A look at Medicaid expansion and Proposition 2

IDAHO FALLS — One of the hottest debated topics on Idaho’s ballot Tuesday is Medicaid expansion, otherwise known as Proposition 2. Here’s a look at the issue from advocates and critics on both sides.

The central issue around Medicaid expansion is the approximately 62,000 people who fall into a gap of not being able to reasonably afford health insurance. They can’t meet the requirements to qualify for Medicaid and they make more money than is required to get federal tax subsidies for Obamacare.

State legislators have already tried to address the problem this year. Medicaid expansion legislation was introduced to the Idaho Legislature during the 2018 session, where it failed to make it out of committee.

Then, in an attempt to create a solution to the Medicaid gap, without expanding Medicaid, legislators attempted to pass a bill that would have created a federal waiver program, granting access to health care coverage for those in the gap. However, that proposal also failed.

So now Idahoans will get to vote on Medicaid expansion directly, and there are plenty of opinions on the issue.

Prop. 2 advocates claim Medicaid expansion will save lives and help poor individuals in the gap by allowing them access to comprehensive health care. They also claim the proposition will not cost taxpayers any more than what they are already paying in federal taxes.

“It would expand Medicaid by bringing our own federal tax dollars back to Idaho,” said Luke Mayville, co-founder of Reclaim Idaho. “Voting yes on Prop. 2 will bring those tax dollars back home to the tune of $400 million.”

Reclaim Idaho is the statewide organization responsible for filing the Medicaid expansion ballot initiative.

Idaho State Rep. Bryan Zollinger (R-Idaho Falls) is arguing against the expansion. He disagrees with Reclaim Idaho’s numbers and says Medicaid will cost more than $500 million. He said spending that much will only go to increasing the nation’s multi-trillion dollar debt.

“There’s not a pool of money we’re sending to Washington right now sitting there for this purpose,” Zollinger said. “Every dollar that an Idahoan spends on federal taxes — we get $1.30 back already. So all we’re really doing is contributing to the national debt.”

If passed, Idaho’s Medicaid expansion initiative would expand Medicaid to cover anyone under 65 with a household income of up to 133 percent of the federal poverty level.

Understanding the Medicaid Gap

The Medicaid Gap is a group of able-bodied adults under 65 who do not qualify for Medicaid and do not earn enough to qualify for assistance under Idaho’s Affordable Care Act insurance exchange.

Those who currently qualify for Medicaid are children with a household income of up to 138 percent of the federal poverty level, pregnant women with a household income of up to 138 percent of the federal poverty level and parents with dependents with a household income of 24 percent of the federal poverty level.

The federal poverty level for a household of three is a yearly income of $19,515. According to Data USA, around 14 percent of Idaho’s 1.7 million people live at or below the federal poverty level.

Single adults without dependents do not qualify for Medicaid, regardless of income.

The ACA originally required all states to expand Medicaid to include everyone, regardless of marital or parental status, with a household income of 133 percent of the federal poverty level. The requirement was removed from the law in 2012 by the Supreme Court, making Medicaid expansion optional for each state.

Idaho is one of 18 states that have not expanded Medicaid.

People by the numbers

According to Census.gov, on average, the 18 states that have not expanded Medicaid have a 10.4 percent uninsured rate. Idaho is right in the middle with a 10.1 percent uninsured rate. Texas has the highest uninsured rate — 17.3 percent. Wisconsin has the lowest at 5.4 percent.

The states that have expanded Medicaid have an average of 6.4 percent uninsured. Arizona, Nevada and Alaska are the only states, with Medicaid expansion, that have over 10 percent uninsured. Alaska has 13.7 percent uninsured.

The largest group of Idahoans living at or below the poverty level are 18- to 34-year-olds. According to the Henry Kaiser Family Foundation, 2.2 million people fall into the gap nationally.

And the 18- to 34-year-olds make up 45 percent of everyone in the gap. The next largest group are 35- to 54-year-olds, making up 37 percent.

The majority of everyone in the gap, 77 percent, do not have children, and nearly 40 percent are unemployed.

It’s important to note, the Kaiser Foundation found 80 percent of people in the gap reported their health is either good or very good. Only 20 percent reported fair or poor health.

Costs of Medicaid expansion

Medicaid expansion advocates cite the state-funded Milliman report, which estimated Medicaid expansion will cost Idaho $105.1 million over 10 years.

Opponents like Zollinger often look to enrollment and cost overages in expansion states, giving a higher total cost estimate for Medicaid expansion.

The Kaiser Foundation looked at 202 studies on the impact of Medicaid expansion.

From 2014 to 2016, the federal government covered 100 percent of Medicaid spending in states that expanded Medicaid. This resulted in data showing expansion states spent less on Medicaid than non-expansion states.

However, that is expected to change as the federal government scales back its contributions to Medicaid expansion from 100 percent to 95 percent for 2017 to 2019 and down to 90 percent for 2020 on.

The Kaiser Foundation’s analysis said Medicaid expansion may even help to lower state Marketplace premiums. The study found people with an income barely above the federal poverty level made up a large portion of Marketplace enrollees. Expansion states have taken that group out of the Marketplace and put them on Medicaid, lowering Marketplace premiums by up to 7 percent.

However, taking insured individuals and placing them on Medicaid may very well be a factor in what caused expansion states to experience enrollment and cost overages.

One area where expansion states have seen a definitive decrease in costs is in uncompensated care.

Uncompensated care is services provided by hospitals and health care providers that don’t get reimbursed, according to HealthCare.gov. These costs come about when uninsured individuals cannot pay for the care they receive.

Studies have found, in total, expansion states saved $6.2 billion on uncompensated care between 2013 and 2015.

Most research demonstrates that Medicaid expansion has positively affected access to care, utilization of services, the affordability of care, and financial security among the low-income population, according to the Kaiser Foundation.

But ultimately, it will be up to the voters to decide based on the impact to public health and to taxpayers bottom line.