Dr. Kenneth Krell: Medicaid expansion still makes sense for Idaho

President-elect Donald Trump has vowed to “repeal and replace” the Affordable Care Act (Obamacare). It would seem logical then that any discussion of Medicaid expansion in Idaho ends with Trump’s election.

Well, maybe not so fast.

First, Trump has already retreated from a complete repeal of Obamacare, indicating he wants to keep the ban on insurance denial for preexisting conditions and continue to allow children to stay on parents’ plans until age 26, and he has indicated vaguely that no one should lose coverage.

To see what dismantling the ACA could look like, H.R. 3762, passed by the House and Senate last January and vetoed by Obama, provides the most draconian scenario, eliminating funding for health insurance exchanges and insurance subsidies, eliminating the Medicare tax that funded much of the ACA and ending Medicaid expansion.

Congress was able to pass the bill and avoid a filibuster, which would have required 60 votes then and now to overcome, under a rule that allows for budget reconciliation with a simple majority. Many Republicans probably voted for the measure knowing it would be vetoed, since no one wanted the consequences of eliminating 20 million Americans from insurance coverage, now about equally split between those enrolled on the exchanges and under Medicaid.

Importantly, H.R 3762’s enactment would have been delayed for two years, presumably to allow for a replacement that would have provided coverage in some manner for those 20 million enrollees. No one wanted to just retreat from the achievement of the lowest uninsured rate in history, about 8.9 percent by 2016.

No one – including Congress – intends to just walk away; thus that two-year extension in the vetoed congressional bill.

In addition, many of the ACA provisions would not be filibuster-proof to repeal, since they don’t directly affect funding. If simply repealed but with the preexisting condition requirement left intact, the death of the ACA would financially wreck the insurance industry, which could not insure patients with preexisting conditions without a requirement that the entire population be enrolled to spread the cost. Also, without the cost controls and taxes brought on by the ACA, the federal deficit would increase by $353 billion over the next decade, according to the Congressional Budget Office, in addition to the number of insured Americans falling by 24 million.

Some changes will – and ought – to come. While the ACA actually slowed the trajectory of increases in health care costs, middle-income Americans are increasingly burdened by rising premiums, especially those who make too much for any federal subsidy.

Maybe we will see changes in the allocation of funds to states for Medicaid, such as block grants rather than per capita payments, but all of that is very unformed at this point, and whatever changes get done through reconciliation or in a bipartisan manner to avoid a filibuster, Congress will not just wipe 20 million citizens off the insurance rolls. The fallout would be too great, and it would most adversely affect the very citizens Trump has vowed to help.

Medicaid will remain an integral part of any program, since coverage for the working poor and disabled cannot be provided as efficiently, both in terms of cost and scope of coverage, by private insurance as it can be through Medicaid.

So I would argue that now is the most efficacious time for Idaho to expand Medicaid. Get the working poor and disabled on the rolls this year so any continued program designed by Congress will include our citizens.

As noted, certainly no “repeal” will come for at least two years, and any “replacement” will include those Americans who achieved coverage under the ACA. Don’t leave hardworking and disabled Idahoans out.

Every day we delay results in the death of at least one Idaho citizen, and untold suffering for thousands more. Now is the time to pressure the Legislature for expansion this session. We must not let legislators off the hook. Sixty-one percent of Idahoans support expansion, and the pathway is clear. Just as we should have done years ago, accept full Medicaid expansion this session, and then apply for whatever waivers will tailor the system to fit our state.

Kenneth Krell is an intensivist at Eastern Idaho Medical Center in Idaho Falls.