BOISE — The best thing Idaho could do to improve health in the state, according to the keynote speaker at the Idaho Healthcare Summit, is something it’s already started, thanks to a November ballot initiative: Expand Medicaid.

“That’s a good start,” Dr. Ian Morrison told a crowd of 260 at the Boise Centre, gathered for a two-day summit this week that attracted representatives of health care providers, employers, insurers, government, nonprofits and more.

Morrison, an internationally known author, consultant and futurist, is a founding partner in a joint venture between Harvard University and Harris Interactive called “Strategic Health Perspectives,” president emeritus of the Silicon Valley-based Institute for the Future, and author of books on the future of health care.

“The average American family cannot afford the average health insurance premium,” Morrison told the crowd, which included some participants taking part via live-stream from Idaho State University in Pocatello. “You think about that for eight nanoseconds — that’s a wee bit of a problem, right? The average French family can afford the average premium, because it costs half as much and they make about the same.”

“The bottom half of the income distribution can’t afford the product,” he said. “The people above that are also feeling the sting.”

He said Americans shouldn’t have been surprised when health insurance premiums rose under Obamacare. “By definition, when you start to community-rate the sick people and the well people, the premiums for the well people are going to go up.” That aroused opposition, as older people, conservatives, retirees and the self-employed saw their premiums go up, he said. “But the big story in my review of Obamacare is Medicaid expansion.”

States that expanded Medicaid have seen a “very significant” difference in overall coverage levels, he said. In some cases, that’s meant lower profits for hospitals, as the percentage of their patient loads covered by Medicaid, which pays at lower rates than private insurance, went up from around 15 percent to 20 percent.

“I would argue that if you look holistically at all the research evidence, expanding Medicaid is a good thing to do for your state,” he said. “People say to me all the time, ‘Well, Medicaid is a failing program.’ Not if you’re on it, it’s not.”

But most Americans have employer-sponsored health coverage, he said, noting there are “150 million-odd people who get health insurance at work.” And a third of Americans “are powerless, depressed and angry when they deal with the health system.”

“The real source of angst behind people with employer-sponsored coverage is you can lose it, and you’re paying way more for it than you did 10 years ago,” Morrison said. “It’s out-of-pocket cost and it’s vulnerability. If you change jobs, you could be in real trouble. That’s what’s coming out in poll after poll, study after study.”

Plus, he said, “The percentage of Americans covered by employer-provided coverage is not going up, it’s going down. … It’s not Obama. It’s the progressive unaffordability.”

The U.S. is unlikely to move to a single-payer health care system, he said. “We don’t have enough money. Think about what we’ve done over the last couple of years as a country.” Government revenue was cut through the tax bill, he said; federal deficits are rising, and we’re facing a trade war. “So we basically have dug ourselves an enormous fiscal hole going forward that I think is going to be like a dark shadow over health care.”

Getting serious about cutting costs is essential, Morrison said.

Former Idaho Health & Welfare Director Dick Armstrong told the Healthcare Summit that there’s a strong business case for payment reform, to convert the state’s health care system from its current fee-for-service approach to a value-based system that bases payment on outcomes. “We have to start paying for what we want, and stop paying for what we don’t want,” he said.

In a fee-for-service system, health care providers are paid per patient, per visit, regardless of outcomes. In a value-based system, providers generally are paid per-patient for keeping their patients healthy, regardless of how many visits or services are provided.

The fee-for-service system, all across the country, “Drives up costs and drives up utilization, and it has for decades,” Armstrong said. The United States spends nearly double the percentage of its gross national product on health care as the rest of the world. “It is becoming a huge drag on the economy.”

“We in the industry need to get this moving,” Armstrong said.

The two-day summit opened Tuesday morning with remarks from Idaho Gov. Brad Little.

“I am incredibly bullish about where the state of Idaho is right now,” he said.

“I don’t know what’s going to happen at the federal level, but frankly, for us, I believe it’s prudent to just power through it” and to “do the right thing for the people of Idaho.”

He said between Medicaid expansion and other efforts underway in Idaho, including ongoing work with federal authorities on lower-cost health insurance plans for people who’ve opted not to buy insurance otherwise, Idaho will succeed in increasing the number of people who are covered by health insurance.

“For the 56 percent of Idahoans that work for small business, there’s so many of those where they don’t have coverage that are at risk if some big catastrophic event occurs,” Little said. A variety of approaches will help more Idahoans get covered, he said. “It’ll just elevate the quality of life for everyone.”

The governor also said he believes the timing of Idaho’s Medicaid expansion plan will work well, with coverage slated to start Jan. 1, 2020. “It gives us time to calculate what waivers are going to be available, what kind of potential gaps we’re going to have,” including whether some would still end up without coverage, and how to address that, he said. “From a timing standpoint, I think it’s going to be very workable.”

After voters approved Medicaid expansion in Proposition 2 in November, the Legislature this year added requests for federal waivers to tack on mandatory work requirements and other restrictions for participants.

House Speaker Scott Bedke, R-Oakley, speaking on a panel at the summit on Wednesday, said, “If we’re unsuccessful in getting the waivers, it is full Medicaid expansion as per Proposition 2. So when we have this discussion a year from now, I don’t know what we’ll be talking about.”

State Insurance Director Dean Cameron noted that from 2015 to 2017, at a time when Idaho was one of the fastest-growing states in the nation, nearly 130,000 Idahoans dropped their health insurance coverage. Since 2009, the average premium in Idaho has risen from $159 a month to $438 a month per insured person, he said.

That’s why he’s continued to negotiate with the federal government to craft state-based insurance plans that could be sold in Idaho at lower costs, to attract the young and healthy back into the coverage pool.

“Over the past year, we have met regularly, had multiple face-to-face meetings and taken part in many phone conversations, all with much frustration,” Cameron said. But he’s kept at it, he said. The current version of the proposal calls for the lower-cost plans to include all 10 “essential health benefits” that plans offered under Obamacare must cover, and drop restrictions on coverage of pre-existing conditions.

Cameron also cited some progress Idaho’s made in the past year, including becoming the first state to include coverage for children born with autism in all health insurance plans. Idaho will save money as a result of the coverage for early intervention, he said, and other states have now followed Idaho’s lead.

The fifth annual summit was sponsored by Blue Cross of Idaho, Saint Alphonsus Health System, and an array of other sponsors including the University of Idaho and Idaho State University; it was produced by APG Signature Events, a division of Adams Publishing Group, which owns the Idaho Press and the Post Register.

Betsy Z. Russell is the Boise bureau chief and state capitol reporter for the Idaho Press and Adams Publishing Group. Follow her on Twitter at @BetsyZRussell.

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