Remember in November: Fight to expand Medicaid

For seven years the Idaho Legislature refused to expand Medicaid. 

It was predictable. After all, Idaho was one of the states that fought in court to do away with the Federal mandate for Medicaid expansion. This good Republican state wasn’t about to accept medical insurance for people a fraction above the poverty line, even when it was 100% paid for by the Federal government. 

Voter demand grew strong enough, however, that a Senate committee did hold a hearing in 2016. Hundreds of supporters showed up to testify about problems for people earning too much to qualify for Medicaid and too little for subsidies on the insurance exchange–those that Medicaid expansion was meant to cover..    

The chief results of the hearing were an angry scolding for Dr. Kenneth Krell for saying that the Legislature’s refusal to expand Medicaid had caused 10,000 deaths, and a pompous statement by U.S. Rep. Raul Labrador that made national news, “Nobody dies because they don’t have access to health care.”  

In November 2018 over 365,000 Idaho voters–60%–voted for an initiative to expand Medicaid. But the fight was far from over.  

There was a bright moment when newly-elected Governor Brad Little, previously opposed to expansion, accepted that the people had spoken and included funding in his budget request. 

But the Legislature wasn’t nearly as gracious. 

The 2019 legislative session limited expansion every way it could, passing rules that were only minutely different than ones already rejected by the courts.

And, adding insult to injury, legislators lectured voters.  

Initiatives should include their own funding. Yes, there was money for expansion–tobacco settlement funds, medical emergency funds that Medicaid Expansion would replace, and various savings. But initiatives should have to request a tax increase.   

Healthcare should not be cheap. People will overuse it and make the current physician shortage more serious. It will reward people for not working. (That was a particularly galling argument since people were in the gap because they made too much to be covered by traditional Medicaid.)  

Then, Sen. C. Scott Grow called for a fight against the entire initiative process. “Running a state government by voter initiative,” he claimed, “defeats the basic fundamental premise of the Constitution. We elect representatives and trust them with responsibility.”

Grow was apparently referring to the national Constitution, for Idaho’s says differently. “The people reserve to themselves the power to propose laws, and enact the same at the polls independent of the legislature.”  (Only 24 states grant citizens the power to initiate laws.)

And legislators leaped to join in the attack.    

It shouldn’t have been a surprise. After voters passed the term limits initiative, legislators increased the number of signatures needed to get a proposition on the ballot. After voters rescinded the Luna Laws, legislators increased the number of legislative districts that had to reach the required percent.  

Now legislators set out to make initiatives and referendums more difficult in three ways: cutting the time limit from 18 to six months; requiring signatures from 10% rather than 6% of the registered voters; and requiring that 32, rather than 18, of Idaho’s 35 districts reach the 10% goal.  

The bill passed the Senate, 18-17, and the House, 40-30. 

Gov. Little vetoed it.

Unsure how your legislators voted? 

You can find their names at https://legislature.idaho.gov/legislators/whosmylegislator. Then visit https://https://legislature.idaho.gov/sessioninfo/, 2019 session, and look up bills HO249a and SO1159.   

No Internet?  Call your local library. They provide some great services.  

Imagine just how much more suffering this year’s pandemic would have caused if 80,000 more Idahoans couldn’t have afforded health care.   

Medicaid expansion & initiative process in peril?

“Voters serious about seeing insurance coverage for the ‘gap’ population would be wise to vote for legislators who agree” (Idaho Press, Oct. 16, 2018).

I wrote it once before the 2018 elections–I now regret not repeating it weekly.

Last November, in the privacy of the voting booth, Idahoans passed Medicaid expansion while electing legislators who opposed it.

We’ve known since then that it’d be a fight to get expansion through the legislature, but a second unexpected fight has erupted.

I feel many voters thought their representatives would, as Gov. Brad Little has, graciously accept the decision of the voters. Unfortunately, plenty are either openly opposing covering more people with insurance or mouthing support while undercutting the implementation of the bill.

Supporters of HB 249 know that Arkansas, the only state with a work requirement underway, found that the requirements added few people to the workforce. Ninety-eight percent of new Medicaid recipients were already meeting work requirements through the SNAP program; thousands of others failed to report and continue to rely on emergency medical services.

These legislators know the Feds have never approved anything like the waiver HB 249 would request that would include the gap population on the insurance exchange with 100 percent of subsidies paid by the Federal government. Just making the request could delay implementation most of a year.

And they know that no funds have been budgeted to cover the $1.5 million a year that the Idaho Department of Health and Welfare estimates as the ongoing cost of the bureaucracy HB 249  would require.

In short, some legislators are working to add elements to Medicaid expansion that make  implementation impossible while claiming they are just being responsible and frugal.

Will they succeed in crippling  Medicaid expansion?

That’s the question many Idahoans have been asking since November.

What Proposition 2 supporters weren’t expecting was an attack on the initiative process itself.

Maybe we should have.  After the term limits initiative, the number of signatures needed to get a proposition on the ballot was increased to six percent of registered voters–or roughly 10 percent of those who actually vote.

After the Luna Laws were rescinded, the legislature required the total to include six percent of registered voters from 18 of Idaho’s 35 legislative districts.

Now Sen. C. Scott Grow’s SB 1159 would not only require 10 percent of registered voters in 32 legislative districts, it would cut the time allowed to gather signatures from 18 to six months.

The weekly Inlander quotes Grow as saying, “Running a state government by voter initiative defeats the basic fundamental premise of the Constitution. We elect representatives and trust them with responsibility.”

The Senator can’t be referring to Idaho’s Constitution. It says, “The people reserve to themselves the power to propose laws, and enact the same at the polls independent of the legislature.”

Grow’s bill awakens the fight-or-flight response in me even though I believe it will never take effect. There’s a very real chance that Chair Patti Ann Lodge, district 11, will see it dies in the State Affairs Committee. The two bills to rescind Proposition Two failed in committee in spite of supporters asserting only representatives should have the right to make laws.

Even if the bill did pass both houses, it’s doubtful that Gov. Little would sign it or, if he did, that it would pass a court challenge.

Still, my blood pounds and my neck feels stiff.

We will have many more months of worry about the fate of Medicaid expansion if  HB 249 passes.

Note this editorial by Judy Ferro published by Idaho Press – 2019

Fame & Infamy

Hey, Idaho made national news again.

This time no child came down with bubonic plague, no teacher fed a sick puppy to a turtle, and no one lured a gay man to his death.

No, this time 39 members of the legislature earned Idaho 400 words on Newsweek.com by voting down HB 98, a bill “to prevent forced or coerced marriages and the trafficking of children and to limit marriage to those with the legal and practical ability to protect themselves from abuse.”

Apparently, from 2000 to 2010 over 4,000 children married in Idaho, earning the state the highest child marriage rate of the 38 states that released data.

It didn’t help that Rep. Bryan Zollinger stated the government should have no place in licensing marriages.

All that was missing was haunting music from Deliverance. Though, to be fair, the article did say that only two states do have a minimum age for marriage.

“No” votes by Jarom Wagoner (District 10), Tammy Nichols (D 11), and Gary Collins (D12) all helped earn Canyon County this national notice. .

The good bills–e.g., extending time to report wage theft, giving judges leeway on drug sentencing, covering  PTSD care for first responders–don’t get such attention.

We’d have to pass something big to get national coverage, like add the words,  a minimum wage increase—or expanding Medicaid.

For six years Republican legislators failed to come up with an “Idaho way” to cover people in the health insurance gap. Now they feel pressed to graft an Idaho way on the law voters passed.

According to reporter Nathan Brown, the bill Rep.John Vander Woude is introducing has four main provisions: kill Medicaid expansion if Federal support falls below 90 percent and reevaluate the program in 2023, allow Medicaid funds to cover residential mental health treatment, ask the Feds to give those with incomes over the poverty level access to the subsidies through the ADA exchange, and add a work requirement.

The first is mostly swagger. Yes, it threatens the program and raises the possibility it’ll take another initiative to rescue expansion. But future legislatures aren’t bound by directives from 2019; they may do what they will.

The extension of coverage to residential treatment of the mentally ill is a good move. The state will pay less and patients will have more options.

Having the majority of new recipients receive ADA subsidies rather than Medicaid, is ingenuous. Not only would Idaho’s share of costs shrink from 10 percent to zero, Republicans could rest easy that people would contribute what their income allowed. Moreover, no one would price themselves out of the program as their income rose.

Unfortunately, there’s no reason to believe the Feds will ever grant such a waiver. It seems a pipe dream designed that could postpone expanded coverage.

The work requirement, though, deserves research. Work is good, right?  But a late February release from the Kaiser Family Foundation says Arkansas–the only state with a work release waiver in operation–found that 98 percent of those qualifying for continued coverage were already meeting the work requirements of the SNAP program work. They’d created another bureaucracy and left 18,000 depending on indigent care.

In contrast, the Idaho Medical Association reports that a voluntary job promotion program in Montana made real gains in labor force participation.

Data on the two programs may explain why the Wyoming House voted 32-28 for work requirements one week and 39-20 against them the next.

A voluntary program can be put in place region by region as the funds are available.

Maybe that’s the real “Idaho way.”

Note this editorial by Judy Ferro published by Idaho Press – 2019

Legislature – Good & Bad News

With March in sight and budget bills ready, the legislature moved into high gear this week, making some people happy, some sad, and others both happy and sad.

The most cheering news was that a bipartisan majority managed to kill two bills aimed at  repealing Medicaid Expansion while they were still in the House Health and Welfare Committee.

Representatives Julianne Young and John Green both argued that voters just weren’t bright enough to be trusted with such an important decision.  Okay, according to reporter Nathan Brown, their phrasing was more politically correct–the voters were “misinformed.” I imagine them doing some hand-wringing as they told committee members that voters weren’t aware that the state would have to pay 10 percent of the cost and, possibly, more than 62,000 would be enrolling.

I can also imagine Gov. Brad Little gritting his teeth as the pair carried on as though his State of the State address had not included a plan for funding the expansion. (Talk about misinforming voters.)

And Green went so far as to claim legislators may ignore the voters because, “we’re a constitutional republic, not a democracy.”

Don’t forget the names: Julianne Young, John Green.  And add the three who voted with them: Mike Kingsley, Megan Blanksma, and Bryan Zollinger.

And be thankful for Chair Fred Wood–and the three Republicans and three Democrats who joined him in killing the bills.

Bills to add work requirements and lifetime limits to Medicaid expansion are in the works.  Other states have spent millions administering such restrictions; that spending is not budgeted.

Many are also happy that the bill to create a committee within the Idaho Department of Health and Welfare to review childbirth-related deaths passed the House last week.

Opponents of HB 109 nearly carried the day by arguing we didn’t need more bureaucracy to look into five to six deaths a year. The study, however, will become part of national data that may indicate why the U.S. maternal death rate is rate is three times that of Germany or the United Kingdom.

We will soon see how the Senate votes.

On a sad note, a bill to allow charter schools to hire non-educators as administrators, passed 21-12.  According to reporter Nathan Brown, Education Committee Chairman Dean Mortimer said “this bill is about giving charter schools a way to be more flexible and creative.”

Is there a stereotype that says educators are stuck in their ways? Or is it simply a feeling that education doesn’t require much expertise?

I’m sure necessity would make a non-pilot both flexible and creative in the cockpit, but It wouldn’t make up for lack of knowledge.

If a leader doesn’t have the experience to anticipate problems and work to prevent them, he or she won’t have the respect of the teachers. If a leader doesn’t understand the full scope of situations, he or she be inconsistent and follow the latest advice.

 And a leader without experience organizing playground activities and assemblies can get people hurt.

Idaho has many charter schools happy to have educators as leaders. Unfortunately, there are chains wanting to move in that are interested in milking the system for what they can get. They now have permission to hire “teachers” whose main job is recruiting. Do we really want them to hire directors who are more business-oriented than kid-oriented?

Now the House may act on SB 1058. I’d love to think members would stand up to the corporations pushing this, but I have doubts.

Expect the legislative roller coaster to pick up even more speed in the next few weeks.

 

Note this editorial by Judy Ferro published by Idaho Press – 2019

Medical Updates – IMA

During the legislative session I get weekly updates from the Idaho Medical Association on the bills they are following.  And, week after week, I note that this is what lobbyists are supposed to do–educate legislators and voters.

Medical bills are a substantial portion of the legislative endeavors. At this stage in the session–when only a few special committees may yet submit bills–297 bills have been introduced.  Of these, 23 pertain to schools, 30 to courts, and 32 to health.

The IMA Status Report usually summarizes and tracks about half the health bills in five or so pages.

Last week’s report points out that several changes to the Medicaid Expansion proposition are still in the draft stage, but the IMA Board has voted not to endorse any bill which would delay implementation, add to the cost, or take coverage from individuals.

That puts the IMA squarely behind Medicaid expansion as the voters passed it.

Two issues I would otherwise be unaware of are labelled “top priority.” One would implement the second year of a 10-year plan for graduate medical education developed by the State Department of Education by creating 19 new slots for medical residents and fellows and increasing the funding per person.

The request for an additional $1,657,500 per year is before JFAC, the Joint Finance-Appropriations Committee.

The other, an IMA proposal, would create a Maternal Mortality Review Committee within the the Department of Health and Welfare. The report quotes the medical journal The Lancet: “The US has a maternal death rate of 26.4 per 100,000 live births compared to other countries such as UK (9.2), Germany (9), France (7.8), Canada (7.3), Spain (5.6), Italy (4.2) and Finland (3.8).”

Six maternal deaths in 2017 put Idaho’s rate just over the US average. The House Health and Welfare Committee will decide whether HB 109 advances.

That’s positive lobbying–no hardsell, just quickly getting someone from uninformed to equipped with relevant facts from reliable sources.

This IMA Status Report supports six other issues. One bill, allowing all licensed medical personnel access to opiod antidotes, has already been signed into law. Another, that allows the Board of Medicine to discipline doctors for “unprofessional or disruptive behavior” even if a patient is not harmed, has passed both houses. Also, a new administrative rule requiring a meningitis vaccine for students entering their senior year has been accepted.  Other supported bills include requirements for pharmacy benefit managers, expansion of a drug donation plan, and better insurance coverage of oral chemotherapy.

The IMA opposes only one issue, HCR 4, that would do away with vaccine requirements for students.  Apparently, it is dead in committee.

Although the IMA does not take a stand on other bills, the status report summarizes others, notably ones that were new the preceding week or that are progressing through the legislature.

The House has passed HB 59 which allows drivers as young as 15 “to volunteer as organ donors on their driver’s licenses” and and HB 64 which revises the legislation passed last year that requires reporting of complications resulting from abortions.

The Senate has passed SB 1049 to bring Idaho’s law on partial-birth abortion in line with the Federal law.

The IMA Status Report covers a wide range of issues that don’t always make the press. Those who would like to receive this report, may call (208) 344-7888 or send their email address to membership@idmed.org. (As an organization for those in the medical profession, IMA doesn’t expect others to join.)

Note this editorial by Judy Ferro published by Idaho Press – 2019