I am a fan of Netflix’s reimagining of the old television show ‘Lost in Space’. The robot is famous for the phrase: “Danger, Will Robinson!” That means some threat is imminent.
There was news late last week that could upend Idaho’s voter-approved Medicaid expansion. On Friday evening the Washington Post broke the story that the Trump administration will deny full federal funding to Utah’s effort to expand Medicaid with state-imposed limitations. Here is the opening paragraph:
The Trump administration will not give Utah or other states generous federal funding to partially expand their Medicaid programs under the Affordable Care Act, funding that Utah hoped to receive after the administration earlier this year authorized the state to move forward on an expansion of the government health insurance program.
The Affordable Care Act gave states the option of expanding Medicare to those with income up to 138% of the poverty level, with the federal government picking up 90% of the tab. Utah voters last fall passed a ballot measure conforming with the federal requirements but the Utah Legislature cut the coverage back to 100% of the poverty level and imposed work requirements. Utah asked for a waiver in order to get the 90% federal match.
With the denial, Utah will only receive 70% of the cost of Medicaid expansion. If the story is accurate (and nothing changes), this means Utah’s policymakers will be required to come up with three times the expected sum for the state match.
According to the Washington Post, the Trump White House has concluded that with its opposition to the Affordable Care Act (currently winding through the courts), they will not grant the full 90% federal funding to states that are not in full compliance with the act’s requirements.
This is serious warning sign to Idaho. Idaho’s Legislature in the most recent session imposed a set of “sideboards”, or deviations from a straight Medicaid expansion.
Governor Little expressed his concern when he signed the measure stating “negotiations with the federal government will be challenging . . . .” He also noted that work requirements might be problematic as the federal courts have struck similar requirements in Arkansas and Kentucky.
The Idaho Department of Insurance on July 15th requested a waiver for the following, based on the Idaho law:
- Work requirements – Would require individuals in the expansion population who are 19-59 years old to be working 20 hours/week or volunteering or enrolled in school to receive Medicaid coverage. Exemptions include mental or physical illness, disability, caring for child/other, tribal members, or receiving substance use disorder treatment.
- Mental illness treatment – Would allow individuals in an institution, with a mental health diagnosis, to receive mental health and substance use services and to bill Medicaid for those services
- Family planning services – Would require individuals seeking family planning services to have a referral from a medical home if the provider is outside established medical home.
- Coverage choice – Would allow individuals with income of 100 to 138 percent of the Federal Poverty Level (FPL) to maintain a tax credit to purchase health insurance on the state-based marketplace or decline the tax credit and choose to enroll in Medicaid.
There is risk that all or most may be struck, either by the Trump Administration or the federal courts. Based on the Utah example, the real danger is that Idaho will only receive 70% of the cost from the federal government.
If so, that opens a Pandora’s box. The legislative measure requires, if the 90% match is not met, for the Idaho Senate and House health & welfare committees to recommend a course of action.
The options would be stark. The Legislature could eliminate the requested waivers and resubmit for approval. Or, they could somehow scrape together the funds at three times the level expected, squeezing critical needs like education and transportation. Most risky would be a vote to set aside expansion altogether, potentially triggering the wrath of voters who backed expansion 61% to 39%.