One big decision Idaho lawmakers will make next year is how to pay for Medicaid expansion in the long term.
While nothing is set in stone, an initial proposal to levy counties for part of the cost has some local officials worried. Preliminary estimates suggest some eastern Idaho counties could be hit harder than anywhere else in the state under the proposed formula.
“We’re not in favor of that because the formula they used was to charge based on estimates (of the number of) people eligible,” said Bonneville County Commissioner Roger Christensen, who also heads the state’s Catastrophic Health Care Fund board. “Our indigent costs, I think we do a good job of scrutinizing and paying what’s appropriate. Costs per capita are lower over here.”
An interim legislative committee will study how to pay for Medicaid expansion, which is estimated to cost the state $40 million in the first full year if enrollment is as projected. Rep. Fred Wood, R-Burley, introduced a bill late in the session to create a new “levy for charities” fund, which would make counties responsible for paying almost half of the cost of county residents covered under expansion.
The bill didn’t advance, and Wood said he introduced it just as a starting point for the committee’s discussion. Using estimates of how many residents of a given county are expected to be covered under Medicaid expansion, the formula would lead some counties to pay less and others more than they are paying in indigent health care costs now.
A total of 21 counties would save a combined $7.2 million under the “levy for charities” assessment, while 23 counties, including nine of 10 in the Post Register’s coverage area, would be assessed an additional combined $4.1 million. Three of the state’s most-populated counties, Ada, Canyon and Twin Falls, are among those that would save money under the “levy for charities” projections with Ada County saving more than $4 million.
Lemhi County would be the only eastern Idaho county to win out under that formula, saving $11,607 a year. Other would pay more — much more in some cases. Jefferson County, which spent just $37,589 on indigent medical care in 2018, would pay $316,018 to cover the cost of Medicaid expansion under this proposal. This would eat up most of its 3-percent-plus-growth property tax cap, meaning that if the county were to raise taxes to the maximum, generating $363,202, just 23 percent of that money would be available for needs other than Medicaid.
Bonneville and Madison counties would be the hardest hit. Bonneville, which paid health care providers $56,080 in 2018 for indigent health care costs, would pay the state almost $1.42 million under the formula given the county’s estimated 7,308 people who would be covered by expansion. This would leave just 7 percent of the county’s estimated maximum tax increase for other needs. Madison, which spent about $61,000 in 2018, would be levied $597,680, which would eat up the entire tax cap plus another $49,000.
Kootenai County, the state’s third-largest county which has 40,000 more residents than Bonneville County, would be levied an additional $395,000, a fraction of the projected cost for Bonneville County.
Senate President Pro Tempore Brent Hill, R-Rexburg, said he has already named three of the five Senate members to the interim committee — Sens. Dave Lent, R-Idaho Falls, Van Burtenshaw, R-Terreton, and Jim Rice, R-Caldwell. He also said the Idaho Association of Counties would be involved.
Christensen, who has headed the CAT fund board for years, said he plans to advocate against the concept that property taxes should be used to pay for health care. He said it unfairly hits businesses and farms more than others, and that counties are already struggling to pay for other state mandates such as improving public defense services.
“A lot of our presentations over there in the past have been questioning why it is the responsibility of property taxpayers to pay for medical indigent health bills,” he said. “Our belief is it should come from a broader source and not just focusing on property taxpayers.”
Christensen thinks county indigent funds and the CAT fund should be unnecessary once Medicaid expansion kicks in. Idaho is the only state with a similar program, he said.
“It’s basically to pay bills to hospitals,” he said. “It’s not a medical care program. We just pay the bills, and I think it’s outdated and probably should be eliminated.”
Hill said the state will need some sort of dedicated funding source for Medicaid expansion and the committee will examine different options, including proposals from the counties. One idea that could come up is raising taxes on hospitals to pay for part of it — two bills to do this were introduced toward the end of the legislative session, and several states have used taxes on hospitals or health insurance plans to pay for part of the cost of expansion.
The state is applying for several waivers to make changes to Medicaid expansion, and Hill said the ultimate cost will depend on which ones the federal government approves. For example, he said, a waiver that would add work requirements for expansion could “create its own smaller gap” due to some people losing coverage.
“As we get into summer (we) might have a better feel,” he said.
Hill said there are several reasons indigent health care spending might be lower in eastern Idaho, although he hasn’t been able to find a definitive answer. Some county commissions here, he said, might be more reluctant to approve the spending than elsewhere. There could be fewer claims, possibly because more people have family to help them, or are more reluctant to ask for help, or because more doctors provide services to the poor either for free or at a lower rate.
“It could be a multitude of factors,” he said. “I think that’s one thing we need to look into.”