Idaho, Medicaid Expansion and optionality

Idaho’s voters passed an unrestricted Medicaid Expansion last November as state law.

Idaho’s Republican led legislature passed a convoluted Medicaid Expansion this week.

Idaho’s Republican governor signed the convoluted bill on Tuesday.

There is a lot going on in the law that requires significant policy waivers from the federal government. Work requirements are de rigeur and will likely be challenged in court.

The interesting, to me, segment concerns optionality of Exchange versus Medicaid coverage for people who earn between 100-138% Federal Poverty Level.

Another piece of the bill would put people on private health insurance, through the Your Health Idaho exchange, by default. If someone wanted Medicaid coverage instead, they could opt in. The carve-out would apply only to people with incomes between 100% and 138% of poverty level — $12,490 to $17,236 for a single person.

It’s a lighter version of Utah’s “bridge” expansion — a federally approved plan to expand Medicaid in Utah only up to the poverty line, leaving people who are slightly above poverty out of Medicaid but allowing them to get private insurance on Utah’s exchange.

Supporters said Idaho’s carve-out would save Idaho money, since those people would be getting insurance paid for by federal tax credits.

This idea is not shocking. Idaho has been playing around with partial expansions and carve-outs to pull people with high medical costs out of the Exchange risk pool before. If this optionality is approved, it would lead to a complex set of choices for people who make between 100% and 138% FPL.

Within the context of previous Idaho initiatives, this optionality makes local sense given local assumptions.

Staying on Exchange means no work requirements, continuation of network and some predictable cost sharing and premiums. Looking at the RWJF HIX Compare data, Idaho has few low net of subsidy Silver plans as the Silver Gap is minimal in most rating areas. Premiums will be a little higher.

An individual who elects Medicaid would face potentially more restrictive networks and potentially face work requirements and eligibility requirements but would gain lower premiums and lower cost sharing.

I am not sure which way the risk will flow if this waiver is approved. I could see an argument that high cost individuals would move to Medicaid as they would be eligible for a work requirement exemption and see their premiums and cost sharing go down. I could see an argument that low cost individuals would move to Medicaid as they would see their premiums go down and since they don’t use medical services all that much, networks and cost sharing are almost irrelevant.

The actuaries have to be sweating bullets. And the academics have to be submitting data requests to Idaho Medicaid and the Idaho exchange board for de-identified, risk stratified microdata for the 2020 policy year already.

14 replies
  1. 1
    OzarkHillbilly says:

    Idaho’s Republican led legislature passed a convoluted Medicaid Expansion this week.

    Prisoners of their own prejudices.

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  2. 2
    Ohio Mom says:

    The United States: fifty laboratories of how to do health coverage wrong. Or at least in the most inefficient and least compassionate ways possible.

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  3. 3
    TomatoQueen says:

    @Ohio Mom: Absolutely. After 5 long years, Virginia has expanded Medicaid and is now diddling about with a work requirement to make the blue side scream. The population that most needs the expansion also lives in the most economically deprived area of the state, hours and hours away from jobs. And who did they vote for? Of course they did. Oh Mr Anderson mentioned some months back the transition of Medicaid from direct to managed care companies and the heartbreak and hassle to ensue therefrom. Of course it does and did and I want to throttle whoever thought this was a good idea.

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  4. 4
    Kent says:

    I’d love to see Dems start imposing work requirements on farm aid. No more cashing your crop subsidy checks from that retirement villa in Florida or Arizona or Hawaii. If you want a check from the Gvt you gotta spend 20 hours per week on a tractor or with a shovel in your hand back on that Kansas or Nebraska farm that is generating the subsidies. Or whatever the hourly work requirements are that they impose for medicaid. And the work has to be on the farm that generates the subsidies, not some random fake work somewhere else.

    After all, we can’t have free riders. People have to learn the value of work.

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  5. 5
    J R in WV says:

    Seems to me that if the Idaho Lege didn’t follow the instructions of the referendum more or less exactly, their new law isn’t legal… so it needs to be unrestricted, not more or less, but strictly unrestricted. So to speak, anyway.

    Or else it isn’t adhering to the successfully passed referendum at all!

    I smell a court case brewing…

    ETA readability.

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  6. 6
    Duane says:

    Thanks for keeping us informed on all these various Medicaid schemes. Republican rule is a cold- hearted way to go.

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  7. 7
    rikyrah says:

    Idaho’s Republican led legislature passed a convoluted Medicaid Expansion this week.

    Idaho’s Republican governor signed the convoluted bill on Tuesday.

    Because, we can’t do what the voters ACTUALLY Wanted…now, can we…

    Uh huh
    Uh huh

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  8. 8
    Brachiator says:

    There is a lot going on in the law that requires significant policy waivers from the federal government. Work requirements are de rigeur and will likely be challenged in court.

    What’s up with this fetish for work requirements? I guess I kinda understand this conservative idea that people should not just get “handouts” from the gummint, but health issues are not things that people can always or easily control, and I think that health care makes it easier for people to get and keep work.

    * I note that I understand the right wing idea about “handouts” but don’t agree with it at all.

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  9. 9
    Kent says:

    @Brachiator:

    What’s up with this fetish for work requirements? I guess I kinda understand this conservative idea that people should not just get “handouts” from the gummint, but health issues are not things that people can always or easily control, and I think that health care makes it easier for people to get and keep work.

    * I note that I understand the right wing idea about “handouts” but don’t agree with it at all.

    It’s a surprisingly popular idea among the the working poor and working class world who frankly live in much closer contact to the non-working poor than most middle and upper class Americans. I got lots of people in my extended family like this. People who work 2-3 jobs, driving trucks, waiting tables, prison guard, roofing and construction work, small-time farming, etc. etc. It is a hard fucking life to live on the working class edge in this country and try to get ahead. To see people who they think are lazing about and scamming the system enrages them. Sometimes it is a racist thing too. But not always. In Appalachia, for example, it’s all white people for the most part. As it is up here in the Pacific Northwest.

    My wife is in healthcare and she gets enraged at all the Medicaid scamming she has to deal with. A popular scam is to get your doctor to sign off on a motorized wheelchair for mobility issues. Then once Medicaid pays for it you turn around and sell it for big $$$. Motorized wheelchairs can go for between $10k and 20k. So she has to deal with these obnoxious 20-something loser assholes who come in demanding that Medicare or Medicaid pay for a motorized wheelchair for the hugely obese diabetic mom who mostly needs to just get off her ass and walk more and start eating better. My wife is a liberal democrat, but when she starts talking about Medicaid she sometimes starts sounding like Trump, honest to God.

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  10. 10
    RW Force says:

    @J R in WV: Idaho law allows the legislature to amend laws passed by referendum. By the way, they’ve also been trying to amend the laws to make citizen referenda difficult, if not impossible. They can’t do away with them as they’re part of the constitution, and would require a vote of the people to abolish.

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  11. 11
    Brachiator says:

    @Kent:

    My wife is in healthcare and she gets enraged at all the Medicaid scamming she has to deal with.

    OK. Makes a certain sense. But I don’t see that a work requirement would solve this problem. Scamming is a job, in a way, being employed in the criminal enterprise industry. And sometimes doctors and other medical folks are involved as well.

    But good points. I had not thought about this angle. Thanks.

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  12. 12
    Kent says:

    @Brachiator:

    OK. Makes a certain sense. But I don’t see that a work requirement would solve this problem. Scamming is a job, in a way, being employed in the criminal enterprise industry. And sometimes doctors and other medical folks are involved as well.

    But good points. I had not thought about this angle. Thanks.

    I don’t agree with work requirements. The rest of the world seems to do just fine with giving everyone a medicare card and going from there with health care being considered a basic right.

    But my larger point is that I don’t think those of us on the left can just write this sort of thing off as gratuitous cruilty on the part of GOP politicians. What they are really doing, I think, is pandering to their rural working class base who likes to see this sort of thing. In much of the country the idle nonworking poor don’t vote for the most part whereas the working poor and working class do tend to vote, or at least vote at much higher rates than the non-working poor who are often completely disengaged. So it is a safe bet for GOP politicians angling for votes in the “Trump working class base” to tout work requirements for government benefits. It is a popular thing to sell and a way to distinguish the GOP from the Dems who “want to give free stuff like “obama phones” to the undeserving and pay for it with your tax dollars”

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  13. 13
    Brachiator says:

    @Kent:

    But my larger point is that I don’t think those of us on the left can just write this sort of thing off as gratuitous cruilty on the part of GOP politicians.

    OK, but it is gratuitous stupidity on the part of the voters in order to get reasonable policy accommodated.

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  14. 14
    prob50 says:

    @Brachiator: Unfortunately there is no law against gratuitous stupidity. In many states gratuitous stupidity almost seems like a prerequisite voting requirement at both the citizen and legislative levels. Any seemingly reasonable policy resulting from it will almost certainly end up creating unpleasant unintended consequences.

    The devil(s) often lay within the details

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