BOISE • The governor’s plan to extend primary care coverage to the poor is in the hands of lawmakers.
The House Health and Welfare Committee voted unanimously to print the bill Thursday morning after a brief presentation from Health and Welfare Director Dick Armstrong.
The bill is “a very positive step in improving the health of Idaho citizens who are caught in the insurance gap through no fault of their own,” he said.
Committee Chairman Fred Wood, R-Burley, said he would likely hold a full hearing in about a week-and-a-half. Idahoans will have another opportunity to weight in on PCAP or other health-related issues before then — the House and Senate Health and Welfare committees are holding a joint hearing in the Lincoln auditorium at the Capitol from 8 a.m. to 10 a.m. Friday to take public testimony.
Idaho policymakers have been debating for several years what to do about the estimated 78,000 Idahoans who are in the “Medicaid gap,” who don’t qualify for Medicaid but are too poor to qualify for subsidized insurance on the state exchange.
Work groups appointed by Gov. C.L. “Butch” Otter have recommended two Medicaid expansion plans — full Medicaid expansion and a state-designed “Healthy Idaho” proposal. Neither has passed, and many GOP lawmakers are against the idea.
“The pushback on us was always, ‘We’re not going to start another federal program,’” Otter said at a breakfast with the Idaho Press Club Thursday.
The two bills got a hearing in Senate Health and Welfare last week, the farthest they have gotten so far. Committee Chairman Lee Heider, R-Twin Falls, said he wanted to wait to see the PCAP bill before acting.
“I wasn’t surprised but I am grateful,” Otter said of the hearing. “I’m grateful because we’re finally having a discussion on it,” noting that the conversation is now about what to do and not whether to do something.
Otter also fired back at his critics who say Medicaid expansion would be better. He challenged Democrats, who support expanding Medicaid as an alternative to his program, to come up with the votes. Otter doubts they’ll find them — he couldn’t, he said, even as a Republican governor in a GOP-controlled state.
“If they want to push Medicaid expansion, they’re going to have to get a whole lot more encouragement than I’ve ever gotten,” he said.
One big question that still needs to be settled is where the money for PCAP — $19 million the first year, $30 million a year after that — would come from. Otter’s original plan called for redirecting cigarette and tobacco tax money, but there has been talk of other sources, such as taking funds from the Millennium Fund. Others have suggested using savings the catastrophic health care program for the poor has seen as more of people get insurance through the state exchange.
Otter didn’t directly answer the question of funding Thursday, but he did point to the savings in the catastrophic fund as a sign that his decision to create a state exchange, which was opposed by many more conservative Republicans, is working.
“I don’t hear anybody yelling from the top of the roofs,” he said. “When we created the insurance exchange, we actually took a lot of pressure off the CAT fund.”
Many of the people who PCAP would cover already get primary care treatment at community health centers and would continue to if the bill passes. For example, 18,000 of the 30,000 people treated at the Boise-area Terry Reilly group of clinics in 2015 fall under the poverty level and would qualify, CEO Heidi Traylor told the House Health committee.
So how will PCAP help?
Basically, Traylor said, it means the clinics would get more money — $32 per month per covered patient — that they would use to expand the services they offer and treat more patients.
“Instead of waiting for patients to come in, you’re actually doing that outreach,” said Yvonne Ketchum, CEO of the Idaho Primary Care Association and the Community Health Center Network of Idaho.
Other providers could take part. For example, St. Luke’s officials told the Times-News in January they would likely look to participate in PCAP.
Minority Leader John Rusche, D-Lewiston, a Medicaid expansion supporter who is on the Health committee, asked Traylor a series of questions designed to elicit a comparison between PCAP and expansion. Traylor said she would prefer Medicaid expansion, which would let the Terry Reilly clinics help patients who need to see a cardiologist, a neurologist, or need bypass surgery or other procedure clinics don’t do.
“My worry with PCAP (is), it helps me do what I’m doing as a patient-centered medical home … but it stops at my walls,” she said.
At the same time, Traylor said, she knows Medicaid expansion would be a big step, so if lawmakers pass PCAP “we will do our darndest to make sure we’re good stewards of the money.”
Lawmakers also asked how the money spent on the program would be tracked. PCAP includes reporting requirements for the participating providers,” Ketchum said.
“As we understand the program, there will definitely be accountability on how the money is spent,” she said.
Noting that 9 percent of the people treated at Terry Reilly in 2015 were farm workers, Rep. Brandon Hixon, R-Caldwell, asked if they have a way to verify whether their patients are U.S. citizens. The PCAP bill requires participants to be U.S. citizens and Idaho residents.
“If that is a restriction that is imposed on us by this,” Traylor said, “we will build that into our intake process.”
Ketchum, Traylor and Mike Baker, head of Heritage Health in Coeur d’Alene, also spoke more generally about the work their clinics do and initiatives they have taken to improve health-care delivery, like building teams of nurses and mental-health specialists to work with doctors. Many of their patients, Traylor said, have both mental-health problems and other chronic physical conditions, which means they have had to expand and improve on the typical primary care model.
“Our people are too sick and need more support, both for them and for providers for that model of care,” she said.
Community clinics, which serve about one in 10 Idahoans — many of them uninsured — help reduce the toll of disease and the expense of hospital visits by providing primary care and giving people a doctor they know they can go to, Ketchum said. Although fees are on a sliding scale or nominal for the poorest, she said, poverty often deters people from even coming in.
“There are a lot of people who are lost in the health-care system and they don’t decide to seek care unless they’re actually ill,” she said.
Wood said his first choice, rather than either PCAP or Medicaid expansion, would be for the state to get its Medicaid money as a federal block grant and use it to design a system incorporating some of the work being done at the state’s community health centers.
That way, Wood said, “we could actually spend the money where the money is really needed and spend the money within the state without … interference from anybody else.”