Idaho Gov. Brad Little gives his annual State of the State address on Jan. 6, 2025, on the House floor at the Statehouse in Boise. (Pat Sutphin for the Idaho Capital Sun)
For years since voter-approved Idaho Medicaid expansion took effect in 2020, Republican state lawmakers have pointed to the program’s rising costs as a reason for reform.
Two weeks ago, as Idaho House lawmakers debated and narrowly passed a Medicaid expansion reform-or-repeal bill, many critics said it would effectively repeal Medicaid expansion — because Idaho couldn’t get federal approval for the proposed policy changes in time.
The bill, House Bill 138, by Rep. Jordan Redman, would demand 11 policy changes to Idaho Medicaid.
If the bill becomes law, Idaho failing to implement a single one of its 11 policy demands by July 2026 would trigger a repeal of Medicaid expansion in Idaho.
Medicaid expansion, approved by nearly 61% of Idaho voters via ballot initiative, extended Medicaid coverage to a population commonly called the “working poor” that fell in a health care assistance gap.
Idaho has already attempted — or to some extent, already adopted — five of the bill’s 11 proposed policy changes, an analysis by Idaho Voices for Children found.
Idaho Legislature introduces tweaked Medicaid cost bill, with work requirements
The remaining six would be new to Idaho. Other states failed to receive federal approval or never tried for many of them, the analysis found.
Ten of the 11 policy changes in Redman’s bill require federal approval, the analysis found.
Idaho already tried to implement two similar policy changes — work requirements, and an option for the state-based insurance exchange — which were not approved by the Trump administration during President Donald Trump’s first term in office that ended in early 2020.
On top of the mixed historical success states have had getting federal approval on similar policy changes as Redman’s bill proposes, the bill’s timeline is too fast, critics say.
“It’s simply not enough time to even go through the waiver process and public comment period — not to mention implement at the state level — by the deadline given,” Hillarie Hagen, senior policy associate at Idaho Voices for Children, told the Idaho Capital Sun in an interview.
Agreeing the bill would likely repeal Medicaid expansion, Senate Health and Welfare Committee Chairwoman Julie VanOrden, R-Pingree, has stopped the bill from advancing in the Senate. But on Thursday, Sen. Glenneda Zuiderveld, R-Twin Falls, unsuccessfully tried to schedule the bill for a hearing in committee — citing the rising costs of Medicaid and the bill’s House passage.
In her newsletter, Zuiderveld said she’ll continue trying to advance the bill this year.
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Rep. Redman says bill is aimed to reform, not repeal, Idaho Medicaid expansion
Redman, a Republican from Coeur d’Alene, says the bill is intended to reform, not repeal, Idaho Medicaid expansion by adding accountability to control the program’s budget.
He says federal approval of his bill’s provisions is likely, suggesting that the new Trump administration is different.
“As far as new things being done, I don’t think we’ve ever seen an administration move as fast and do as many new things as we’re seeing this year,” he told the Sun in an interview.
Trump supported a congressional budget plan that critics say would massively cut Medicaid. All but one U.S. House Republican passed the plan last week, with a slim majority over the opposition of all Democrat U.S. House lawmakers, States Newsroom reported.
But Trump has assured Republicans won’t “touch” Medicaid, Medicare or Social Security.
Speaking to reporters last week, Idaho Gov. Brad Little said he doesn’t say what he’ll do with a bill until it arrives on his desk.
The governor said he’s in favor of controlling Medicaid’s costs, but he acknowledged Medicaid expansion “was passed overwhelmingly by the public.”
He hadn’t fully read the bill, he said, “but I’ve read enough of it to know I’ve had concerns.” But Little expressed optimism the new Trump administration would grant more Medicaid waivers.
Last week, Redman and other Idaho lawmakers introduced a Medicaid cost-control bill — without an expansion repeal trigger.
House Bill 138 would remove tens of thousands of Idahoans from Medicaid
If House Bill 138, the Medicaid repeal-or-reform bill, becomes law, Idaho successfully implementing all of the bill’s policies would mean kicking tens of thousands of Idahoans off Medicaid expansion.
One of the bill’s provisions would cap Medicaid expansion enrollment at 50,000 people, or less than all disabled and senior Idahoans on Medicaid — whatever is lower. Asked how many disabled and senior Idahoans are on Medicaid by another lawmaker on the House floor, Redman said about 35,000 people.
Medicaid enrollment can change over time. But if the bill took effect now, that provision alone would cut off Medicaid expansion access to more than half of Idahoans currently enrolled — which is about 89,300 people, according to state health figures.
Another provision in the bill would make people ineligible for Medicaid expansion after three years of being on the program.
On average, Idahoans spend almost five years on Medicaid, state health data show. But Idahoans only spend about nine months on Medicaid expansion, on average, according to a report released late last year by Idaho Voices for Children.
‘People are going to die’ if Idaho repeals Medicaid expansion, doctor says
In 2016, before Idaho voters approved Medicaid expansion, Dr. Kenneth Krell told an Idaho legislative committee lawmakers had killed about 1,000 Idahoans over three years by refusing to expand Medicaid.
Krell, a former ICU director in eastern Idaho, advocated for Idaho Medicaid expansion after one of his patients died. He says her death was preventable.
If Idaho repeals Medicaid expansion, “a whole lot of people are going to die,” he told the Sun in an interview.
He isn’t sure how many. But he says primary care doctors will feel how patients are impacted.
“Because suddenly those patients are unable to access the care they’ve been receiving because they’re no longer funded,” Krell said. “And a lot of those patients are just going to quietly disappear.”
And he believes the Legislature knows the bill would end Medicaid expansion.
It “kind of gives them a quieter way to do that” than a straight-forward repeal bill, Krell said.
Research has found lower mortality rates in states that expanded Medicaid. A 2022 study found states that expanded Medicaid had lower mortality rates “from any cause after Medicaid expansion than in non-expansion states.”
Debating the bill on the House floor, Idaho House Minority Leader Ilana Rubel, D-Boise, said before Idaho expanded Medicaid, tens of thousands of Idahoans were in a coverage gap. “People were dying of preventable illnesses,” she said.
“It was not a magical wonderland here before we passed Medicaid expansion, where people just pulled … themselves up by their bootstraps, and everybody had coverage, and everybody just worked that much harder,” Rubel said. “… It was terrible.”
Idaho’s 2019 federal waiver for Medicaid work requirements is still pending
In 2019, the Idaho Legislature passed a bill requiring Health and Welfare to seek a range of federal Medicaid waivers, including work requirements for able-bodied adults on expansion and giving expansion-eligible Idahans the option to receive tax credits for insurance on Idaho’s health exchange, Your Health Idaho.
In August 2019, a month after Idaho submitted Idaho’s insurance exchange option waiver application, the federal Centers for Medicare and Medicaid Services, or CMS — then under the first Trump administration — denied it.
Idaho’s application “contains no information to support a conclusion that the proposed … waiver would not increase the federal deficit,” CMS wrote.
Fuhriman, the representative from Shelley, doesn’t agree that waiver would actually increase costs for the federal government.
“To the federal government, 90% is less than 100%. Therefore, they’re not (deficit) neutral,” he said. “Pretty stupid, right?”
Idaho’s work requirement waiver is still listed as pending by CMS. Redman’s proposed work requirement is more stringent than Idaho’s law that spurred the state’s pending work requirements application, the Idaho Voices for Children analysis says.
If agencies don’t work ahead, Idaho bill gives 10 months to implement policy changes
If passed, Redman’s bill would take effect in July.
By October, Idaho state agencies would be required to submit to the federal Centers for Medicare and Medicaid Services, or CMS, waivers for the bill’s proposed policies.
If those policies aren’t in effect about 10 months later, by July 2026, Idaho Medicaid expansion would be repealed.
Repealing expansion also requires federal approval, lawmakers say.
Redman told the Sun his bill leaves a lot of the process in the hands of the Idaho Department of Health and Welfare. But he said the agency can package together many of the policies into one waiver.
Lumping together the conditions into one waiver would add complexity and time needed for federal review, Hagen told the Sun. “For something of that magnitude, you’re likely looking at something a year and a half or more,” she said.
“There is zero chance that every single one of them passes and meets rules to satisfy requirements,” Hagen told the Sun.
Redman understands the bill’s timeline is ambitious. But he thinks the federal government is moving at record speed.
“We’ve never seen that. And good or bad, we’ve seen speed right now. We have seen efficiencies, and so I think that’s what we’re going to see on these waivers, too,” Redman told the Sun.
Asked about how several of his bill’s policies haven’t been attempted, Redman said “Idaho needs to take the lead.”
“We’re not the only state that’s dealing with this,” he told the Sun. “So I think that (federal regulators) are highly likely to really approve these waivers and let this model play out in our state.”
Redman, a second-term North Idaho lawmaker, co-owns a health insurance company and several pharmacies. He told the Sun his insurance company only has one policy on Idaho’s insurance exchange — saying the bill’s passage wouldn’t impact him.
Rep. Ben Fuhriman, a first-term Republican lawmaker from Shelley and a financial planner and health insurance agent, opposed the bill — saying it would repeal Medicaid expansion.
“In my personal opinion, my belief — there is 0% chance that all 11 of these waivers get approved and implemented in the timeline,” he told the Sun in an interview.
The day Fuhriman first saw the bill, he stayed up until 2 a.m., studying how CMS has reviewed states’ Medicaid waivers, he told the Sun.
When Idaho lawmakers return next January for the 2026 legislative session, Redman says they could revisit the bill before the repeal trigger would take effect.
“There’s time to see what kind of movement we have on this. I mean, again, this is a goal to save the program. And I’m willing to do whatever that takes to save the program,” Redman told the Sun. “I do want urgency from the federal side. I think we’re going to see that.”
The bill also requires several administrative changes to broader Medicaid policy — not related just expansion — to avoid triggering a repeal of expansion.
“Those elements of the bill have not been attempted before in other states and have a lot of legal questions,” Hagen told the Sun.
New Trump administration and changes to Medicaid program
Hagen agreed the Trump administration is looking for new ways to change the Medicaid program. But she said Redman’s bill’s proposed waivers “are not necessarily creative or innovative.”
“They simply just take people off of the program,” she told the Sun.
Several of those waivers, she said, violate federal rules that state “these waivers (types) must expand coverage and increase access to the program or healthcare services.”
“Even if the Trump administration has a desire to approve some of these requirements, they still don’t meet waiver rules. And if approved, will likely end up in federal court, as many other state waivers have,” Hagen told the Sun.
Fuhriman said he doesn’t think work requirements alone can be approved.
“The thing that people don’t realize, I think, in this, is that this isn’t the Trump administration that gives these waivers willy nilly. It’s — it’s law,” Fuhriman said. “And some of these waivers are built into the Affordable Care Act. The changes they’re trying to make — the only way that they could approve those changes would be for Congress to come in and change the law.”
Speaking to reporters last week, Little, Idaho’s governor, seemed more optimistic about the prospect of federal approval. He said he guarantees there are going to be more Medicaid waivers.
Asked how the Trump administration could grant waivers previously rejected, Little suggested federal legal interpretations might change.
“We shall see. The one thing I will tell you about Donald J. Trump is he doesn’t mind pushing the envelope on some of those,” Little told reporters. “And I know that’s a real shocker to everybody in this room.”
CMS, which evaluates states’ Medicaid waivers, did not reply to a request for comment from the Sun about the likelihood of Redman’s bill’s demands receiving federal approval.
A spokesperson for the Idaho Department of Health and Welfare declined to comment on the likelihood of federal approval for the proposed waivers, saying the agency does not comment on pending legislation.
Trump officials’ mass firings of federal workers, spurred by billionaire Elon Musk’s Department of Government Efficiency, or DOGE, led to layoffs of federal health officials, including at CMS, Politico reported.
To Hagen, those layoffs are likely to extend the time needed to review waivers.
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