In spite of the dismay of GOP leaders (and Rush Limbaugh’s promise to move to Costa Rica), the U.S. Supreme Court has upheld the Affordable Care Act.  When one reads the decision, it appears the court majority used reasoning that is consistent with the values of Idahoans – Republicans, Democrats and others.

The biggest question involved the requirement that everyone have insurance or pay a fee, the “individual mandate.”  The court ruled that Congress can tax for certain purposes; in this case, to have a functioning health insurance marketplace. To function, the marketplace cannot include “free riders” who make everyone else cover their health care costs. Freedom to dump on everyone else is not a constitutionally protected right.

Much of the act outlines how to discharge our personal responsibility to cover health insurance costs: expanded Medicaid (government insurance) for those who are impoverished, and premium support and a better insurance marketplace for those better off.  Those who are well off can choose plans without using the exchange or premium support mechanisms if they desire. Or, they may pay a fee/tax.

Here is what Chief Justice Roberts said:

“… Those subject to the individual mandate may lawfully forgo health insurance and pay higher taxes, or buy health insurance and pay lower taxes. The only thing they may not lawfully do is not buy health insurance and not pay the resulting tax.”

This is in line with the Idaho value of personal responsibility. 

The second big part of the decision was about federal coercion on Medicaid expansion.  Previously, there was a big carrot and a big stick – 100 percent federal funding for those newly eligible, but the threat of removal of existing Medicaid funding if the expansion didn’t occur.  The majority opinion found that stick too big a threat.

Most states will look at the expanded eligibility and see if it makes financial sense.  Then they will make the decision.  That also is as it should be.

In Idaho, I believe it is a real no-brainer.  We have a legal obligation through our Indigent Program for care of individuals who cannot pay health care costs. Last year, Idahoans spent roughly $75 million on indigent care.  Almost all of those would be covered by the federal Medicaid funds. In fact, it will cost about $100 million to $120 million for our share of the coverage for the six years between 2014 and 2019. The $70 million Idaho pays for indigent costs would greatly diminish or disappear. That is six times $70 million, or $420 million, or net savings of almost $300 million, in the same period.

There is another financial value: ending the cost shift by providers of care. Today, the typical family pays about $1,000 extra in insurance premiums each year to pay for those who have no insurance and are bad debts.  If fewer uninsured people seek care, that burden on individual families will decrease. 

So where from here? 

First, abandon the electioneering and partisan rhetoric around this issue. Idaho’s four electoral votes aren’t seriously in play.

Second, rapidly re-establish the state’s role in health insurance. Rate review, benefit plan and the insurance marketplace (exchange) were all intended under the ACA to be within the state’s control. Through legislative action or inaction, we are in danger of defaulting to the feds.  Whether by executive order or special legislative session, we need an acceptable insurance exchange plan for the feds before November.

Third, we need to seriously assess the costs and benefits of Medicaid expansion – not partisan positioning, but a realistic analysis and the leadership to act on the results.  Previous assessments, confirmed by the Legislative Service Office analysts, showed that expansion is likely financially beneficial to Idaho.

Finally, we need to work with insurers, hospitals, docs and businesses to develop cost control tools that help Idahoans.  Hospitals and physicians are developing integrated networks, ACOs, in response to Medicare changes.  How can these changes improve clinical quality, primary care access and treatment decisions, and involve patients and families in health care decisions? 

We have a great opportunity to use the tools of the ACA and to begin to fix Idaho’s health care deficiencies.  Responsible, caring citizens and their legislative leaders can make it happen.