“You may delay, but time will not.”- Benjamin Franklin
For a year now, I’ve waged a campaign to warn of legislative incompetence at best, malfeasance at worst. Last March, I wrote about the bait-and-switch from House Bill 138 to House Bill 345. The legislature brought Medicaid reform by first throwing out what Scott Adams termed “The First Big Ask.” The first big ask is a negotiating tactic President Trump often uses by throwing out extreme terms, only to return to where he hoped to be all along. In this case, they offered Medicaid Expansion Reform to settle on Medicaid Managed Care.
What is Medicaid Managed Care? It’s Medicaid as run by insurance corporations versus state entities. This is a win, right? Think of all of the money the private sector will save. Not exactly. Managed Care Organizations cost three times as much to administer as our existing system, so we can expect as much as 10% of current healthcare dollars to be diverted from healthcare to bureaucracy and profits in places like California or Minnesota. What’s worse, since those healthcare companies reside outside Idaho, expect hundreds or thousands of jobs in local Idaho communities to be lost. Managed Care can save you money if you go from an unmanaged fee-for-service system to a managed Medicaid system. But we’re not.
You see, for the last 33 years, each of 350,000 Medicaid enrollees was assigned to an Idaho clinic or doctor’s office, which was tasked with approving medical spend based on necessity and appropriateness under a system called Healthy Connections Primary Care Case Management. The Department of Health and Welfare set requirements for doctors’ offices, and in return for managing Idaho’s Medicaid patients, the state paid a supplement for services such as 24/7 phone access, late-night walk-in clinics, and care coordination that handled referrals and managed services for complex patient needs. Since Idaho’s Medicaid reimbursement is often below the cost of providing services, this cost-saving tradeoff made Medicaid acceptable.
To get HB 345 through, its authors needed to show cost savings, so they slashed the only primary care cost-containment tool Medicaid providers had: Case Management. The total program cost is $24 million annually, but after Federal matching dollars, Idaho has been responsible for $6.3 million annually. This cost represents less than 0.1% of Idaho’s $5.2 billion annual Medicaid budget. Still, it saves the state as much as $400 million a year by diverting patients from Emergency Rooms and from duplicative or inappropriate specialty therapies and services. As of January 01, Case Management no longer exists. Medicaid patients are decoupled from doctors, and there is no expectation that patients get permission to spend taxpayer dollars.
When this bill passed, it was understood that the cost-containment program would be rolled into the Managed Care Organizations’ contracts. In this way, primary care would continue its responsibilities, and only the payer would shift from government to insurance. What was not anticipated was a 3-year ramp-up period to Managed Care. Nobody is expected to resume this work until 2029. This delay has left Medicaid patients unmanaged as of January 01, and many primary care clinics are financially underwater due to Medicaid. The state’s budget has no gatekeepers between the emergency room and the public credit card. Add in Governor Little’s additional 4% rate cuts, and Medicaid is not only unmanaged, but it’s also unacceptable. Healthy Connections Case Management should never have been terminated.
As the husband of a community pediatrician, I’m keenly aware of the state of medicine in Idaho. Because one-third of Idaho’s kids are on Medicaid, this disproportionately affects pediatrics. As the vice chair of a county political party, I’m uniquely positioned to discuss the matter with elected officials. One aspect, in particular, that rarely gets discussed is that our social policy is being blamed for what are clearly fiscal policy problems. Idaho lost OBs because Medicaid is unacceptable, and it was blamed on the inability to kill babies in the womb. Prepare to lose pediatricians because Medicaid is unacceptable, but hear that it’s because doctors couldn’t perform pediatric gender transitions. Idaho already ranks dead last in the United States for pediatricians per capita.
In response to the fallout from HB345, we drafted an amendment to patch the hole left in Idaho Medicaid and have spoken with the majority of the legislature and the Lt. Governor’s office on the issue. We received support from 35 Idaho hospitals and clinics, the Idaho Chapter of the AAP, and the Idaho Academy of Family Physicians. We acquired legislative sponsors in the Health and Welfare Committees of the legislature, and we’re merely awaiting the opportunity to make our case before the legislature. To date, the chairs of the respective committees, Representative John VanderWoude and Senator Julie VanOrden, have refused a hearing, citing budget concerns.
Idaho hasn’t yet felt the bleeding in its primary care infrastructure or budget. Primary care is currently working extra hours at their own cost and holding out hope that the legislature that broke Medicaid can fix it before we bleed out. Since reimbursement is delayed by months and the program only ended on January 01, the first impacts will be felt when the legislature adjourns in March or April, when doctors begin reducing after-hours services or eliminating Medicaid contracts altogether. In the meantime, legislative pushback stems from budget hesitancy over the cost of the tourniquet to stop the bleeding. As others have noted, Idaho is sitting on $1.6 billion in rainy-day funds, but the government says it’s not yet raining. It will be a sad day in Idaho when we realize we allowed our primary care infrastructure to collapse for $6.3 million, while $1.6 billion sits in the other pocket.
If you or your child is on Medicaid, this affects you. If your doctor isn’t maximally impacted and can keep their lights on, even those not on Medicaid will feel this, as after-hours access and services begin to dry up. Keep Idaho’s primary care solvent and protect Idaho’s fragile budget. Call Senator VanOrden and Representative VanderWoude and tell them to hear RS33073 to restore the Healthy Connections Case Management program. Your doctor’s ability to care for you may depend on it.
- When The Tourniquet Costs Too Much - February 24, 2026
- A Season Of Change - November 24, 2025
- A House To Call Home - November 11, 2025