In the fall of 2011, doctors found a fist-sized tumor lodged near Tory Bodily’s spine.
The tumor wasn’t cancerous, but doctors worried it could leave her paralyzed if it grew larger. Removing the mass would require surgery.
At the time, Bodily was a 22-year-old nursing assistant working at a cash-strapped Casper nursing home. Her employer had cut back on her hours and she couldn’t afford health insurance, which would have consumed about half her paycheck.
The surgery succeeded and Bodily recovered. But she was left with $90,000 in medical debt.
“I had no options,” she said. “I had to get the surgery.”
Before the operation, Bodily applied for Medicaid, a government health program that covers the poor and medically needy. They told her she didn’t qualify because she made too much money, was single and didn’t have any children.
Bankruptcy became her only option. It came with consequences.
“My credit is shot,” she said. “I have no chance of buying any kind of house or getting a truck loan or anything like that. So that’s pretty devastating.”
Bodily is one of roughly 83,000 people without health insurance in Wyoming. Like her, many have jobs that don’t earn enough to buy coverage.
The federal health reform law passed by Congress in 2010 included a provision that enabled the state to extend Medicaid to about 17,600 low-income adults in Wyoming. But lawmakers, wary of federal promises to fund the expansion, voted it down last month.
Wyoming lacks an alternative that could significantly reduce the size of its uninsured population, according to interviews with people who are familiar with the state’s health care system. Nor does it have a proposal to address the $200 million in uncompensated care that hospitals provide each year — costs that ultimately result in higher bills for people with insurance.
For the time being, Bodily and others like her are left with few options. They can’t afford health insurance and don’t qualify for government coverage. And in the aftermath of the Supreme Court ruling on health reform, many will miss out on subsidies when an insurance exchange launches in Wyoming next year.
“We just have to admit it. Some of our neighbors are subsisting on such low incomes that they cannot buy insurance,” said Dan Neal, who represents the Wyoming Coalition for Medicaid Expansion. “That is the reality of their life. Without this safety net of Medicaid expansion, they are going to be left out in the cold.”
Medicaid already provides coverage to about 77,000 people in Wyoming. It’s expected to cost the state $560 million during the current, two-year budget cycle, making it among the state’s most expensive programs.
Federal health reform requires states to extend Medicaid coverage to more low-income people. However, a ruling last year by the U.S. Supreme Court allowed states to reject certain parts of the expansion.
For Wyoming, optional expansion would have made poor childless adults eligible for Medicaid based on income alone. It would have also extended eligibility to more low-income parents. Combined, those expansion groups represent more than 20 percent of the state’s uninsured population.
At the Downtown Clinic in Laramie, expansion would have provided coverage for at least half of its 400 patients, said Executive Director Sarah Gorin. The clinic offers primary care to poor people who lack insurance.
Rejecting the expanded program means more misery for Gorin’s clients, she said. They already have a difficult time obtaining specialty care, and a number can’t work due to health problems.
“Nothing changes for them basically … it means more time without care for people without access to it,” she said.
When they rejected expansion, lawmakers argued they needed more time to understand health reform’s implications. Gorin has little sympathy for that sentiment.
“I wouldn’t react so strongly if there was an alternative,” she said. “But I don’t see the point in waiting when there is nothing else to offer.”
Many lawmakers remain skeptical that federal officials will honor their promise to fund at least 90 percent of the cost of growing Medicaid. They worry that committing to the program would eventually force the state to choose between spending millions more on health or booting thousands off the expanded Medicaid rolls.
“I don’t want to make promises that I can’t keep,” said Sen. Bill Landen, a Casper Republican who voted against expansion. “I think it would be worse for us to put 30,000 people on coverage we can’t sustain.”
Voting down expansion didn’t end the state’s health care problems, Landen acknowledged. But he contends it’s better to ensure the state can support an expanded program before acting.
“It is okay to put this in neutral for now, find out what the ramifications are, and then sort them out as we go,” he said.
Next year, the federal government will launch a health insurance exchange — a sort of online marketplace for consumers shopping for coverage. Many people who use the exchange will qualify for subsidies based on their income, making it easier for them to buy insurance.
But subsidies won’t be available to some of the people who lost out on coverage when lawmakers defeated Medicaid expansion. Ironically, it’s because they don’t earn enough.
Congress designed the subsidies to cover people whose incomes are at or above the federal poverty level. That translates to at least $23,500 for a family of four. People below that level would have been covered through Medicaid expansion.
However, the expansion, at least for childless adults and most low-income parents, isn’t going to happen in Wyoming. So members of that group who earn less than federal poverty level will now miss out on both Medicaid and the exchange subsidies.
Health officials aren’t certain exactly how many people are stuck in the gap between the two programs.
“I’m not sure they are going to have meaningful options at all,” said Mike Fier-berg, a spokesman for the Centers for Medicare and Medicaid Services. “Obviously, they will be able to go into the marketplace and purchase a policy. However, without the [subsidy], that policy might be unaffordable to them.”
Congress, when it wrote the federal reform law, didn’t anticipate a Supreme Court ruling that allowed states to opt out of Medicaid expansion, Fierberg said. The law would have to be revised in order to change who can receive the exchange subsidies.
Given the current composition of the Congress, that seems unlikely.
“We have to obey the law,” Fierberg said. “It’s Wyoming that decided what to do about it. Under the Supreme Court decision, that is their right to do so. But we can’t change the law.”
The federal government issued regulations last month that will offer some measure of help for people stuck in the gap between Medicaid and exchanges subsidies. According to the new rules, they won’t be penalized under the individual mandate for lacking health insurance.