BOISE, ID – More than seven years after Idaho voters approved Medicaid expansion, the Republican supermajority-controlled Legislature is still talking about repealing it.

In the past, repeal bills haven’t gone that far. But this year seems different — since the state is facing multimillion projected budget shortfalls after years of tax cuts, Idaho’s DOGE committee recommended repeal, and even Idaho House Speaker Mike Moyle is open to the idea.

“Heck yeah (it’s on the table),” Moyle told the Idaho Capital Sun last week. “I don’t have a problem with that. Everything is on the table. I don’t have a problem with that at all.”

The debate over repealing expansion has largely settled into two camps: Some Republican lawmakers complain that expansion is much more expensive than initial projections, and that it could eat into the state’s budget for other services such as education.

But opponents say expansion has saved lives, repealing it wouldn’t save the state money since the feds pay so much into the program and the policy saves state money in other areas. They also say repeal could jeopardize the state’s health care system in ways that everyone — not just the almost 90,000 Idahoans on expansion — would feel.

That’s pretty much what folks have been saying for years.

“It’s Groundhogs Day,” Idaho Cancer Society Cancer Action Network government relations director Randy Johnson said in an interview.

What’s frustrating, he added, is that “we’re spending so much time on talking about repeal, we never get to the real issue: What is driving up health care costs?”

What is Medicaid expansion? And how did it close the ‘Medicaid gap’?

Under the Affordable Care Act passed in 2010, the federal government incentivized states to expand Medicaid to a broader range of low-income earners by offering to cover Medicaid expansion policies at a higher federal matching rate of 90%.

Idaho was one of several states that didn’t expand Medicaid.

Idaho Republican lawmakers have long worried states would be left to pay higher costs for expansion if the federal government reduced its extra pay.

But by not expanding Medicaid, tens of thousands of Idahoans were left in a medical insurance assistance gap, dubbed the Medicaid gap. People in the gap earned too much to qualify for Medicaid, but too little to qualify for tax subsidies on Idaho’s health insurance marketplace, Your Health Idaho.

Medicaid expansion set one eligibility cap for everyone: 138% of the federal poverty level, which is now roughly $21,600 annual earnings for a single person.

In 2018, after years of stalled legislative efforts to address the Medicaid gap, nearly 61% of Idaho voters approved a ballot initiative to expand Medicaid.

Since then, support for expansion has risen, polling from 2023 shows.

Idaho spent $92M this year in general funds on Medicaid expansion. The feds pitched in $1 billion.

In 2020, Idaho Medicaid expansion took effect, extending the health insurance public assistance program to more low-income workers for a population commonly called the working poor. Before expansion, they were in what advocates called the gap; they earned too much for Medicaid, and too little for subsidies to buy insurance on the state’s exchange.

Republican lawmakers often call Idaho’s Medicaid budget out of control, and they frequently point to the program’s full budget — not the state’s portion. Advocates have said Medicaid’s budget growth is stable.

Here’s a few snapshots of Idaho’s costs to expand Medicaid:

• States only pay 10% of costs of Medicaid expansion, with the federal government paying the other 90%. That’s much higher than Idaho’s usual share of Medicaid costs, which is more than 30% for other Medicaid populations such as people with disabilities and children.
• Overall, Idaho Medicaid expansion’s budget is appropriated about $1.34 billion this fiscal year, about twice as high as the program’s roughly $670 million budget in fiscal year 2021, the first full year that expansion was implemented.
• Medicaid expansion’s current budget in Idaho has the state paying $91.7 million in general funds this fiscal year, and the federal government paying more than $1 billion.
• Savings from expansion surpasses the state’s costs for the policy, the Idaho Center for Fiscal Policy found in a report last year. In 2023, the Idaho Department of Health and Welfare said repealing expansion would cost the state $78 million more.
• Expansion has also contributed $1.5 million to the state’s economy and generated almost $47 million in state taxes last year, a report by a University of Idaho economist found.

Speaking to reporters Friday, Idaho Gov. Brad Little cautioned against repealing Medicaid expansion, saying it’d spark unintended consequences. After expansion, he said the state took away some health care safety nets that were in place before — like the Catastrophic Health Care Fund, a state indigent health care program that gave financial assistance to people who were uninsured.

When asked, Little stopped short of saying he would veto a bill to repeal Medicaid expansion. Instead, Little said he doesn’t say what he will do with bills before they arrive on his desk.

Idaho Senate Minority Leader Melissa Wintrow, a Boise Democrat, called repealing expansion “probably one of the most expensive cuts we’ll make.”

And there’s also a health cost, doctors say.

“It just doesn’t make sense. It’s cruel and unusual punishment. And it’s not going to save the state money. It’s going to cost us money and lives in the long run,” said Dr. Kenneth Krell, a former ICU director in eastern Idaho.

He advocated for Idaho Medicaid expansion after one of his patients died. He says her death was preventable.

If the state repealed expansion, that would pile onto a range of cuts headed for Idaho Medicaid and health care: to doctor pay cuts, mental health cuts that could risk public safety, reforms from the state’s Medicaid law last year, federal cuts from the “One Big Beautiful Bill Act,” and expired federal health insurance subsidies.

Dr. Brian Birch, who leads the Treasure Valley’s Children’s Clinic in Meridian, said the state can’t handle more health care cuts.

“There are pediatric practices that are on the brink of going out of business with the existing cuts,” Birch told the Sun in an interview. “… Ultimately, more cuts will lead to less access to care for everyone. Because if a (medical) practice closes down, they’re not just closing down to just Medicaid patients or Medicaid expansion patients — they’re closing down to everybody.”

Ballot initiative to expand Medicaid didn’t come as surprise to some lawmakers, Republican senator says

Last year, a bill, pitched as a reform measure but which would’ve likely repealed expansion, narrowly passed the House. But Senate Health and Welfare Committee Chairwoman Julie VanOrden, a Republican from Pingree, halted the bill in her committee, preventing it from going to a full vote before the Senate.

Then she banded together with Republicans to back the big Medicaid bill that successfully became law. The bill, a comprehensive cost-cutting measure, proposed work requirements, shifting to privatized management of Medicaid benefits, and more policies that will take years to materialize.

So far this year, she said she hasn’t seen a bill drafted to repeal expansion. She said she hasn’t supported a repeal because of all the ripple effects that could come.

“It’s just not repealing expansion and doing away with an expense that we have on our budget,” she told the Sun last week. “It’s not as plain and simple as that.”

She remembers the legislative debates leading up to the ballot initiative that expanded Medicaid. She was serving in the House in 2018, as the ballot initiative was gearing up.

Legislative leadership was trying to find a way to address the gap, but they couldn’t reach an agreement on a bill, she said.

“So when Medicaid expansion became a citizens initiative and made it to the ballot and passed, it wasn’t surprising to some of us because we knew that there was a problem and it needed to be addressed. And the Legislature had failed to address it,” VanOrden said. “And so the citizens took it into their own hands.”

This story first appeared on Idaho Capital Sun.