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Senate Bill 1204 — Medicaid expansion waivers

Senate Bill 1204 — Medicaid expansion waivers

Phil Haunschild
March 21, 2019

Bill description: SB 1204 would establish work requirements for Medicaid expansion enrollees, would allow enrollees above the poverty line to receive coverage on the private market, and make other amendments to Medicaid Expansion.

Rating: +3

This legislation would require individuals to volunteer or work for at least 20 hours per week or to attend school part-time.  The legislation would also exempt the following groups of individuals from work requirements:

  • Under 19 years of age.
  • Over 59 years of age.
  • Physically or intellectually unfit for employment.
  • Pregnant.
  • A primary caretaker of a child under 18
  • A caretaker of an individual with a disability.
  • Participating in other state or federal work requirement, drug or alcohol rehabilitation, or disability programs.
  • Eligible to receive medical care as a Native American or Alaska Native.

Any individual subject to these work requirements would have to verify that they are complying with the provisions every six months. If an individual is not working, volunteering, receiving training, or attending school she would lose her Medicaid benefits for two months, then be eligible to re-apply for coverage.

This bill does stipulate that if the work requirements are not approved, then the Medicaid enrollees would be assessed the maximum allowable Medicaid co-payments for six months if the individual is out of compliance with the work requirements.

The state has many existing resources which can be repurposed or extended to administer the work requirements. Many employees who administer the work requirements for SNAP could move to administer these work requirements. Idaho has seen SNAP enrollees drop, yet H&W staff has gone up, indicating that there are many extra employees in this department. In both Maine and Arkansas, there were no estimated costs for implementing work requirements, as the states were able to repurpose existing employees and programs.

The work requirements implemented through SB 1204 should save Idaho taxpayers substantially, as has been the case with similar requirements for SNAP benefits. SNAP enrollment has decreased from over 200,000 persons in FY14 to around 150,000 in FY18. If able-bodied adults choose to leave the Medicaid program by not participating in a job training program, working, or caring for family members, then there will be reduced costs to the taxpayers. We should not assume that everyone who leaves Medicaid will go into a “secondary gap,” where they are not eligible to obtain care under any program. These individuals may actually find a job and earn enough money to not need Medicaid.


SB 1204 would have the Department of Health and Welfare seek a waiver from the federal government to automatically enroll individuals who are eligible to receive Medicaid benefits and who are above the Federal Poverty Line to receive Advanced Premium Tax Credits (APTC) instead of participating in the Medicaid program.

These credits, made available under federal law, give people subsidies for purchasing health insurance. But they are not available to someone enrolled in Medicaid, and the person who receives the credit and then becomes eligible for Medicaid becomes ineligible for the credit.

The waiver, if approved, would allow individuals the option to purchase health insurance, subsidized by these tax credits, on the market. Even though the subsidy is borne by federal taxpayers, it could save Idaho taxpayers money. This would be accomplished as private individuals would continue paying at least a small portion for their health coverage on the private market if they use the tax credits, rather than contributing nothing if they were on the Medicaid program. As the federal government provides 90 percent of the funding for Medicaid expansion enrollees and the state provides 10 percent, Idaho taxpayers do pick up a portion of the tab for Medicaid enrollees. This change could shift the financial cost of insurance for these individuals so that the majority of the cost would come from the federal government and the remainder would come from the insured person. Idahoans would then not be bearing this cost through their state taxes.

SB 1204 would specify that if the federal government does not approve this waiver by January 1, 2020, those who are above the poverty level and would otherwise be eligible will automatically receive Medicaid benefits.


Does it violate the principles of federalism by increasing federal authority, yielding to federal blandishments, or incorporating changeable federal laws into Idaho statutes or rules? Examples include citing federal code without noting as it is written on a certain date, using state resources to enforce federal law, and refusing to support and uphold the Tenth Amendment. Conversely, does it restore or uphold the principles of federalism?

SB 1204 would require the Legislature to declare that Idaho’s Medicaid expansion is void if a court rules that the increased Federal Medical Assistance Percentage (FMAP) rate—the portion of the cost for Medicaid enrollees born by the federal government—for Medicaid enrollees who are eligible under expansion is unconstitutional.

This would ensure that Idaho maintains some sovereignty over the programs offered by the state. If the federal government were to make such a substantive change to the Medicaid program, SB 1204 would ensure that Idaho has the opportunity to affirmatively approve these changes.


Update: This analysis reflects the House amendments made to SB 1204 on 4/4.

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