Comments on Idaho State Innovation Medicaid Waiver (§1115) Application for People with Complex Medical Needs.

DisAbility Rights Idaho is Idaho’s Protection and Advocacy System for people with disabilities.  We provide advocacy, legal assistance and public policy analysis on behalf of Idahoans with disabilities.

We recognize that this waiver, in conjunction with a proposed §1332 Affordable Care Act, State Innovation Waiver, seeks to provide health care coverage for about 35,000 Idahoans who are currently without coverage, and to provide Medicaid eligibility for Idahoans with certain diagnoses. We support the waiver application as a significant first step in shrinking the coverage gap and providing an appropriate range of long term services and supports for some Idahoans with disabilities.

The last comprehensive attempt to quantify the number of Idahoans without access to affordable health coverage fond approximately 78,000 people in the insurance gap[note]Milliman, Inc. “2015 Financial Impact of the Medicaid Expansion on the Idaho Medicaid Budget Including State and County Cost Offsets.” Jan. 2016.[/note]. Several years of improved economic conditions and increased employment have probably substantially reduced that number. Current estimates using SNAP data and other sources suggest that the population is currently around 54,000. It is likely that the people who remain in the gap are even more disproportionately people with disabilities, and chronic health conditions, since these people are the least likely to benefit from increased job availability.

By far the best option for Idaho and Idahoans with disabilities is to take advantage of the enhanced federal match associated with the Affordable Care Act’s expansion provision to provide coverage for everyone in the gap. The Legislature has not been willing to do that so far. This proposal is a positive step in that direction.

We recognize that the selection of conditions for the §1115 waiver are based primarily on the impact that these conditions have on private insurance costs, and the impact that those costs have on premiums. Our concern however, is the impact on people with disabilities. We are very supportive of the changes released on November 22, 2017 to the list of eligible conditions to include, spinal cord injuries, and others.

The Application for the Complex Medical Condition waiver (CMC) will provide Medicaid coverage for some people with disabilities, that is, people with the listed conditions. This is obviously a significant benefit for those people currently in the “gap”, but it is also a significant benefit for people with disabilities who have an insurance policy on the state exchange. Private health insurance policies do not provide significant coverage for either long term care or for Home and Community Based Services (HCBS). Under the CMC waiver, both are covered. This will improve the risk pool for the exchange plans while providing coverage better suited to the needs of people with complex health conditions. Appropriate HCBS can delay or eliminate the need for long term care facility placements, and can prevent deterioration in health conditions, thereby reducing preventable hospitalizations, surgeries and other high cost treatments.

The CMC waiver does not include any coverage for people with serious mental illness (SMI).  We strongly recommend that the department include people with SMI.

Although their inclusion will increase the cost of the Medicaid program, those costs to the state are offset by savings in the Division of Behavioral Health, the State Catastrophic Care fund, the county indigent programs, and  the regional crisis centers. Indirectly, there will eventually be savings to local law enforcement, emergency departments, jails, first responders and the courts. Medicaid coverage for people with SMI is an overall fiscal benefit to Idaho.

It may be argued that the 1332 waiver will provide an opportunity for coverage for Idahoans with SMI who are “in the gap”. First, it is not clear how people without taxable income will qualify for the 1332 waiver. This is likely to be a problem for people with SMI. Second, private insurance plans will cover psychiatrist visits, prescription drugs, and some level of hospitalization. But private policies do not cover the range of services that have been demonstrated to be needed to support people with SMI in the community. Some of the most critical services such as psychiatric rehabilitation, intensive outpatient, peer supports, case management, partial care, and medication management, are covered by Medicaid, but not by insurance. Without some of these supportive services many people with SMI will not be able to comply with their psychiatrist’s appointments, or their medication regime. DBH provides some supports like ACT teams, but only for people who are already in crisis, not as ongoing supports.

It may be the case that the inclusion of people with SMI, makes it more difficult to establish the budget neutrality component of the application, if the Medicaid costs are not offset by reduced premium credits. We do not have the actuarial information needed to assess this issue. However, if it is possible to develop a waiver application which includes people with SMI, we should not let the opportunity pass by.

Idaho has a broken and fragmented mental health system which provides few services for people with SMI until they are in a serious crisis, posing a risk to themselves or others. We have little to offer these Idahoans unless they qualify for Idaho Medicaid. This approach to mental health has filled our jails and clogged our courts with people whose only offense is having inadequately treated mental illness. By failing to implement the expansion offered by the ACA, we have refused funding which could help Idaho make significant improvements to our system. If there is any way that we can use this waiver to improve mental health services for Idahoans with SMI, it would be a shame to let another opportunity pass by.


Submitted by James R. Baugh, Executive Director, DRI