Idaho physicians gather Thursday, March 14, 2019, at the state Capitol to call on lawmakers to implement Medicaid expansion as passed by voters, without any modifications or restrictions.

Almost all of the emails the state Department of Health and Welfare received on a proposal to require Medicaid recipients to get a referral from their primary care doctor to access outside family planning services urged the state not to move forward with the idea.

“Since when are the legislators experts in health care and how it should be administered?” wrote Jim Carter of Pocatello. “These requirements seem to be disproportionately aimed at women. I think that the predominately male lawmakers would be in a total upheaval if this type of requirement process was aimed at their prostates and testicles not to mention having to pay for two providers when one would have been sufficient.”

DHW received 371 emails opposing the proposal, four in favor, and one that didn’t directly address the waiver but argued public money shouldn’t be used on family planning at all. Five emails weren’t clear or were on other topics, including two that didn’t mention the family planning waiver but instead opposed a proposal to add work requirements for Medicaid expansion enrollees, which is part of a different pending waiver request.

Public comment closed on Oct. 12, and DHW submitted the proposed waiver to the Centers for Medicare and Medicaid Services on Friday. DHW held two public hearings in Boise in September, at which a total of 13 people testified against the proposal and none in favor.

Idaho voters voted to expand Medicaid in 2018, over the wishes of many Republican lawmakers. The Legislature voted to fund Medicaid expansion this year but also passed a bill requesting federal approval for several changes to the program. Unlike some of the requested waivers, such as the one to add work requirements or another that would give some people the option of getting insurance through the state exchange instead, the family planning one would apply to most people on Medicaid, not just people covered by expansion.

Many of the waiver’s opponents said it would discriminate against women and create unnecessary barriers for women seeking reproductive health care, or that it would be especially burdensome in rural communities where access to health care is already limited. Others said it goes against conservative principles such as freedom of choice and limited government.

“Women in Idaho, particularly in the many rural parts of the state, have a hard enough time finding adequate health care,” wrote Julie Stomper of Victor. “This additional obstacle will add cost and bureaucracy and reduce families’ ability to care for themselves. It is a nonsensical and shameful attempt to expand government regulation over citizens. It is simply un-Idahoan.”

Daphne Stoner of Driggs said it would continue the ideas that women are subordinate to men and that men can control their reproductive choices.

“This legislation imposes restrictions or hurdles that uniquely target women,” she wrote. “Men can readily access condoms at their local grocery stores, pharmacies as well as coin-operated vending machines in restrooms. Men are not be subjected to bureaucratic interference in their personal choices.”

DHW says in the waiver application that it hopes it will improve coordination of care and lead to better health outcomes. The draft waiver says it won’t affect costs. However, Idaho Freedom Foundation President Fred Birnbaum, one of the few who emailed in favor of the proposal, said it could save money if this works out.

“If the (program) ... does improve the participant’s overall well-being, that may lead to lower overall health care costs, and we believe that this is worth trying,” he wrote. “As it stands now, the overall Medicaid budget in Idaho is projected to increase 10% or $284 million from (fiscal year 2020) to FY21 based on the budget request, so strategies are needed to reduce the consumption of health care.”

DHW didn’t make any changes to the waiver in response to the public comment. The completed application goes over some of the common reasons for opposing it and explains why the department didn’t make any changes. In several cases, DHW said it couldn’t due to the language of the bill directing the department to ask for the waiver.

The applications says DHW will monitor referral patterns and any shifts in utilization of health care services if the application is approved. It also says the proposed waiver is gender neutral.

“The same referral requirement applies whether the patient is a man or a woman seeking a Medicaid covered method of birth control,” it says. “While it is true that women are involved in birth control use more than men, we cannot resolve this concern within the context of this waiver or the requirement in Idaho code.”

Whether any of these waivers are approved by CMS or not, Medicaid expansion enrollment will open on Nov. 1 and coverage will kick in on Jan. 1, 2020.

Reporter Nathan Brown can be reached at 208-542-6757. Follow him on Twitter: @NateBrownNews.