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Idaho’s House has a Medicaid expansion modification bill under consideration.  The big thing it wants is work requirements.  It is unlikely to get that without an act of Congress given the litigation that went against work requirements for Medicaid during the Trump administration.  However, it also wants to transfer a lot of funds to its state’s hospitals from the middle class via its Medicaid program:

The department has, with federal approval if necessary, allowed  persons eligible for medicaid under this section who have a modified adjusted gross income at or above one hundred percent (100%) of the federal poverty level to receive the advance premium tax credit to purchase a qualified health plan through the Idaho health insurance exchange  established by chapter 61, title 41, Idaho Code, instead of enrolling in Medicaid, except that a person may choose to enroll in Medicaid instead of receiving the advance premium tax credit to purchase a qualified health plan;

This is a modification of the Arkansas Private Option where Arkansas placed its Medicaid Expansion population into ACA exchange plans instead of traditional Medicaid under an Obama administration waiver.  Arkansas enrollees are placed into the ACA unless they meet certain complex medical conditions.

However this is discretionary in Idaho as currently written. This optionality changes the dynamics. It is an invitation for a huge transfer to hospitals from the 138% federal poverty level and above ACA enrollees.

Hospitals get paid substantially more from an ACA enrollee than a Medicaid enrollee.  CSR-94 plans, which is what these enrollees would be eligible for have some premium and cost sharing (~$500 deductibles is not uncommon) while Medicaid has token premiums and minimal cost-sharing.  We know from Allen et al that ACA plans have substantially more spending mainly due to price levels than Medicaid expansion plans for individuals who barely qualify for one of the two programs.  We know that most people have minimal spending and minimal interest in buying access to care.

I’m working on a project with several collaborators where we examine the impact of consolidation in the dialysis industry on ACA premiums.  Duopolies in dialysis means substantially higher premiums for the ACA.  A good chunk of the hypothesized mechanism is that dialysis firms are very happy to pay for the premiums and cost-sharing of an ACA enrollee who needs dialysis through a charitable foundation.  They are happy to do this because ACA plans pay the dialysis center substantially more than Medicare or Medicaid so even net of paying the premium and cost-sharing, the dialysis firms come out WAY AHEAD!

I would be shocked if hospitals don’t send their social worker to every Medicaid Expansion patient who has cancer, hemophilia, or other very high cost disease with an offer for the patient to elect an ACA plan with hospital foundation grants to pay the premium and any additional cost-sharing.  Doing this would be a massive windfall to the hospitals and it would mainly be paid for by either the federal government in the form of higher premium tax credits OR really sick individuals with incomes that are high enough to make them subsidy ineligible.

Idaho wants to kidney-ize its hospitalsPost + Comments (11)