Repeal or reform: The Idaho Legislature’s plans for Medicaid expansion in 2025

BOISE (Idaho Capital Sun) — For years, Idaho Republican lawmakers have said the rising budget for Idaho’s largest government program, Medicaid, needs to be controlled.

Some think 2025 may finally be the year for big changes in Idaho Medicaid expansion, which made more lower-income earners eligible for the health insurance assistance program.

Idaho voters widely approved the policy in 2018. But many Republican lawmakers say expansion is a key driver behind Medicaid’s budget growth.

Lawmakers expect several bills on Medicaid expansion — ranging from flat-out repeal bills to proposals that would require reform as a condition of expansion to continue — to be introduced in the 2025 legislative session, which starts Jan. 6. 

In the past, those types of bills haven’t advanced far in the Legislature. But significant turnover in the House Health and Welfare Committee — combined with Republicans securing control of the White House and both chambers of the U.S. Congress — may pave a path forward for the bills next year.

“Medicaid expansion will very unlikely look the same as it has in years past,” Rep. Jordan Redman, R-Coeur d’Alene, told the Idaho Capital Sun in an interview.

To Redman, the question is: Is adding sideboards, such as work requirements, to make the program more efficient and accountable the way, “or is a full repeal the only option that we have?”

RELATED | GOP lawmakers set up roadblocks to voter-approved Medicaid expansion (2019)

RELATED | Idaho Republicans have ‘grave concerns’ about Medicaid expansion. What they decided (2023)

“In my meetings with multiple folks in health care, I think they like the thought of having sideboards,” he continued. “And not everyone does, right? … But I know that the current makeup, at least in the House, knows that we need to make some corrections to Medicaid expansion.”

What is Medicaid expansion in Idaho?

Under the Affordable Care Act passed in 2010, the federal government incentivized states to expand Medicaid to a broader range of low-income earners by offering to cover Medicaid expansion policies at a higher federal matching rate of 90%. 

Idaho was one of several holdout states that didn’t expand Medicaid.

Idaho Republican lawmakers have long worried states would be left to pay higher costs for expansion if the federal government reduced its extra pay. 

But in not expanding Medicaid, tens of thousands of Idahoans were left in a medical insurance assistance coverage gap, dubbed the Medicaid gap. People in the gap earned too much to qualify for Medicaid, but too much to qualify for tax subsidies on Idaho’s health insurance marketplace, Your Health Idaho. 

To qualify for subsidies on the exchange, people need to earn at least 138% of the federal poverty level. To qualify for Medicaid before expansion, people could earn up to 100% of the federal poverty level. Medicaid expansion raised that income cap to 138%, closing the gap.

In 2018, after years of stalled legislative efforts to address the Medicaid gap, nearly 61% of Idaho voters approved a ballot initiative to expand Medicaid. 

Since then, support for expansion has risen, public polling from 2023 shows.

But that doesn’t mean the will of the public “will prevail,” Idaho House Minority Leader Ilana Rubel, D-Boise, told the Sun in an interview.

“I’m concerned that the Republican politicians in there might be more concerned with catering to an extremist fringe, than they are to catering to the clearly expressed wish of the majority of Idahoans,” she said. 

Why Idaho Republicans worry about Medicaid’s budget

Idaho Medicaid expansion took effect in 2020. Many Republican Idaho lawmakers say Medicaid expansion has been much more expensive than initially expected, and is straining the state’s budget.

“Budget wise, it was sold to the public that it’s going to cost $400 million, and it’s at $1.1 billion right now,” Idaho House Health and Welfare Committee chairman John Vander Woude, R-Nampa, told the Sun in an interview. “… We’re going to try to have to rein some of that in. Because even even 10% of that is $110 million to the state”

In 2019, before Medicaid expansion, Idaho Medicaid’s total budget was almost $2.5 billion, including $1.6 billion in federal dollars and about $880 million in state dollars. For next fiscal year, which starts in July 2025, the Idaho Department of Health and Welfare requested $5.3 billion — including $3.5 billion in federal funds and $1.8 billion in state funds.

Some health policy advocates say a closer look at the state budget shows Medicaid has actually had steady budget growth and Idaho’s expansion has saved state spending in other areas, like for the state’s prison system, mental health services, the courts and state financial aid services for indigent health care. 

And expansion has saved lives, advocates say.

“Idaho voters know what they voted for. They were voting to close the health coverage gap for their families, for their neighbors who didn’t have any other option and would be uninsured without it,” Hillarie Hagen, senior policy associate at Idaho Voices for Children, told the Sun in an interview. 

House Speaker Mike Moyle, R-Star, said if the Medicaid budget isn’t controlled, it could mean less funds for other areas — like education and tax relief. And he says the rising Medicaid budget isn’t just affecting Idaho.

He said he worries that since the “federal government can’t afford all this stuff either, they’re going to get to a point where they’re going to try to shift those costs up on the state.”

If the federal government cut its extra Medicaid expansion funding, over three million adults could immediately lose their health care coverage because of Medicaid-expansion repeal trigger laws in nine states, KFF Health News reported. 

Idaho isn’t among those states. But Idaho is one of three states that has a law that would require mitigating financial impacts of losing Medicaid expansion funds, the health news outlet reported.

And since potential congressional federal funding cuts to Medicaid expansion would leave state legislatures to cover more costs, policies in all states would be at risk, University of Michigan’s School of Public Health associate professor Renuka Tipirneni told KFF Health News. 

Medicaid expansion reform-or-repeal bill likely to return

In 2024, the House Health and Welfare Committee narrowly voted to hold a bill that would’ve required a range of reform to avoid repealing Medicaid expansion. 

The move came after wide opposition from doctors, patients and health care representatives, many of whom saw the proposal as an expansion repeal with more steps. 

Five Idaho Republican state lawmakers joined three Democrats in voting to hold the bill in committee, preventing a full Idaho House floor vote.

But after the 2024 elections saw more than a dozen incumbent lawmakers unseated, two of those Republicans and two Democrats are no longer serving in the Legislature.

The committee is also short one Democrat seat, down to just two. 

Redman, who’s returning to the committee, sponsored the repeal-or-reform bill in 2024. Next year, he expects the Legislature will consider a similar bill.

Redman says he favors reforming Medicaid expansion by adding sideboards like work requirements and reducing improper payment rates rather than outright repealing expansion.

“There’s a worry that expansion has gone off the rails a little bit,” Redman said. “And so there’s probably a large amount of the group that would look to repeal expansion. … I actually think if we just had sideboards on it, it actually benefits the state more. Because if we have these sideboards that can be adhered to, it actually saves the state more money to keep expansion.”

Vander Woude and Redman said they think the GOP winning control of both chambers of Congress and the White House means modifications to Medicaid, like adding work requirements, are more likely to get required federal approval. 

Moyle, the House speaker, expanded the House Health and Welfare Committee from 13 seats to 15 members. That’s because more lawmakers expressed interest in serving on the committee, partly to get involved in Medicaid policy, he told the Sun in an interview. 

“A lot of legislators, especially new ones coming in, realize that this is a burden on the state that has to be addressed in a way that we take care of the needs of the citizens. But at the same time, we don’t break the state,” Moyle said. 

Vander Woude said the committee has only had 13 members in the 12 years he’s served on it.

At least eight of the 15 Idaho House Health and Welfare Committee members have pledged support for the Idaho Republican Party’s platform, which calls for a repeal of the federal Affordable Care Act that created Medicaid expansion.

How has the Idaho House Health and Welfare Committee changed?

Four former Idaho House Health and Welfare Committee members — two Democrat and two Republican state lawmakers — who opposed advancing the 2024 bill that many said would’ve likely repealed Medicaid expansion no longer serve in the Legislature. 

Three of those former committee members lost re-election bids: Rep. Megan Blanksma, R-Hammett, lost in the GOP primary election. So did Rep. Chenele Dixon, R-Kimberly. Democrat Rep. Nate Roberts, from Pocatello, lost the general election in November. Former Rep. Sue Chew, D-Boise, died in April; Rep. Megan Egbert, D-Boise, won Chew’s legislative seat and will serve on the committee.

But three lawmakers who supported advancing the bill to the Idaho House are also not on the committee now. 

Former Rep. Mike Kingsley, R-Lewiston, and Idaho Freedom Caucus member, didn’t seek re-election, the Lewiston Tribune reported. Rep. Jacyn Gallagher, R-Weiser, and also an Idaho Freedom Caucus member, lost in the May GOP primary. Rep. Brandon Mitchell, R-Moscow, won his re-election bid but was not placed on the House Health and Welfare Committee. He is now vice chair of the House Transportation and Defense Committee, and serves on the appropriations committee. 

As incumbents lose re-election, House Health and Welfare Committee welcomes new faces

The committee now has seven lawmakers serving their first terms in the Legislature, and one lawmaker who previously served in the statehouse but not on the committee itself. 

Moyle said he isn’t sure how the committee would vote on new Medicaid expansion repeal bills.

But Rubel, the House Democrat leader, said she expects a reform-or-repeal bill like this year’s would probably advance to the floor.

She said she hasn’t seen specifics of bills planned, but if it looks like last year’s reform-or-repeal bill, she said she’d “bet heavily that a bill like that would pass” the committee under its new membership.

“It has a far lower composition of mainstream Republicans and Democrats than it had last year, which was really the coalition that defeated the bill. And it’s predominantly at this point those who align more closely with the (Idaho) Freedom Foundation and with the current version of the Idaho Republican (Party) platform, which calls for total repeal of the Affordable Care Act,” Rubel told the Sun.

Redman said it was hard to say how new Medicaid expansion reform or repeal bills would fare. But the committee’s membership changes show promise, he said.

“I believe there’s probably a path forward there. It’s going to be a matter of meeting with the different members, educating on the subject, and trying to see if we can build consensus to move something forward,” he said. 

Medicaid costs are up, but program’s impact on state budget is complex, advocates say

Health policy advocates say determining Medicaid expansion’s impact on the state budget is complicated — but shows steady budget growth and savings.

“When you take into consideration the ongoing state savings programs from Medicaid expansion, state investments are minimal while having a significant positive impact on access to health care to working Idahoans who don’t have any other options without Medicaid expansion,” Hagen said. 

While Idaho Medicaid state general fund expenditures rose nearly 15% since fiscal year 2020 — by nearly $100 million, Medicaid’s average year over year budget increase on the state general fund is 3.2% from fiscal year 2019 to Idaho’s fiscal year 2024. That’s according to a report by Idaho Voices for Children. 

Idahoans on expansion policies are lower utilizers of Medicaid, compared to other populations covered, the report also found. 

Expansion policies make up 32% of Idaho’s Medicaid enrollment, or around 90,000 people recently, but account for 25% of Medicaid expenditures, the report found. Meanwhile, adults dually enrolled in Medicaid and Medicare account for 26% of expenditures but just 7% of Medicaid enrollment. 

Idahoans spend nine months, on average, on Medicaid expansion, according to the report. A quarter of Idahoans on Medicaid expansion have a serious mental illness.

The cost of prescription drugs has been a major driver for Idaho Medicaid’s budget growth, particularly expensive drugs for difficult-to-treat conditions, the Idaho Capital Sun previously reported.

Hagen says she’s optimistic that Idaho lawmakers will see the value of Medicaid expansion.

Randy Johnson, Idaho government relations director for the American Cancer Society Cancer Action Network, said Idaho Medicaid is working.

“It’s hard to say exactly where we’re at and what’s going to happen. But what we know is when people are covered — when people have health insurance— they’re able to get vital screenings, like cancer screenings, or they’re able to get care. And if they can get screenings earlier, cancer outcomes are better,” Johnson told the Sun in an interview.

“Can it be better? Absolutely,” he said of Medicaid. “So how can we get to that point, rather than just deleting the entire system?”

Rubel thinks repeal bills can be stopped “if that silent majority speaks up.”

“We can stop this effort. But if people stay home and don’t say anything, then I think we’re in a world where 100,000-odd people are going to lose their health care,” she said. 

Idaho Capital Sun is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Idaho Capital Sun maintains editorial independence. Contact Editor Christina Lords for questions: info@idahocapitalsun.com.