Amy Dowd has accepted the job offer, and will be the executive director of Idaho’s new state-based health insurance exchange. “She’s accepted, she’s very excited, she’s eager and ready to go,” reported Stephen Weeg, interim exchange board president. “She’s happy to be back in Idaho, and she’s told her husband it’s time to find a place to live.”

Dowd, currently a health care consultant with Ernst & Young in Portland, was one of three key consultants who helped develop Idaho’s initial blueprint for a state-based exchange in 2010-11, working as a contractor for the state Department of Insurance. She also formerly worked as a health care consultant and for Blue Cross Blue Shield in New York, and early in her career, from 1993 to 2000, was an IT project manager and lead analyst for information systems and Web development projects for Idaho Power.

The 19-member exchange board interviewed Dowd for an hour today in executive session before deciding to offer her the job; she previously was one of five candidates interviewed by state officials who selected her as the finalist. “She’s one of the people that can hit the ground running,” said board member Margaret Henbest. “She has a strong project management background, a strong insurance background. She has state relationships in Idaho.”

Board member Zelda Geyer-Sylvia noted that the Department of Insurance “gave her very high marks for the work she had done before.” Board member Kevin Settles said, “She’s got a great skill set for our needs right now.” Said board member Frank Chan, “I believe she was very well qualified, and I’m looking forward to working with her. I can’t wait ‘til she gets on board and just hits the ground running.”

Amy Dowd, a health care consultant with Ernst & Young LLP in Portland, Ore., has been selected as executive director of Idaho’s new state-based health insurance exchange. The exchange board this morning voted unanimously to offer Dowd the job, which will pay in the range of $175,000 a year.

Dick Armstrong, Idaho Department of Health & Welfare director, said in anticipation that the state-based exchange would be established, “We began to do some searching of individuals that would be qualified as executive director. I used standard procedures that I use with Health & Welfare’s HR department.” Five individuals were interviewed, he said, “in preparation for this moment.”

As for the salary level, Armstrong said, “I felt comfortable that the market is going to demand the $175,000 level. There is a high risk involved here … it does come with risk for the individual. So that’s where I came to make the recommendation to the governor’s office, based on those processes.”

After the board’s unanimous vote to make Dowd the job offer, Stephen Weeg, interim chairman of the exchange board, said, “I will proceed now and get hold of Amy today and start the negotiation, and hopefully we have someone on board and starting to help us out tomorrow.”

The 19 board members of Idaho’s new state-based health insurance exchange got a surprising welcome soon after they were appointed – anonymous calls to each of them, threatening that they’ll each individually be targets in a lawsuit. “I got a call from a guy who did not want to identify what firm he worked for,” said Stephen Weeg, the board’s interim chairman. “He just wanted to give us all a notice that within three months’ time we would all be sued for being on this board – I think he called everybody on this board, just to let us know that we were already in trouble.”

Weeg said his first reaction was, “Wait a minute – we’re just doing what the law requires.”

Rep. Kelley Packer, R-McCammon, a board member, said, “I actually chuckled, because I thought, you know, we’re here trying to provide a service.” She said she was disappointed that opponents of the exchange would “stoop to these tactics,” and said, “I did call the speaker and let him know. He said, ‘Don’t worry – the state will have anybody on the board covered and indemnified.”

Weeg said the board will make sure it has good legal counsel and board member indemnification. “But it was somewhat of a surprise welcome to the board. It was quite a reminder for me of how much attention is being paid to what we do and how we do it.” You can read my full story here at spokesman.com.

The board of Idaho’s new state-based health insurance exchange board opened its first meeting this morning in the Lincoln Auditorium in the state Capitol; it is being video streamed live online here. “We have a challenge ahead of us,” said interim exchange board chairman Stephen Weeg, the retired head of a community health center, Health West, in eastern Idaho. “There was a huge amount of work on the part of a lot of people … to see Idaho create its own health insurance exchange. And the little task that we have before us is between now and October, get a business started and make an exchange operational and make it work for the citizens of Idaho.”

The 19-member board is scheduled to meet from 8:30 to 4 today, and tomorrow until noon. Today’s agenda includes overviews of the law that set up the exchange and Idaho Open Meeting Law requirements; a review of the exchange’s scope and requirements and the roles of the state departments of insurance and health and welfare; and setting of key tasks and time frames. Tomorrow morning at 9, the board is scheduled to go into executive session for a telephone interview with a candidate for executive director of the exchange.

The exchange will provide a voluntary marketplace for Idahoans to compare and buy health insurance plans online and access new government subsidies. David Hensley, Gov. Butch Otter’s chief of staff, told the board, “We’re going to be counting on each and every one of you to make this successful. … One of the most critical things to the governor is the openness, accountability and transparency of this board. He believes that we are directly responsible to the people of Idaho.”

Weeg encouraged all the board members to be active participants, saying, “My sense on this is that we'll need the collective intelligence of all of us and best work from all of us in order to make this work.”

Gov. Butch Otter today announced the members of the 19-member board of Idaho's new state-based health insurance exchange, including 14 he appointed; two non-voting ex-officio members, the directors of the state departments of Insurance and Health & Welfare; and three lawmakers appointed by legislative leaders. The legislators named to the board were Sen. Jim Rice, R-Caldwell; Rep. Kelley Packer, R-McCammon; and Rep. John Rusche, D-Lewiston.

The governor's appointees include a doctor, a nurse, employers, health insurers, and three consumer representatives. “I’m grateful that people with the talent, experience and ability to serve effectively on this board accepted the challenge,” Otter said in a statement. “We have decided to build and operate a voluntary, state-based health insurance exchange rather than defaulting to total federal control. The folks who have agreed to serve on the board will be our eyes, ears and most importantly the voices of Idaho in this process.” Click below for the governor's full announcement.

The Milk Producers of Idaho have come out in favor of Gov. Butch Otter’s proposal for a state-based health insurance exchange in Idaho. “The board strongly felt that it is important to have decisions regarding health insurance coverage in Idaho to be determined by Idahoans and not federal bureaucrats,” said Brent Olmstead, the group’s executive director. “Whether we like it or not, the Supreme Court has upheld the PPACA. It is the law and simply ignoring it is not a viable option.” You can read the dairy group’s full announcement here.

Idaho Gov. Butch Otter was notified today that the U.S. Department of Health & Human Services has “conditionally approved” Idaho’s plan to operate a state-based health care exchange. “We got a phone call from HHS informing us of that decision,” said Jon Hanian, Otter’s press secretary; the call came yesterday afternoon, and was followed by a letter today  from HHS Secretary Kathleen Sibelius to Otter. “It shows that despite an extremely difficult timeline, staff did a pretty good job of pulling all the various required components together,” Hanian said. “If we get approval from the Legislature, then we have HHS’s approval to go ahead and move forward with the plans we submitted. … It means that we’d eventually probably have their full approval for running it on our own, which is what the governor identified as the reason we’re doing this.”

Otter convened a working group that studied the issue for months, before overwhelmingly recommending that Idaho opt for a state-based exchange to enable residents to shop for health insurance plans and access government subsidies, rather than let the federal government run Idaho’s exchange. The exchanges are required under the national health care reform law, but Idaho had been exploring the idea well before the law passed.

Sibelius, in a news release today announcing conditional approval for state exchanges in Idaho, California, Hawaii, Nevada, New Mexico, Vermont and Utah, said, “States across the country are working to implement the health care law and build a marketplace that works for their residents.” Nineteen states and the District of Columbia have now been conditionally approved to partially or fully run their own exchanges.

Here's a link to my full story at spokesman.com on Gov. Butch Otter's announcement today that he's recommending a privately operated, state-based health insurance exchange in Idaho as the best option for Idaho to maintain control over how health care reform operates in the state. Said Otter, “I know the earnest and well-intentioned debate will continue,” as lawmakers consider the exchange legislation he'll propose in January.

The Idaho Health Exchange Alliance, a coalition of more than 400 insurers,  businesses, individuals and trade associations in Idaho, applauded Gov. Butch Otter's decision today to recommend that lawmakers approve a privately operated, state-based health insurance exchange. “We're very grateful that Gov. Otter has shown Idaho the way forward on this issue,” said Heidi Low, executive director of the group.  “A state-based exchange will help Idaho have more control over Idaho's health insurance costs and keep Idaho in the driver's seat on health insurance issues.” You can read the group's full statement here.

Meanwhile, Wayne Hoffman, executive director of the Idaho Freedom Foundation, decried the governor's announcement, issuing this statement: “I have a great deal of respect for my friend, Gov. Otter. However, I strongly disagree with his decision. More than 20 states have indicated that they will not implement a state exchange. States are opposed because they understand that Obamacare depends entirely on states to implement it. States are opposed because they know that a state exchange affords almost no flexibility and makes states co-owners of the looming disaster in medicine: higher insurance premiums, more expensive medical care, reduced accessibility and worse patient outcomes. Gov. Otter's decision makes the national effort of resistance much more difficult and more likely the law will remain in place, at great cost to Idaho families, businesses and our nation's economic vitality. Idaho Freedom Foundation will do everything it can, along with other opponents of Obamacare, to make sure Idaho never implements this destructive law.”
  

Among lawmakers reacting to Gov. Butch Otter’s health care exchange announcement today is Sen. John Goedde, R-Coeur d’Alene, who spoke from Denver, where he’s attending an education meeting. “ I think the governor did the right thing in the face of certainly a lot of opposition,” said Goedde, who served on Otter’s working group. “I don’t think that we have any choice - we’re going to establish  a state-based exchange, or we are going to get the federal exchange by default.”

Goedde, a longtime insurance broker, said Idaho’s health insurance premiums are among the lowest in the nation, in part because Idaho has so few state mandates on what insurance plans must offer. If the state were lumped in with other states in a federal exchange, “There’s no question in my mind … it’s going to drive the cost of insurance up.”

Some Idaho  lawmakers have been outspoken in opposition to doing anything required by “Obamacare,” and ideological groups like the Idaho Freedom Foundation have been lobbying hard against a state-based exchange, even as Idaho business groups and insurers  pushed for it.  Last year, the Idaho Legislature took no action on an insurance exchange, gambling that the U.S. Supreme Court would overturn the law. Instead, it upheld it.

“I’m just proud of our governor,” Goedde said. “He knows he’s going to be taking heat, but he did the right thing.”

Rep. Vito Barbieri, R-Dalton Gardens, has been among the most outspoken opponents of a state exchange. “My inclination is to resist,” he said after the governor’s announcement. “The bottom line is if the federal government is going to control it, they should run it. I’m just not inclined to believe that the Legislature should just rubber-stamp this, but there’s a lot of new people there and we’ll have to see how they go. I’m just not going to be able to go along. I don’t think it’s good for my state, I don’t think it’s good for my constituents, and I’m absolutely convinced that my constituents do not want it.”

House Minority Leader John Rusche, D-Lewiston, a retired physician and former health insurance excecutive, said, “Idaho’s a low-cost health insurance state. And if we’re pooled with the national average, you can expect that you’d be paying the national average.” He estimated that Idahoans pay $500 to $1,000 less in annual premiums than the nation as a whole, mainly because of few state manda and low utilization rates. Putting Idaho into a federal exchange would force Idahoans to pay national rates, he said.

“It’s the better decision,” Rusche said of Otter’s announcement.  He added, “The politics of this are going to be really interesting.”

Gov. Butch Otter’s recommendation for a state-run health insurance exchange matches that of his working group that studied the issue for months – it’d be a privately operated, state-based exchange. Jon Hanian, Otter’s press secretary, said the privately run feature was a “better option” because it can get up and running more quickly than a traditional state agency. But, he said, “Let’s be honest. There was very little in these options that he liked. … But I think given all the work that the working group did and the fact that this decision kind of preserves some options and preserves flexibility for Idahoans, I think that’s why he came down where he did on this.” He added, “It’s going to be a work in progress.”

Health insurance exchanges, under the national health care reform law, will provide an online marketplace where consumers can shop for the plans, rates and features they want, and also access government subsidies if they qualify for them. States have the option of setting up their own exchanges, partnering with the federal government, or doing nothing and allowing the federal government to operate their state exchanges.

Said Otter, “All the criticisms of the exchange mandate that I and many others have expressed remain valid and troubling. The law is governed by an evolving set of increasingly complex rules and requirements. It is onerous, unwieldy and fraught with unknowns. That makes it all the more important to remember that my decision today can be rescinded if the Legislature disagrees or withdrawn by me if circumstances warrant – a real possibility on such a constantly moving target. But with what we know today, this is our best option.”

Otter will propose legislation when lawmakers convene in January to set up the new exchange. “We will have details about it in the State of the State,” Hanian said, the message the governor delivers to a joint session of the Legislature on its opening day, Jan. 7.

Idaho Gov. Butch Otter announced today that he's notifying the federal government that Idaho will opt for a state-run health insurance exchange, subject to legislative approval. “This is not a battle of my choosing, but no one has fought harder against the mandates and overreaching federal authority of the Affordable Care Ac,” the governor said in a statement. “No one has more consistently and clearly demanded that Idaho retain the authority and flexibility to chart our own path forward. There was a judicial process for challenging Obamacare, and the presidential election was at least in part a referendum on its enactment. But despite our best efforts, the law remains in place, and almost certainly will for the foreseeable future. There will be a health insurance exchange in Idaho. The only question is who will build it.”

He added, “Our options have come down to this: Do nothing and be at the federal government’s mercy in how that exchange is designed and run, or take a seat at the table and play the cards we’ve been dealt. I cannot willingly surrender a role for Idaho in determining the impact on our own citizens and businesses.” Click below for his full announcement, including a Q-and-A about the decision.

Idaho Gov. Butch Otter has decided to delay a decision on how to proceed on a health insurance exchange in Idaho, now that HHS chief Kathleen Sibelius has agreed to give governors more time; a decision had been due today, but now the deadline has been pushed back to December. Click below for Otter's full announcement.

“I have my working group’s recommendation, and I have been listening carefully to stakeholders and citizens about this important choice,” Otter said. “This extension gives us more time to get answers from HHS about what the federal requirements will be.” Otter noted that he consulted with other GOP governors at a Republican Governors Association meeting in Las Vegas this week from which he just returned today. “I don’t want us buying a pig in a poke,” he said, “so with this extension I’m hoping we’ll get answers to the questions and concerns we’re hearing from legislators and the public.”

In response to a request from the Republican Governors Association, U.S. Secretary of Health & Human Services Kathleen Sibelius has sent out a letter giving governors extra time to make their decisions on how to proceed on health insurance exchanges - a decision for which the deadline was looming tomorrow. Last week, Sibelius gave governors until December to file the “blueprint” that will flesh out the details of the decision, but didn't move the Nov. 16 deadline for a “letter of intent” declaring the state's decision. If states don't opt to set up their own, state-based exchanges or enter partnerships with the federal government, the feds will take over and operate the exchange for those states.

Idaho Gov. Butch Otter has been considering the decision, and convened a working group that studied the issue for months, then recommended overwhelmingly that the state go with a state-based exchange operated by a private non-profit. Otter is at the RGA meeting in Las Vegas today, where the issue was among the discussion topics, and his office just received Sibelius' letter late this afternoon. Otter's press secretary, Jon Hanian, said, “I think over the next 24 hours you should know whether or not we're going to make some decision tomorrow or take additional time.” You can read Sibelius' letter here.

Corey Surber, chair of the governor's Medicaid expansion working group, said, “At this point I'm sensing consensus, but I'd like to do one more check.” She asked working group members, if they didn't agree with Option 3 - expand Medicaid - with the identified caveats about benefit design, personal accountability and the like - to turn on their microphone lights. None did. That means it's unanimous - the group is backing Medicaid expansion for Idaho.

Still to be finalized is the group's formal report to Gov. Butch Otter, which will be word-smithed and completed over the next few days. You can read my full story here at spokesman.com.

Here are some of the working group members' comments as they debate options for Medicaid expansion in Idaho:

Sen. Patti Anne Lodge, R-Huston, said, “This would be good for our people in Idaho. But we also …  don't know what the future's going to hold, and we don't know what the federal government is going to  do with its $16 trillion deficit and the fact that they're going to be putting bigger burdens on the states.” She said, “I'm not quite there totally. I know it's good for Idaho, but I'm very concerned about what this burden is going to place upon our people.”

Dr. Ted Epperly said he's “strongly in favor” of expanding Medicaid in Idaho. “Really what we have an opportunity to do here is shape a new health care system and a new insurance program. … I love a benefit redesign that really puts a lot of personal accountability and incentivization onto patients for their health.” He added, “I think we need to focus on what we can control, and what we can control is what we do here in Idaho with this program. … It's a real opportunity for us.”

Dan Chadwick of the Idaho Association of Counties said, “The CAT program, the county indigent program, has run its course. It's time for it to end in this state because it has not done its work. It's becoming financially and administratively unsustainable.”

Tom Faulkner said Idaho's now paying 100 percent of the costs for health care for the working poor from its state general fund and from county property taxpayers. “If we could have 90 percent to 100 percent of that paid by the federal government, why wouldn't we do it?”

Beth Gray said, “The data that's been presented today seems to me to be overwhelmingly compelling.”

Gov. Butch Otter's Medicaid expansion working group is now considering what recommendation to make to Otter. Member Mike Baker spoke out in favor of expansion. “There's financial benefits, there's the opportunity to do something right here,” he said. “From the state perspective, you look at the numbers, you look at the things we've learned through these discussions, and I think it's great - a great opportunity for us to put together a different model.” He said he hoped Idaho could develop an appropriate benefit plan that would fit the state and the targeted population, and provide the appropriate incentives.

Rep. Fred Wood, R-Burley, said he's concerned about “how to control costs and how to bring the best medical care at the cheapest cost to patients in that population. And that we do get away from the perverse incentives in the American health care industry that are going on today, we get away from fee for service medicine, we get away from the old traditional managed-care concept.  We actually have to get a system whereby the consumers and the providers … actually own the system, as opposed to feeding off the system. If we're going to go down that road, then I can wholeheartedly endorse the concept.” But, he said, “If we're going to just have another entitlement program … then no, you don't have my support, nor do I think you'll have the Legislature's support.” Said Wood, “We aren't just signing a blank check. That's not what we're about. We're about doing it right or we're not going to do it.”

Gov. Butch Otter's Medicaid expansion working group is receiving a report from consulting group  Milliman this morning on the potential impacts to the state. “On a purely financial basis, it would make sense to expand,” Justin Birrell of Milliman told the working group. “You save $6.5 million if you expand. It would cost you $284 million if you don't.” That's over a 10-1/2 year period starting in the second half of state fiscal year 2014. Added the firm's Ben Diederich, “The state and local offsets are what's very unique to Idaho.”

That's because of how Idaho currently funds health care for the indigent; through the state's medical indigency/Catastrophic Health Care program, the money comes entirely from the state general fund and from local property tax money. This afternoon, the working group is scheduled to decide on its recommendation to Otter on what the state should do; under the national health care reform law, states have the option of expanding their Medicaid programs largely at federal expense.

Gov. Butch Otter's health insurance exchange working group has voted overwhelmingly in favor of a state-based health insurance exchange, opting for the model of using a private non-profit group set up by the state to run it. The recommendation now goes to Otter, who must notify the federal government of which way the state will go by Nov. 16. If the state does nothing, it gets a federally run health insurance exchange and loses state regulatory control over its health insurance industry. Rep. Lynn Luker's substitute motion to hold off on any decision for a year was overwhelmingly rejected. Only two members, Luker and Wayne Hoffman, dissented in the panel's decision.

Rep. Lynn Luker, R-Boise, has offered a substitute motion at the Health Insurance Exchange Working Group to defer a decision for one year; Wayne Hoffman seconded his motion. Luker said he wants to “defer this decision 'til after the election, 'til after we see what the federal government does with implementing a federal exchange, which we're probably going to get anyway given our level of preparation, and that we reconsider this in a year.” If the substitute motion fails, Alex LaBeau's original motion is still on the table.

Rep. John Rusche, D-Lewiston, said opting for a federal exchange would mean much higher health insurance costs for Idahoans, “charging the citizens of the state of Idaho $120 million more for basically the same insurance they're getting now.”

Panel member Tom Shores said, “I think the problem is we've waited long enough. We couldn't get the Legislature to do anything.” Waiting again, he said, would be “folly.” John Watts said, “I just don't know why we'd want the federal government to control absolutely everything if we have an option to avoid that.”

As the Health Insurance Exchange Working Group ponders Alex LaBeau's motion to support a state-based health insurance exchange, Wayne Hoffman, a group member, spoke out in opposition, comparing the state's relationship with the federal government to “the relationship of an abuser to a spouse. We keep getting beat up by the federal government and we keep running back to the federal government, and we have done it time and time again.” He said, “I think the best interest of the state is  to continue to resist this constitutionally dubious federal law. … The only way you're going to get the federal government, Congress and the executive branch to reconsider the law is just to resist its implementation.”

LaBeau said, “We're all paying for everybody's health care as it is, whether it's thru Medicare and Medicaid, your property taxes or your insurance. The other important thing to remember, in a small state like Idaho, this is going to impact small employers.” He said small employers - those with 50 or fewer employees - are 96 percent of Idaho's employers, and they employ half of Idaho's workers. “That's a substantial number of Idahoans that are going to be impacted by the decision that is made here today.” LaBeau called for a state-based exchange, using a private non-profit model, “because it's the most flexible.” He said a state-based exchange is the only way Idaho can protect small employers from big jumps in their costs and maintain Idaho's regulatory role over its insurance industry.

Panel member Kevin Settles said, “We need to get past arguing the legality of the law. The Supreme Court settled the issue.” He said, “We can make something good out of this. … With the state-based non-profit exchange, we can make it reflect Idaho.” He noted that Idaho's current insurance premiums are among the lowest in the nation.

As Gov. Butch Otter's health insurance exchange working group holds its final meeting today, to settle on its recommendation to the governor, a group calling itself the Idaho Health Exchange Alliance has swelled to 316 members around the state, pressing for a state-based insurance exchange, rather than allowing the federal government to run an exchange for the state. The members include insurers and insurance agencies large and small, construction and manufacturing firms ranging from Oppenheimer Companies and Contractors Northwest to General Pneumatic Tools LLC and Madison Roofing, the Boise Metro Chamber of Commerce, the Idaho Academy of Family Physicians, Idaho Forest Group, the Twin Falls Canal Co., two auto-body repair businesses, the Idaho Association of Commerce and Industry, the Idaho Hospital Association and the Idaho Mining Association.

The alliance has sent a letter to the working group saying, “Our members encourage you to support the creation of a state-based health insurance exchange. Such a strategy is far superior to ceding design and control of something as important as health insurance to the federal government;” you can see the full letter here.

Meanwhile, the Idaho Main Street Alliance and the Idaho Community Action Network have scheduled a news conference this morning at 9:30 in room WW53 of the state Capitol, prior to the working group meeting, calling for an exchange plan that “works in the best interst of Idaho's small businesses and families, not cater(s) to insurance CEOs.” That group wants to make sure big insurers don't dominate the new exchange's board. “We need an exchange that will negotiate on our behalf, using our bargaining power to get the best plans at the best prices,” said Main Street Alliance leader Christina McNeil. “Small businesses deserve nothing less, and we should demand nothing less.”

The working group meeting is from 10 a.m. to 3:30 p.m. today in the Capitol Auditorium; you can see the agenda here, and watch live online here.

  

The Idaho Legislature's Health Care Task Force, a joint committee of 14 senators and representatives, is hearing updates this morning on the progress of two working groups looking into how Idaho should proceed under the national health care reform law on two fronts: A health insurance exchange, and expansion of Medicaid. State Insurance Director Bill Deal told the lawmakers that the exchange working group will hold its final meeting this Friday, and will settle on its report and recommendations to Gov. Butch Otter on how to proceed.

State Health & Welfare Director Dick Armstrong told the task force that the Medicaid expansion working group is working through three options: Don't expand Medicaid and keep Idaho's current medical indigency/catastrophic health care fund as-is; don't expand Medicaid and revise the CAT fund system; or expand Medicaid. The no-change option would lead to very fast-growing costs both for the state and for county property taxpayers, Armstrong said. Forecasts show county costs would rise from $29.6 million a year today to $39.6 million a year in 2020, and state costs to the state's general fund from $39 million this year to $52.5 million in 2020.

Revising the CAT program likely would save only about 2 percent on costs, he said, with a new, standardized claims-processing system costing between $1.5 million and $3.5 million. Medicaid expansion, combined with other expected increases in Medicaid, would push Idaho's Medicaid program from the current 229,000 participants to an estimated 453,000 in 2020. Costs would be almost entirely borne by the federal government, though Armstrong warned that that could change in the future if federal policies change.

Sen. Dan Schmidt, D-Moscow, said the three options don't include one he's been hearing questions about when he goes door-to-door campaigning for re-election: Don't expand Medicaid and eliminate the CAT program, and just say Idaho won't pay for indigent people's medical costs. “Could the state of Idaho just say we're not going to pay for indigent health care?” Schmidt asked. “People argue that that's something we should consider.”

Armstrong responded, “Well, then the bad debt would fall on the hospitals and the providers. My first-blush guess is all of us that pay for our own hospital care through insurance, that difference would be immediately transferred. It would be an immediate cost shift to anybody and everybody that's paying for health care - they would have no choice.” He added, “It would mean all of the dollars would then end up moving to another pocket.”

Here's a news item from the Associated Press: BOISE, Idaho (AP) ― With a looming deadline approaching, insurers are making a last-ditch plea to Gov. C.L. “Butch” Otter for a nonprofit, state-based insurance exchange in Idaho as part of President Barack Obama's health care overhaul. On Tuesday, Idaho's advisers said the state likely has too little time ― and too much work still to complete ― to establish a state-run exchange by 2014. But insurance companies including Blue Cross of Idaho, Regence Blue Shield and PacificSource urge the state not to default to a federal exchange, like many states are doing. Jack Rovner, an attorney working for the insurers, says Idaho can still develop a state-based nonprofit to manage this online insurance marketplace. Insurers fear a federal exchange would invite regulation from Washington, D.C. Idaho must announce its intentions by Nov. 16.

Consulting firm KPMG has offered some estimates of the costs for a state-based health insurance exchange: $77 million to set it up, and $10 million a year for operations. A partnership or “hybrid” exchange, in which the federal government would handle some aspects and the state others, would have a lower startup cost of about $15.5 million, and operating costs of about $1.7 million a year. Costs for the federally run option, as far as Idaho, couldn't be estimated. “There are grant funds available under all these scenarios,” said Sandy McBride of KPMG. Nevada, for example, received a $75 million federal grant for start-up of its exchange; Washington has received $152 million.

Gov. Butch Otter's health insurance exchange working group is meeting today in the Capitol Auditorium and will meet again in its final meeting on Oct. 24; you can see the agenda here and listen live here (a lunch break is planned from noon to 1 MT). Otter will have to declare by Nov. 16 whether Idaho will set up its own state-based exchange; default to a federally run exchange; or go with a partnership between the two. States do have the option to change their choice on that same date each year thereafter, presenting a fourth option: Start with a partnership, and transition toward a state-run exchange over time; a state-run exchange would allow Idaho to continue to control the regulation of its health insurance market.

Rep. John Rusche, D-Lewiston, said of the consultant's report today, “I think that they're saying what some of us have been saying for a while: That by dawdling, we've taken options off the table.” He said, “I'm not surprised - I'm disappointed.” But he noted that not all the information is in yet as far as whether Idaho could pull together some form of state-run exchange. “There are people that are still hopeful,” he said. Click below for a full report from AP reporter John Miller.

Consultant Jack Grovner was asked by Gov. Butch Otter's health insurance exchange working group to look into whether Idaho could pursue a privately run model and still meet federal requirements under the health care reform law. The answer: Yes, if it comes through a state-established private non-profit corporation. That's a subset of the state-run exchange option; Idaho must decide whether to go with a state-run exchange, default to a federally run exchange, or go with a partnership between the two.

Rovner found that Idaho has a precedent for a private, non-profit model: Its Idaho Health Data Exchange, a non-profit created in 2008 to carry out the initiative started by President George W. Bush in 2004 to move toward a nationwide tech infrastructure for exchange of medical data. The Idaho Health Data Exchange, incorporated by state Health & Welfare Director Dick Armstrong, was designated by Otter in 2009 as the entity carrying out that initiative for the state, qualifying it to receive federal grant funds.

A similar model could be adopted for an Idaho state health insurance exchange, Rovner said; Hawaii already has gone that route. The non-profit could receive federal grant funds for set-up, but not for operations; the state could set it up so that the exchange would have to be self-sustaining through fees or assessments, and would receive no state taxpayer funding. Hawaii's private, nonprofit exchange already has received a $62 million federal grant for set-up.

“What Idaho did on that health data exchange is really the perfect template,” Rovner said. “This is an option that will work, if you're interested in it - it's legal.” Rovner will make a presentation to the working group this afternoon; you can read his memo here.

Sen. John Goedde, R-Coeur d'Alene, has been promoting the idea of a private option, but possibilities he raised earlier, including “renting” an existing exchange structure, or essentially contracting out the service to a private firm, haven't proven workable under federal requirements. Goedde called the private non-profit model “intriguing,” and said it may offer a path that's more politically appealing in Idaho. “I think we need to take a look at every viable option we've got,” Goedde said. “Idaho, I think, traditionally has been a state where they feel less government is better. And if we can move something into a nonprofit arena as a viable option, certainly we need to consider that.”

Last month, hopes for a private model dimmed after State Insurance Director Bill Deal addressed lawmakers on the Health Care Task Force; but Deal said he was addressing the prospect of using an existing outside firm. “Basically what I was saying was if you go out to the marketplace today, you cannot find a not-for-profit or even a for-profit organization that has all of the pieces that could come in and hire them to run an exchange,” he said. “There's just not one out there.”

Rovner said a private non-profit could be established by executive order, and wouldn't necessarily require legislative action. However, Deal said, “That's a political issue. … This has been such a controversial issue in Idaho,” that it might be better for lawmakers to weigh in. “I just think in the long haul, it would be a cleaner method of getting to a conclusion of what that exchange should look like.”

Legislation that was prepared last year, but never acted on, called for a quasi-governmental entity to oversee a state-run Idaho exchange, rather than a private non-profit. Deal said either way, a board would have to be set up and all the details determined as to how the exchange would work, and timelines are tight for that. “That isn't going to be set up like magic no matter what,” he said. “The timeline is our enemy.”

Gov. Butch Otter's health insurance exchange working group is meeting today; you can watch live here. First up, the panel is hearing a cost analysis report from consulting firm KPMG. Among the conclusions, KPMG project manager Robert Mitchell told the panel: “We believe it's impractical for Idaho to try to build your own exchange by Oct. 1, 2013.” He added, “There is a whole lot to be done.”

Other states that are much farther along still are wrestling with details, he said. Idaho faces a Nov. 16 deadline to tell the federal government whether it wants to go with a state-run exchange; a federally run exchange; or a partnership between the two. If it makes no decision, the state defaults to a federal exchange. A partnership could allow the state to maintain control of plan management and/or customer outreach components, and then, in the future, move toward a state-run operation, Mitchell said.

As the governor's Medicaid working group wrapped up its meeting today, Idaho Health & Welfare Director Dick Armstrong said it was “nice to hear such agreement on many of these principles - that's very encouraging.” He said he'll work on “simple graphic illustrations of costs and impacts” to bring to the panel at its next meeting Oct. 23rd. “I believe we have added to our information base and understanding,” he said, including today's point that administrative costs of the current county medical indigency system haven't yet been included in cost estimates. “We're going to try to put a dollar savings to that, so that was a good find today,” he said. The next meeting may be the group's final one, Armstrong said, but it'll reserve a date for an additional meeting just in case. “It depends on what happens with the November election - we may be back,” he said.

Members of the governor's Medicaid expansion working group are now each sharing “guiding principles” they want to see help guide the panel's future decision on how to proceed. Rep. Fred Wood, R-Burley, a physician, said the group needs clear, easily understood graphics comparing the costs of each option. “If we really believe that it's going to cost us less in the future, we have to be able to show that,” he said. He said there's concern about “creating an adverse business environment in the state of Idaho because we won't expand Medicaid,” to the point that a business considering relocating to the state might say, “Wait a minute, you want me to come to the state of Idaho and pick up a part of your indigent care? We're not coming.”

Susie Pouliot of the Idaho Medical Association said the IMA physicians took a policy position in July in favor of expanding Medicaid in Idaho. She said their hope was not only to get patients into “the appropriate care … at a more appropriate cost,” but also to make the move part of a transformation of health care in Idaho, into a more managed-care type environment, with a medical home model, with community care networks, so that “coordination and transitions are managed in a way that produces good health results.”

Sen. Patti Anne Lodge, R-Huston, said this summer she's received more letters, emails and personal contacts than ever before in a campaign season, and they're on this issue. Lodge said many of her constituents are telling her “they don't like Obamacare and they don't want anything that has anything to do with it,” and it's challenging to explain to them the issues involved. “We are not doing a good enough job … to show the taxpayers and the citizenry what the costs are going to be,” she said.

Gooding County Commissioner Tom Faulkner said, “I think we do want to make the point that we want to promote a strong business environment by minimizing the taxes and the costs to the citizens of the state. That is a big deal.” He added, “Part of the problem with our health care is our providers are going through the roof with the costs … just because they could get away with charging us whatever they want to charge us.”

Dan Chadwick, head of the Idaho Association of Counties, said of the existing medical indigency program, “They're unsustainable numbers. We cannot afford those any longer. And those same people that are going to the county now for assistance are the ones that are paying those increased property taxes or state taxes.” He said the current system “puts incredible pressure on county governments trying to keep up with those costs, simply because they're not predictable.”

Mike Baker of the Idaho Primary Care Association is now briefing the governor's Medicaid working group on Option 3: Expanding Medicaid in Idaho. “You look at the numbers, and this thing, this problem is just ginormous,” he told the panel. But, he noted, “We're paying for a lot of these things right now. They're coming out of inefficient systems, they're probably being paid at higher rates. … I don't think we're working as smart as we could.”

He noted a reference earlier in the day to Idaho's medical indigency program as a type of “debtors' prison.” “There's funding available to help these folks in our community access the care that they need, and it's up to us to figure out how do we utilize what we're paying now … to cover the gap,” Baker said. “There are all these holes in the system.”

He said, “We all know at the end of the day we're going to have some folks that fall through the holes, no matter what program we put together, but the goal here is to reduce the number of people falling through those cracks. … reduce the cost of their care … and stop requiring other folks in the community” to cover the costs through cost-shifting.

Baker, who noted that he sees patients who are part of this population every day at the Kootenai County community health center where he works, said, “This really can work, and get us closer to the day where we can say, 'Access to health care is not a problem.'” He said, “We have 65 percent of patients in our clinic are uninsured.”

He shared data that for Idaho's mentally ill patients, 95 percent could be shifted to an expanded Medicaid, saving $11 million in state general funds. About 75 percent of AIDS Drug Assistance Program clients would qualify for the Medicaid expansion, saving the state about $800,000. Shifting the uninsured population from the state's indigency program to Medicaid would save millions both for the state and for county property taxpayers. “We know cost-shifting is occurring,” Baker said. “This should be a no-brainer decision.”

He told the panel, “If your neighbor is healthy and they're able to work, your community starts getting better.”