As the 2018 election season kicks into high gear across the country, lawmakers in some red states find themselves at odds over how to grapple with continually rising premiums, large swaths of low-income uninsured and overall insurance market instability.
Nowhere is that more evident than in Idaho. The state nabbed headlines by asking carriers to use "creativity" in designing plans for the exchanges—including going outside the essential health benefit criteria set by the Affordable Care Act.
The state's so-called super-waiver—a merged 1332-1115 deal—aims to let people at poverty level qualify for exchange subsidies while using Medicaid as a high risk pool for expensive care. The controversial plan has pitted Republicans against Republicans.
The state Legislature must approve the waiver before it can be submitted to the CMS, but policymakers are in gridlock even though the measure has become a key campaign issue for Lt. Gov. Brad Little, who is seeking the gubernatorial seat this year since sitting GOP Gov. Butch Otter is term-limited out.
"What's really happening right now is just politics," state Rep. Bryan Zollinger, a conservative Republican who opposes the measure, told Modern Healthcare.
Leadership and Otter are afraid they don't have the votes to pass the bill, Zollinger said.
"People are frantically counting votes and trying to sway people," Zollinger said, adding that he thinks the vote won't happen until March 9 or after—which incidentally is the filing deadline for the state primaries. This potential delay indicates a reluctance on the part of state policymakers to go on record with a vote in case it would generate a primary challenge.
"We know those running for election are focused on wanting to get back in, and I don't blame them; so if it helps them to put it off until they have an opportunity, that's fine with us," said Dean Cameron, director of the state's insurance department.
The delays and inter-party controversy has healthcare stakeholders on edge.
"Getting this waiver passed is by no means a sure thing," said Jim Baugh of Disability Rights Idaho. "If it does pass, it will be close."
Similar to the national debate, the controversy essentially boils down to Medicaid. The measure is projected to expand coverage for about 35,000 of the roughly 68,000 uninsured Idahoans.
As Yvonne Ketchum-Ward, CEO of the Idaho Primary Care Association, put it: "There's something in it for everyone to love and everyone to hate."
Ketchum-Ward said the controversy lies with the waiver's use of Medicaid to siphon off the most expensive patients from the insurance risk pool. Idaho would move people with complex chronic conditions including stage 4 cancer, auto-immune diseases and hemophilia to Medicaid. The conditions were selected "strictly based on how much they are costing insurance companies," Baugh said.
Officials estimate about 2,500 to 3,500 people would move to Medicaid coverage, and it would reduce the private carriers' claims cost by about $200 million.
This is where they lost Zollinger and other conservatives.
"I have heard a full range of concerns, and philosophical concerns of people who can pay for their own insurance and don't want to get pushed to Medicaid," Zollinger said.
He said he's spoken to people who are also scared of Medicaid coverage, uncertain whether they can keep their doctors or whether all the medications they need would be covered.
But Cameron pushed back. He said patients would not be forced to go on Medicaid, and Medicaid might actually be the better option as the program has a wider provider network. He noted that the biggest industry push against the idea comes from pharmaceutical companies that provide high-cost biologics to these patients and don't want the lower Medicaid rebate.
"If the hard right wants to support the pharmaceutical industry, that's their choice," Cameron said.
Also complicating the issue is the growing grassroots push to put Medicaid expansion on the ballot, called Medicaid for Idaho.
All stakeholders who spoke to Modern Healthcare for this story described expansion as the best option even though they doubted it would ever pass in Idaho.
"We choose to see the glass half full," Idaho Hospital Association CEO Brian Whitlock said of the dual waiver. "The Idaho Legislature has been resistant to full Medicaid expansion, but we see the dual waiver as an opportunity to lower premiums on the exchange, take care of some of the sickest, most medically complex Idahoans and allow working Idahoans the opportunity to purchase subsidized coverage."
Still, the grass-roots effort for Medicaid expansion is gaining momentum, and the Medicaid for Idaho campaigners are optimistic they can get their measure on the ballot for the upcoming November election, citing a Boise State University survey that says 70% of Idahoans "favor legislative action to close the Medicaid gap."
"Our state lawmakers have balked at the idea of Medicaid expansion, but the vast majority of Idaho voters say they are disappointed with the failure of the Idaho Legislature to address the Medicaid issue," the group's website states.
The next few weeks however will show whether the Legislature will pass the dual waiver as the first step toward coverage expansion that Republicans can buy into. Ketchum-Ward said the dual waiver has nonetheless inspired new optimism that coverage can be expanded.
"It's likely the best statement Idaho can pass, and it's a good solution," she said.
GOP U.S. Sen. Mike Crapo, the state's senior senator and one of the lawmakers in line for the coveted Senate Finance Committee gavel after sitting Chair Orrin Hatch retires after this term, threw his support behind the waiver during a committee budget hearing with HHS Secretary Alex Azar.
The waivers, Crapo noted, showed the attempts of states "seeking flexibility from the federal government to do creative work and help find the right path" for their health markets.
But finding a path that Republicans of all stripes can agree on may be the biggest challenge.
Azar and CMS Administrator Seema Verma met with Otter and Cameron over the weekend in Washington, and praised the dual waiver as "one of the most innovative and creative approaches they have seen," according to Cameron.
Cameron noted the dual waiver is an important piece of the state's effort to improve its insurance market, together with the executive order that allows noncompliant plans.
