Uncertainty over the fate of health care reform has legislators playing a waiting game

While they work through debates over budgets, taxes and policies this year in their respective state Capitols, officials in Olympia and Boise will have to keep one eye on Washington, D.C., in an effort to determine what Congress will do about health care.

For years, Republicans who control Congress have talked about repealing the Affordable Care Act, or Obamacare, but after Jan. 20, they’ll have a Republican president who could sign anything they pass.

That would affect both states, although they have approached Obamacare differently. But without knowing whether any replacement will be approved, or a possible timeline for any changes or phase-out, lawmakers in both states are playing a waiting game.

In Washington, which accepted federal money to expand its Medicaid system, an estimated 750,000 residents get health insurance that they would lose if the law is repealed without any replacement.

Washington Gov. Jay Inslee said there is no contingency plan to make up for nearly $3 billion in federal money that pays for that expansion, or the hundreds of millions of dollars the state’s health care facilities get treating people who now have insurance. Instead, he urged residents to contact their congressional delegation to urge them not to repeal the law, which doesn’t just expand Medicaid but also offers extra benefits to seniors on Medicare.

A former congressman, Inslee took several shots at his former colleagues, citing an aborted effort to rein in the House Office of Congressional Ethics earlier in the week. A Congress that can’t be trusted to manage its own ethics shouldn’t be trusted if it repeals the Affordable Care Act with a promise to replace it later.

Inslee wrote to the state’s highest-ranking Republican in Congress, U.S. Rep. Cathy McMorris Rodgers last month, urging her not to kill Obamacare. The chairwoman of the House Republican Conference, McMorris Rodgers voted against the law in 2010 and has consistently voted to repeal the law ever since.

“I have not heard a response from her,” Inslee said.

Idaho Gov. Butch Otter urged his state’s lawmakers to be careful with any changes they might be considering.

“There’s a great expectation – and I think there’s good reason for that expectation – that the Trump administration is going to do something relative to Medicaid expansion, relative to Obamacare, as we know it,” Otter said. “And you know, if we get too far out ahead we may be in a territory that’s not prepared to do what the Trump administration is going to do.”

Idaho did not accept federal money to expand Medicaid. But a joint legislative committee worked over the summer to find ways to close the state’s health coverage gap, which has left 78,000 Idahoans without options for insurance because they make too much to qualify for Idaho’s limited Medicaid program, but not enough to qualify for subsidized health insurance through the state insurance exchange.

The panel agreed strongly that the state should do something – but didn’t agree on what. And with uncertainty over what will happen at the federal level, many lawmakers are taking a wait-and-see approach.

Idaho Health and Welfare Director Dick Armstrong has one solid proposal he’ll present to lawmakers – to cover recently released parolees and probationers for mental health and substance abuse treatment at a state cost of $10.5 million a year. If Idaho had expanded Medicaid, that already would be covered.

“This does not go into other kinds of health care – it’s very focused on mental health,” he said. As part of Idaho’s Justice Reinvestment initiative, studies have shown that 54 percent of the state’s newly released prison inmates end up back in prison. They’ve received treatment for mental health and substance abuse disorders while behind bars, but once free, the treatment ends.

Justice reinvestment studies estimated that recidivism figure could drop to 30 percent if the parolees and probationers received continued mental health treatment after their release. That would mean “a lot of money” in savings for the state, Armstrong said. The estimated treatment cost is $1,500 per inmate per year; sending them back to prison costs the state $55,000 per inmate per year.

Armstrong expects lawmakers also to take action on the coverage gap. “There’s uncertainty at the federal level, but there’s no uncertainty about the gap population,” he said. “The gap population was not addressed. If you dismantle the Affordable Care Act, they’re still not addressed.”

In Washington, there’s a clear partisan divide over the impact of Obamacare. Inslee and other Democrats note the higher rates of people who have insurance and the care they get because of the law. Senate Minority Leader Sharon Nelson, of Maury Island, suggested their GOP counterparts talk with the Trump administration about the law’s benefits in Washington.

“We will develop a contingency plan, but part of the problem is not knowing what the federal government is doing from minute to minute or tweet to tweet,” said House Speaker Frank Chopp, of Seattle.

Republicans like Senate Majority Leader Mark Schoesler, of Ritzville, acknowledged that while the law has helped those who were previously uninsured, those who had medical coverage before the law passed have seen their rates go up and their plans change.

“We’ve waited a long time and all we’ve gotten is higher prices and higher deductibles,” Schoesler said. As for the prospect that the federal government withdraw the money it had promised to send the states that expanded Medicaid, he noted some Republicans “said their concern was just exactly this, what happens when the money runs out, what happens when something changes.”

Idaho’s state health insurance exchange is continuing forward despite the federal uncertainty; Armstrong, the Idaho Health and Welfare director, said he expects it to survive.

The insurance subsidies for the exchange are funded by tax credits that could be repealed if the Affordable Care Act is repealed, but Armstrong said House Speaker Paul Ryan’s past proposals to repeal and replace Obamacare included keeping the tax credits. “As long as there’s a tax credit, I think our exchange would continue to deliver commercial products to everyone above 100 percent of poverty level that’s eligible, because that has worked very well here,” he said.

It’s because of the successful exchange program that Idaho’s indigent care and catastrophic health fund is now spending millions less each year, Armstrong said, as more low- to middle-income Idahoans got health coverage.

Senate President Pro-Tem Brent Hill, R-Rexburg, said he’s hearing national debate about turning Medicaid into a block-grant program to states, and wants the Idaho Legislature to study state solutions.

House Speaker Scott Bedke, R-Oakley, agreed that if the Trump administration gives states the power to find their own solution, Idaho should be ready. But, he said, “We’re not going to be going down different paths that we can’t get out of.”