work group. S1205 would require a waiver from HHS, but the basics have already been pre-approved by HHS.
  • H484 would have implemented Governor Otter’s Primary Care Access Program.

In mid-March, Republican lawmakers blocked attempts to bring the two Medicaid expansion bills out of committee and onto the floor of the Senate; the 2016 legislative session ended in late March, with no progress made towards Medicaid expansion or Otter’s PCAP proposal.

In March 2016, in response to fellow Senators’ failure to even consider Medicaid expansion during the 2016 session, Senator Dan Schmidt (D, Moscow), announced that he would relinquish the health insurance benefits he receives as a member of the Idaho legislature. Sen. Schmidt is a family physician, and has worked for three years to expand Medicaid in Idaho. He expressed his disappointment that lawmakers once again failed to come up with a solution for the people in the coverage gap in Idaho. Schmidt noted that: “My state-funded health insurance is quite expensive for the taxpayer, yet the coverage for the gap population would require no tax increase—indeed, even reduce some costs to the taxpayer. But I receive this benefit, and they don’t. It’s not fair, and my wife and I agree we should not participate in this unfairness.

2014 workgroup proposed Healthy Idaho Plan

The Affordable Care Act envisioned two key strategies to reduce the uninsured rate. First, health insurance marketplaces would make it easier for individuals to shop and compare policies. In addition, individuals with income up to 400 percent of FPL (who aren’t eligible for Medicaid or affordable coverage from an employer) would qualify for subsidies to help them afford policies sold on the marketplace. Second, Medicaid would be expanded to cover non-elderly adults with incomes up to 138 percent of FPL.

A Supreme Court ruling made the Medicaid expansion strategy of the ACA optional, and each state had to decide whether it would participate. Idaho decided against expansion, and is one of 19 states that has continued to reject federal funding to expand Medicaid.

The Kaiser Family Foundation estimates 22,000 Idahoans are in the coverage gap — meaning they earn too much to qualify for Medicaid, but too little to reach the 100 percent FPL level that would trigger subsidies to purchase private coverage through the health insurance marketplace. But according to the Spokesman-Review and The Idaho Statesman, the coverage gap population is much higher – at least 78,000 people. And Your Health Idaho (the state-run exchange) has said that 54,000 people applied for coverage through the exchange in 2014 and were unable to get subsidies because their income was below the poverty level). For the population in the coverage gap, health insurance is essentially unavailable, as their only option would be to pay full price for a private plan – clearly not feasible for people with income below the poverty level.

Idaho’s Medicaid Redesign Group in November 2014 recommended the Healthy Idaho Plan. The workgroup, formed by Gov. Otter, has repeatedly come out in favor of Medicaid expansion.

The Healthy Idaho Plan would extend Medicaid eligibility to adults up to 100 percent of the federal poverty level (FPL) and provide subsidies to help those between 100 and 138 percent of FPL to purchase coverage through Your Health Idaho, the state-run health insurance marketplace. Proponents say implementing the Healthy Idaho Plan would save the state $173 million over ten years by eliminating the Catastrophic Health Care Cost Program. The CAT program, as it is commonly called, covers some health care costs incurred by the very poor. The CAT program is funded through the state general fund and county property taxes.

Support for Healthy Idaho Plan

In his 2015 State of State address, Otter asked state legislators to consider the recommendations from the Medicaid Redesign Group, but he stopped short of endorsing it. Republican leaders said they would consider the option, but they remain skeptical of Medicaid expansion. County Commissioners throughout the state voted to support the Healthy Idaho Plan in September 2015, and the Idaho Medical Association has thrown their support behind the Healthy Idaho Plan.

Dan Ordyna, CEO of Portneuf Medical Center (PMC) has urged lawmakers to find a way to expand Medicaid, noting that the ACA’s cost-saving measures implemented by hospitals only work if the state also expands Medicaid. Ordyna explained that Idaho’s hospitals are “providing a financial windfall to hospitals in expansion states at the expense of Idaho hospitals.” He also told lawmakers that PMC treated nearly 12,000 uninsured residents in the emergency room in 2014, and that treating those patients created a loss of $1.4 million for the hospital. Not only does the uninsured rate remain high when states refuse Medicaid expansion, but the ACA is gradually phasing out federal funding that offsets losses for hospitals that treat a large number of uninsured patients (because those patients were supposed to get Medicaid under the ACA; states like Idaho decided independently to refuse expansion).

If Medicaid is expanded in Idaho and federal funds begin to cover the newly eligible population, proponents note that $18 to $22 million in annual property taxes could potentially be eliminated, as those funds are used to help pay for the existing indigent care program.

Stephen Weeg, Chairman of the Your Health Idaho board of directors, has also called on legislators to expand Medicaid, noting that in 2014, there were 54,000 people who applied for coverage through Your Health Idaho but were unable to obtain coverage because their income was under the poverty level. Subsidies are not available for people with incomes under the poverty level, because Medicaid was supposed to be there for that population. Weeg explained that “sadly, they [the 54,000 applicants] were found to be too poor to be helped and left uninsured. Idaho can do better.

Otter’s primary care plan failed in 2016 session

On January 8, 2016, Governor Otter proposed a state-funded alternative to Medicaid expansion, but critics have been quick to note that while it’s better than nothing, it’s not nearly enough. The Governor’s proposal, called the Idaho Primary Care Access Program (PCAP), would provide a medical home and primary/preventive care for people who are in the coverage gap. It would need to be approved by the legislature in order to be implemented, and was introduced as House Bill 484 in February. However, the bill did not make it out of committee during the 2016 legislative session.

The Otter Administration estimated that the cost of providing PCAP to 78,000 residents would be about $30 million per year. The program would be funded with existing tobacco and cigarette taxes, so while no new taxes would be implemented, programs that currently use tobacco and cigarette tax revenue would likely see funding cuts.

Governor Otter has noted that PCAP is better than the status quo, which is no coverage at all for people in the coverage gap. But the “Close the Gap Idaho” coalition is working to ensure that the state continues to push for the Healthy Idaho Plan to be enacted. They agree that expanding access to primary care for people in the coverage gap is beneficial for those residents, but caution that PCAP is not health insurance, and would not cover anything other than primary and preventive care (ie, it would not cover hospitalization, emergency room care, ambulance transport, a full range of medication needs, or specialty care).

There is also concern that implementation of PCAP might slow or halt progress towards Healthy Idaho Plan implementation, since people might assume that PCAP is a replacement for the Healthy Idaho Plan, when in fact, it is far less comprehensive and would leave low-income Idaho residents without realistic access to a significant portion of healthcare services.

Who qualifies for Idaho Medicaid?

Compared to other states, Idaho has a more restrictive Medicaid program. As of September 2016, Idaho Medicaid eligibility levels are as follows:

  • Children ages 0-5 qualify with family income up to 142 percent of the federal poverty level (FPL)
  • Children ages 6-18 qualify with family income up to 138 percent of the FPL
  • Pregnant women qualify with family income up to 138 percent of the FPL
  • Parents with dependents qualify with family income up to 24 percent of FPL
  • Children qualify for CHIP (Children’s Health Insurance Program) with family income up to 185 percent of the FPL.

Adults who aren’t disabled and who don’t have minor children are ineligible for Medicaid in Idaho, regardless of how low their inome is. See the Idaho Medicaid website for eligibility criteria for individuals who are aged or disabled.

This table from shows various poverty levels (e.g., 100 percent FPL, 150 percent FPL) as dollar amounts for families of various sizes.

How to apply for Medicaid

Print and complete an application; English and Spanish versions are available online; call 1-877-456-1233 for other languages.

You can submit your completed application:

  • In person to a local office
  • By mail to Self Reliance Programs; PO Box 83720; Boise, ID 83720-0026
  • By fax to 1-866-434-8278 (toll free)

History of Medicaid in Idaho

Idaho implemented its Medicaid program in July 1966, one year after the program was authorized at the federal level.

The Idaho Department of Health & Welfare oversees the Idaho Medicaid program. A department publication details three Medicaid benefit plans: a Basic Plan to provide medical services for low-income children and working-age adults; an Enhanced Plan that provides medical services, developmental disability services, enhanced mental health coverage, and long-term care services for individuals with special needs; and a Coordinated Plan that provides medical services to individuals who are dually eligible for Medicare and Medicaid.

Despite the fact that Idaho has not expanded Medicaid, total enrollment grew by more than 57,000 between the end of 2013 and the end of 2017. Enrollment was 238,150 people in the fall of 2013, before the first open ACA enrollment period. As of December 2017, enrollment reached 295,591 — a 24 percent increase. In every state, there are people who were already eligible for Medicaid but had not enrolled prior to 2014. The extensive outreach and enrollment activities conducted by the exchanges have boosted Medicaid enrollment nationwide, even in states that haven’t expanded Medicaid yet.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

How to apply in ID

Complete an application in English or Spanish; call 1-877-456-1233 for other languages.

Eligibility: Children ages 0-5 with family income up to 142% of FPL. Children ages 6-18 and pregnant women with family income up to 138% of FPL. Parents with family income up to 24% of FPL. See additional eligibility criteria for individuals who are aged or disabled.

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