President Barack Obama's health care overhaul envisioned adding many low-income singles, among others, to the program, but the U.S. Supreme Court left the final decision up to states.
Gov. C.L. "Butch" Otter told reporters at the Capitol in Boise during The Associated Press's legislative preview that expanding Medicaid without revamping the government-backed health care system for low-income, elderly and disabled people wasn't acceptable. Proposed changes he seeks include a system in which payments go to health care providers based on treatment outcomes, not just services provided, as well as boosting co-pays to penalize people who don't follow doctors' orders, including losing weight when instructed to do so.
"It doesn't do any good if you're just paying for every time a patient crosses that threshold," Otter said. "I want to see better outcomes."
While likely relegating Medicaid expansion to beyond 2014, Otter indicated he favors investigating what Arkansas has done with additional federal money to help poor people buy private insurance. He hinted he may address the topic Monday during his State of the State speech, to kick off the coming session.
Tom Shanahan, a spokesman for state Department of Health and Welfare Director Dick Armstrong, said Idaho worked last year to get "verbal approval" from the U.S. Department of Health and Human Services to deviate from existing Medicaid programs for newly covered residents, to help meet Otter's goals.
But the state would have to actually agree to expand Medicaid before seeking a formal waiver, Shanahan said. That's unlikely to happen soon, he said, since expansion discussions have largely ended.
"Unless the state says it's going to do it, we really can't apply," Shanahan said Friday.
By eschewing expansion along with 25 largely Republican-led states, some 54,780 Idaho residents will fall into this gap: They'll be eligible neither for Medicaid coverage nor tax subsidies to help them pay for insurance plans sold via the Your Health Idaho exchange, another key provision of Obama's 2010 health care law.
Democrats, including House Minority Leader John Rusche of Lewiston, are pushing expanding Medicaid to cover people up to 138 percent of the federal poverty line, on grounds it will save Idaho counties hundreds of millions over the next decade that they would otherwise spend on Idaho's existing county- and state-financed Catastrophic Health Care program that covers medical bills for indigent people. That program could be eliminated, with the federal government covering the cost of Medicaid expansion that would replace it.
At Friday's event, Rusche labeled the GOP's refusal to expand Medicaid as "fiscally irresponsible" and a sign the issue has fallen victim to May 2014 primary election politics: Republicans still smarting from a bruising 15 hours of debate last session over a state-based health insurance exchange don't relish repeating such a divisive exercise over Medicaid expansion, especially just before facing conservative voters for whom Obama's law is unpopular.
"I said at the end of the last session that if we didn't deal with it last year, we wouldn't deal with it this year, because it's an election year," said Rusche, a former pediatrician and health insurance executive. "And I still stand by that statement."
Senate President Pro Tem Brent Hill, R-Rexburg, countered that merely considering the savings Rusche expects Idaho to reap from Medicaid expansion ignores broader costs to a federal government already running big budget deficits.
"I'm an accountant, I like numbers," Hill said. "We're sitting on top of a $16 or $17 trillion dollar debt right now that some of us think is a problem."
House Speaker Scott Bedke, R-Oakley, suggested even if he wanted to expand Medicaid, he didn't have the votes in his GOP caucus.
"I temper my response with what I think we can do as a Legislature or what I have votes to move," he said.