Gov. Brad Little (R) has signed on to a compromise between the Idaho House and Senate that would add mandatory work requirements for those enrolling under the state’s voter-approved Medicaid expansion plan.

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The state will need permission from the federal government to implement such a program.

Little signed the bill Tuesday despite concerns about the constitutionality of such requirements that were repeatedly brought up during public testimony and debates.

“We must encourage self-sufficiency among those receiving public assistance,” Little wrote in a letter approving the bill.

Idaho will now seek a waiver that would force anyone receiving health coverage under Medicaid work, study or volunteer for at least 20 hours a week on average per month. If a person doesn't meet those requirements, they would be kicked off of coverage for two months. They could be re-enrolled if they can prove they're working enough.

There are several exemptions under the proposal, including parents of children under 18, those receiving disability insurance and those who are caretakers.

“I’m very pleased. I think a lot of the people in the House did a lot of work to make that an Idaho solution to Medicaid expansion. I think the concerns have been overblown,” said Rep. Megan Blanksma (R-Hammett), one of the key architects of the bill.

Last month, U.S. District Court Judge James Boasberg struck down similar work programs in Arkansas and Kentucky.

“The Court cannot concur that the Medicaid Act leaves the [Health and Human Services] Secretary so unconstrained, nor that the states are so armed to refashion the program Congress designed in any way they choose,” Boasberg wrote.

“The negotiations with the federal government will be challenging, but I have confidence in my directors of the Department of Health and Welfare and the Department of Insurance and their ability to work with our federal partners and pursue the waiver required to implement this approach,” Little wrote.

Backlash from those opposed to adding work requirements was swift.

Democratic leadership in both the House and Senate qualified Little’s decision to sign the bill as “both fiscally irresponsible and inhumane.” Planned Parenthood Votes Northwest and Hawaii, the political arm of the healthcare group, called the governor’s decision “cowardly.”

Rebecca Schroeder, executive director of Reclaim Idaho, the group behind the Medicaid expansion initiative approved by nearly 61 percent of Idaho voters, said she was disappointed.

“I believe everyone has acknowledged that there’s a good chance that some of the waivers may not be accepted by the federal government and an even greater chance that this will end up in court, costing Idaho taxpayers who knows how much to defend,” Schroeder said.

In his letter, Little even said the legislature needed to revisit “key tenants [sic]” of the bill over the next several months and into the next legislative session that helps those receiving assistance spring out of poverty.

“Unfortunately, this bill fails to utilize our existing work and training program, which focuses on outcomes to help individuals find employment, complete training programs, and enroll in education programs to increase employment and enhance wages,” Little wrote.

The original version of the bill did include money for a new, state-funded training program, but it was cut out amid negotiations between the Senate and House.

“This is a burden on Idaho taxpayers any way you cut it up,” Blanksma said, referring to Medicaid expansion.

Adding extra money for a training initiative when there are private sector options, she says, isn’t necessary. “I can understand his concerns, but I don’t know that funding one more work training program is an effective use of those dollars.”

The proposal will also ask the feds for several other waivers, one of which would allow those earning between 100-138% of the federal poverty level to stay on the state health insurance exchange, though they would have the option to enroll in Medicaid.

Under Medicaid expansion, the federal government pays 90% of the costs – a much higher portion than it typically does.

A waiver like this has never been granted that includes that bigger match. Most recently, Utah received permission to enroll people earning up to 100% of FPL, albeit with the feds only picking up 70% of the tab.

Another controversial piece of the bill will, if a waiver is approved, force someone seeking birth control or other family planning services to first get a referral from their primary doctor.

Should the U.S. Supreme Court find part of the cost sharing agreement unconstitutional, the Idaho legislature would immediately invalidate the law.

One portion of the bill that saw widespread support would seek permission to use Medicaid dollars to help treat those who have significant mental illnesses.

In the meantime, legislative leadership will appoint a task force to study the potential effects Medicaid expansion will have on county and state indigent healthcare funds.

Those who are eligible for health coverage under the expansion should be able to enroll for coverage starting January 2020.

Follow James Dawson on Twitter @RadioDawson for more local news.

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