House recommends Medicaid expansion stay, but with concerns

BOISE — The House Health and Welfare Committee is recommending Medicaid expansion remain in Idaho, although it has “serious concerns” in its five-year review of Medicaid expansion.

The committee finalized its letter addressed to House Speaker Mike Moyle, R-Star, Tuesday morning and it was later read across the House floor. The committee voted 9-3 to approve and send the letter.

The letter said members have concerns over the “unsustainability of the current increased budget request” and made six recommendations for the program, which Idaho voters approved in 2018 and provides coverage to adults who made too much to qualify for traditional Medicaid health coverage but not enough to qualify for subsidies on the state’s health care exchange.

​​For fiscal year 2024, the division of Medicaid is requesting around $67.4 million from the state general fund for the Medicaid expansion program; in fiscal year 2023, spending on the program totaled around $68 million. Although state general fund expenditures are expected to decrease, the overall cost of the program is anticipated to rise through the use of federal and dedicated funding, Idaho Division of Medicaid Administrator Juliet Charron told the committee last week. Charron provided an overall update on the program to both the House and Senate Health and Welfare committees as part of the review, during which she said it's expected there would be higher costs to the state if Medicaid expansion was not in place. 

The committee is recommending the program notify and remove people who aren’t still eligible but have been protected by the program during the public health emergency order by July 1. With the emergency order expiring, around 67,000 expansion participants are expected to be notified that they potentially no longer qualify for coverage and if so they will be unenrolled, Charron said in her presentation.

The process for removing these ineligible participants is expected to be complete by Sept. 1,  Department of Health and Welfare spokesperson Niki Forbing-Orr said, "which is one of the fastest timelines in the nation." 

The department was not allowed to remove anyone from the program unless they moved out of state, requested to be removed, or died, during the emergency order and therefore enrollment was higher than expected.

Notifications of people who may no longer qualify begin Feb. 1.

Rep. Sue Chew, D-Boise, said during the meeting that she’s concerned that accelerating the timeline for finding, notifying and un-enrolling people may lead to mistakes, which come with steep fines, she said. Chew voted against approving the letter.

Committee Chairman John Vander Woude, R-Nampa, said he has talked to the Health and Welfare director about looking into getting outside help for the department to complete that process more quickly.

“My concern is it takes too long and we’re in a fiscal year ending July 1,” Vander Woude said. “… I can’t keep them from making errors, if they make errors then it’s on them, but I do think, to me, there’s an urgency to get this wrapped up and moving forward.”

The recommendations also include submitting a revised budget request that includes the removal of ineligible participants who were previously protected.

Forbing-Orr said the current budget proposal was made with a projected decline in caseload as well as a phased decline in federal matching funds throughout 2023. 

The committee also included submitting a waiver to the federal government, called a 1332 waiver, to allow households with income of 100% to 137% of the federal poverty line the option of either using Medicaid for health coverage or the state health exchange, which was set up through the Affordable Care Act. Section 1332 of the Affordable Care Act allows states to propose unique ways to implement the act, as long as they can prove that residents will have access to health insurance that’s at least as comprehensive as it would be without the waiver, premiums would be at least as affordable, and it wouldn’t cost the federal government more.

Another recommendation is to submit a waiver if necessary to place Medicaid expansion participants on managed care, which is a system to manage cost, utilization and quality of care. Through managed care, enrollees are assigned a primary care physician who is paid a monthly case management fee to coordinate care. 

The Division of Financial Management has also contracted with a consultant to create a report of cost-saving recommendations for Medicaid; an initial report with short-term recommendations was released in December and will provide a full report in April with long-term actions. The agency is reviewing the first set of recommendations, Charron said last week. Some of the cost-saving measures the report recommends include reducing the in-state pay-to-cost ratio of hospital reimbursement for inpatient stays and eliminating the adult dental benefit.

The committee additionally called for a report on the implementation of recommendations in 2024 and another evaluation of the continuation of the program in 2025.

Vander Woude said he anticipates it will be incumbent on the lawmakers to now start drafting legislation that could implement its recommendations.