Disability advocates voice fears on Medicaid

BOISE — Much of the conversation on a sweeping Medicaid-reform bill that’s making its way quickly through the Legislature has centered around its implementation of work requirements, and disability advocates are worried that the potential for disruption of critical services is completely absent from debate.

“I have so much fear about the state being thrown into utter chaos if this comes to be,” said Christine Pisani, executive director of the Idaho Council on Developmental Disabilities.

House Bill 345 would make major changes to the way Idaho administers its Medicaid program, including contracting with a third-party managed care organization to oversee the entire program and repealing all of the administrative rules over how Medicaid is overseen.

“This bill actually provides for immediate savings to the state and provides for long-term sustainability and accountability in the entire Medicaid program,” bill sponsor Rep. Jordan Redman, R-Coeur d’Alene, previously said to the House Health and Welfare Committee.

The hundreds of pages of rules that are being repealed include provisions regarding recipients with disabilities getting home- and community-based services covered, which are essential for many people with significant disabilities and allow them to stay in their homes. Other parts of the rules regard coverage for early screening diagnostics, which can help diagnose disabilities in children early and significantly ameliorate the impact of their conditions.

Mel Leviton, executive director for the state Independent Living Council, said she and other advocates, providers and people with disabilities have worked on refining those roles for the past 20 years.

“It’s really taken a lot of trial and error and refinement to get that established the way it is now so that it really works for folks, and to see all that work go away and not know what the replacement is, it’s really scary for people,” Leviton said.

Pisani echoed Leviton’s concerns.

“There’s just a lot of questions because this is all happening so fast,” Pisani said.

The first version of the Medicaid reform bill was introduced Feb. 25. An amended version of it, HB 345, was introduced a few days later on Feb. 28, and passed out of the committee Tuesday.

The full House passed the amended bill Thursday. A hearing is scheduled Monday in the Senate Health and Welfare Committee.

Leviton was signed up to testify at the Tuesday public hearing but did not get a chance to speak. Most of the testimony at the hearing revolved around work requirements for the Medicaid expansion population. Pisani also noted there was no discussion regarding the impact to home- and community-based services.

Those systems could be significantly disrupted by a sudden change to managed care, Pisani said. Under the bill, the Idaho Department of Health and Welfare would be required to submit an application to the federal government with its plan to implement managed care by July 1, 2026.

The contracts with managed care organizations are typically large, complicated and take a long time to implement, Pisani said.

In 2023, the Legislature contracted with a third-party firm to create recommendations for containing costs in the Medicaid program. The final report from Sellers Dorsey did include a recommendation considering using managed care, but specifically called out a separate recommendation for home- and community-based services.

Other programs within Idaho, such as behavioral health, are administered by managed care organizations, called MCOs, and have had rocky introductions.

Idaho’s $1.2 billion contract with the MCO Magellan of Idaho to implement the behavioral health plan was the state’s largest in history. The contract went live July 1, 2024, and many of the providers have still not been paid by Magellan, Pisani said.

“We don’t have a good record in the state of Idaho of implementing any of our managed care contracts in a quality way that doesn’t cause a lot of chaos for providers and, more importantly, for people with disabilities and families,” she said.

Another concern has been that the bill sponsors and supporters have focused on the potential cost-savings of the bill, but Pisani said she’d like equal prioritization of good health outcomes.

“I think that it’s important not to be short-sighted when thinking about cost-containment and thinking about, how are we supporting people well to live really quality lives, supported in their home communities,” she said.

Pisani highlighted that in 2011, when the Legislature eliminated preventive dental coverage for Medicaid participants, emergency costs later rose significantly.

She and other advocates are not necessarily opposed to moving toward managed care, but the condensed timeline — and the fact that those with disabilities have not been at the table yet — is where the fear lies.

Leviton and Pisani both highlighted Tennessee as an example of moving its administration of Medicaid for people with disabilities to managed care in an effective way. The state held listening sessions and worked with stakeholders to develop its plan effectively, Pisani said — but it took a long time.

“I’m concerned about it happening too quickly and not including participants,” Leviton said, “because, as you can imagine, if you’re relying on these systems, really to keep you alive, and they suddenly change, that can be really scary.”

Guido covers Idaho politics for the Lewiston Tribune, Moscow-Pullman Daily News and Idaho Press of Nampa. She may be contacted at lguido@idahopress.com and can be found on Twitter @EyeOnBoiseGuido.