Idaho’s poorest fare worst in state’s health care reform

Obamacare is coming, even to Idaho. While other states including Washington have worked for years to implement it, and now are unveiling comprehensive health coverage options for the uninsured, Idaho’s Republican-controlled state government tried for years to fight it. The long fight left a legacy: Tens of thousands of the poorest of Idaho’s poor will still be without affordable care under the Affordable Care Act.

On Oct. 1 the 222,533 Idahoans who have no health insurance will be able to go to a website and seek more comprehensive, affordable coverage than was available in the past. Federal law requires it, and federal taxes will pay for it.

But adults with incomes between 26 percent and 100 percent of the poverty level will be out of luck; no assistance will be available.

The problem, acknowledged by Idaho officials, began to get attention last month after an analysis by the nonpartisan Kaiser Family Foundation.

As written, the Affordable Care Act of 2010 prescribed a broad spectrum of remedies. Three key provisions contribute to the dilemma facing Idaho’s poor:

• The law required Medicaid to expand, becoming a government-funded health plan for everyone below 138 percent of the poverty level. Federal funds would pay for the expansion.

• The law provided federal subsidies to reduce the cost of health coverage for uninsured Americans with incomes between 100 percent and 400 percent of the poverty level.

• The law called for exchange websites, one for each state, where Americans could sign up for Medicaid or purchase private insurance, with help from the subsidies.

But states that opposed the federal law, including Idaho, filed suit. The U.S. Supreme Court upheld the federal law, with a big exception: Medicaid expansion could not be mandatory.

It’s the Medicaid decision that creates a problem for Idaho’s poorest adults.

Twenty-seven states, including Idaho, have not expanded Medicaid. In these states, the decision leaves in place an inconsistent patchwork of old Medicaid eligibility rules.

Idaho’s Medicaid rules, according to the state Department of Health and Welfare, are as follows: Children qualify for Medicaid if their household income is below 185 percent of the federal poverty level. Adults, however, do not qualify for Medicaid unless they have children and their income is below 26 percent of the poverty level. Childless adults don’t qualify.

Meanwhile, the federal law’s insurance-buying subsidies are available only to Americans between 100 percent and 400 percent of the poverty level. The law assumed Americans below the poverty level would not need subsidies because they’d get coverage from the expansion of Medicaid.

But when the Supreme Court made Medicaid expansion optional, and Idaho’s Legislature did not embrace the option, it left Idaho’s poorest adults without coverage.

How many Idahoans could be affected? By 2016, the number might reach 75,000, according to one study by the Kaiser Family Foundation.

For now, the federal poverty level is an income of $11,490/year for a one-person household, or $15,510 for a two-person household.

According to the U.S. Census Bureau:

• 37,121 Idaho households have incomes below $10,000.

• 33,657 Idaho households have incomes between $10,000 and $15,000.

So how will those federal insurance subsidies work?

The subsidies are available only to those who buy health insurance on the new exchange websites; they limit premiums to a percentage of income, defined in federal law. To calculate a subsidy, it’s necessary to know the cost of insurance as well as the applicant’s income.

Idaho’s Department of Insurance recently approved health insurance plans to be sold on its exchange, but is keeping the rates secret for now.

The rates insurance companies plan to offer on Washington’s exchange are publicly available and cover the same federally mandated benefits packages that the Idaho policies must cover.

Using estimates based on the Washington rates, here are some scenarios illustrating Idaho’s relative situation:

• A 21-year-old woman, working 29 hours a week at Idaho’s minimum wage. Annual income: $10,933 or $911 a month, just below the poverty level. Monthly health insurance premium: approximately $220. Medicaid? Not available. Subsidy? Not available. (In Washington, this person would qualify for Medicaid.)

If another 21-year-old earned $11,600, just above the poverty level, she could purchase federally subsidized insurance on Idaho’s exchange. Her monthly premium: about $18.

• Married 40-year-olds with part-time jobs and a household income of $15,000/year. At $1,250 a month, this is just below the poverty level. Monthly health insurance premium: approximately $562. Medicaid? Not available. Subsidy? Not available. (In Washington, this couple would qualify for Medicaid.)

If another 40-year-old couple earned $16,000 a year, or $1,333 a month, slightly above the poverty level, they could purchase subsidized insurance from Idaho’s exchange. Their monthly premium: about $27.

• Married 40-year-olds with two children, earning Idaho’s median household income of $47,459 a year or $3,955 a month. (Median income means half of Idaho’s households earn more, half earn less.) Assuming the breadwinners work for a small business offering no health coverage, this family could buy subsidized coverage on Idaho’s exchange. Their monthly premium: about $249. (Under Washington’s rules, Medicaid would fund most of the coverage for the two children; not so under Idaho’s rules.)

After Idaho reveals the rates insurance companies plan to charge, and after the insurance-buying website begins running for Idaho at a subsection of www.healthcare.gov, any Idaho resident can find out exactly what the options are. By entering their income and some information about their age and family size, users will find either that they qualify for Medicaid or can choose among several private insurance plans, each with several levels of coverage. Or, the news might be bad: They could be too poor to get assistance with the cost of coverage.

Federal poverty level

The federal poverty level is used to determine eligibility for Medicaid, the government-funded health plan for low-income people.

Poverty level also determines eligibility for federal subsidies to reduce the cost of health insurance, when purchased on the exchange websites. In Idaho, no subsidies will be available below 100 percent of poverty, although subsidies will be available from 100 percent to 400 percent of poverty. In Washington, Medicaid is available below 138 percent of poverty and subsidized insurance can be purchased up to 400 percent of poverty. Poverty level is based on income and family size, as follows:

Family size	Income, as percent of poverty level
	26%	100%	138%	185%	200%	300%	400%
1	$2,987	$11,490	$15,856	$21,257	$22,980	$34,470	$45,960
2	$4,033	$15,510	$21,404	$28,694	$31,020	$46,530	$62,040
3	$5,078	$19,530	$26,951	$36,131	$39,060	$58,590	$78,120
4	$6,123	$23,550	$32,499	$43,568	$47,100	$70,650	$94,200