After years of inaction from the Legislature on Medicaid expansion, voters will be given the opportunity to decide the issue at their polling places next month.

The election on Nov. 6 will decide the fate of Proposition 2, which has been years in the making in Idaho. A vote in favor of the proposition would expand Medicaid to the 51,000 to 62,000 people currently in the “gap”—those who earn too much to qualify for Medicaid but too little to get subsidized care under the Affordable Care Act.

How did Idaho reach this point? Congress passed the Affordable Care Act in 2010, and one of the major components was expanding Medicaid. The program matches state dollars with federal funding to provide health insurance for “low-income individuals, children, their parents, the elderly and people with disabilities,” according to the National Conference of State Legislatures.

The program has 74.5 million participants now, including Idaho residents. The question of whether to expand it to cover the gap population springs from a 2012 U.S. Supreme Court that upheld the ACA but gave states the option of whether to expand Medicaid.

Medicaid expansion has been roiling state legislatures, including Idaho’s, in the years since then.

Twenty-four states have expanded Medicaid. Another 17, including Idaho, have declined to do so thus far.

In addition, eight states have used a waiver to implement expansion. The waiver applications provide states flexibility in how they operate Medicaid programs. States apply to the federal government for the ability to change Medicaid eligibility, benefits, provider payments or cost-sharing, according to the Kaiser Family Foundation. Gov. Butch Otter and the Idaho Department of Insurance proposed a waiver in 2017. The Legislature did not pass that proposal in the 2018 session.

Voters in Maine passed Medicaid expansion at the ballot box in 2017, but the state government has not yet implemented it. Maine Gov. Paul LePage has ignored the ballot measure, which has spawned a lawsuit that seeks to force implementation. Earlier this year, the Maine Legislature passed $60 million to fund the state’s portion of implementing Medicaid expansion, but LePage vetoed the funding, according to Maine Public Radio.

What will happen if Idaho voters pass Proposition 2? The Legislature and the next governor—either Democrat Paulette Jordan or Republican Brad Little—will be tasked with implementing the expansion.

That will be a major issue in the 2019 legislative session. The actuarial firm Milliman has estimated that implementing Medicaid expansion will cost the state government about $10 million in the first year and about $105 million over the 10 years after that. That would bring in about $4.7 billion in federal funding.

Little has said he will respect voters’ wishes—that if they pass the initiative, he would work to implement it.

Jordan is unequivocal in her support of Proposition 2.

“They’ll bring our resources back to the state,” she said in an interview earlier this week. “The current administration has failed Idahoans. We have a right to our government. The government should work for us and not against us.”

The conservative Idaho Freedom Foundation has criticized the measure.

“Planned Parenthood, Hillary Clinton, Bernie Sanders and Nancy Pelosi love Medicaid expansion,” IFF President Wayne Hoffman wrote on the organization’s website this month. “So if you love them, you’ll love Proposition 2. … Obamacare expansion has the unflinching support of the most radical liberal politicians and organizations of our time.”

The liberal-leaning Center for American Progress issued a report estimating that 218 lives would be saved in Idaho each year by expanding Medicaid.

Among candidates for seats representing District 26 in the Legislature, the Democratic candidates uniformly support Proposition 2.

Republican Mike McFadyen, who is running against Rep. Sally Toone, D-Gooding, said he would not support the measure without a means of funding its implementation. Rep. Steve Miller, R-Fairfield, supported the waiver measure presented to the Legislature earlier this year. He said that if voters passed Proposition 2, it would present the Legislature with another opportunity to do a waiver application in 2019.

Republican Julie Lynn, who is challenging Senate Minority Leader Michelle Stennett, D-Ketchum, wrote that she supports Proposition 2 “with the caveat that there is considerable work that needs to happen to make it work in a fiscally responsible way.”

She advocates for a waiver that would “let those who self-insure buy plans that fit their needs,” and move residents with complex medical-care needs off the health exchange and into Medicaid. That would have reduced premiums in the broader pool; this proposal was included in the waiver bill that failed in the Legislature.

“The sad part is that the proposed Medicaid expansion would do nothing for the estimated half a million Idahoans who self-insure,” Lynn wrote. “They are dealing with premium costs that are spiraling out of control.”

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