Idaho doctors say some will ‘live sicker, die younger’ with Medicaid cuts

BOISE (Idaho Statesman) — Randi La Salle said Medicaid was a lifesaver for her family. When her youngest son was born without a fully developed ureter, a tube that carries urine from the kidney to the bladder, he had to undergo several costly surgeries that were covered by the government program, which provides health insurance to low-income adults.

Without it, she would have gone bankrupt.​

But in 2023 the state began reevaluating Idahoans covered by Medicaid.

More than 185,000 residents were dropped from the program, including La Salle and her four children.

La Salle’s family has been on and off Medicaid after being dropped in 2023.

Now, she worries that coverage is in jeopardy once more, since Congress passed President Donald Trump’s “Big Beautiful Bill” that slashes federal spending on Medicaid to help pay for tax cuts and introduces new work requirements that Medicaid recipients would have to verify at least twice a year.

“They didn’t make it easier, they made it harder,” La Salle told the Idaho Statesman. “There’s a lot of families, ours included, who even recently have had to choose: Do I get the extra meat for the house, or do I save the money for a medical expense?”

Tens of thousands of Idahoans at risk of losing health coverage

Under the legislation, about 36,000 more Idahoans — on par with the populations of Eagle or Lewiston — are projected to be uninsured by 2034, the Congressional Budget Office estimates.

Thousands of additional Idaho residents are expected to lose coverage, too, because of changes to the Affordable Care Act, according to an analysis by KFF, formerly the Kaiser Family Foundation, a nonprofit health policy group.

The bill doesn’t extend the Affordable Care Act’s enhanced premium tax credits that were passed by Congress in the American Rescue Plan.

Those credits, which are scheduled to expire at the end of 2025, lowered the cost of health insurance premiums for many people who bought plans through the state marketplace.

The federal cuts to Medicaid aren’t scheduled to take effect until January 2027. But on Sept. 1, the Idaho Department of Health and Welfare cut 4% of Medicaid reimbursements for all providers and services, reducing general fund spending on the program by nearly $40 million this fiscal year, a spokesperson for Health and Welfare previously told the Statesman.

Gov. Brad Little had ordered nearly all state agencies in August to reduce their budgets for the 2026 fiscal year, which started in July, after state lawmakers reduced income and property taxes by over 20%. He also said the state needed to “make way” for the tax cuts in Trump’s bill.

The combined cuts to the Medicaid, which insures about 355,000 children and adults in Idaho, are expected to strain hospitals, nursing homes and community health centers that bear the cost of treating uninsured people.

Among all enrollees in the state, 42% are children and 35% live in a rural area, according to the KFF.

Many recipients ‘already challenged with life circumstances’

One of the biggest changes to Medicaid in the bill is a new federal requirement that mandates most people enrolled through Medicaid expansion spend at least 80 hours a month working, volunteering or in school.

The requirement applies to all able-bodied recipients ages 19-64. To maintain coverage, recipients will have to verify every month that they’ve met the requirement.

Dr. David Pate, a retired physician and the former CEO of St. Luke’s Health System, told the Statesman that the requirement adds another layer of bureaucracy that could ultimately lead to enrollees losing coverage, even if they’ve met the requirement.

“These are people that are already challenged with life circumstances,” Pate said. “When you make it really challenging and burdensome to requalify, there are going to be people that are knocked off merely because they didn’t or couldn’t comply, not because they were actually abusing the program.”

Most adults under age 65 who are enrolled in Medicaid are already working, a data analysis by the KFF shows.

Those who aren’t are either disabled, have caregiving responsibilities, an illness or health condition that prevents them from working or are attending school, and are exempt.

Nationwide, about 18.5 million people will be subject to the work requirements each year beginning in 2027. By 2034, the CBO projects federal Medicaid coverage will decrease by 5.2 million adults, with the work requirement increasing the number of people without health insurance by 4.8 million.

“I think that people may have the impression that this sounds like a really logical thing to do, to say, ‘If you can work, you need to work, instead of getting a quote unquote handout,’” Pate said. “But what most people may not be aware of is that when you put work requirements in place, it increases the overhead for Medicaid, and that cost is going to be absorbed by the state or counties or both.

“The other thing is that I have not seen the evidence that there are many people milking the Medicaid program. These are people who have really needed this lifeline.”

Most of the estimated federal savings in the bill are from the work requirement for the expansion group.

Idaho voters approved a ballot initiative in 2018 to expand Medicaid, extending health coverage to thousands of low-income Idahoans in a so-called coverage gap who earned too much for traditional Medicaid but not enough for marketplace subsidies.

The expansion took effect in 2020. By January 2023, around 145,000 Idaho residents were enrolled in the expansion. Those who qualify include individuals with monthly incomes of $1,563 or less or families of four with monthly incomes of $3,192 or less, according to Health and Welfare.

Over 80% have reportable income. Some, about 24%, are diagnosed with serious mental illnesses.

Mother works 3 jobs to pay for health insurance, expenses

La Salle was making just $75 over the income limit to qualify.

“We were hesitant to go to the hospital when he had issues,” the 39-year-old from Bliss said by phone. “Not having insurance is hard. You make a lot of tough decisions on whether or not it’s really worth it to go in, and you learn how to do first aid pretty quick, because if you can fix it, you don’t have to go to the hospital to do it.”

La Salle had to enroll in private insurance through her work. She started working two part-time jobs on the side to afford the insurance for herself and her children on top of her other expenses.

She took a part-time job working twice a week to clean the same office where she worked her full-time job, and worked as a DoorDash driver too.

“I was trying to make sure we had grocery money, soccer money, field trip money — all those little things that come with being a parent,” she said.

La Salle has been stuck between making just over the limit to qualify for Medicaid and not making enough to be able to comfortably afford to pay for private insurance, rent and family expenses.

After she divorced her husband, her two youngest sons were able to get on their father’s Medicaid. But once he remarried, the two sons were again kicked off, because he no longer qualified.

La Salle’s 13-year-old daughter by a different father is the only member of their family who was able to qualify for Medicaid.

Thousands of Medicaid patients in area could lose care

When people don’t have health coverage, they do not go get routine care, said Pate, the former St. Luke’s CEO.

People without insurance are far more likely to postpone or forgo health care visits entirely because of concerns over the cost, research shows.

And many doctor’s offices don’t accept uninsured patients, so when those people do need care, they often end up in emergency rooms with illnesses that are more difficult and expensive to treat than they would have been had they seen a doctor sooner, according to Pate.

“I still remember this time I was in the emergency room and a woman came in with left-sided chest pain,” he said. “I ran over to evaluate her because you have to move quickly if it’s a heart attack, and when I pulled back her gown, she had a breast cancer that had completely eaten through the skin, so I was looking at the muscles and bones in her chest cavity.”

She couldn’t afford to see a doctor and had waited until she couldn’t stand the pain any longer, he said.

By then, it was too late.

“Most of the time, if we can get breast cancer early, we can cure it,” Pate said. “She now had a condition that could not be cured and was going to kill her. When people don’t think they have options, they will let things get to a point where … really bad things happen.”

Dr. Ted Epperly, the CEO of Full Circle Health, a federally qualified teaching health center with over 40,000 patients across 10 clinics in the Treasure Valley, worries about the how cuts will affect his patients.

Federally qualified teaching health centers provide comprehensive care to low-income and uninsured populations and have primary care residency programs that train doctors to serve underserved communities.

Full Circle Health has about 18,000 patients on Medicaid.

Epperly expects that number to fall by about 2,000 to 4,000 after the changes to Medicaid take effect. He told the Statesman by phone that the cuts will disproportionately afffect the working poor, rural populations, people of color and the providers and health systems that care for them.

“Because of this, they’ll live sicker and they’ll die younger, mainly because of not having easy access in a timely way to getting appropriate health care,” Epperly said. “And the way it’s been constructed, most of this won’t come into effect until after the next election cycle. People will kind of forget about it because it’s delayed, but it’s going to be a significant impact, and that is the looming specter of all of this.”

The downstream effects could affect everyone, he said.

Hospitals, clinics and nursing homes in rural areas could suffer

Epperly said that clinics like his, as well as nursing homes and rural hospitals, may have to reduce services, lay off employees or close.

“All of this has a ripple effect,” Epperly said. “When you get out to rural areas, the biggest employer is one of two places — it’s either the hospital in those small communities or the nursing home in those small communities. So if you take away the No. 1 or No. 2 job in a rural area for people having a place to work, not only have you negatively impacted their health care, but you have negatively impacted their employment.”

In many small communities, hospitals are among the largest employers and economic drivers. Health and Welfare reports on its website that Medicaid expansion in Idaho actually reduced costs for health care providers.

Hospitals reporting spending $42 million less on charity care and had $61 million less in bad debt from 2019 to 2021.

Bad debt is money owed that a creditor determines is unlikely to ever be paid.

An increase in the cost of uncompensated care could disproportionately affect rural hospitals, many of which are already operating with negative margins.

The Emergency Medical Treatment and Labor Act, or EMTALA, requires hospitals to treat people during a medical emergency, regardless of their insurance status or ability to pay.

When a hospital treats a person who doesn’t have insurance and can’t otherwise pay, the hospital has to eat the cost of that care, often referred to as uncompensated or charity care.

To make up for it, hospitals could raise prices for other people who do have the means to pay.

Abner King, the CEO of Syringa Hospital and Clinics, the lone hospital in the small farming community of Grangeville in rural north-central Idaho, said the cuts to Medicaid will likely exacerbate his hospital’s finances.

The hospital, originally built before World War II, is overdue for a replacement, but it doesn’t have the money. For most of the last two decades, the hospital has been operating at a loss, King said.

Syringa isn’t alone.

Over a dozen other rural hospitals in Idaho are in a precarious financial position, worsened by rising costs and workforce shortages.

“It’s always a struggle to make rural health care work,” King told the Statesman by phone. “It comes down to volumes. Financial success, particularly for hospitals, is usually attributed to economies of scale, which you get with high volumes. That’s the thing we don’t have in rural health care.”

Medicaid cuts could exacerbate ‘extremely tight’ margins

King said his hospital could be forced to cut some services if the cuts to Medicaid cause an increase in uncompensated care.

“Delivering babies is always something you look at,” he said. “You want to be able to do that. You don’t want to think of an expectant mother in labor having to travel any more distance than absolutely necessary. You certainly don’t want to say, ‘Hey, now you’re going to have to go 70 miles further to deliver your baby.’

That’s something that’s always been a priority for us, but that is an example of a service line that may have to be taken back if we can’t carry the cost of providing it with the other business that we do.”

In the last few years, a growing number of hospitals in Idaho have made the decision to close certain units that bring in less money than they cost to operate. That includes three labor and delivery units in the state, at West Bonner General Health, a critical access hospital in Sandpoint; Valor Health, a nonprofit hospital in Emmett; and West Valley Medical Center in Caldwell.

The closures mean many pregnant patients must travel further to receive care.

Brad Turpen, the CEO of Valor Health, said by email that his hospital sees a higher percentage of Medicaid patients and in general, margins in rural health are “extremely tight.”

Brian Whitlock, the president of the Idaho Hospital Association, which represents 51 rural hospitals across the state, told the Statesman that half of those hospitals have less than 100 days of cash on hand. And half of county, district or nonprofit hospitals have operating margins of less than 1%.

He said that if hospitals can’t absorb the cost of uninsured people seeking emergency care, hospitals would likely have to shift the costs onto other payers.

“The cost for your health insurance and my health insurance — the premiums are going to go up when those costs for the uninsured get shifted to us,” Whitlock said. “They have to get paid one way or the other. The only other alternative is to close your doors and go out of business.”

He said the effects of Medicaid cuts could further dampen physician recruitment to rural parts of the state.

But there’s work that can be done before the changes are implemented, he said.

Whitlock urged residents to contact the state’s congressional delegation, which includes Sen. Mike Crapo, Sen. Jim Risch, Rep. Russ Fulcher and Rep. Mike Simpson.

“Change is coming, and it’s going to impact every Idahoan in one fashion or another,” Whitlock said. “We would hope that Idahoans would reach out to their Legislature and to their delegation and say, ‘Enough. Stop the war on health care. We want access to health care and cuts don’t get you there.’”