Medicaid expansion in Idaho likely dead with Trump win

Nov. 10--BOISE -- The election of Donald Trump as president means the likely repeal of the Affordable Care Act and even more doubt about whether lawmakers will expand Medicaid in Idaho in 2017.

"No sense in working on the branches of a problem if the root is going to be pulled up," House Speaker Scott Bedke, R-Oakley, said Wednesday.

"Certainly, I think, it'll have an effect on not only the actions that might be taken, but the attitude of the legislators themselves," said Senate President Pro Tem Brent Hill, R-Rexburg. "Part of the problem all along has been the uncertainty going along with the Affordable Care Act, and this greatly increases that uncertainty."

President-elect Trump has promised to repeal and replace the ACA, and he will enter a Washington, D.C. with the U.S. House and the Senate both controlled by Republicans. The House has voted numerous times to repeal the act over the past few years. And although the Republican majority in the Senate won't be filibuster-proof, the Senate did pass a bill in January 2016 to get rid of the ACA, including defunding both Medicaid expansion and the subsidies to buy insurance on the exchanges, using the budget reconciliation process to get around a filibuster. President Barack Obama vetoed it.

Republicans expanded their super-majority in the Idaho Legislature, going from 28 to 29 out of the state Senate's 35 seats and from 56 to 59 of the 70 in the House.

The political bent of the Magic Valley delegation stayed the same -- two Democrats in District 26, the rest all Republican -- but Democratic losses elsewhere include House Minority Leader John Rusche, D-Lewiston, and Sen. Dan Schmidt, D-Moscow, both doctors and major Medicaid expansion proponents. Schmidt authored the two expansion bills that got a committee hearing for the first time during the 2016 session, and he announced in March he was giving up his state health insurance to protest the Legislature's inaction.

The ACA as originally written envisioned that all states would expand Medicaid eligibility to everyone with incomes at or below 138 percent of the poverty level, but the U.S. Supreme Court struck down the Medicaid expansion mandate in 2012, and it has been debated at the state level since then, with the state-organized Medicaid Redesign Workgroup recommending it and the Democrats in favor but many Republicans opposed.

This year, the state Senate passed a bill to authorize the state to apply for a Medicaid expansion waiver and then adjourned for the year, but the House shot it down the next day. A group of state lawmakers has been studying coverage for people in the "Medicaid gap" -- people who don't qualify either for Medicaid or for tax credits to buy insurance on the state exchange -- over the interim, and its last meeting is scheduled for Nov. 22. However, both Bedke and Hill said Wednesday they expect the Legislature will wait to see what Trump does when lawmakers reconvene in January.

"We'll probably defer long enough to see what alternatives the new administration proposes," Hill said. "I guess, to be more blunt, I would be surprised to see the Legislature take any action until we see what alternatives might be coming from the new administration."

Bedke, too, said lawmakers would be in a "wait and see mode," and that "the approaches that have been pushed forward nationally up to this point, those are going to be non-starters."

"I don't think the issue is going to go away, but the underlying policy that created the problem is," Bedke said.

What could those alternatives look like? Trump has proposed giving states more control over Medicaid by turning it into a block grant to states, letting people deduct insurance costs from their taxes, buy insurance across state lines and expanding health savings accounts. House Speaker Paul Ryan, R-Wisc., came out with a proposal this year that includes some aspects of this, with added elements such as subsidized high-risk pools and keeping a few aspects of the ACA, like letting children stay on their parents' insurance until they turn 26 and letting states that have already expanded Medicaid keep it.

A possible ACA repeal also throws into question the future of Your Health Idaho, the state-run health insurance exchange created in 2013 over the opposition of many Republicans in the Legislature. About 95,000 Idahoans have insurance through the exchange, of whom about 90 percent pay for it with tax credits.

Senate Minority Leader Michelle Stennett, D-Ketchum, said repeal means "we won't be taking care of our people and we won't be taking care of our veterans." According to some estimates, there are 10,000 uninsured veterans in Idaho, of whom 3,800 would be covered by Medicaid expansion.

Stennett said repeal could endanger the coverage of many people who have insurance now and put more costs on hospital emergency rooms and county and state taxpayers.

"The problem doesn't go away," she said. "It just shifts to another place that would have to provide the service."

Stennett also doesn't expect lawmakers to do anything without seeing what Trump is going to do first.

"I just don't see this year (there) being any political will to do anything," she said.

Fred Birnbaum, the vice president of the conservative Idaho Freedom Foundation, wrote an op-ed Wednesday calling on the Legislature to "stand down" on Medicaid expansion, pointing to Rusche's and Schmidt's losses and the national election results. Obamacare defenders, he writes, "did not seem to notice that many self-employed and small business people were being brought to their knees over premium increases" while others were getting free insurance.

"It is fundamentally unfair for the government to force someone, who is working full-time, to purchase a product they may not want or can't afford and turn around to offer another person 'no-cost' health insurance -- even if he or she could afford to pay a small premium," he writes.

Yvonne Ketchum-Ward, CEO of the Idaho Primary Care Association, said repeal could mean millions of Americans lose health coverage, both those covered by the exchanges and those in states that have expanded Medicaid.

"There certainly is concern about the momentum to repeal the Affordable Care Act," she said.

However, she expressed hope that the discussion would continue at the state level in Idaho and that lawmakers will do something.

"The good thing is, I have seen a recognition of the gap population," she said. "Through the last legislative subcommittee, all agreed Idaho has to do something. And that hasn't changed."

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