Medicaid expansion in Idaho
- Idaho voters approved ballot initiative to expand Medicaid, and coverage took effect January 2020. More than 53,000 residents have enrolled.
- Idaho has enacted legislation to implement expansion but with various provisions, including a work requirement.
- Idaho submitted a proposed 1115 waiver to CMS in September 2019, seeking federal approval for the work requirement.
- Idaho’s proposal for a “coverage choice” provision was deemed incomplete by CMS, and the agency has noted that even with revisions, the proposal “would not be approvable.” The state wanted to allow people with income from 100-138% of the poverty level to choose between Medicaid and private plans in the exchange (the latter is cheaper for the state).
- BYU-Idaho had said they would no longer allow students with Medicaid to waive coverage in the school’s non-MEC student health plan, but reversed course in the face of strong backlash.
- Idaho Supreme Court rejected a case challenging the expansion ballot initiative
of Federal Poverty Level
Prior to 2020, there were an estimated 78,000 Idaho residents in the coverage gap — ineligible for subsidies in the exchange and also ineligible for Medicaid. But these individuals — in addition to people with income from 100-138 percent of the poverty level who had previously been eligible for subsidies in the exchange — are eligible for Medicaid in Idaho as of January 2020.
Proposition 2, which Idaho voters approved by a wide margin in the 2018 election, directed the state to expand Medicaid as called for in the ACA. The text of the ballot initiative (see page 10 of the voter guide) called 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.”
But Idaho lawmakers took a round-about approach to implementing the ballot initiative. Early in the 2019 legislative session, some of the state’s conservative lawmakers began working to draft legislation that would call for various restrictions on Medicaid expansion, including things like work requirements, copays, premiums, or lifetime limits on coverage. Rep. John VanderWoude, R-Nampa, noted in early 2019 that although the details were still being sorted out at that point, “if we do nothing, then we’re left with full-blown Medicaid expansion.”
Proposed modifications for Medicaid expansion: “Coverage choice” provision has been rejected by CMS; Work requirement proposal is pending approval
Idaho S.1204 was designed to move the state forward with expansion, but with various additional restrictions — most notably, a work requirement — despite the fact that 61 percent of Idaho’s voters approved a “clean” (ie, not modified) expansion of Medicaid in the November 2018 election, and a poll conducted in February 2019 indicated that nearly three-quarters of the state’s residents wanted lawmakers to implement Medicaid expansion as called for in Proposition 2, while just 17 percent wanted lawmakers to make changes to how expansion would be implemented.
S.1204 passed both chambers of the Idaho legislature and was signed into law by Governor Brad Little on April 9, 2019. The legislation calls for some notable deviations from a “clean” Medicaid expansion, some of which require approval from CMS (Idaho has submitted a waiver proposal to CMS for a Medicaid work requirements, although such requirements are currently in legal limbo pending the outcome of appeals in cases in other states; Idaho’s “coverage choice” proposal has been rejected by CMS):
- Work requirement: A work/community engagement requirement, under which able-bodied enrollees aged 19-59 would have to work/attend school, etc. for at least 20 hours a week in order to maintain Medicaid eligibility. CMS has approved Medicaid work requirements for several states since 2018, and thousands of people lost coverage in Arkansas (the first state to implement a work requirement) as a result. A federal judge blocked Medicaid work requirements in March 2019, and did so again in July 2019, leading to uncertainty about the future of work requirements. But CMS has vowed to continue to implement work requirements. Idaho officials accepted public comments on the proposed Medicaid work requirement until September 22, and submitted a proposal to CMS shortly thereafter (it’s notable that the majority of the people who provided public testimony were opposed to the work requirement). The proposal is still under review, and Idaho officials have noted that they’re meeting with CMS officials on a weekly basis to hammer out the details of the work requirement and gain approval as quickly as possible.
- “Coverage choice”: A provision allowing people with income between 100 percent and 138 percent of the poverty level to continue to receive premium subsidies to buy coverage in the Idaho exchange (as they’ve been able to do since 2014), or to switch to expanded Medicaid. In his approval letter for S.1204, Governor Little noted that the negotiations with CMS over this provision would be “challenging,” but expressed his confidence that Idaho regulators would be able to work out a solution with CMS. In July 2019, the state submitted a waiver proposal to seek federal approval for this. But CMS responded in August, noting that the waiver proposal incomplete, and that “even if the application were revised to include the correct elements, Idaho’s application would not be approvable because it could not demonstrate compliance with the statutory guardrails, in particular, the deficit neutrality guardrail.” [1332 waivers can only be approved if they won’t increase the federal deficit; it’s noteworthy that it’s cheaper for a state to keep the 100-138 percent of poverty level population in the exchange, since premium subsidies are funded entirely by the federal government, whereas Medicaid expansion is funded with a 90/10 split (as of 2020) with the state paying 10 percent of the cost.] Idaho’s Governor and legislative leaders have indicated that they were surprised by the CMS decision, and are continuing to work with the agency to provide more information in hopes that the waiver proposal can still gain approval.
- A health risk assessment that includes questions about substance use disorders (the legislation notes that the data would be used to refer enrollees to substance abuse treatment; there is nothing in the legislation that would restrict access to Medicaid coverage based on answers to the health risk assessment).
- Managed care: The use of Medicaid managed care for all Medicaid expansion enrollees. This has been a fairly standard approach used by most states.
S.1204 noted that Medicaid expansion wouldn’t be delayed if there was a delay in CMS approval of the state’s proposal or if CMS fails to approve some portions of what the state proposes. So Medicaid expansion in Idaho is still set to take effect January 1, 2020, and enrollment began November 1, 2020—despite the fact that the state has failed to gain federal approval for the “coverage choice” proposal and has not yet received federal approval for a work requirement (Idaho’s work requirement proposal was submitted in late September, only a little more than a month before enrollment in expanded Medicaid began).
The state has noted that if the federal government doesn’t agree to the “coverage choice” proposal prior to the end of 2019, roughly 20,000 Idaho residents with income between 100 and 138 percent of the poverty level (who are currently enrolled in subsidized coverage through Your Health Idaho) will be switched over to Medicaid. When CMS notified Idaho that their proposed waiver was incomplete and likely “not approvable” even with revisions, Governor Little and Idaho’s legislative leadership issued a statement saying that “CMS pulled the rug out from under us,” and noted that the state was “already taking steps to submit the additional information required by CMS so that our application can be fully considered on its merits.”
BYU-Idaho reverses course, says they will continue to accept Medicaid as an alternative to the school’s non-ACA-compliant student health plan
After significant student backlash and public attention, BYU-Idaho has retracted its new rule that would have prevented students with Medicaid from waiving coverage under the school’s student health plan. Students with Medicaid, including those newly-eligible under Idaho’s Medicaid expansion that takes effect in January 2020, will continue to be able to waive the school’s health plan and rely on Medicaid instead. The school’s statement about the retracted rule notes that they “apologize for the turmoil” that had been caused by their earlier decision.
Soon after enrollment in Idaho’s Medicaid expansion began November 1, BYU-Idaho had revised its rules for waiving the school’s student health plan. When we contacted the school at that point, a representative confirmed that as of the spring 2020 semester, Medicaid (from Idaho or any other state) would no longer be considered coverage that will allow a student to waive enrollment in BYU-Idaho’s student health plan.
[Many schools, BYU-Idaho among them, require students to maintain health insurance. Previously, the waiver form indicated that students with Idaho Medicaid could waive the student health plan, but that Medicaid coverage from another state could not be substituted for the school’s student health plan.]
Somewhat ironically, BYU’s student health plan is not considered minimum essential coverage under the ACA, while Medicaid is. BYU-Idaho’s student health plan is self-insured, and while nearly all student health plans are regulated by the ACA, those regulations don’t apply to the small minority of student health plans that are self-insured.
More than 12,000 people signed a petition asking BYU-Idaho to reverse course, and the story quickly garnered national attention in the days before school officials decided to reverse course and allow students to continue to use Medicaid as their health coverage. The school had put out a statement indicating that they were concerned that students on Medicaid would overwhelm the resources of the local medical providers, but doctors and medical facilities in the area had indicated they had no such concerns.
And although most students will be able to continue to go to school at BYU-Idaho with their health coverage uninterrupted, the uncertainty created by the university’s initial decision caused some students to change their plans for the spring semester, and some of those changes cannot be undone.
Medicaid expansion upheld by the Idaho Supreme Court
After voters in Idaho overwhelmingly approved Proposition 2, the state added a new section to its insurance statutes. Section 56-267 codifies Medicaid expansion into Idaho law, under the terms of the ballot initiative.
But soon thereafter, local GOP leader Brent Regan filed a lawsuit, asserting that Section 56-267 was unconstitutional. Regan is the Chairman of the Kootenai County Republican Central Committee, and also serves as Board Chair for the Idaho Freedom Foundation. Regan’s lawsuit was centered around his belief that Section 56-267 gives too much power to the executive branch, and relies on federal rules that could be changed in the future (the statute says that the state’s Medicaid expansion should apply “in accordance with sections 1902(a)(10)(A)(i)(VIII) and 1902(e)(14) of the Social Security Act.” Those sections describe who is eligible for Medicaid expansion under the ACA, including income limits and how income is calculated).
Opponents of Regan’s lawsuit note that the only power granted to the Department of Health and Welfare is related to implementation of the law — not making or changing anything about Idaho law.
The Idaho Supreme Court heard oral arguments in the case on January 29, 2019, and issued a ruling the following week (summary of the ruling is available here). The Court ruled that Section 56-267 is not unconstitutional and does not delegate excessive authority to the Department of Health and Welfare or the federal government. Numerous Idaho laws reference federal statute, and Section 56-267 is no different. The Court also noted that Idaho case law clarifies that such references to federal policy apply to the federal policy at the time the state statute is adopted.
Idaho’s path to Medicaid expansion
Former Governor Otter supported a modified version of Medicaid expansion but opposed the ACA overall, and had said previously that he would not act unilaterally to expand Medicaid, as he felt it was 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 also 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 bypassed the legislature altogether and took the issue to the state’s voters. Proponents of Medicaid expansion gathered enough signatures to get Proposition 2 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.
Otter supported Proposition 2, but he was term-limited, and the state’s lieutenant governor, Republican Brad Little, won the gubernatorial election in November 2018. Although Little’s victory speech noted that he was “look[ing] forward to working with President Trump to continue to allow Idahoans to be the masters of their own destiny,” Little had said previously that he would respect the will of the voters on the Medicaid ballot initiative.
House promised to come up with a solution in 2017, but failed to do so
Before voters passed Proposition 2, debate over Medicaid expansion in Idaho had been ongoing for years.
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 were critical of lawmakers’ failure to act on this issue, and viewed the legislative work group as a stall tactic that was unlikely to make much progress, 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 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.
History of Idaho’s Medicaid expansion debate
For years, more than 75 percent of Idaho residents had been in favor of Idaho lawmakers coming up with a solution to allow the people in the Medicaid coverage gap to gain access to comprehensive health insurance. And by not expanded Medicaid, Idaho has been 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 has been 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 had long considered the Healthy Idaho Plan, which would have eliminated 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.
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.
The Healthy Idaho Plan would have extend Medicaid eligibility to adults up to 100 percent of the federal poverty level (FPL) and provided 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 said that 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 its support behind the Healthy Idaho Plan.
Dan Ordyna, CEO of Portneuf Medical Center (PMC) 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 were “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).
Proponents of Medicaide expansion in Idaho noted that $18 to $22 million in annual property taxes could potentially be eliminated, as those funds were being used to help pay for the existing indigent care program.
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 April 2019, 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 income is. However, this will change as of 2020. Enrollment begins November 1, 2019 in Idaho’s expanded Medicaid program; adults with income up to 138 percent of the poverty level will be eligible for Medicaid coverage at that point.
See the Idaho Medicaid website for eligibility criteria for individuals who are aged or disabled.
How to apply for Medicaid
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. But net enrollment growth had dropped to about 34,000 people by mid-2019. 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 healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.