Wyoming lawmakers are proposing moving many Wyomingites under Medicaid’s coverage when it comes to one specific and often costly medical service: air ambulances.
“We’ve gotta come up with other ways to deal with it,” Rep. Eric Barlow, the bill’s sponsor and a Republican from Gillette, said Monday. “It’s needed health care, but it’s gotten to a place where it’s just not affordable or accessible.”
Under the bill — designated House Bill 194 — the state would ask the federal Department of Health and Human Services and the Centers for Medicare and Medicaid Services to allow it to move air ambulance coverage under the state Medicaid plan. The state would pay a minimum of 80 percent of each transport’s cost, with the individual patient paying up to 20 percent of the ride.
“What we’re trying to do is limit, if not eliminate, balanced billing,” Barlow said, referring to the practice of patients receiving bills for medical services not covered fully by insurers.
He said the state would pay the air ambulance companies enough to cover their costs and to keep them interested in coming to Wyoming, as — he said — they’re a needed service. But he said the state would not pay as much as the companies typically charge now.
According to a 2017 federal report, the average air ambulance ride from Air Methods — one of the largest operators in the nation that also flies in Wyoming — was over $49,000.
The question of how to pare down air ambulance costs is a difficult one to answer, primarily because of a 1978 federal law that prohibits states from regulating the transports. That law was the basis of a lawsuit against Wyoming and its Department of Workforce Services brought by Air Methods and three other companies. The state had attempted to cap how much money it would pay the companies for workers’ compensation-related flights, but courts ruled that the federal law preempted any fee schedule.
Barlow said this bill would automatically include those insurers regulated by the state — including Blue Cross Blue Shield, which would be heavily affected. Other insurers could choose to opt in.
Multiple messages left for a Blue Cross Blue Shield spokeswoman were not returned Monday afternoon.
The bill would create an “air ambulance coverage account” to pay for the expanded coverage. The funding would be drawn from multiple sources, including a 0.75 percent tax on participating insurers’ premiums and considerations. Barlow said the state would also draw federal funding because the bill would essentially expand Medicaid in a very limited scope, for one singular purpose.
The goal is to shield Wyomingites from facing financial hardship — if not ruin — as a result of an air ambulance ride.
“My belief is that an air ambulance is one of those things that a majority of Wyomingites can’t afford,” Barlow said.
Richard Mincer, a Cheyenne attorney who represented air ambulance companies during their litigation against the state, expressed some skepticism about the measure. He and several attorneys and officials close to labor expressed concern about another air ambulance bill before Barlow’s committee, which would have allowed companies to balance bill Wyoming workers if they chose not to accept a roughly doubled Medicare rate. Barlow said that bill had been gutted and acknowledged it had been flawed.
“It’s either a creative way to try to address the whole issue of air ambulance bills or it’s a creative way to try to accomplish what they can’t through the workers’ comp system,” Mincer said Monday of this latest effort. “I’m not sure which one it is from the committee’s standpoint.”
“If the reimbursement rate is enough, if the reimbursement rate was enough to make it work, well it’s probably a good idea,” he added. “But I don’t think at this point that the Legislature is looking at the whole thing. I think they’re looking at what they’ve read about what an average air ambulance ride costs and they’re not factoring in how much of the people that are transported pay much less than what it costs and what that all ends up meaning.”
He pointed to a recent article in Aviation International News, a monthly publication that covers the air industry, that quoted an Air Methods executive as lamenting the low reimbursement pay of Medicare and Medicaid patients. That low pay, the executive and Mincer argued, explained why insured patients who ride air ambulances are charged as much as they are: In order to stay open, the companies have to charge the privately insured more to balance out the low amounts paid by the majority of patients.
The average flight costs between $6,000 and $13,000, according to the 2017 government report, which also quoted one company as saying that they had to increase prices 15 percent to grow revenue 3 percent.
Mincer said the air ambulance industry was not the “gold rush” it was made out to be. He disputed several claims made at the beginning of the bill about the high cost — and the effects of those costs — of transports.
Prices jumped significantly — by nearly 300 percent for Air Methods — between 2007 and 2016, according to the 2017 Government Accountability Office report. The number of actual transports has stagnated, but the number of aircraft has increased (industry officials told investigators this may be affected by rural areas, where more helicopters are needed to cover a wider area but with fewer people). Three large companies told government investigators that they charged an average price of $40,000 per flight.
Similarly, the industry is becoming increasingly consolidated, often under the umbrella of private equity firms. One provider was purchased four years ago for $2 billion. Air Methods announced in 2017 that it would be acquired for $2.5 billion.
“The presence of private equity in the air ambulance industry indicates that investors see profit opportunities in the industry,” the report’s authors wrote.
Further, the report states that air ambulance companies could charge what they liked, as the patients who used their services were typically not in a position to weigh one company’s prices against another.
The report found that the majority of revenue for the large air ambulance companies comes from those with private insurance — a group that would largely fall under Barlow’s Medicaid proposal. Between 2010 and 2014, three large insurers reported paying 70 percent more to air ambulance companies — from $15,600 in the earlier year to $26,600 in 2014.
At the very least, both Barlow and Mincer agree that Wyoming needs air ambulances. It’s just a question of how to best serve that need.
Barlow said some have suggested waiting for a federal fix — for Congress to change the 1978 law that stops states from regulating the industry. But he said such a fix did not appear to be coming.
“We’re probably millions of dollars away in cost to Wyoming consumers before anything even gets proposed there,” he said, “much less accomplished.”
After an hour of climbing, Mark Jenkins said he reached the summit of Mount Sinai, a mountain in Egypt that’s considered a holy site by the Abrahamic religions.
Pilgrims of many faiths sat peacefully beside one another, watching the sunrise, he recalled.
“There were probably 100 people there and everyone gave one another the space and the dignity to pray to their own god,” he said. “Fifty-five years ago, Martin Luther King said that someday black men and white men, Jews and gentiles, Protestants and Catholics, will be able to join hands. We are fractured by divisive politics and extremists agendas, but we can rise above it and we can coexist.”
Jenkins — a graduate of the University of Wyoming who now travels the world writing for National Geographic — was speaking Monday, Martin Luther King Jr. Day, at First United Methodist Church in Casper as part of Wyoming’s Equality Day Celebration.
The annual event was organized by Serve Wyoming, an organization that promotes collaborative efforts among private, nonprofit and governmental organizations that advance community service. A handful of other groups, including the Wyoming Food For Thought Project and the NAACP’s Casper branch, also helped.
Jenkins told the crowd that the media often focuses on conflicts and violence. But after his extensive travels, the writer said he’s seen too much good in the world to give up hope.
“Humans can live in harmony,” he said.
Casper Mayor Charlie Powell also spoke at the event and acknowledged that society has a long way to go before equality is achieved. But like Jenkins, he urged the crowd not to be discouraged.
“We are not helpless,” he said. “I think we can, in our little community here, serve as an example of how to do things the right way.”
Prior to the service at the church, a march for equality was held in downtown Casper. About 80 bundled-up residents, including toddlers riding in strollers and seniors who leaned on their canes, walked along Midwest Avenue and East Second Street.
Some carried signs emblazoned with empowering messages or quotes from King.
“Only love drives out hate,” read one poster board. “We must learn to live together as brothers or perish together as fools,” read another.
Casper resident Leann Rogers said she attended because she wanted to make a statement against hate.
“I was raised to treat people with respect,” she said. “I’m not from a family that judges people by their skin color. You should judge people on their character. You should treat other people how you want to be treated.”
Rogers said she believes everyone should seek out conversations or friendships with those from diverse backgrounds.
Casper resident Becky Goddard said she came out to stand up for social justice.
Explaining that she participated in an LGBTQ pride march last year in Casper, Goddard said she believes the community has become more tolerant over the years.
“There is a long way to go, but it has gotten better,” she said. “That (pride march) wouldn’t have happened in Casper back when I was in high school.”
Goddard said she appreciated the Casper Police Department, who helped out by closing off a few streets and watching over the march.
Following the service, participants gathered in the church’s basement to assemble kits for the homeless.
“The more people who can help, the more people we can serve,” Serve Wyoming executive director Shelly McAlpin said.
A group of five black men shouting vulgar insults while protesting centuries of oppression. Dozens of white Catholic high school students visiting Washington for a rally to end abortion. Native Americans marching to end injustice for indigenous peoples across the globe who have seen their lands overrun by outside settlers.
The three groups met for just a few minutes Friday at the base of the Lincoln Memorial, an encounter captured in videos that went viral over the weekend — and again cast a spotlight on a polarized nation that doesn't appear to agree on anything.
At first the focus was on a short video showing one of the high school students, Nick Sandmann, wearing a red "Make America Great Again" hat and appearing to smirk while a crowd of other teens laughed derisively behind him as a 64-year-old Native American, Nathan Phillips, played a traditional chant on a drum.
Pull back further and a different view emerged, however, in a separate video showing members of a group calling itself the Black Hebrew Israelites taunting everyone on the mall that day, calling the Native Americans who had gathered there for the Indigenous Peoples March "Uncle Tomahawks" and "$5 Indians" and the high school students "crackers" and worse.
It was an ugly encounter of spewed epithets but one that nevertheless ended with no violence.
Still, the videos were all over social media, again appearing to illustrate a nation of such deep divisions — racial, religious and ideological — that no one was willing to listen to the others' point of view. Add to that the political tensions spilling over from a government shutdown that has gone on for a month and the stage was set for a viral moment. But in this case it didn't tell the whole story, all the parties involved agree.
"I would caution everyone passing judgment based on a few seconds of video to watch the longer video clips that are on the internet, as they show a much different story than is being portrayed by people with agendas," Sandmann, a junior, said in a statement released late Sunday.
Sandmann's statement seems at odds with some video from the confrontation that showed students from his school, Covington Catholic High in Park Hills, Kentucky, laughing at Phillips' Native American group and mockingly singing along with him, as well as interviews with Phillips who said he heard the students shout "Build that wall!" and "Go back to the reservation!"
The fullest view of what happened that Friday afternoon came from a nearly two-hour video posted on Facebook by Shar Yaqataz Banyamyan. It showed members of his Black Hebrew Israelite group repeatedly interacting with the crowd as people from the Indigenous Peoples March and the high school students vigorously argued with them for a few minutes.
Sandmann said in his statement the students from his all-male high school were waiting for their buses near Banyamyan's group when the latter started to taunt them. One of the students took off his shirt and the teens started to do a haka — a war dance of New Zealand's indigenous Maori culture, made famous by the country's national rugby team.
Phillips, an elder of the Omaha tribe, and Marcus Frejo, a member of the Pawnee and Seminole tribes, said they felt the students were mocking the dance and walked over to intervene.
Phillips and Sandmann locked eyes, their faces inches apart. Both said their goal was simply to make sure things didn't get out of hand.
The high school students felt they were unfairly portrayed as villains in a situation where they say they were not the provocateurs.
"I am being called every name in the book, including a racist, and I will not stand for this mob-like character assassination," Sandmann said in his statement.
The Roman Catholic Diocese of Covington apologized for the incident, promising an investigation that could lead to punishment up to expulsion if any wrongdoing by the students was determined.
The Indigenous Peoples Movement felt the encounter was a reminder the U.S. was founded on racism and President Donald Trump's presidency is rekindling hatred based on skin color.
"Trump has riled up a reactionary voting block that reminds us that we are a nation founded on patriarchy, genocide and racism. Trump is clearly giving these archaic instincts license, encouraging the kind of aggressive goading that I witnessed," movement spokesman Chase Iron Eyes said in a statement.
Trump himself weighed in with a tweet Monday night as some news reports questioned whether the early criticism of the students was warranted. The president tweeted, in part: "Looking like Nick Sandman & Covington Catholic students were treated unfairly with early judgements proving out to be false - smeared by media. Not good, but making big comeback!"
Banyamyan posted his own reaction on Facebook, referencing the dozens of high school students in their Make America Great Again gear coming over to his group of five and chanting. In a rambling video, he also praised Phillips and compared Sandmann to the devil.