Idaho might require Medicaid expansion population to work through new policy proposal

Idaho will attempt to require people who receive Medicaid through expanded access to work in order to receive insurance.

Details on the new proposed policy, announced Monday, were slim. Idaho Gov. Brad Little — who addressed Idahoans through his State of the State address as the Legislature began its 2024 session on Monday — did not address the new policy proposal in his speech, themed “Idaho Works.”

But, budget highlights his office released Monday show Idaho would pursue a work requirement for the Medicaid expansion population.

Little’s budget chief Alex Adams told reporters on Monday that federal regulators expressed some openness to a work policy. But, asked how likely federal approval for Idaho’s policy is, Adams said he wouldn’t forecast the Biden administration’s actions — or who would win the 2024 presidential election.

The Idaho Department of Health and Welfare could not be immediately reached for comment.

If Idaho’s work requirement takes effect, it’d be the second Medicaid work requirement still existing in the U.S.

Georgia is the only state to implement work requirements for its Medicaid program. While Politico reports that Georgia Republican Gov. Brian Kemp expected 31,000 Georgians to enroll in the first year of the program, which started in July, state records from last month show that only 2,344 Georgians have enrolled.

Under the Trump administration, the Centers for Medicare and Medicaid Services — which oversees Medicaid — approved work requirements in 13 states, Politico reports. The Biden administration rescinded the approvals, Politico reports.

The Medicaid work requirement is philosophical for the governor, not about cost savings, Adams, told reporters before Little’s speech Monday. But the budget for Idaho Medicaid — funded mostly by the federal government — is bound to be a top issue for Idaho lawmakers this legislative session.

Little in 2019 — after Idaho voters approved Medicaid expansion through a ballot initiative — signed legislation that would’ve created work requirements for Medicaid. Federal regulators still say that request for a waiver is still pending.

Democratic legislative leaders on Monday said they opposed the Medicaid work requirements, pointing to Idaho’s past attempt to implement such rules, which Idaho House Minority Leader Ilana Rubel said the federal government rejected.

“Basically, you have to be living on about $16,000 a year for Medicaid expansion. There are not a lot of people living at that level of poverty voluntarily,” Rubel said.

Idaho lawmakers brace for Medicaid budget battles

Legislators last year — worried about Medicaid’s rising costs — approved the Medicaid budget by just one vote.

Little’s budget, unveiled Monday, would put $4.7 billion of combined state and federal tax dollars toward the Medicaid budget — keeping the program at its same spending level.

“One of the things we didn’t move the ball on enough was Medicaid,” Idaho House Speaker Mike Moyle, a Republican, told reporters Thursday in an event previewing the legislative session. “We’ve got an issue there. The costs keep going up. We’ve got to figure out how to reign that in.”

And there’d be consequences if it isn’t addressed, he said.

“If we don’t,” Moyle said, “it could have an impact on education and other issues.”

This year, the Idaho Department of Health and Welfare requested funds to support 60 more staffers, saying in its budget request that Medicaid struggled to handle day-to-day operations at current staffing levels. The department requested funds to boost reimbursements to providers of direct care services, which a watchdog report earlier this year found was in crisis.

Idaho expanded Medicaid in 2020, as approved in a 2018 vote by voters, to include a broader range of low-income earners. Idaho Medicaid grew by more than 100,000 people during Medicaid expansion, the program’s director previously told the Sun. Meanwhile, Medicaid in 2022 had 17 fewer employees than it did in 2009, a watchdog report by the Office of Performance Evaluations found.

The federal government is planning to pay less for Idaho’s Medicaid program than in other years. Moyle, a Star Republican, said last week that the changes will drive up the cost of Medicaid by $50 million, and said the Medicaid program is “already drawing resources away from public schools and road and public safety.”

The federal government is set to pay $3.6 billion of Idaho’s Medicaid’s total budget, under Little’s proposed budget released Monday.

Idaho Senate Minority Leader Melissa Wintrow, a Boise Democrat, struck a different tone.

The Medicaid budget — often criticized by Idaho Republican lawmakers as growing uncontrollably — has stabilized, Wintrow said Thursday. And Idaho had reverted $300 million back to the federal government during the pandemic years earlier, she pointed out.

“You hear the vigor in my voice — the Medicaid program is the most efficient and effective way to get access to quality care for our citizens,” Wintrow said. “It does need more staffing. We have to stop starving government agencies like this department. We over scrutinize, we overestimate on what they can do.”

House Assistant Minority Leader Lauren Necochea, a Boise Democrat, called Medicaid a lean, efficient program. The Medicaid program only collects 2% of funds to administer services, while the rest of funds go toward services, Necochea said Thursday.

“I think better running the program can help us get better outcomes,” Necochea said.

Necochea said Idahoans want a strong Medicaid program they can rely on, whether they’re children, pregnant mothers or Idahoans with disabilities.

“We need to make the math work for them,” she said.

Idahoans want Medicaid expansion kept as is, poll suggests

Four years after Idaho expanded Medicaid, voters largely think Medicaid expansion should be kept as-is and that Idaho needs to spend more money on schools without cutting Medicaid, independent polling shared with the Idaho Capital Sun on Monday found.

The poll, conducted July 10-16 by Boise-based public opinion research firm GS Strategy, surveyed 600 likely voters, including an oversample of 100 Republican voters. The poll’s margin of error is plus or minus 4%.

Seventy-three percent of respondents said Medicaid expansion should be kept as is — including 65% of Republicans, 93% of Democrats and 78% of independents polled. About 74% of respondents said Medicaid is mostly helping low-income Idahoans, children and seniors who need it, as opposed to offering mostly welfare for able-bodied workers who just won’t work. Only 14% of people polled — including 18% of Republicans — said they say Medicaid is mostly welfare for able-bodied workers who just won’t work.

Seventy-five percent of Idahoans — including 69% of Republicans, 81% of independents and 91% of Democrats — said they had a favorable opinion of Medicaid. Thirty-one percent of respondents said they were not sure Medicaid was working well — compared to 26% who said Medicaid was working well and 44% who said they were not sure whether the program was working well. Eighty-seven percent of respondents — including 84% of Republicans — agreed that it is important for Idaho to have a strong, sustainable Medicaid program.

Most respondents — 81% — said they believe the government should help some people who, because of poverty or disabilities, need help obtaining and paying for health care. Sixty-seven percent said they support the results of Medicaid expansion. Idaho voters approved Medicaid expansion by 61% in a 2018 ballot initiative.

Idahoans said they don’t want more support for schools – a top priority for Little — to come at the expense of Medicaid funds. Sixty-four percent of respondents also said Idaho needs to spend more money on schools without cutting Medicaid. 13% of respondents said Idaho should spend more on schools by cutting from Medicaid, while 16% said the state spends enough on schools.

Idaho has saved $26 million since Medicaid expansion, a new network of organizations called Idaho Supports Medicaid said in a separate report, pointing to savings in the Idaho Department of Correction, behavioral health and indigent health care funds that exceed the state’s spending this fiscal year on Medicaid expansion.

“Not only is Medicaid expansion saving lives, it’s saving the state a significant amount of money,” Hillarie Hagen, senior policy associate for Idaho Voices for Children, said in the news release. “Idaho voters, health providers, and community organizations all see Medicaid as a worthy program, important to the health of our families, and an economically beneficial investment.”

Idahoans on Medicaid expansion account for 26% of Medicaid accounts, but only 8% of Idaho’s Medicaid general fund costs, the organization’s report shows.

One third of the Medicaid expansion population are Idahoans with a serious mental illness, Idaho Supports Medicaid, a new coalition of groups, said in a news release on Monday.

Expect the debate over managed care to continue

Idaho lawmakers on a task force that met while the Legislature was out of session just wrapped up a close look at how Medicaid funding is structured.

Private companies manage Medicaid benefits in 40 states. That structure is commonly called managed care. Managed care organizations deliver care to over two-thirds of everyone on Medicaid in America, KFF reports.

Some of Idaho’s Medicaid benefits are managed that way, such as mental health care, dental care and non-emergency medical transportation. But inpatient and outpatient hospital services are run by medical providers through a model that Idaho policymakers call “value-based care.”

The panel of Idaho lawmakers late this year studied how to save money on Medicaid, possibly through switching Idaho’s Medicaid programs to managed care. That group concluded its work last month without deciding whether Idaho’s Medicaid program should be restructured.

That task force’s recommendations passed some work on to legislators to continue, like looking into Medicaid contracts and setting benchmarks for those contracts.

“There’s an appetite out there to do something, “ Idaho Sen. Julie VanOrden, a Republican from Pingree, told the Sun on Friday.

That’s why the Legislature assembled the task force, she said, “and why we’re starting down a road of doing some incremental things to address the concerns that people have. Because it was pretty evident, blowing up the whole thing and starting over wasn’t going to be an option.”

But she doesn’t think the Legislature would approve another $4 billion budget for Medicaid again. The Joint Finance-Appropriations Committee is set to hold a hearing on Medicaid on March 7 — about three weeks before legislators hope to adjourn. VanOrden worries that cuts to the program might not do enough to stave off concerns over the programs’ budget.

“It might give people reason to run legislation to do away with Medicaid expansion,” she said — which she assured at the Medicaid Managed Care Task Force’s final meeting in November was not the goal of policymakers.

Whenever there’s talk about limiting access to care, Randy Johnson, the Idaho government relations director for the American Cancer Society, is worried. If cancer patients get regular treatments and visits, cancer is caught earlier, helping drive down costs, Johnson said.

“That’s our biggest concern, making sure that where you live and how much you make doesn’t determine whether you live,” Johnson told the Sun on Friday.