The only state to create its own health insurance exchange but then reject Medicaid expansion, Idaho has taken a different approach to implementing the Affordable Care Act. The model seems to be working, with the state near the top of per-capita exchange enrollment. However, uninsured rates remain above the nation’s average.
This guide takes a closer look at Idaho’s approach to the ACA, how it fares in public health rankings, and what lies ahead for the state’s health and healthcare.
Idaho health ratings
Idaho ranks 25th in overall health in the 2015 Scorecard on State Health System Performance, a leap of six positions higher than in the 2014 scorecard. The ranking compares various health indicators, including Access, Prevention and Treatment, Avoidable Hospital Use and Cost, Healthy Lives, and Equity, and gives each state and the District of Columbia a composite score.
Idaho performed best in indicators related to Avoidable Hospital Use and Costs; however, it had the greatest room for improvement related to Access. Its uninsured rates, percentage of adults who went without care due to cost, and percentage of individuals with high out-of-pocket costs relative to income were all lower-performing areas. See Idaho’s scorecard for its performance on the individual measures.
In America’s Health Rankings, which looks at a different set of health indicators, Idaho fares much better. The Gem State placed 17th in the 2014 survey, down six spots from 2013. Limited availability of primary care physicians, a lack of health insurance, disparity in health status, and low immunization rates among adolescents all negatively impacted the state’s ranking. The state’s healthcare strengths include low rates of infectious disease and preventable hospitalizations along with strong public health funding.
The 2015 edition of Trust for America’s Health also scores Idaho on a variety of public health measures; however, it doesn’t provide a composite score. See Key Health Data About Idaho.
If statewide data is too general, you can review county-by-county health rankings for Idaho from the Robert Wood Johnson Foundation and the Population Health Institute at the University of Wisconsin.
How has Obamacare helped Idaho?
The uninsured rate in Idaho dropped 4.7 percentage percentage points to 15.2 percent between 2013 and late 2015, according to Gallup. Nationwide, the uninsured rate fell to 11.7 percent in the same time period.
While Idaho elected to run its own health insurance exchange, it opted not to expand Medicaid under the Affordable Care Act. Were the state to expand Medicaid to low-income adults, it is likely its uninsured rate would see greater improvement as has been the case in other states that have expanded Medicaid, created a state-run exchange or both.
In a July 2015 progress report evaluating states by how patient-centered their health insurance markets, Idaho was among the lowest-scoring states. The report notes that Medicaid expansion would help it improve in the continuity of care metric.
The state’s exchange, Your Health Idaho, has been called a “model for state based adoption [of an exchange]” for its below-average budget, lean organizational structure and strong financial controls.
2017 open enrollment rates, health plans
Idaho’s exchange will include plans from five carriers in 2017:
- Blue Cross of Idaho
- Mountain Health CO-OP
Mountain Health CO-OP initially joined Your Health Idaho for 2015 open enrollment. Mountain Health CO-OP is an offshoot of Montana Health CO-OP. The insurers were launched with the help of the ACA’s Consumer Operated and Oriented Plan (CO-OP) Program, and are intended to increase competition. Several ACA CO-OPs have announced their closure in recent years. Montana Health CO-OP, which operates as Mountain Health CO-OP, is not among them.
2017 rates are currently under review and negotiation by the Idaho Department of Insurance, which does not have the authority to prevent health insurers from implementing rates that are deemed unjustified. Proposed increases range from 8 to 35 percent.
Idaho enrollment in qualified health plans
By April 2015, Idaho’s state-run exchange had enrolled more than 85,000 individuals in QHPs during the second open enrollment period. The state was fourth in the nation in terms of per-capita enrollment and highest among all states running their own exchanges. Of Idaho residents with QHPs, 81.6 percent were enrolled in plans with advanced premium tax credits and 63 percent were receiving cost-sharing reductions.
Enrollment grew 5 percent in 2016, with 102,353 people enrolled through Your Health Idaho by mid-February. Per capita enrollment was second in the nation to Florida for 2016.
Idaho and the Affordable Care Act
Idaho is a solidly “red” state, and many politicians and residents staunchly oppose the Affordable Care Act. At the federal level, both Idaho senators voted against the ACA in 2010, as did one of two representatives. Rep. Walt Minnick (D) was the sole “yes” vote from Idaho, and Raúl Labrador has since replaced him in the U.S. House. Labrador is in favor of repealing the ACA.
Idaho is one of the only Republican-controlled states that implemented a state-run marketplace. Gov. Butch Otter, while critical of the ACA, advocated for a state-run marketplace as a better option than the federally facilitated marketplace. Legislation authorizing the state-run exchange, which is named Your Health Idaho, passed and was signed into law in 2013.
With not enough time to get all functions operational before ACA’s open enrollment period, Idaho residents used HealthCare.gov to sign up for coverage in 2014.
For 2015 open enrollment, Your Health Idaho completed its transition to a state-run exchange and began operating independently of the federal marketplace. Your Health Idaho reported a successful launch, with the executive director saying he was “really, really pleased” with the site’s performance during the first days of open enrollment.
Idaho’s Medicaid program
Idaho is the only state that implemented a state-run marketplace, but not Medicaid expansion. According to the Kaiser Family Foundation, the decision against expansion leaves about 30,000 low-income, non-elderly adults in the coverage gap, meaning they don’t qualify for Medicaid or for subsidies to help them purchase private coverage.
In November 2014, Idaho’s Medicaid Redesign Group, a workgroup formed by Gov. Otter, recommended the Healthy Idaho Plan. This 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 238 percent of FPL purchase coverage through Your Health Idaho. Though Gov. Otter has not outright endorsed the plan, he asked state legislators to consider the Medicaid Redesign Group’s recommendations when giving his 2015 State of the State address. County Commissioners throughout the state voted to support it in September 2015.
Currently, in Idaho, non-disabled adults without dependent children are not eligible for Medicaid. Medicaid is only available for parents of dependent children if their household income is under 27 percent of the federal poverty level.
Visit the Idaho Department of Health and Welfare to learn more about Idaho Medicaid and the State Children’s Health Insurance Program (SCHIP).
Does Idaho have a high-risk pool?
Before the ACA’s individual health insurance market reforms, coverage was underwritten in nearly every state, including Idaho. People with pre-existing conditions were often unable to purchase private plans, or could only get policies that excluded their pre-existing conditions or charged them increased premiums because of their medical history.
The Idaho Individual High Risk Reinsurance Pool (HRP) was created in 2001 to give people an alternative means of obtaining coverage if they were unable to purchase a private plan because of their medical history. By 2010, there were 1,565 members in the Idaho HRP.
One of the primary reforms brought about by the ACA is guaranteed issue individual coverage; medical history is no longer taken into consideration when an application is submitted. Thus the need for high-risk pools has largely disappeared, and the Idaho risk pool stopped enrolling new members at the end of 2013. But the plan has not yet terminated coverage for existing members; they can voluntarily transition to the exchange unless notified otherwise by the HRP.
Idaho Medicare enrollment
Idaho Medicare enrollment reached 282,024 in 2015, about 17 percent of the state’s population, which is consistent with the percentage of the U.S. population enrolled in Medicare. Eighty-four percent of Idaho Medicare recipients qualify for the program based on age alone, while the balance are on Medicare as the result of a disability.
Idaho’s Medicare spending is below the national average. Medicare pays about $7,478 per Idaho enrollee each year, and the state ranks 42nd in overall Medicare spending with $1.75 billion annually.
Idaho Medicare beneficiaries may select a Medicare Advantage plan instead of original Medicare if they wish to gain some additional benefits. In 2015, about 32 percent of Idaho recipients opted for Medicare Advantage instead of traditional Medicare, while 31 percent made this selection nationwide.
Medicare recipients in the state of Idaho can also purchase Medicare Part D plans to gain stand-alone prescription drug coverage, and about 38 percent do so. Forty-five percent of all Medicare recipients nationwide choose these Rx plans.
State-level reform legislation in Idaho
Here’s a look at state-level legislation that would affect health reform in Idaho: