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Eye On Boise

Close the gap? Some Idaho lawmakers still leery of Medicaid expansion

Idaho state Capitol dome (Betsy Z. Russell)
Idaho state Capitol dome (Betsy Z. Russell)

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By Betsy Z. Russell

BOISE – Even after months of hearings, overwhelmingly positive public comments and stacks of statistics showing Idaho would save millions, some state lawmakers remain reluctant to accept federal Medicaid expansion funds to close the state’s health coverage gap.

“I am not for Medicaid expansion,” said Rep. Judy Boyle, R-Midvale, as an interim legislative committee wrapped up an all-day hearing at the state Capitol on Monday. “I think we’ve heard of some other options. … I think we can come up with a really good solution that fits Idaho.”

Sen. Steven Thayn, R-Emmett, said he favored state funding for primary care for some of the 78,000 Idahoans who fall into the coverage gap and have chronic health conditions. “The reduction of overall medical costs, I don’t think it can be done within the structure of federal rules – that’s my big concern,” he said.

While Idaho hasn’t expanded Medicaid to cover low-income working adults, it does spend tens of millions each year on a much-criticized catastrophic care program in which state and local tax funds pay off the catastrophic medical bills of patients who can’t pay. That help comes only after the fact, and liens are placed on the patient’s property, and even their estates after they die, though little is generally recovered. If Idaho expanded Medicaid, that program would largely go away.

The legislative panel heard a presentation Monday from an Idaho Falls family practice doctor who said he’s closed the gap in his own practice – by following a unique business model, in which he doesn’t take any insurance, collects directly from patients, and has low rates. “Patients pay me directly, which means that I do not need a group of clerks to try to collect my fees,” Dr. James Brooks told the lawmakers. “My overhead is about a quarter of the overhead of a typical family practice doctor.”

Sen. Marv Hagedorn, R-Meridian, co-chair of the legislative panel, said, “We need more Dr. Brooks in the world, but I don’t think we have enough doctors to do that, unfortunately.” He noted that Idaho ranks 49th in the nation for its number of doctors per capita.

The panel also heard from a Seattle non-profit that connects patients with medical specialists willing to provide care for free.

Rep. Fred Wood, R-Burley, said he couldn’t see Idaho’s answer being a “system where if you’re poor you have to rely on charity care, vs. what everybody else gets.” Wood, a physician, said, “I don’t have a path forward yet. I think there are multiple things we can look at.”

“Just expanding Medicaid for the sake of expanding Medicaid and continuing the current health care delivery system is not acceptable to anybody,” Wood said. “I think we have to have a package deal, where we can transform the delivery system, bend the cost curve, and come out with a product that is sustainable – because what we have at this point is unsustainable.”

Thirty-one states, including Washington, have expanded their Medicaid programs under the national Affordable Care Act, a step the U.S. Supreme Court made optional for states. Idaho’s not among them, but it’s been debating the question for the past four years. The state’s current Medicaid program is so limited that most adults don’t qualify at all unless they’re disabled. And only those earning at least 100 percent of the federal poverty level are eligible for subsidized insurance through the state’s successful and popular health insurance exchange.

That’s left 78,000 people in a coverage gap, with no help to obtain health coverage they can’t afford. At a legislative hearing in February, Dr. Kenneth Krell, director of critical care at Eastern Idaho Regional Medical Center in Idaho Falls, estimated that more than 300 Idahoans a year are dying prematurely as a result.

Sen. Jim Guthrie, R-McCammon, said Idaho needs to act. “To be honest with you, I’m having to set aside some political and philosophical biases that I have, and recognize the public opinion that’s out there that’s overwhelming,” he said. “The economic data is overwhelming.”

He noted, “The speaker of the House said that we will do something on Medicaid this time around, and I’ve heard him say it twice.”

Sen. Maryanne Jordan, D-Boise, called for full and immediate Medicaid expansion – which a national consultant told the lawmakers on Monday they could do right now, with no need for a federal approval. New Hampshire took that step while working on an application for a federal waiver to do a state-specific program for its newly covered population 15 months later.

“That meets the immediate need,” Jordan said. “We’re already being taxed to pay for Medicaid – the money just isn’t coming back to Idaho. It’s going to other states. Four years of inaction have left millions of dollars on the table that could be growing the Idaho economy.”

Idaho lawmakers have been debating applying for a federal waiver to create a new managed-care program for the gap population, with requirements for things like co-pays and coordinated care. One option would have the state use the federal expansion funds to subsidize premiums for private insurance.

All those things have been approved through federal waivers for other states, consultant Deborah Bachrach told the panel.

Bachrach, former Medicaid director for the state of New York, told the lawmakers, “Medicaid is in your hands – you decide what you want to do and how you want to do it.” She said, “You don’t have complete freedom, it’s a federal-state partnership … but a lot of it is state-directed.”

Thayn said he believes the real problem with rising medical costs is the third-party payer system, and he said Medicaid expansion wouldn’t address that. He also decried the “creep of federal rules and federal involvement,” noted the federal deficit, and said he doesn’t believe “that federal rules with food stamps or Medicaid encourages people to become productive.”

“If we’re really, truly looking at an Idaho solution, we need to look at what we can do with Idaho money, Idaho rules, and what we can do to change the cost of medical care,” he said.

Bachrach had a detailed response. She said Thayn’s right that Medicaid is a third-party payer, like others in the current system. “The one point I would make is with Medicaid expansion, we dramatically increase the state’s leverage to reform the health system,” she said. She noted that states already have control over medical care for state employees, through the insurance programs they offer. And they have control over the private insurance market through regulations set by the state Department of Insurance. If Medicaid expands to cover up to a quarter of the state’s population, she said, “The leverage the state has to influence where the system is going does go up.”

She noted that the Affordable Care Act was scored as paying for itself in terms of the federal deficit, and the Congressional Budget Office has scored repeal of the ACA as having a negative effect on the deficit. “About federal entitlement programs tending to increase dependence: I would resist that with respect to Medicaid,” she said. “Medicaid is health insurance. It started in the ‘60s as a welfare program. It was linked to welfare.” But it was decoupled from welfare in 1996, she said, and now is “purely health insurance.”

“We know that individuals who work in some small employers, who don’t work full-time, they’re not dependent – they just don’t have access to health insurance. The whole premise of Medicaid is have people covered, have them covered full-time, continuity of coverage, so that we can influence health and allow people to be better able to enter the workforce. So I have a different philosophy, if you will, on the dependency point.”

Hagedorn said, “In a perfect world, we would have control over all the things we do in the state, but we don’t live in that world. We live in a world where people are using emergency rooms because they don’t have insurance … and hospitals are mandated to provide that medical care. And they’re passing those costs on to you and I and the insurance companies that you and I pay for. And that’s the world in which we live, and we’ve got to figure out how do we start to reduce those costs.”

Sen. Patti Anne Lodge, R-Huston, said she wants any move Idaho makes to incentivize personal responsibility. “I think we have to take into consideration that there are those in the 78,000 who could pay for their health insurance if they just worked a little more,” she said.

Bachrach said work requirements are the one condition that federal authorities haven’t approved in any state’s waivers for Medicaid expansion programs.

Jordan said, “While I wish we may have come up with a solution sooner, I’m seeing enormous benefit in these discussions, with us being able to benefit from the data that’s been collected over the last few years with programs that have already begun.”

Since the panel’s last meeting Aug. 11, it has received 82 public comments. None opposed covering the people in the gap. Thirty-four called for either traditional Medicaid expansion or a waiver program. Twenty wanted a comprehensive coverage package of some kind for those in the gap. Twenty-two didn’t advocate specific policies, but called for covering people in the gap. One wanted Idaho to make health care a public utility and cover everyone. Five didn’t advocate any policy, but shared their experiences with lack of coverage in Idaho.

The panel made no decisions; it’ll meet again Sept. 28.

Betsy Z. Russell
Betsy Z. Russell joined The Spokesman-Review in 1991. She currently is a reporter in the Boise Bureau covering Idaho state government and politics, and other news from Idaho's state capital.

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