Idaho, Partial Medicaid Expansion and the 400% FPLers

Medicaid is primarily health insurance for poor people or very sick people.

Idaho’s legislature is monkeying around with the voter approved straight-up Medicaid expansion to 138% of the Federal Poverty Level (FPL).


This will harm middle class Idaho families who need community rated, guaranteed issue insurance from the individual market.

How does that work if Medicaid is health insurance for poor people?

Cost Sharing Reduction (CSR) work-arounds of Silverloading and differential morbidity matter.

Adrianna MacIntyre and I argued in a Health Affairs blog that full expansion has two paths to decreasing premiums for people earning over 400% FPL that are not available if a state elects and receives a waiver for a partial expansion to only 100% FPL.

 evidence found that Medicaid expansion improved the risk pool of state individual markets, suggesting that the population between 100 and 138 percent FPL is sicker and more expensive, on average, than other exchange enrollees. Insuring this cohort through Medicaid is associated with a seven to eleven percentage point decrease in individual market premiums. …

household incomes between 100 percent and 150 percent FPL, those that would be eligible for 94 percent AV silver plans.  This income bracket overlaps the Medicaid expansion income group significantly.  States that fully expand Medicaid end up with far fewer people in the most generous CSR bucket, as they have moved the 100-138 percent population to Medicaid

CSR 94 Enrollment by all APTC receiving enrollees 2018

Keeping a cohort that is more expensive than the rest of the ACA individual market risk pool in the risk pool raises premiums. Pulling the 100-138% population out of the ACA risk pool lowers market premiums as long as this group is more expensive than average. Furthermore while Idaho has engaged in the Silver Switcheroo, Silverloading increases premiums for folks who want a Silver plan and buy it on Exchange either because they don’t know if they will be just over or just under the subsidy cut-off point of 400% FPL or they can’t access an off-Exchange plan that meets their requirements.

Full Medicaid expansion reduces the premium pain of the middle class. Partial expansion continues the pricing pain for the middle class.

17 replies
  1. 1
    Duane says:

    Republicans don’t care about anything except their warped destructive ideology. Costs of any kind don’t matter. Will of the people. Ha ha ha. They’ll destroy the place rather than admit they’re wrong.

  2. 2
    jonas says:

    Partial expansion continues the pricing pain for the middle class.

    Well, if it actually helped people and was good public policy, Idaho Republicans wouldn’t vote for it, so here we are.

  3. 3
    West of the Rockies says:

    The Republican health plan: don’t get sick; if you do, that’s on you moocher.

  4. 4
    rikyrah says:

    The voters voted to expand Medicaid. It absolutely disgusts me to see these phuckers mess with that.

  5. 5
    RepubAnon says:

    The new Republican-approved universal health care plan: everything’s covered, but only if you go to a preferred provider.

    Alas, the preferred providers are Christian Science reading rooms. Motto: Pray the appendicitis away!

  6. 6
    Amir Khalid says:

    At some point in their deliberations, someone in Idaho’s Reublican party will have said, “We’re not here to do what the people want. We’re here to do what the party wants.” I find that a saddening thought.

  7. 7
    Another Scott says:

    (The graphic for “CSR 94 Enrollment by all APTC receiving enrollees 2018” is missing, at least here.)


  8. 8
    Yutsano says:

    @Another Scott: Doesn’t work for me either.

    Sigh. I knew this would be too good to be true for my Idaho peeps. And of course they’ll mostly get re-elected because Mormons like Republican policies. Actually it’s mostly the bebehs. And keeping blahs down.

  9. 9
    Amir Khalid says:

    @Another Scott:
    It’s missing for me too.

  10. 10
    Matt McIrvin says:

    @Amir Khalid: The formula is that the people who don’t support them are not legitimate people. They’re takers, or too young to know better, or “the mob”, or secretly non-citizens voting fraudulently. They’ve got a million of these excuses.

  11. 11
    dr. bloor says:

    @Amir Khalid: More saddening: few, if any, will face any serious challenges to reelection by those same people.

  12. 12
    rikyrah says:


    And keeping blahs down.

    There are, what, 3 blahs in the entire state?

  13. 13
    Anonymous At Work says:

    Question: How hard would it be for a judge to re-write the legislation to provide a clean Medicaid expansion up to 138%? Pages upon pages of regulations? Or take the complicated framework the Idaho Lege set up and use a red marker to remove the complications?
    Follow-up Question: If the process is not moderately difficult, is that what either Idaho Republicans planned?

  14. 14
    Salty Sam says:

    Plans! Going away for a weekend retreat with my men’s group. We’ll burn some sage, do a sweat-lodge ceremony, and have powerful, meaningful interactions with one another. Very spiritual.
    I am also bringing a jar of “fart putty” noisemaker to prank the guys at the dinner table. (“Jeezus Doug, you’d better go clean your shorts…”)

  15. 15
    Raoul says:

    There’s the expansion stuff itself, which is discouraging.

    Then there is the blatant anti-democratic bullshit of the GOP, which is infuriating. FL screwing over ex-cons who have outstanding fines. States rolling back voter measures on health insurance.

    At least sometimes, the courts won’t put up with this claptrap. But really, the GOP *hates* democracy. Their contempt is plain to the naked eye.

  16. 16
    Raoul says:

    On my same theme from #15, via ThinkProgress:

    “Indiana Republicans push anti-trans legislation days after gender-neutral license victory.
    Transgender people would face more barriers to get correct identification.”

  17. 17
    Your Friendly Neighborhood Economist says:

    So the question in my mind is whether the increased premiums are an unintended or intended consequence. Higher premiums undermines political support for ACA, so killing the poors is a win-win for Idaho Republicans.

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