The potential for change in health care is great and the future uncertain, said Richard Armstrong, director of the state Department of Health and Welfare. But he finds himself hopeful rather than pessimistic.
“I actually feel fairly optimistic — some people think I’m crazy — but I’m optimistic that we’re ready to start making some significant changes that will be good for all of us,” Armstrong told the Statesman editorial board. “It’s going to be a bumpy road. I didn’t say it’s going to be easy.”
Armstrong said it’s not clear what a Trump administration and the Republican-controlled Congress actually will do, given the president-elect’s conflicting statements on health care changes. Among his best guesses:
▪ Your Health Idaho, the state exchange created under the 2010 Affordable Care Act, will continue to operate.
▪ Medicaid expansion never will happen in Idaho, but the program will continue in states where it exists.
▪ A legislative committee will propose, and the Legislature will adopt, some lesser, state-funded option to address care for uninsured Idahoans, but it won’t meet the needs of all 78,000 in the so-called gap group.
▪ Obamacare will change and get a new name. What it will become, and how long that will take, is anyone’s guess.
Regarding Medicaid expansion in Idaho, a hot topic the past four years, Armstrong said: “If you think about the votes necessary to pass an ACA-related bill, it’s more remote than ever. Furthermore, (lawmakers) get a free pass because of all of the rhetoric around repeal and replace — which now ... we’re already hearing, ‘Well, maybe we’ll just get rid of the things we don’t like and keep the things we like,’ which is more logical. ... So I would say that this Legislature will say there’s no reason to talk about Medicaid expansion or anything to do with ACA because we don’t know what it will look like. We don’t know what it will be.”
Following are excerpts from the 75-minute meeting, edited for clarity.
Q: Has there been any talk about getting rid of the state exchange?
No. I have heard none of it. The state exchange has been working very well.
Q: Is there going to be a state solution for the gap group?
The problem is still there. The good news is that (legislative) committee has universally acknowledged that it’s a problem, which is progress. They know it’s not going to go away. They want an Idaho solution. ...
Now if it is as basic as the Primary Care Access Program, that’s fine. At least they’re doing something to improve the quality of life of those individuals that don’t have the financial resources to have insurance. So that’s a responsible thing to do, and I don’t think the election allows them to stand down on that issue, because the gap is not going to be filled with anything that we’ve seen out of the election. ...
Trump (has said) he was going to use Medicaid as the solution for low-income folks. ... We have heard talk about block grants to Medicaid. ... The challenge with a block grant with Medicaid is that today, we don’t have an upper limit to the amount of money that we can pull down from the federal government to meet the need. A block grant means that you get a fixed amount of money, and generally speaking, the obligations don’t change, so it becomes a much more challenging problem for states to manage.
Q: If it came as a block grant, would Idaho get the money it hasn’t been getting because it didn’t apply for Medicaid expansion?
I don’t know what the terms of engagement would be. It would seem unlikely that a block grant would be based on a national formula. They tend to look at what you’re doing locally, and what you’ve been spending locally, and then just reconstitute what you’re already spending. ... It’s way early (to know), and I think it’s years out.
We’re all in that same predicament of not knowing what might happen. It will be incremental, whatever happens.
Q: So what do we do between now and then?
I think we look at this (legislative) committee and say, what are you going to do within the state of Idaho using state dollars to improve the lives of these individuals? ... I think they feel an obligation to do something. It certainly won’t be using federal money.
Q: What do you think the forecast is for health insurance in Idaho? What are the scenarios out there?
I think the insurance exchange will probably stay in place because it’s a tax credit, and everything that we’ve seen favors tax credit concepts. ... As far as reforming the ACA, I think they’ll have the ability to adjust it (in Washington) because you’ve got the Republican control. So some adjustment could be made. And I would say that that’ll keep the current level of enrollment in Medicaid nationwide. Unfortunately, I don’t think it really opens a door for us (to expand coverage via Medicaid).
Q: What do you see now in the next four or five years in terms of health care inflation?
I can only speak to Medicaid. Our per-member-per-month numbers — the full enrollment divided by the cost — have been relatively flat over five years. Private insurance by and large has increased in excess of 30 percent over that five-year period. Now why is that? We’ve deployed a series of managed care concepts within the Medicaid population. ...
This notion of skin in the game, I think, is kind of mean-spirited.
Q: Trump has been talking about allowing insurance companies to operate across state lines. If that happens, what are the implications?
I never understood that statement at all. It makes no sense to me. It’s the silliest argument I’ve ever heard. Think about it: Insurance is regulated by the states. Is he suggesting that we’re going to federalize health insurance? It doesn’t seem like a GOP principle to me. ...
Idaho health care costs are lower than in other states. Now, do you think we want to allow people from California, living in California, to buy a product based on Idaho costs when they’re not going to use the Idaho hospitals? No. ... You cannot afford to sell an Idaho rate to somebody living in New York and think that your rates are going to stay put. They won’t. They’ll migrate completely through the roof and then Idaho will look just like those other states.
Q: What does a replaced Obamacare look like? What survives, what doesn’t survive? And is it in phases? What do you expect?
I have not a clue. Everybody that uses that language never provides any detail as to what the replacement product is. They dance around and say it’s going be wonderful, it’s going to be less expensive — oh, a Health Savings Account. Well, we’ve been doing Health Savings Accounts in Idaho for 15 years. It hasn’t amounted to anything. The only people that buy them are the wealthy people who have a lot of assets to protect and buy a huge deductible. It doesn’t do anything for the person that has no money.
Q: What are some of the options then that are going to come in to replace it?
Part of ACA was essential health benefits. That’s really pretty generous. … That was a blow to being able to design products with lower prices because you weren’t able to segregate out certain services and have (the consumer) decide. ... So if they repealed ACA, then I would assume that we could start seeing benefits vary dramatically, and we’d start maybe skinnying down the benefits package to get a lower price.
(Armstrong told the Statesman that kind of change would force consumers to be more educated about what plans offer and which one they choose.) I think it’s been difficult for all of us to understand what the repeal and replace actually means. My guess is the replace will be something that has a lot of features that we’ve seen before, but it will be described differently. ... It’ll be called something else.
Charity is important. But it hasn’t been growing. I don’t know where this flood of new philanthropy’s coming from. We look at household income in Idaho and it’s been flat for the last 10 years.
Q: Does charity play a role, where they can come to the rescue for the people in the gap?
Charity is important. ... But it hasn’t been growing. I’ve talked to a number of charitable organizations about what their state of affairs is and they’re always on the ragged edge of being able to meet the current needs with the contributions they have. I don’t know where this flood of new philanthropy’s coming from. ... Every one of the proposals using a charitable approach, when we’ve studied it, we’ve found that it only handles just this little handful of people. ... I just think it’s an interesting idea that isn’t based in reality.
Q: Who’s leading the advocacy for this?
Well, it’s the folks that don’t like government: If you don’t want government to do it, well, then get the private sector to do it. But charity only happens when there’s surplus that can be given and given freely. And we look at household income in Idaho and it’s been flat for the last 10 years, and I don’t see it changing much. ... In order for health care to work, there has to be sustainable, predictable funding.
This legislature will say there’s no reason to talk about Medicaid expansion or anything to do with ACA because we don’t know what it will look like.