Medicaid bill advances with work requirements, private insurance carve-out

March 20-- Mar. 20--A House panel on Wednesday sent the latest Medicaid expansion bill in the Idaho Legislature on to the House floor, but without a recommendation to pass it.

The bill -- from Nampa Republican Rep. John Vander Woude -- includes controversial provisions, such as a work requirement. It also requires people who are just above the poverty line to buy private health insurance plans from Idaho's insurance exchange.

The Idaho House Health and Welfare Committee voted to advance the bill after hearing hours of testimony from Idahoans in the Medicaid gap, their advocates and doctors, and health care trade groups who opposed the measure.

The bill includes a requirement for Idahoans to work, or be otherwise occupied (such as people who are going to college or are in work training programs), while they receive Medicaid benefits. Vander Woude's last proposal for Medicaid expansion with sideboards included a work requirement, too, with various groups of people being exempt from the rule.

'Difference of opinion' on Medicaid expansion

Vander Woude said the bill's opponents have a "difference of opinion of what is a good, responsible way of implementing" the expansion, approved by 61 percent of voters under Proposition 2.

He acknowledged concerns about people losing coverage because of work requirements.

Arkansas's Medicaid work requirement has had well-publicized problems, with many people being dropped from the rolls. Vander Woude told the committee Wednesday that he wants Idaho's version to help people get back into the workforce, not to deny them health care.

Vander Woude has told the Idaho Department of Health and Welfare to "make this as easy as possible and as accessible as possible."

Not all health insurance is the same

The requirement for private insurance would apply to people whose incomes are 100 to 138 percent of the federal poverty line. For a single person, that's $14,381 to $19,844 a year.

Idahoans in that income bracket already can buy private insurance on Idaho's exchange. So the proposal by Vander Woude would continue the status quo, instead of moving them onto Medicaid.

Opponents say Vander Woude's proposal will create a new "gap" income level where people would neither get Medicaid nor be able to afford exchange plans.

Vander Woude told the committee Wednesday morning that he sees a lot of good reasons for having those residents buy private insurance instead of Medicaid. For one thing, it would mean their health care providers get paid more instead of Medicaid's low rates.

There are some big, important differences between Medicaid and private insurance sold on Idaho's health insurance exchange.

Medicaid, private insurance don't cover the same things

For people with mental illness, one type of insurance could be much better or worse than the other. Medicaid covers outpatient services, while private insurance doesn't; private insurance covers psychiatric hospitalization, while Medicaid doesn't.

Medicaid covers non-medical services like vision and dental. Private insurance usually doesn't.

Exchange plans can require people to choose between, say, St. Luke's and Saint Alphonsus health systems. Medicaid can't.

They don't cost the same

There's also a financial difference between Medicaid and private insurance that could be significant for Idaho's working poor.

Medicaid generally doesn't have premiums, copays or deductibles. It also doesn't have an out-of-pocket maximum -- the most a patient will have to pay in a year. Private insurance has all of those.

For the plans Vander Woude's carve-out population would probably buy, the premiums range from $17 to $135. (That's based on this year's offerings for a 38-year-old nonsmoker in the Treasure Valley.) They come with special subsidies to make some things cheaper, like copays. But they also have a maximum out-of-pocket obligation of $600 to $1,750 -- as much as 12 percent of the annual income of someone in this group.

Protecting a patient's choice of doctor? Not really.

Vander Woude told the committee Wednesday that one reason for moving people onto the exchange instead of Medicaid is that Idaho doctors don't always take Medicaid. Some of them limit how many Medicaid patients they'll take, he added.

That is accurate. While all Idaho hospitals take Medicaid, not all doctors take it.

But doctors also don't have to take all private insurance -- and, increasingly, neither do clinics and hospitals.

Some private insurance plans sold on the Idaho exchange have "narrow networks" that exclude entire health systems. If you get medical care outside those networks, you're on the hook for much higher bills, such as $200,000 for the year. (A true medical emergency is generally considered "in network" in Idaho.)

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