Idaho Republicans might push through work requirement tied to Medicaid expansion

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 Republican 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 Monday that federal regulators expressed some openness to a work policy. Asked how likely federal approval for an Idaho work policy would be, Adams said he wouldn’t forecast the Biden administration’s actions.

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

If Idaho’s work requirement takes effect, it would be the second one in the U.S.

Georgia is the only state to implement work requirements for its Medicaid program. While Politico reported 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 have enrolled.

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 The Biden administration rescinded the approvals.

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

After Idaho voters approved Medicaid expansion through a ballot initiative in 2019 — following years of inaction from the Legislature — Little signed legislation that would have created work requirements. Federal regulators 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 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 approved the Medicaid budget by just one vote, with Republicans saying they were worried about the program’s rising costs.

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 last 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 rein that in.

“If we don’t, 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 by voters, to include a broader range of low-income earners. Idaho’s rolls grew by more than 100,000 people during 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 said last week that the changes will drive up the cost of Medicaid by $50 million.

The federal government is set to pay $3.6 billion of Idaho’s Medicaid’s total budget under Little’s proposed budget, meaning the state’s cost is about $1.1 billion.

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

The Medicaid budget — often criticized by Idaho Republicans 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 overscrutinize, 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 collects only 2% of funds to administer services, while the rest of funds go toward services, Necochea said last 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

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 was plus or minus 4%.

Seventy-three percent of respondents said Medicaid expansion should be kept the same — 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 welfare for able-bodied workers who just won’t work. Only 14% of people polled — including 18% of Republicans — said Medicaid is mostly welfare for able-bodied workers who refuse to work.

Seventy-five percent of Idahoans — 69% of Republicans, 81% of independents, 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. 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, approved by 61% of voters 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.

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 Corrections, 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 the program’s 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 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 Van Orden, a Republican from Pingree, told the Sun on Friday.