The Affordable Care Act’s (ACA) Medicaid expansion expanded Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level ($21,597 for an individual in 2025) and provided states with an enhanced federal matching rate (FMAP) for their expansion populations.

To date, 41 states (including DC) have adopted the Medicaid expansion and 10 states have not adopted the expansion. Current status for each state is based on KFF tracking and analysis of state expansion activity.

These data are also available in a table format. The map may be downloaded as a Powerpoint.

Minimum Wage Should the Federal Minimum Wage Be Increased? Ask the Chatbot a Question Contents Ask the Chatbot a Question Chicago protest for a higher minimum wage. Should the federal minimum wage be increased? (more)

The federal minimum wage, introduced in 1938 during the Great Depression under President Franklin Delano Roosevelt, was initially set at $0.25 per hour. The federal minimum wage has been increased by Congress 22 times, most recently in 2009 from $6.55 to $7.25 an hour. Most states plus D.C. have a minimum wage higher than the federal minimum wage, though several states do not have minimum wage laws (which means workers in those states default to the federal minimum wage). [7][85][186]

Early Supreme Court Decisions on the Minimum Wage The 1917 case of Stettler v. O’Hara was the first case brought before the U.S. Supreme Court that challenged the constitutionality of minimum wage laws. An evenly divided court (4-4) upheld the state of Oregon’s minimum wage law. Following the success of this case, three more states and D.C. passed minimum wage laws between 1918 and 1923. [99][102] In 1923 the U.S. Supreme Court in Adkins v. Children’s Hospital determined (5-3) that D.C.’s law was unconstitutional and “an arbitrary interference with the liberty of contract which no government can legally justify in a free land.” By Dec. 1932, minimum wage laws in six states had been repealed or deemed unconstitutional. [99][103][104][105] In March 1937 the constitutionality of state minimum wage laws was again debated in the U.S. Supreme Court in West Coast Hotel v. Parrish. The Supreme Court overturned (5-4) its prior anti-minimum wage ruling in Adkins by declaring that “the legislature has necessarily a wide field of discretion in order that there may be suitable protection of health and safety, and that peace and good order may be promoted through regulations designed to insure wholesome conditions of work and freedom from oppression.” By mid-1941, 26 states, D.C., and Alaska (still a territory at this time) had minimum wage laws. [99][115][116][117] In 1940 the Supreme Court upheld the constitutionality of federal minimum wage provisions within the Public Contracts Act (PCA) in case of Perkins v. Lukens Steel Co. The PCA is still in force today with the minimum wage provisions tied to the federal minimum wage as set by the Fair Labor Standards Act (FLSA). [118] In 1941 the constitutionality of the FLSA was upheld by the Supreme Court in the United States v. Darby, in which the court ruled unanimously that the “wage and hour provisions of the Act do not violate the due process clause of the Fifth Amendment” and that the “statute is not objectionable because [it is] applied alike to both men and women.” [114]

State Minimum Wage Levels and Restrictions As of Jan. 1, 2025, 45 states plus D.C. and all five inhabited U.S. territories had their own minimum wage laws in place. Twenty-nine of those states, D.C., and three territories had minimum wages higher than that of the federal minimum wage of $7.25 an hour – the highest being D.C. at $17.00 an hour. When a state minimum wage is set at a higher rate than the federal minimum wage, the highest rate prevails. Thirteen states and the Northern Mariana Islands set their minimum wage in line with the federal minimum wage; and two states – Georgia and Wyoming – set their rates lower at $5.15 an hour. However, Georgia and Wyoming must pay the federal minimum wage to those employed in positions covered by the FLSA. [85][117] Only workers employed in positions not covered by the FLSA, such as outside salespersons and certain domestic service workers providing companionship services, may be paid $5.15 an hour. Five states – Alabama, Louisiana, Mississippi, South Carolina, and Tennessee – do not have minimum wage legislation on their statute books and as such are required to pay workers covered by the FLSA a minimum of $7.25 an hour. [85][120] Many cities and counties now have minimum wages higher than their state-mandated minimum. As of August 2024, Tukwila, Washington, had the highest minimum wage at $20.29 per hour for large employers, which is almost 25 percent higher than Washington’s $16.28 state minimum wage and almost 180 percent higher than the U.S. federal minimum wage of $7.25. Seattle’s $19.97 rate and SeaTac, Washington’s $19.71 rate were the second and third highest in the United States. When a city or county minimum wage is set higher than its respective state and the federal minimum wage, the highest rate prevails. [136][208] Many states also have laws prohibiting cities and counties from setting their own minimum wage levels. [167]

Proposals to Raise the Federal Minimum Wage Since the Fair Minimum Wage Act of 2007 raised the federal minimum wage to $7.25 an hour starting in 2009, there have been numerous unsuccessful attempts by Congress to raise the wage further. The two main efforts are the Harkin-Miller proposal to raise the wage to $10.10 and the Living Wage Movement to raise the wage to $15. [150][151][153][154][156] U.S. Senator Tom Harkin (D-IA) and U.S. Representative George Miller (D-CA) introduced legislation in 2012, 2013, and 2014 to raise the minimum wage, but none of those efforts passed. When their proposal to raise the minimum wage to $10.10 was re-introduced for a third time in 2014 under the Minimum Wage Fairness Act, it was supported by President Obama. However, their bill failed by four votes to overcome a Republican-led filibuster in the Senate on April 30, 2014. [150][151][153][154] [156][168][169] On Jan. 14, 2021, President Joe Biden included a $15 minimum wage in the America Rescue Plan, a $1.9 trillion COVID-19 (coronavirus) rescue package. The Senate Parliamentarian ruled that the measure could not be included. As a result, Biden signed an executive order on April 27, 2021 that increased the minimum wage for federal contractors to $15 an hour effective in 2022. The raise was expected to impact hundreds of thousands of workers. [191][192] [193]

Who Earns the Federal Minimum Wage? According to the U.S. Bureau of Labor Statistics, 181,000 workers earned the federal minimum wage of $7.25 an hour and 910,000 workers earned below the federal minimum wage in 2021. The collective 1.1 million workers who earned at or below the federal minimum wage represented 1.4% of all hourly workers (76.1 million workers age 16 and older). [197] Those earning the minimum wage and lower are mostly: young: 44% are under 25 years old

female: of hourly workers, 2% of women and 1% of men earned at at below minimum wage

of any race: about 1% of white, Black, Asian, and Hispanic workers earned the minimum wage or lower

never married: 2% of minimum wage or less workers have never been married versus 1% who have been or are married

have an associate’s degree or less: 2% of workers without a high school diploma, high school graduates (no college), and those with some college or an associate degree earn minimum wage or less versus 1% of workers with a bachelor’s degree or higher

part-time employees: 3% of part-time workers earned minimum wage or less versus 1% of full-time employees

service industry workers: 5% of service workers (such as food preparation or serving) earned minimum wage or less, the highest percentage of any occupation.

living in the South [197]

Public Opinion Public support for raising the minimum wage has been over 70% as far back as 1994. [93] A 2013 Gallup poll found that 50% of small business owners were opposed to raising the minimum wage to $9.50 an hour and 60% believed such an increase would hurt most small business owners. A 2015 poll by the Wall Street Journal and Vistage International found that 49% of small business owners favored raising the minimum wage while 49% were opposed. [50][178] A May 2015 poll conducted by CBS and the New York Times found that 86% of Democrats, 50% of Republicans, and 76% of independents were in favor of raising the minimum wage to $10.10 per hour, and 67% of men and 75% of women were in favor. [91] A 2017 poll by the University of Maryland and Voice of the People found that 73.8% of Americans support raising the minimum wage to $9 an hour, while 56.8% support raising it to $10.10 an hour. A 2017 Quinnipiac University poll found that 54% of Americans would support raising the federal minimum wage to $15 an hour with 44% opposing. [184][185] A July 30, 2019 poll found 67% of Americans supported raising the minimum wage to $15 an hour. An April 22, 2021 poll reported similar support at 62%. By Dec. 2, 2022, support for raising the federal minimum wage was up to 70%, with American adults reporting that the federal rate was “not sustainable to live on for any period of time.” [194][195] [196]

Pros and Cons at a Glance PROS CONS Pro 1: Raising the federal minimum wage would not only allow minimum wage workers to afford basic living expenses but would also reduce income, gender, and racial inequalities. Read More. Con 1: Raising the minimum wage would increase housing and consumer goods costs for everyone and greatly disadvantage minimum-wage workers. Read More. Pro 2: Raising the minimum wage to match inflation and productivity would benefit the economy by increasing consumer activity and spurring job growth while lowering the federal deficit. Read More. Con 2: Raising the minimum wage, instead of allowing the free market to determine an appropriate rate, decreases employee compensation, while forcing businesses to close, use automation, or outsource jobs. Read More. Pro 3: Increasing the minimum wage would have numerous social benefits including reducing poverty and crime. whileimproving school attendance and family health. Read More. Con 3: Raising the federal minimum wage would exacerbate income disparities and the cycle of poverty. Read More.

Congress has passed a budget resolution that targets up to $880 billion or more in federal spending cuts from Medicaid over ten years. While specific proposals are not yet known, policies under discussion could limit financing and coverage for the Affordable Care Act (ACA) expansion group. Recent KFF polling shows there is little support for cuts to federal Medicaid spending overall, and a majority of adults (59%) oppose eliminating the enhanced federal match rate for adults covered under Medicaid expansion specifically.

The ACA expanded Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level ($21,597 for an individual in 2025) and provided states with an enhanced federal matching rate (FMAP) of 90% for their expansion populations over time, which is greater than the matching rate for Medicaid generally. While federal funding finances 90% of spending on the expansion population, states are responsible for the remaining 10% of costs for enrollees eligible under Medicaid expansion. As a result of a Supreme Court ruling in 2012, the expansion is effectively optional for states, and as of April 2025, all but 10 states have adopted the expansion. While expansion has led to higher government spending on Medicaid, a large body of literature shows that it is linked to reduced rates of uninsurance, increased health care affordability, improvements in access and health and outcomes, and economic benefits for states and providers. KFF polling shows that of people living in non-expansion states, two-thirds (66%) said their state should expand Medicaid to cover more low-income uninsured people.

This issue brief examines Medicaid expansion enrollment and Medicaid spending in expansion and non-expansion states and describes the characteristics of adults covered by the Medicaid expansion.

1. Medicaid expansion is widely adopted by both red and blue states.

Over the past 11 years, Medicaid expansion has been broadly adopted. The 41 states including the District of Columbia that have adopted Medicaid expansion are split nearly evenly between states that voted for Trump (21 states) and those that voted for Harris (20 states) in the 2024 Presidential election (Figure 1). Over half (27) of states adopted Medicaid expansion in 2014, while 14 states have implemented expansion since 2014, with South Dakota and North Carolina adopting most recently in 2023. Most states adopted expansion through legislation; however, in seven states, the expansion was adopted via a ballot measure. As of June 2024, over 20 million people were enrolled through Medicaid expansion, representing nearly a quarter of total Medicaid enrollment across all states and 31% of total enrollment in expansion states.

Medicaid expansion is linked to gains in coverage, access, increased health care affordability, and economic benefits for states and providers. Although establishing direct causality between health insurance and health outcomes is complex, evidence generally shows Medicaid expansion is associated with improved health outcomes, including increased early-stage cancer diagnosis, improved disease management, and lower mortality rates for many chronic conditions.

2. Medicaid median income eligibility for children, pregnancy, and parents, and Medicaid spending per enrollee are higher in expansion states compared to non-expansion states.

Overall, per enrollee spending for the expansion group was higher than for other adults and children but well below per enrollee spending for enrollees over age 65 and people with disabilities. While some critics of Medicaid expansion have argued that expansion diverts resources away from other groups of Medicaid enrollees, including people with disabilities and children, data show that expansion states spend more per enrollee overall and on each eligibility group than non-expansion states. Per enrollee spending for people with disabilities in expansion states is nearly 2.5 times the spending in non-expansion states ($25,170 per enrollee vs. $10,494) (Figure 2). The difference in per-enrollee spending for expansion and non-expansion states holds true for more detailed eligibility pathways for people based on age or disability. Expansion states also spent nearly $2,000 more per child enrollee than non-expansion states ($6,001 vs $4,295). The differences in per enrollee spending may reflect state policy choices about benefits and eligibility, in addition to payment rates, regional variation in health care costs, and state demographics.

In addition to difference in spending, expansion states have higher median income-based eligibility limits compared to non-expansion states for children (266% FPL in expansion states compared to 234% in non-expansion states), pregnant individuals (213% FPL compared to 203% FPL), and parents (138% FPL compared to 33% FPL). There is substantial variation in adoption of optional eligibility and other policies for seniors and people with disabilities, with state expansion status not a strong predictor of these policy choices.

3. Nearly four in ten women of reproductive age and over six in ten 50-64 year olds enrolled in Medicaid are covered through Medicaid expansion.

Medicaid expansion provides coverage across age groups for those 19 to 64 (Figure 3). Many expansion adults are working; however, they work for employers and in industries that are less likely to offer health insurance, leaving them without affordable health coverage options. As discussed below, older enrollees are more likely to have chronic conditions and may face more barriers to work.

Medicaid expansion also provides an important eligibility pathway for women of reproductive age, covering 38% of women ages 19-49 enrolled in Medicaid. For those who become pregnant, Medicaid coverage prior to pregnancy can promote pre-pregnancy health care, which can lead to healthier pregnancies and help reduce the risk of complications. Previous KFF analyses show that in expansion states, pregnant individuals are more than twice as likely to be enrolled in Medicaid prior to pregnancy (59%) than in non-expansion states (26%) (the difference in income eligibility levels for pregnant adults vs. other adults is large in non-expansion states, explaining the difference in pre-pregnancy enrollment rates). Medicaid expansion can provide stable coverage to pregnant individuals after the postpartum coverage period ends. Medicaid expansion coverage of parents also increases enrollment of their children: evidence shows that if children are eligible for Medicaid or CHIP coverage but unenrolled, when their parents gain coverage through Medicaid expansion it has a spillover, or “welcome mat” effect, increasing the number of children who enroll in health coverage. Medicaid expansion also covers adults as they age – more than six in ten Medicaid enrollees ages 50-64 are covered through expansion – and before they become eligible for Medicare.

4. One third of Medicaid expansion enrollees have a chronic physical health condition and a quarter have a chronic behavioral health condition.

Nearly half (44%) of expansion adults have at least one chronic condition, including 33% that have a chronic physical condition and 24% that have a behavioral health condition. Of Medicaid enrollees with at least one chronic condition, 53% are enrolled through Medicaid expansion (data not shown). Similar to all adults on Medicaid, the share of expansion adults with at least one chronic physical condition increases with age (Figure 4). Nearly six in ten (57%) expansion adults ages 50-64 have at least one physical health condition compared to just 16% of expansion adults ages 19-26. While the share of expansion adults with physical health conditions increases with age, the share with behavioral health conditions remains relatively stable, ranging from 19% to 26% across age groups.

Research finds that expansion is associated with improved access to care and outcomes related to behavioral health conditions. For other chronic conditions, expansion has positive impacts on access to care and may improve certain health outcomes. Medicaid coverage helps expansion enrollees manage chronic conditions and supports workforce participation. Medicaid expansion also provides coverage to individuals who have chronic conditions or disabilities that may limit their ability to work. Although some people with disabilities qualify for Medicaid because they receive Supplemental Security Income, most are eligible for Medicaid through other pathways, including the expansion group. While many adults who need long-term care may qualify for coverage through other Medicaid pathways, Medicaid expansion covers some individuals with costly health needs who may otherwise be unable to afford care; two percent (2%) of expansion enrollees, or 395,000 individuals, use long-term care services (LTC) which support activities of daily living such as eating, bathing, or dressing (data not shown). Medicaid expansion is also the primary pathway for Medicaid coverage for people with HIV.

5. Policy changes targeting Medicaid expansion would reduce government spending but also could put coverage for 20 million enrollees at risk.

There are several options under consideration in Congress to reduce federal Medicaid spending that could have implications for enrollees in the expansion group, including work requirements and changes in financing for the expansion. Congress may debate federal legislation requiring states to impose work requirements as a condition of Medicaid coverage. Most adult Medicaid enrollees are already working without a work requirement; estimates of national work requirements show $109 billion in federal savings over 10 years, and an increase in the number of uninsured, but no increase in employment. Beyond legislative changes, a number of states are pursuing waivers to condition Medicaid expansion coverage on meeting work requirements since work requirement waivers were encouraged and approved during the first Trump administration.

Congress may also consider proposals that would alter the financing for the Medicaid expansion. Any approach to reduce federal Medicaid spending for the expansion would shift costs to states, forcing governors to make tough choices about whether to drop the ACA Medicaid expansion, provide alternative coverage options or make up the loss of federal funding by cutting other state programs or raising taxes. Twelve states have “trigger” laws in place that would automatically end expansion or require other changes if the share of federal funding drops below 90%, and two additional states, Ohio and South Dakota, are considering similar action. But all states, including those without trigger laws in place, would examine their ability to maintain the ACA Medicaid expansion if Medicaid expansion financing was altered. An analysis of the impact on Medicaid enrollment if all states eliminated the expansion shows the decline in enrollment would vary across states, ranging from 19% in Massachusetts, Minnesota, North Carolina, and South Dakota to 49% in Oregon (Figure 5).

If states eliminate the Medicaid expansion, individuals with incomes 100-138% FPL would be eligible for subsidies in the Marketplace, but could face barriers transitioning to Marketplace coverage and could face higher out of pocket costs, especially if the enhanced subsidies expire at the end of 2025. However, current Medicaid expansion enrollees with incomes below 100% FPL are not eligible for subsidies in the Marketplace and could fall into the “coverage gap” and become uninsured if they are unable to qualify for Medicaid under a different eligibility pathway, for example based on a disability. Currently, 1.4 million adults are in the coverage gap in the ten non-expansion states; however, that number would likely increase significantly under proposed policy changes targeting the Medicaid expansion. Eliminating the Medicaid expansion could have additional spillover effects, including children whose eligibility status is unchanged but become uninsured after their parents lose Medicaid coverage. People without insurance have more difficulty accessing care and are more likely to have medical debt, with almost one in four uninsured adults in 2023 not receiving needed medical treatment due to cost. Uninsured individuals are also less likely than those with insurance to receive preventive care and treatment for major health conditions and chronic diseases.

Methods Medicaid Claims Data: This analysis uses the 2021 T-MSIS Research Identifiable Demographic-Eligibility and Claims Files (T-MSIS data) to identify Medicaid expansion enrollees, spending, and chronic conditions in Figures 2-4. State Inclusion Criteria: Expansion states: Though Idaho and Virginia expanded Medicaid prior to 2021, adult expansion enrollees primarily show up in the traditional adult eligibility group. Therefore, those expansion states are excluded from Figures 2-4. West Virginia is excluded from Figure 2 (but included in Figures 3-4) of this analysis due to unusable spending data, according to quality assessments from the DQ Atlas.

Non-expansion states: Mississippi was also excluded from Figure 2-3 this analysis due to data quality concerns flagged by the DQ Atlas. Enrollee Inclusion Criteria: Enrollees were included if they were ages 19-64, had full Medicaid coverage for at least one month, and were not dually enrolled in Medicare. Dually enrolled individuals were excluded from these calculations since they may not have had sufficient claims in T-MSIS to identify chronic conditions. Calculating Spending (Figure 2): This figure reflects spending from all states except Idaho, Virginia, West Virginia, and Mississippi. Average annual per capita spending calculations include fee-for-service spending and payments to managed care plans. Spending was calculated by summing the total spending of all claims per enrollee in the T-MSIS claims files. Estimates here do not include prescription drug rebates and most supplemental payments to providers. Defining Chronic Conditions (Figure 4): This figure reflects chronic conditions from all expansion enrollees in expansion states that expanded prior to 2021 except for Idaho and Virginia. This analysis used the CCW algorithm for identifying chronic conditions (updated in 2020). This analysis also included in its definition of chronic conditions substance use disorder, mental health, obesity, HIV, hepatitis C, and intellectual and developmental disabilities. In total, 35 chronic conditions were included and were further grouped into 3 broad categories: behavioral health, physical health, and cognitive impairment conditions. Specific conditions within these groupings include: Behavioral health conditions : Any mental health condition and any substance use disorder. See KFF’s brief, “5 Key Facts About Medicaid Coverage for Adults with Mental Illness,” KFF brief “SUD Treatment in Medicaid: Variation by Service Type, Demographics, States and Spending,” and the Urban Institute, Behavioral Health Services Algorithm for additional details ( Victoria Lynch, Lisa Clemans-Cope, Doug Wissoker, and Paul Johnson. Behavioral Health Services Algorithm. Version 4. Washington, DC: Urban Institute, 2024).

: Any mental health condition and any substance use disorder. See KFF’s brief, “5 Key Facts About Medicaid Coverage for Adults with Mental Illness,” KFF brief “SUD Treatment in Medicaid: Variation by Service Type, Demographics, States and Spending,” and the Urban Institute, Behavioral Health Services Algorithm for additional details Victoria Lynch, Lisa Clemans-Cope, Doug Wissoker, and Paul Johnson. Behavioral Health Services Algorithm. Version 4. Washington, DC: Urban Institute, 2024). Physical health conditions : Hypertension, transient ischemic attack, acute myocardial infarction, hyperlipidemia, ischemic heart disease, atrial fibrillation, heart failure, obesity, chronic obstructive pulmonary disease, pneumonia, asthma, diabetes, arthritis, hip fracture, osteoporosis, cataracts, glaucoma, chronic kidney disease, colorectal cancer, endometrial cancer, urologic cancer, prostate cancer, lung cancer, breast cancer, hepatitis, HIV, anemia, hypothyroidism

: Hypertension, transient ischemic attack, acute myocardial infarction, hyperlipidemia, ischemic heart disease, atrial fibrillation, heart failure, obesity, chronic obstructive pulmonary disease, pneumonia, asthma, diabetes, arthritis, hip fracture, osteoporosis, cataracts, glaucoma, chronic kidney disease, colorectal cancer, endometrial cancer, urologic cancer, prostate cancer, lung cancer, breast cancer, hepatitis, HIV, anemia, hypothyroidism Cognitive impairment conditions: Alzheimer’s, intellectual and developmental delay, Parkinson’s, and dementia

Appendix

Bill Description: House Bill 345 revises the Idaho Medicaid program to call for the Department of Health and Welfare to pursue waivers and repeals rules. It also imposes cost-control measures on Medicaid by altering sections of Idaho code.

Rating: +3

Does it increase barriers to entry into the market? Examples include occupational licensure, the minimum wage, and restrictions on home businesses. Conversely, does it remove barriers to entry into the market?

House Bill 345 requires the Department of Health and Welfare (IDHW) make a policy change that would end a practice that pays some medical providers more than others, depending on their ownership. Specifically, this bill requires IDHW to set “reimbursement rates for hospital-acquired physician practices at the same rate as physician-owned medical practices for all equivalent outpatient health services,” with limited exceptions.

Presently, Medicaid pays hospital-owned physician practices at a higher rate than others simply for being part of the hospital system. This makes Medicaid unnecessarily costly for taxpayers. It also encourages large hospitals to buy up small physician practices and unjustly picks winners and losers in the health care market. Making the change envisioned in this bill would reduce barriers to entry for small practice providers.

(+1)

Does it in any way restrict public access to information related to government activity or otherwise compromise government transparency, accountability, or election integrity? Conversely, does it increase public access to information related to government activity or increase government transparency, accountability, or election integrity?

This legislation fundamentally changes the way Idaho manages its Medicaid program. Medicaid would go from a government-administered, fee-for-service system to one managed by private insurance companies in a type of system called managed care. The state would pay a monthly, per-enrollee rate determined by actuaries instead of reimbursing providers directly for services.

Managed care would be administered by a private entity, introducing obstacles for transparency in how Medicaid spends public money. For example, Idaho’s current system allows visibility into how much is being spent at the provider level, but these arrangements are generally proprietary in a managed care system, invisible to the public. In essence, managed care makes Medicaid a “black box” program, reducing transparency.

(-1)

Does it increase government spending (for objectionable purposes) or debt? Conversely, does it decrease government spending or debt?

Though managed care systems take program administration out of the hands of the government, there is little evidence they save money or stabilize budgets when compared to the fee-for-service model. Some provisions in this legislation would have an eye for cost containment, but measures suggested in the bill like three-year contracts and performance incentives could have limited results rather than save substantial sums.

This bill also lacks some key program integrity measures, including limits on presumptive eligibility for able-bodied, working-age adults. Presumptive eligibility allows hospitals to treat patients in the emergency room and assume they are eligible for Medicaid coverage. If the person is later determined to be ineligible for the program, the state must pay the hospital anyway. A managed care system makes this worse because someone enrolled under presumptive eligibility will stay on the rolls for up to two months, even if that person was never eligible. Managed care organizations and hospitals alike would also be disincentivized to maintain the integrity of the rolls. In fact, they stand to gain financially from lax security, which increases fraudulent Medicaid spending.

(-1)

The Affordable Care Act — also known as Obamacare —- created health insurance exchanges to provide federally subsidized coverage through tax credits for insurance premiums. Exchange plans have more market accountability due to cost sharing like copays. This legislation would require Idaho to allow expansion enrollees above the poverty line to optionally enroll in an exchange plan instead of Medicaid. It is hard to envision a scenario where enrollees would voluntarily choose the added accountability of an exchange plan. Therefore, this doesn’t promise very many savings overall.

Additionally, this would also only reduce state costs, as the burden of these participants would shift to the federal taxpayer. Notably, if all enrollees above the poverty line switched to the exchange there are some savings to the federal government. This is because the cost of premium tax credits is somewhat less than the cost for Medicaid expansion coverage. But in Idaho’s case, however, these savings would not be very substantial in the near term.

(0)

House Bill 345 provides new authority for the IDHW to make necessary cuts to the Medicaid expansion plan to balance the state budget should the federal government change its participation level, such as reducing the federal government’s funding match for expansion enrollees. This is a positive change since Congress may pursue such cuts this year. IDHW currently has no authority to reduce the program in response, however. Allowing authority for the department to make cuts results in savings for the state since the program would be cut rather than unfunded expenses incurred under this scenario.

(+1)

Finally, this legislation ends the value-care pilot program. Value-care arrangements allow a primary care provider, known as value care organization, or VCO, to cooperate with the state as it treats Medicaid patients. VCOs get to select their risk level, which is their share of a patient’s costs above the standard monthly payment they receive from the state. As they accept more risk, they could share some of the savings. The savings a VCO gets to keep are also tied to how well they manage the health of their patients.

The problem with this program is that virtually all VCOs decided to accept little to no risk, resulting in lackluster performance. Ending this failed program would save an estimated $24 million per year.

(+1)

Does it increase government redistribution of wealth? Examples include the use of tax policy or other incentives to reward specific interest groups, businesses, politicians, or government employees with special favors or perks; transfer payments; and hiring additional government employees. Conversely, does it decrease government redistribution of wealth?

This legislation requires the IDHW to start implementing work requirements for able-bodied, working-aged adults on the program. This is generally a positive reform since it discourages a sedentary welfare collection lifestyle and it encourages enrollees to earn some form of a living or better their lives through work. But the mode for implementing this policy is flawed. The recent federal case of Rose v. Becerra shot down a similar approach in Kentucky. This bill, then, may as well have no work requirements at all since they would not stand up to legal scrutiny.

(0)

House Bill 345 retains existing code authorizing the IDHW to establish state-directed payments — a type of supplemental payment through managed care organizations that grants additional funds for providers. The value of these payments is limited to Medicare rates for comparable services. State-directed payments are funded by a combination of taxes on providers and a federal match. This becomes a type of money laundering scheme where providers pay a tax but then they and the state get that money back with additional federal dollars attached.

This legislation does not change the tax. Instead, it continuously appropriates the revenues. This removes the threat of the Legislature redirecting the funds, which would thwart providers’ ability to recoup their tax contributions. Using a continuous appropriation removes a layer of oversight and accountability and drives more spending in the program.

(-1)

Finally, House Bill 345 would broaden cost-sharing requirements on certain enrollees. This would give these enrollees a stake in their use of services, likely reducing their use and reducing costs.

(+1)

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?

This legislation stipulates that the IDHW may not “seek or implement” a “state plan amendment” that expands coverage, benefits, spending, or eligibility without first obtaining legislative approval. State plan amendments are agreements between the federal government and the state agency for operating the program. These are generally not determined by rule or statute, circumventing legislative accountability and giving undue influence to the federal government. This provision improves accountability and prevents unchecked growth of the welfare state.

(+1)

Does it promote the breakdown of the traditional family or the deconstruction of societal norms? Examples include promoting or incentivizing degeneracy, violating parental rights, and compromising the innocence of children. Conversely, does it protect or uphold the structure, tenets, and traditional values of Western society?

House Bill 345 stipulates that Medicaid may not cover gender-altering procedures for minors or adults. In the case of minors, providing these procedures is illegal under Idaho law. Medicaid should not provide coverage for these optional procedures that cause harm to the patients receiving the treatment. This provision upholds societal norms for the competent and prudent practice of medicine.

(+1)