Medicaid Expansion

A crowd listens to Gov. Matt Mead talk during a 2016 rally in support of Medicaid expansion at the Highlands Presbyterian Church in Cheyenne. Lawmakers have repeatedly balked at expanding Medicaid in Wyoming.

As voters in three of Wyoming’s neighboring states ponder Medicaid expansion, the Equality State’s two primary gubernatorial candidates remain polar opposites on whether to broaden the program here.

“The political and the legal framework that may have made Gov. (Matt) Mead consider it a few years ago is now different, and I’m not sure if it’s a particularly good solution for Wyoming,” said Republican candidate and state Treasurer Mark Gordon. “So I am not in support of Medicaid expansion.”

“We’ve turned down approximately $500 million in federal funding, which is just ridiculous,” said Democratic candidate Mary Throne, adding that the decision should be a “no-brainer.”

The debate over expansion has largely been moot in Wyoming, where the Legislature has repeatedly and firmly killed any attempt to broaden the program, even with support from Mead. In a state facing a number of health-related obstacles, from paying for long-term care to keeping costs down, it remains the most divisive.

Expansion, as allowed under the Affordable Care Act, or Obamacare, would significantly broaden who in Wyoming would qualify for Medicaid. Generally, the program is limited to very low income mothers, people with disabilities and people care for someone with a disability. Under expansion, it would include people who earn up to 133 percent of the federal poverty line.

Under expansion, the federal government pays 100 percent of the increased cost for a few years. If Wyoming were to expand this year, it would pay 10 percent of the cost, and federal coffers would cover the remaining 90 percent. According to Tom Forslund, the director of the state Department of Health, Wyoming would have received $577 million from the federal government between 2012 and 2018 had the state expanded, and roughly 20,000 people would have qualified for care.

Mead, who will be Wyoming’s governor until January, last year lamented that the state hadn’t expanded.

“I’m not going back in time, but when you’re turning away $100 million a year as a state because you don’t want to be part of the (Affordable Care Act), I mean, it’s a problem,” he said in August 2017.

Gordon said he believed Wyoming’s health issues are more on the “cost side” — meaning care is too pricey — rather than the “pay-for side.” He added that expansion would not save all of the state’s health care troubles, which is at least one point that Throne agrees with. To drive down costs, he suggested increased transparency in prices of care, which are notoriously difficult to navigate and pin down.

But she said expansion would prove an important piece and that if more people had coverage via Medicaid, then fewer would be unable to pay for their care — which in turns shifts costs to those who do. It would similarly help rural hospitals, she said, that often have razor-thin margins.

A Kaiser Family Foundation report from March found that expansion has helped avoid hospital closure, “particularly in rural areas.”

But Gordon pointed to Kentucky, which faces a Medicaid expansion shortfall that could reach $296 million by 2020, as evidence that the cost could still be significant to Wyoming.

The state would be “backing into some future costs,” he said.

Asked how she would successfully expand Medicaid when Mead — a two-term Republican governor in a deep-red state — was unable to, Throne said “it would be easier for me to build a coalition” to pass expansion. Besides, she said, it should’ve already passed.

“I shouldn’t be able to run on this issue,” she said, adding that Wyoming should take the money available as long as it is; the program can be ended if the federal government cuts its share below 90 percent.

The fact that the Affordable Care Act “didn’t go away” during the first year of the Trump administration may have helped her cause, Throne said. Now, leery legislators might be more open to the concept.

Indeed, while Washington may not be currently debating gutting Obamacare, there are still ongoing efforts to chip away at it. Arguments began last week on a challenge against the ACA’s protections for people with pre-existing conditions — almost certainly the most popular part of the health law — as part of a lawsuit brought by 20 attorneys general and governors.

Throne said she would not join that litigation and that she would urge the state’s congressional delegation to continue those protections.

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Gordon said he wasn’t familiar with the lawsuit and was hesitant to comment on it, but that those protections are “one of the biggest selling points of the Affordable Care Act and it’s certainly something that people have come to expect.”

Still, it is perhaps unsurprising that health care reform — which sparked waves of protests across the country last summer as Congress debated whether to gut Obamacare — isn’t a popular topic in Washington during an election year. Should it be repealed, what happens to those with pre-existing conditions in Wyoming who don’t have insurance through work?

Gordon said he “absolutely would support” high-risk pools — a state-run program that would, in terms of insurance, separate sicker individuals from commercial insurance. Theoretically, it ensures those Americans have coverage that may otherwise be denied to them because they have chronic health concerns.

Throne said the pools would be “better than nothing” but that “they didn’t work, so why don’t we try to find something that works instead of going back to something that didn’t work?”

Wyoming had a high-risk pool before the Affordable Care Act. Generally, such programs lost significant sums of money, often were more expensive for patients than commercial insurance and frequently had to be shut down.

Gordon said such a program in Wyoming would be a “priority.”

“I think that’s one of those things that you look at the architecture of the system and say, ‘We know this is a loss leader, and we understand that, but we are going to support that within limits,’” he said. “But of course the ‘within limits’ piece is where it gets difficult.”

Both candidates said they supported the state Department of Insurance efforts to bring down the cost of exchange plans. The department is currently working on what’s known as a 1332 waiver, which would “shore up fragile insurance markets, address unique state insurance market issues, or experiment with alternative models of providing coverage to state residents,” according to Kaiser.

In other words, Wyoming has a small population and one insurance provider on its exchange. Without competition and with the possibility that a relatively small percentage of sick patients could drive up costs, prices are unstable here. The waiver would allow the state to tinker with other models.

Throne and Gordon both said they were interested in what Alaska — a similarly rural, lightly-populated state — had done with its 1332 program. It had essentially set up a program in which the state would reimburse insurers for the most expensive patients.

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Follow education reporter Seth Klamann on Twitter @SethKlamann


Education and Health Reporter

Seth Klamann joined the Star-Tribune in 2016 and covers education and health. A 2015 graduate of the University of Missouri and proud Kansas City native, Seth worked for newspapers in Milwaukee and Omaha before coming to Casper.

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