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With the Affordable Care Act coming before the U.S. Supreme Court next month, Idahoans who gained health insurance through the Medicaid expansion worry what the case’s outcome could mean for them.

More than 90,500 Idahoans have enrolled in Medicaid through the expansion, which voters passed in 2018 with more than 60% of the vote.

“If they repeal the ACA, then that means my family will no longer have the ability to go to the doctor,” said Leta Strauss of Grangeville, a small central Idaho city.

Stauss volunteered with the grassroots organization Reclaim Idaho to get a Medicaid expansion initiative on the ballot two years ago. Her daughter, grandson, granddaughter and two of her sisters-in-law gained health insurance through the expansion.

On the table before the U.S. Supreme Court on Nov. 10 is California v. Texas, which challenges the ACA’s individual mandate.

While Idaho is not involved directly in California v. Texas, the highest court in the land could erase Idahoans’ eligibility for the program, and that has folks all over the state very worried. Medicaid expansion was funded with the help of federal dollars. Due to the Affordable Care Act, the federal government agreed to pay for almost all of a state’s expansion in the years after a state government approved it, though that number would drop in subsequent years, eventually settling at 90%.

After voters approved Medicaid expansion, the Idaho Legislature passed a ”sideboards” bill, placing conditions on the expansion. One of them requires the Legislature to “consider” ending the expansion if the federal match rate drops below 90%. The state would find itself in that position if the Affordable Care Act is repealed.

But there are some who think that likely won’t come to pass.

Idaho Department of Insurance Director Dean Cameron said he does not expect the ruling to result in the loss of Medicaid for those who enrolled under the expansion. Even if the act were repealed, he said, he anticipates Congress would move quickly to replace it with something else.

THE LAWSUITCalifornia v. Texas is a challenge to the Affordable Care Act, the Obama-era law that mandated health care for Americans. The case hinges on the act’s “individual mandate,” which requires most adults to have some level of health insurance or else pay a fine to the IRS. But in 2017, Congress set the financial penalty payment at $0. That led to a lawsuit and a December 2019 decision by the U.S. Court of Appeals for the 5th Circuit declaring the mandate unconstitutional because it does not provide any revenue for the federal government. And that case is now approaching the Supreme Court.

Luke Mayville, Reclaim Idaho’s founder and a lecturer at Boise State University, said Medicaid expansion has offered working-class Idahoans the care they needed but couldn’t get before.

Prior to Medicaid expansion, Idaho’s Medicaid program mainly covered only children and people with disabilities; working adults without disabilities mostly weren’t covered at all.

“Idaho had a very restrictive Medicaid eligibility policy…” Mayville said. “What expansion did was say, look, there are a large number of working people in this country and in the state of Idaho who cannot get health care under the current system.”

Reclaim Idaho ran a grassroots campaign in all of Idaho’s counties to get out the vote in 2018 in order to implement the ACA’s Medicaid expansion policy, which offered states extensive federal funding to cover costs if they expanded Medicaid. Mayville is worried that the Idahoans who worked and volunteered for Reclaim Idaho will see their success pulled out from under them.

“Medicaid expansion is for working people who desperately need health care. … That’s part of what made it so appealing to the public, because if you’re working hard, you probably deserve to see a doctor. And that’s part of the stake here; there could be tens of thousands of people who won’t have any kind of health care,” Mayville said.

Dr. David Pate, the former president and CEO of St. Luke’s Health System, was also concerned about the possible loss of the Affordable Care Act and the domino effect for Idahoans on Medicaid. He said at the time the act passed, there were many people who had trouble getting insurance.

“I think people all too often forget what it was like a decade ago,” he said, of the availability of health care to people with less money.

One of Strauss’s cousins died a week after she was able to see a doctor for the first time. The woman had been working two jobs and hadn’t been able to get health insurance.

“It’s not just sad, it’s tragic,” Strauss said.

Strauss sits on the board of Syringa Hospital and Clinics, Grangeville’s local hospital. She knows some people without health insurance or the means to pay for care have to come to the hospital anyway, which impacts its financial health.

“The hospital is impacted by this as well,” Strauss said.

Jodi Peterson-Stigers, executive director the Interfaith Sanctuary homeless shelter in Boise, said Medicaid expansion was a game-changer for people experiencing homelessness. If the shelter’s staff encounters someone who doesn’t have Medicaid, they sign the person up.

“We do it immediately,” she said. “It’s a quick turnaround.”

Peterson-Stigers said the process allows the shelter’s guests to connect with a primary care physician, which means they don’t have to use the emergency room as their go-to resource for health care. It also means people won’t wait as long to see a doctor, which means they will likely get less sick.

“I’m super concerned about it going away,” she said.

Yet Cameron, head of the state’s insurance department, said the effect of repeal of the Affordable Care Act on Idahoans wouldn’t be as black and white as some might fear. The repeal of the act could possibly end the federal government’s payment to the state, which would then require the Legislature to consider ending Medicaid expansion. He didn’t think it would be easy to predict what would happen after that though.

“I do think it forces the legislature to have a pretty tough discussion,” he said.

He also floated a possible scenario in which Congress agreed to continue funding Medicaid expansion for states, even if the act were repealed.

Joseph Antos, a Wilson H. Taylor Scholar in Health Care and Retirement Policy, who is affiliated with the conservative think tank the American Enterprise Institute, also voiced doubts about the possibility of people on expanded Medicaid losing their coverage. The legal debate, he said, is about the individual mandate portion of the act, not the act in its entirety. It’s likely the U.S. Supreme Court would simply rule the mandate would need to be changed.

“The general consensus is that the Supreme Court will keep its focus on the most central issue, which is the mandate,” Antos said.

There’s nothing in the act specifically saying that if any one portion of it were declared unconstitutional, the rest of it would be protected, he said. But that’s not unusual, and he said there were “hundreds if not thousands” of examples of such legislation.

Antos’ arguments against the possibility the court would torpedo the entire act were mostly based on the way the court usually handled such cases. But he also made a more pragmatic, political argument, saying politicians would be ruining their careers if they tried to take expanded Medicaid away.

“Once something good has been given to the public, you can’t pry it back,” Antos said. “That’s a great way to retire from politics.”