Despite federal rules requiring plans to keep up-to-date directories, consumers may lack access to clear information about which health plans have 'narrow networks' of providers or which hospitals and doctors are in or out of an insurer's network.

This article first appeared November 01, 2018 on Kaiser Health News.

By Steven Findlay

As a breast cancer survivor, Donna Catanuchi said she knows she can't go without health insurance. But her monthly premium of $855 was too high to afford.

"It was my biggest expense and killing me," said Catanuchi, 58, of Mullica Hill, N.J.

A "navigator" who helps people find coverage through the Affordable Care Act found a solution. But it required Catanuchi, who works part time cleaning offices, to switch to a less comprehensive plan, change doctors, drive farther to her appointments and pay $110 a visit out-of-pocket — or about three times what she was paying for her follow-up cancer care.

She now pays $40 a month for coverage, after she qualified for a substantial government subsidy.

Catanuchi's switch to a more affordable but restrictive plan reflects a broad trend in insurance plan design over the past few years. The cheaper plans offer far narrower networks of doctors and hospitals and less coverage of out-of-network care. But many consumers are overwhelmed or unaware of the trade-offs they entail, insurance commissioners and policy experts say.

With enrollment for ACA health plans beginning Nov. 1, they worry that consumers too often lack access to clear information about which health plans have "narrow networks" of medical providers or which hospitals and doctors are in or out of an insurer's network, despite federal rules requiring plans to keep up-to-date directories.

"It's very frustrating for consumers," said Betsy Imholz, who represents the advocacy group Consumers Union at the National Association of Insurance Commissioners. "Health plan provider directories are often inaccurate, and doctors are dropping in and out all the time."

These more restrictive plans expose people to larger out-of-pocket costs, less access to out-of-network specialists and hospitals, and "surprise" medical bills from unforeseen out-of-network care.

More than 14 million people buy health insurance on the individual market — largely through the ACA exchanges, and they will be shopping anew this coming month.

Trend Appears To Be Slowing

For 2018, 73 percent of plans offered through the exchanges were either health maintenance organizations (HMOs) or exclusive provider organizations (EPOs), up from 54 percent in 2015.

Both have more restrictive networks and offer less out-of-network coverage compared with preferred provider organizations (PPOs), which represented 21 percent of health plans offered through the ACA exchanges in 2018, according to Avalere, a health research firm in Washington, D.C.

PPOs typically provide easier access to out-of-network specialists and facilities, and partial — sometimes even generous — payment for such services.

Measured another way, the number of ACA plans offering any out-of-network coverage declined to 29 percent in 2018 from 58 percent in 2015, according to a recent analysis by the Robert Wood Johnson Foundation.

For example, in California, HMO and EPO enrollment through Covered California, the state's exchange, grew from 46 percent in 2016 to 70 percent in 2018, officials there said. Over the same period, PPO enrollment declined from 54 percent to 30 percent.

In contrast, PPOs have long been and remain the dominant type of health plan offered by employers nationwide. Forty-nine percent of the 152 million people and their dependents who were covered through work in 2018 were enrolled in a PPO-type plan. Only 16 percent were in HMOs, according to the Kaiser Family Foundation's annual survey of employment-based health insurance.

The good news for people buying health insurance on their own is that the trend toward narrow networks appears to be slowing.

"When premiums shot up over the past few years, insurers shifted to more restrictive plans with smaller provider networks to try and lower costs and premiums," said Chris Sloan, a director at Avalere. "With premium increases slowing, at least for now, that could stabilize."

Some research supports this prediction. Daniel Polsky, a health economist at the University of Pennsylvania, found that the number of ACA plans nationwide with narrow physician networks declined from 25 percent in 2016 to 21 percent in 2017.

Polsky is completing an analysis of 2018 plans and expects the percent of narrow network plans to remain "relatively constant" for this year and into 2019.

"Fewer insurers are exiting the marketplace, and there's less churn in the plans being offered," said Polsky. "That's good news for consumers."

Insurers may still be contracting with fewer hospitals, however, to constrain costs in that expensive arena of care, according to a report by the consulting firm McKinsey & Co. It found that 53 percent of plans had narrow hospital networks in 2017, up from 48 percent in 2014.

"Narrow networks are a trade-off," said Paul Ginsburg, a health care economist at the Brookings Institution. "They can be successful when done well. At a time when we need to find ways to control rising health care costs, narrow networks are one legitimate strategy."

Ginsburg also notes that there's no evidence to date that the quality of care is any less in narrow versus broader networks, or that people are being denied access to needed care.

Mike Kreidler, Washington state's insurance commissioner, said ACA insurers in that state "are figuring out they can't get away with provider networks that are inadequate to meet people's needs."

"People have voted with their feet, moving to more affordable choices like HMOs but they won't tolerate draconian restrictions," Kreidler said.

The state is stepping in, too. In December 2017, Kreidler fined one insurer — Coordinated Care — $1.5 million for failing to maintain an adequate network of doctors. The state suspended $1 million of the fine if the insurer had no further violations. In March 2018, the plan was docked another $100,000 for similar gaps, especially a paucity of specialists in immunology, dermatology and rheumatology. The $900,000 in potential fines continues to hang over the company's head.

Centene Corp, which owns Coordinated Care, has pledged to improve its network.

Pennsylvania Insurance Commissioner Jessica Altman said she expects residents buying insurance in the individual marketplace for 2019 to have a wider choice of providers in their networks.

"We think and hope insurers are gradually building more stable networks of providers," said Altman.

New State Laws

Bad publicity and recent state laws are pushing insurers to modify their practices and shore up their networks.

About 20 states now have laws restricting surprise bills or balance billing, or which mandate mediation over disputed medical bills, especially those stemming from emergency care.

Even more have rules on maintaining accurate, up-to-date provider directories.

The problem is the laws vary widely in the degree to which they "truly protect consumers," said Claire McAndrew, a health policy analyst at Families USA, a consumer advocacy group in Washington, D.C. "It's a patchwork system with some strong consumer protections and a lot of weaker ones."

"Some states don't have the resources to enforce rules in this area," said Justin Giovannelli, a researcher at the Center on Health Insurance Reforms at Georgetown University. "That takes us backward in assuring consumers get coverage that meets their needs."

The U.S. is grappling with a doctor shortage that’s expected to grow to as many as 120,000 physicians by 2030. Foreign-born doctors are vital to the national healthcare delivery system.

This article first appeared October 30, 2018 on Kaiser Health News.

By Max Blau, Andy Miller and Katja Ridderbusch, Georgia Health News and Kaiser Health News

ATLANTA — Dr. Alluri Raju, a native of India, vividly remembers how his ethnicity prompted concern and discrimination in the southwest Georgia town of Richland. Doctors there hesitated to grant the family practitioner and general surgeon privileges to the local hospital when he arrived in 1981.

"I guess they wanted to cut me off so that I wouldn't be a competitor," he recalled.

Yet, in the 37 years Raju has been practicing in Richland, more than 20 doctors have come and gone and he's the only physician left — not just in Richland, but in all of Stewart County and neighboring Webster County, an area roughly half the size of Rhode Island with a population of more than 8,000.

"Today, I'm it," he said. And his patients, he said, treat him with respect — and not as a foreigner.

Stories like Raju's are the common thread for many immigrant doctors in the United States.

The American Medical Association said that, as of last year, 18 percent of practicing physicians and medical residents in the U.S. in patient care were born in other countries. Georgia's percentage of foreign-born doctors is similar, at 17 percent.

Yet President Donald Trump's focus on securing U.S. borders and restricting immigration — and the bitter arguments between the national political parties on the issue during midterm campaigns — have sown concerns about opportunities for foreign-born doctors.

Many of these doctors, like Raju, work in rural areas that are desperate to attract medical professionals. Yet those areas are often reliable supporters of Trump and his strict immigration policies. A recent national poll found that immigration is the top concern for Republican voters.

Some health care experts say Trump's tough stance could make it harder for rural areas such as Richland to relieve critical physician shortages.

Georgia's Republican lawmakers have considered legislation in recent years that opponents say would have restricted the rights of some immigrants. And Republican candidates for governor here campaigned in the primary this year on cracking down on illegal immigrants, though advocates for that position say bias is not the motivation, but rather the need for border security.

Raju's patients say they don't see any problem in seeking care from an immigrant. Raju has been treating Willie Hawkins, a retired road worker, for 30 years, as well as his mother and his sister.

Sometimes, Hawkins said with a smile, he has to ask the nurse what the doctor just said.

"You know, he talks a little funny," said Hawkins, 66. "But who cares?"

Maybe when Raju first came here to practice, people were a bit skeptical, Hawkins recalled. Many had never met someone from India before, he said. "But today it just doesn't matter," he said.

Foreign-born doctors are vital to the national health system. The U.S. is grappling with a doctor shortage that's expected to grow to as many as 120,000 physicians by 2030, according to the Association of American Medical Colleges.

Even now, primary care doctors are relatively scarce in certain areas of the country. Georgia has a few counties without any doctors at all, and many counties lack a pediatrician or an OB-GYN.

These immigrants help fill some of the gaps, especially in primary care, said Dr. William Salazar of Augusta University's Medical College of Georgia, who came to the U.S. from Colombia. And rural Georgia has a higher percentage of immigrant doctors than do urban areas, said Jimmy Lewis of HomeTown Health, an association of rural hospitals mostly in Georgia.

"Foreign-born doctors go to places no one wants to go," said Dr. Gulshan Harjee, a Tanzanian-born physician who co-founded the Clarkston Community Health Center, a free clinic serving mainly immigrants and refugees in metro Atlanta.

Patients' Bias

Several foreign-born doctors here recalled awkward interactions with patients, occasionally experiencing bias.

"When they think you're different, they think you're not as smart, and think they won't understand what you're saying," said Salazar. "You develop skills to overcome that.''

But patients overall are getting used to people from other countries, he added.

Saeed Raees, a pharmacist originally from Pakistan who co-founded the Clarkston clinic, said that "you'll run into a small minority who don't want to be seen by a foreign-born doctor or a Muslim doctor."

Physicians from predominantly Muslim countries face increased pressure after the Trump administration tightened its visa and immigration policies. Several doctors said that their visa applications take longer than before or are on hold, and re-entry into the U.S. after traveling was difficult.

Nearly half of Muslim physicians in the U.S. felt more scrutiny at work compared with their peers, and many said they experienced discrimination in the workplace, according to a study by Dr. Aasim Padela at the University of Chicago. Nearly a tenth of the physicians surveyed reported that patients had refused their care because they were Muslim.

There is also acceptance.

Dr. Buthena Nagi, a native of Libya, is employed as a hospitalist at Navicent Health in Macon. Nagi, 40, completed her residency at Morehouse School of Medicine in Atlanta in 2015. But to stay in the country she has to meet immigration criteria.

Most foreign physicians complete their residency in the U.S., typically on a student visa. To remain beyond that, U.S. immigration law requires them to practice in a medically underserved area for at least three years. Afterward, they can apply for a green card and, eventually, American citizenship.

Nagi wears a hijab — a traditional head covering for many Muslim women — with her scrubs, and sometimes patients and colleagues ask her about it.

"I then explain that this is part of my religion," she said. "And once the dialogue kicks in, the fear dies down, and people seem to understand that I'm not an alien from outer space."

In metro Atlanta's highly diverse DeKalb County, about 75 percent of the patients at the free Clarkston health center are immigrants, refugees or migrant workers. Up to 30 languages are spoken there. Co-founder Harjee said she speaks "only six."

Sameera Vadsariya, 37, said through an interpreter that she loves the services there. She was born in India and is here on a visa. She has no health insurance, so the free services are worth the long wait for treatment.

Most of the volunteer doctors at the Clarkston clinic are foreign-born, said Harjee. "This is a passion for them. They want to give back.''

Opportunity Lost

Belsy Garcia Manrique also wants to play a role.

At age 7, she left her home in Zacapa, Guatemala, and headed north through Mexico with her mother and sister. It was a two-week odyssey — a combination of walking and driving — up to the southern tip of Texas. Her father, Felix, who had come to the U.S. two years earlier seeking political asylum, met them and drove the family to his home in Georgia.

For many years, she dreamed of being a doctor, hoping to treat Spanish-speaking patients in the parts of northwest Georgia where she was raised.

U.S. immigration policy, however, blocked her path to medical school. She was not a legal resident. Most states, including Georgia, prevented undocumented immigrant children like Garcia Manrique from qualifying for in-state tuition at public universities.

But Garcia Manrique caught a break when President Barack Obama issued an executive order six years ago that created the Deferred Action for Childhood Arrivals program. DACA offered more than 800,000 undocumented immigrants brought to the U.S. by their parents a chance to stay without fear of deportation.

From 2012 to 2016, medical schools from California to Massachusetts accepted roughly 100 DACA students, whose families hailed from Mexico, Pakistan, Venezuela and other countries. Garcia Manrique applied to nearly 40 schools. The Stritch School of Medicine at Loyola University Chicago, the first medical school to accept DACA students, was the only one that offered her admission.

Shortly after taking office in 2017, Trump rescinded DACA, a move that has become the subject of ongoing legal and political battles. If the law stands, Garcia Manrique will be allowed to stay in the U.S. But if it's overturned, she and DACA medical trainees won't be allowed to renew their work permits.

Garcia Manrique is finishing medical school and applying for a residency program to train in family medicine. Only two Georgia medical programs — at Emory University and Morehouse College — said they would consider a DACA recipient. She applied to both.

Of her 50 applications, Garcia Manrique received interview offers from nearly a dozen programs, including ones in Illinois, California and Washington. She hasn't heard from the ones in Georgia.

And these days she isn't sure if the Georgia she knew, and the Georgia she loved, is a place where she'd feel welcome.

"After a certain time of being looked down upon, being told 'no,' going the extra mile to get the same benefits, you get tired of that," Garcia Manrique said. "I've seen many immigrants who have talent in the South move out. Why not be somewhere where you're wanted?"

Proposition 8 would wipe out DaVita's earnings in California, according to recent investment firm reports. Passing the initiative 'would be so devastating,' to the tune of $450 million a year, that DaVita 'would likely walk away from the state altogether.'

This article first appeared October 29, 2018 on Kaiser Health News.

By Samantha Young

It's been a year of playing defense for DaVita Inc., one of the country's largest dialysis providers.

A federal jury in Colorado this summer awarded $383.5 million to the families of three of its dialysis patients in wrongful death lawsuits. Then this month, the Denver-based company announced it would pay $270 million to settle a whistleblower's allegation that one of its subsidiaries cheated the government on Medicare payments.

But its biggest financial threat is a ballot initiative in California that one Wall Street firm says could cost DaVita $450 million a year in business if the measure succeeds.

Despite these recent hits, the company continues to rake in profits and receive favorable ratings from stock analysts. Its shares are trading at about $65 a share, only about 19 percent below a 52-week high set in January. That's largely because DaVita controls about one-third of a growing market, health experts say.

"They don't really have many rivals, and they perform a necessary, lifesaving service," said Leemore Dafny, a professor of business administration at Harvard Business School. "If you're producing something people want to buy and you're the only one making it, people are going to buy it."

Patients with chronic kidney failure often need dialysis to filter the impurities from their blood when their kidneys can no longer do that job.

And as Americans live longer and get heavier, more people become diagnosed with kidney disease and possibly need dialysis. In 2015, 124,114 new patients received dialysis, up from 94,702 in 2000, a 31 percent increase, according to the U.S. Renal Data System.

DaVita is one of the largest dialysis providers in the country, operating more than 2,500 clinics nationwide. In California, the company operates 292 clinics, half of all chronic dialysis clinics in the state.

Its parent company, DaVita Inc., reported $10.9 billion in revenue last year and $1.8 billion in profits, almost all of which came from its dialysis business.

This year, company officials project the dialysis group will bring in $1.5 billion to $1.6 billion in profits. It's a big turnaround for a corporation that could barely make payroll in 1999, when it was under review by the Securities and Exchange Commission for questionable accounting practices. Its success has largely been credited to CEO Kent Thiry, a colorful personality who has dressed up as a Musketeer and ridden a horse into corporate meetings to rally workers.

Now those big profits — generated from treating sick patients — has put a target on the company's back, as well as that of its biggest competitor, Fresenius Kidney Care.

The Service Employees International Union succeeded this year in placing Proposition 8 on California's Nov. 6 ballot, which would limit dialysis center commercial revenues to 115 percent of patient care costs. The ballot fight pits a well-funded industry against labor and the California Democratic Party.

DaVita declined to make anyone available for this article, but in a statement said Proposition 8 "will limit patients' access to life-saving dialysis treatments, jeopardizing their care."

Last year, roughly two-thirds of DaVita's dialysis revenue came from government-based programs, such as Medicare and Medicaid. But that isn't enough to cover its costs, according to the company's 2017 annual report, which states that DaVita loses money on each Medicare treatment it provides. (Medicare covers dialysis for people 65 and older, and for younger patients after private insurance has provided coverage for 30 months.)

Instead, DaVita generates profits from commercial health plans, which it acknowledges pay "significantly higher" rates than government programs. The ballot measure targets those higher rates, which Dafny describes as "their bread and butter."

The prospect of the measure passing led DaVita to delay or cancel plans to open new clinics in California despite growing patient demand, Javier Rodriguez, chief executive officer of DaVita Kidney Care, told investors on a call in May, according to the online equity research website Seeking Alpha.

A few months later, Rodriguez declined to provide a dollar amount when asked how the initiative would impact the company. Rather, he warned investors that it would become "unsustainable" for the industry to treat the estimated 66,000 dialysis patients in California, should the measure succeed.

Wall Street analysts agree that Proposition 8 would wipe out DaVita's earnings in California, according to recent reports issued by investment firms J.P. Morgan and Baird. Passing the initiative "would be so devastating," to the tune of $450 million a year, that DaVita "would likely walk away from the state altogether," according to a March Baird report.

DaVita has poured $66.6 million into the opposition campaign as of Oct. 25, and rival Fresenius has contributed $33.6 million. That dwarfs $17.3 million in union contributions in support of the measure, according to campaign records filed with California's secretary of state office.

Both Wall Street firms conclude that Proposition 8 is likely to fail, citing the industry's massive spending and the union's record of failure at the polls on other issues.

The company's legal troubles don't worry stock analysts, either; Baird's October report on DaVita's financial performance dedicates just two sentences to them. It notes that DaVita "is subject to numerous ongoing government investigations and inquiries, similar to most large-scale, high-profile Medicare providers."

There are no specific references to the Colorado jury award this summer, which the company is appealing, over the death of three patients who died of cardiac arrest after treatment at DaVita clinics. Nor was there concern about this month's $270 million settlement over Medicare billing.

That's because those incidents are seen by investors as the cost of doing business — one-time hits that don't affect a company's earnings power in the future, said Matthew Gillmor, a senior research analyst at Baird.

"Almost all companies I follow, at some point, have had to pay a fine to the government," Gillmor said.

Thiry, DaVita's CEO, acknowledged that settlements, which aren't good public relations, are a reality for large corporations, when The Denver Post asked him last year about the company's previous legal battles.

"If, in a trial, you are found to be wrong on even a small part of the case, it could mean that you are excluded from Medicare, which typically would mean bankruptcy for your company," Thiry said. "So, you are essentially forced to settle."

If the push is successful, about 62,000 Idaho adults would be added to the program that covers 73 million low-income Americans. It would be a major advance for the ACA into one of the most conservative parts of the country.

This article first appeared October 26, 2018 on Kaiser Health News.

By Phil Galewitz

BOISE, Idaho — Standing outside the gun shop she co-owns, next to her SUV sporting "NRA" on the license plate, Christy Perry pledges full support for President Donald Trump.

"He's doing a good job," said Perry, a four-term Republican member of the Idaho legislature who has voted for a litany of conservative causes, including weakening labor unions, restricting abortion and boosting charter schools.

With those credentials, Perry hopes for another big win on Election Day — one that puts her at odds with Trump and GOP orthodoxy.

She's helping lead the drive to persuade state voters to expand Medicaid — a central tenet of the Affordable Care Act, the 2010 law embraced by Democrats and derided by many Republicans.

Perry has been pushing for Medicaid expansion the past several years in the state legislature, but those efforts were thwarted by top House leaders. Now a ballot initiative, Proposition 2, puts the matter before Idaho voters.

Perry said Medicaid coverage is desperately needed by people struggling in low-wage jobs and the economics make sense for the state given the federal government will pay a 90 percent share. An expansion will reduce or eliminate the need for other Idaho-funded programs to help the uninsured, she said.

She said the state can't wait any longer.

"The longer you wait, the more people die" because they miss out on care, she said.

If the push is successful on Nov. 6, about 62,000 Idaho adults would be added to the state-federal health insurance program that covers 73 million low-income Americans. It would be a major advance for Obamacare into one of the most conservative parts of the country.

Idaho is one of the remaining 17 GOP-controlled states where lawmakers have steadfastly resisted expanding Medicaid.

But voters in Idaho, Nebraska and Utah will decide next month whether to buck their political leaders and go forward with the expansion. The issue is also on the ballot in Montana, which expanded Medicaid in 2016. There, residents will decide whether to continue it past 2019.

Of those states, Idaho is arguably the least politically hospitable for Medicaid expansion. Trump carried Idaho by the largest margin — nearly 32 percentage points.

Last year, Maine became the first state to approve expanding Medicaid via a ballot referendum, although the GOP governor has stalled implementation.

Unlike Maine, where political power has been split between Democrats and Republicans in recent years, Idaho, Utah and Nebraska are solidly GOP territory.

Trump and Republican congressional leaders have vowed to repeal the health law, which made expansion possible by providing the bulk of the funding for those who qualify for new coverage.

Perry, 50, doesn't see a problem getting Trump voters to back the expansion. She said that the Republican failure to repeal the law last year opened the door for conservative states to go forward.

"I think people here listen to that and it now falls to states to go ahead" with expansion, she said.

Supporters of the referendum were successful at garnering 70,000 signatures to put the vote on the ballot, but they face a steep challenge educating the electorate about the complexities of Medicaid financing.

Tim Dunnagan, dean of the College of Health Sciences at Boise State University, said few Idaho voters know that most states — including neighboring Oregon and Washington — have already expanded Medicaid. Because the issue can be confusing, he said, voters may gravitate to their long-held concerns about paying more taxes and government overreach.

"There is a strong sentiment that if the federal government is involved, it is not a good thing," he said. "There's a fierce individualism out in the West."

Perry and the broad coalition endorsing the referendum — including teachers, employers, county sheriffs and the health industry — seek to remind voters that they are already paying for the health law's provisions through their federal taxes and the expansion would bring $400 million in federal funds into the state.

The expansion would cover residents with incomes below 138 percent of the federal poverty level, or nearly $17,000 a year for an individual. Currently, Idaho adults who do not have children and are not disabled are not eligible for Medicaid. Those with children can only qualify with incomes up to 26 percent of the poverty level, or $3,156 a year.

The expansion also would eliminate a gap for residents whose income is too low to qualify for government subsidies to buy private coverage but who earn too much to qualify for Medicaid.

Supporters have canvassed neighborhoods across the state in recent weeks. Hundreds of volunteers use lists of registered voters and a special app on their phone to detail their results.

On a recent evening, about 20 people gathered about 10 miles east of downtown Boise, where a field organizer gave them voter lists and instructions on how to approach homeowners.

Tracy Olson, 54, a nurse turned real estate agent, and Jill Galanter, 55, a physical therapist, went to an upper-income planned community. About two-thirds of the people they met said they support expansion, and most of the rest had not heard about it. Only a couple of people said they oppose the ballot question.

In their one-minute pitch, Olson and Galanter explained the coverage gap for low-income residents and the millions in federal dollars the state can gain by expanding. They didn't mention the ACA. That's not an oversight, organizers said.

"Obamacare has a negative connotation here," Perry said.

Mike Brown, 50, an engineer, told Olson he didn't know the issue but added that his health costs have soared in recent years. He nodded as Olson explained whom the expansion would help.

"I can sympathize," he said. They recorded him as a "leaning yes."

Richard Rapp, 75, a retired head of the career center at Boise State University, said he will support the expansion for humanitarian reasons. "Too many people don't have adequate coverage, and that ends up costing us all," he said.

Later that week, another volunteer, Lauren Necochea, also found support in the Nampa area, west of Boise.

Norm Holm, 67, listened to her pitch. "It makes sense to me," said Holm, a registered Republican. "Everyone deserves a decent shot at health care."

Asked if he knew that the Medicaid expansion is part of the ACA, Holm shook his head. "If they can't do away with it, maybe this is a way to make it better," he said, adding that he believes the health law has good and bad parts.

In contrast, opponents of the referendum stress how Medicaid expansion is part of what they call the "failed Obamacare."

The Idaho Republican Party and the conservative Idaho Freedom Foundation are fighting the ballot initiative. Foundation officials say it would divert dollars that could be spent on roads and education.

"Medicaid expansion is a cornerstone of Obamacare, which has failed to cover everyone and has led to increasing health costs," said Fred Birnbaum, vice president of the foundation.

His group plans to run radio commercials, use social media and put out flyers.

Lawmakers opposed to expanding Medicaid have argued that the state could not afford its share of the cost without having to raise taxes. Under the law, the federal government pays about 90 percent of the costs for expansion and states cover the rest.

But a state-funded report this year found it would cost Idaho relatively little — $105 million over 10 years, which includes savings from state and county funds that would no longer be needed to help the uninsured. Idaho's budget tops $3 billion a year.

Brad Little, the GOP nominee for governor who is widely expected to win in November, said he would abide by the will of the voters.

Perry is not the only Republican state lawmaker who has come out in support of expansion, but she is one of the most prominent. Perry tried — and failed — to get lawmakers to expand Medicaid. She is not running for re-election.

"Christy is well-known among GOP women and well-liked," said Toni Lawson, vice president of government relations at the Idaho Hospital Association, which supports the initiative. She said persuading GOP women to vote for expansion will be key to a victory.

Perry said her gun store ownership and mainstream conservative values will help gain voters' trust on Medicaid.

"Idaho is a conservative, Christian and right-to-life state, and Medicaid expansion fits right in with our morals and values we have," she said. "It's about doing the right thing."