Myra Garcia had health insurance until she got cancer.
About three years ago, Garcia took medical leave from her job as a manager at the Laramie Dollar Tree for hand surgery from a previous injury.
She didn’t plan to be away from work long. But after she developed side effects from one of the painkillers her doctor had prescribed after the surgery, things began to spiral. She found herself at an urgent care clinic and then, a few months later, in the office of a specialist who told her she had stage four colorectal cancer.
It took months of doctors’ appointments to get that diagnosis, but Garcia was too sick to go back to work. After two or three months of not working, her marketplace health insurance was revoked. She hadn’t been able to pay her monthly bills, which between her and her husband cost the family of six $600 a month.
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“So I’m over here having to have chemotherapy, radiation, lab work done, just a bunch of stuff and the money is just adding up like so much money that I’m just lost,” she recalled. “Like, how do I pay all this when I’m unemployed?”
Garcia fell into the coverage gap — the space between folks who qualify for traditional Medicaid and those who can afford a plan through the Affordable Care Act’s insurance marketplace.
Tens of thousands of Wyomingites are like Garcia. A federal program to expand government health insurance could get them coverage, but state lawmakers have debated the particulars of doing so for nearly a decade.
This year, that debate has gotten farther than it ever has before: A bill to expand Medicaid in Wyoming passed a legislative chamber, advancing out of the House of Representatives. Advocates say that’s a reason for cautious optimism as lawmakers enter their final days of the 2021 session.
For the sake of families like hers, Garcia hopes lawmakers consider her story.
“When this first happened, the first thing that hit my mind was my children, my family ... the first thing that runs through my mind is my kids and my husband,” she said of her cancer diagnosis. “Like, if I’m gone what’s going to happen to them?
“And then after that kicks in, then the whole kicking in of, you know, I’m going to go through all this and then am I even going to make it out of it and then leave my family with all this debt? That’s something that I would always think about when I was sick.”
While undergoing exhausting bouts of chemotherapy and radiation treatments, Garcia was also scrambling to pay for the treatments that would keep her alive. She recalls writing letters to doctors, begging to have some of her bills written off. She applied and was denied for Medicaid. She received financial counseling from the hospital. But her family was drowning in bills.
“I was always tired,” she remembered. “Just knowing that you have the cancer is a shock in itself because you’re just constantly thinking like how did this happen? Why me, you know these things run through your head.”
“And then on top of it, you have piles and piles and piles of bills coming in daily from these collectors,” she continued.
The initial surgery to remove her tumor cost more than $285,000. Chemotherapy cost about $200,000, and radiation treatments were close behind, Garcia said:
“And it’s like, if you’re just a regular family, where are you going to get over a half a million dollars to pay these bills?”
‘I see no plan B’
Advocates have been working to expand Medicaid in Wyoming for nearly a decade, since it was introduced as part of then-President Barack Obama’s Affordable Care Act.
Wyoming has some of the highest health care costs in the nation, and advocates have said expanding Medicaid could help.
But lawmakers have balked at each proposal, looking instead for a “Wyoming-specific solution” to the mounting costs and the increasing number of people without coverage. Gov. Mark Gordon, too, has favored looking for “state-centered options,” he told the Star-Tribune last May, though he said at the time he would give expansion a “fair hearing,” if it came to his desk.
Editorials, news articles, testimony and social media posts going back as far as 2014 reference this “Wyoming solution,” often speaking of the lack of one.
Cheyenne Republican Rep. Sue Wilson, the chair of the Legislature’s House Labor, Health and Social Services Committee, touched on these efforts in her testimony in favor of expansion earlier this week.
“This wasn’t just something that came up out of anyone’s head this year,” Wilson said. “Since I’ve been in the Legislature (in) 2013 … we’ve been looking at Medicaid expansion, we’ve been looking at insurance options, we’ve looked at selling insurance across state lines, we’ve been looking at ways to fund family practice clinics.”
She continued: “There’s been … close to 10 years’ worth of attempts to find other programs. … After 10 years of trying to come up with plan B, I see no plan B, but I do see people coming through the labor committee having serious, serious needs.”
Studies show expanding Medicaid leads to fewer uninsured people. It makes sense, given that most uninsured people cite the cost of health care as their reason for being uncovered. In a poll from the health care think tank Kaiser Family Foundation, nearly 74% of uninsured adults cited cost as the reason.
Research from a variety of sources shows fewer uninsured people leads to a healthier population, better mental health and less medical debt on the system as a whole.
Pete Gosar, director of the Downtown Clinic in Laramie, provides low-cost health care to residents who can’t afford medical care elsewhere. He explained many of their patients have put off seeing doctors and come in more sick because of it.
“A lot of our folks come here with really advanced disease, but they have not had health care,” Gosar said. “Most of the folks that come here … have been without health insurance and without health care for quite some time.”
“It makes their conditions really difficult to treat and they’re much more complex than if they had access to care early on,” he added.
There are not many clinics in Wyoming that provide care at nearly no cost, as the Downtown Clinic does. Gosar said he knows there are people who have moved to Laramie from elsewhere in the state to receive their care.
“Just like I think there have people that have moved from Wyoming to Colorado to access care because (Colorado has) expanded Medicaid,” he added.
Medicaid is a federal insurance program that serves certain low-income individuals. Medicaid expansion takes that program and opens it up to a much larger pool.
To qualify for Medicaid in Wyoming, you have to meet both a financial and a categorical criteria. So, you have to either be pregnant, be a child or have certain disabilities while also making under a certain income, depending on the category you fall into.
The program right now serves roughly 12% of the state’s population — about 65,000 people as of December.
“So it’s not like it’s a small program, but traditional Medicaid is very categorical,” explained Stefan Johansson, Wyoming Department of Health’s deputy director.
Expanding Medicaid would make it available to any non-disabled adult making at or less than 138% of the federal poverty level. For a single person, that’s about an $8.50 hourly wage.
If expanded, the Wyoming Health Department estimates between 13,000 and 38,000 people could apply, but assumes the true number would fall closer to 25,000.
The time to act?
The debate being had by lawmakers now deals largely with incentives offered by the federal government to promote medicaid expansion.
The federal government right now pays about half of the state’s traditional Medicaid costs. The Affordable Care Act also guarantees federal money will pay no less than 90% of Medicaid expansion costs for states. (That number was 100% when Medicaid expansion first became an option but decreased to 90% under the phased plan.)
And this year, advocates say new federal incentives make it a hard deal to turn down.
Federal dollars will pay a larger chunk of the state’s traditional Medicaid costs for two years as part of the newly passed American Rescue Plan if a state expands Medicaid. For Wyoming, that means the state would pay roughly 45% of its traditional Medicaid costs, and federal money would cover the rest.
“We estimate that the savings from that, essentially the additional federal revenue that would offset state general funds from that 5% match over that two-year period, would be approximately $54 million,” Johansson said.
Expanding Medicaid would cost the state roughly $20 million.
“So the net savings from this in a two-year period we estimate to be $34 million” to the state’s general fund, he added.
But because that extra 5% federal match is only promised for two years, some lawmakers have worried the savings won’t last into the future.
The House bill has an amendment that would drop expansion if that 5% match dropped.
But lawmakers have questioned how willing the state will actually be to withdraw from the program down the line.
“Once we expand, we’ll never go back to the way it was,” Rep. Scott Heiner, R-Green River, said testifying against the bill on third reading Wednesday. “I don’t think once you get these individuals on Medicaid that you’ll ever roll it back.”
Johansson said logistically it wouldn’t be difficult to eliminate the program.
“It really comes down to timing,” he said, “because as with any federally funded program, there are certain rules if you’re going to terminate services or eligibility of notifying patients, you know, there’s a certain time period for that.”
The bigger question, he said, is whether there would be the political will to do so.
Learning from elsewhere
Wyoming is one of 12 states that has not expanded Medicaid, and lawmakers have often pointed across state lines as a reason against adopting the federal program. But numerous studies show most expansion states have had success across a range of metrics after implementing the insurance program.
The health care research foundation The Commonwealth Fund found Medicaid expansion actually cut states’ traditional Medicaid costs by roughly 4.5% between 2014 and 2017. The study found Medicaid expansion cuts the costs of corrections, mental health costs and uncompensated care (money spent by the state on unpaid medical bills).
A Center on Budget and Policy Priorities data analysis found the latter fell by an average of 45% in states that expanded Medicaid.
Wyoming Hospital Association Director Eric Boley said in Wyoming those costs could be cut up to 30% under expansion.
During third-reading testimony against the bill, a number of lawmakers raised concerns about experiences neighboring states have had with the program, ranging from more people applying than anticipated to higher than estimated costs.
Medicaid expansion in Utah is basically “breaking the budget,” Rep. Robert Wharff, R-Evanston, said during testimony.
But Utah Republican lawmaker Dr. Raymond Ward says that’s not quite right.
“The short answer is it’s been great,” Ward said of Medicaid expansion in the state. “It did exactly what you wanted it to do and it’s been fine.”
Utah first passed Medicaid expansion on a ballot initiative in 2018, but lawmakers sought to re-imagine the program and implemented a pared-down version in spring 2019. Full-fledged Medicaid expansion went into effect in early 2020.
Ward is a family physician in the Ogden area, and he said he’s seen expansion’s impact on the state firsthand. He said he sees between three and four patients a week who have health insurance now who wouldn’t have before expansion. He added many of those people are receiving care that has ripple effects for the state.
One of his patients is a formerly incarcerated person recovering from substance abuse. With Medicaid expanded, he can get medication to help with withdrawal symptoms, which makes him less likely to relapse and become incarcerated again, Ward said.
“Even if all you care about is the state budget, that’s a person who’s not back in prison,” he said. “That’s a person who is not back asking for other state assistance.”
He added that from a budget perspective, Utah is comfortable, with an 8% revenue bump this past year — illustrating, he said, that Medicaid expansion has not wreaked havoc on the bottom line.
“Even if there was some amount of state money that has to be put in, which there is, the benefit that it’s giving to us outweighs that cost and we’re very happy overall to continue the program,” Ward said. “And that’s what we’re doing in Utah and no one is saying, ‘This has ruined us, we’re going back.’”
Down to the wire
Without a freshman Republican lawmaker, the debate being had about health care access in Wyoming never would have happened.
Rep. John Romero-Martinez, R-Cheyenne, introduced just three bills in his first session as a state lawmaker: one to prevent government officials from infringing on religious freedoms, one to restrict abortions and one to expand government health insurance.
A longtime proponent of expansion Sen. Chris Rothfuss, D-Laramie, also introduced a bill to expand the program, like he’s done many times before. The bill died at a procedural deadline Monday without a floor debate, after gaining approval of three of five members of the Senate Labor, Health and Social Services Committee.
“I’m very disappointed that we had no chance to hear or debate the bill,” Rothfuss said afterward.
Something very different played out the same afternoon in the House, however. Leadership agreed to hear Romero-Martinez’s bill as the last of the night. One after another, lawmakers who had been staunchly opposed to expanding the federal program in the past were changing their minds.
“I’ve had kind of a change of heart, frankly,” onetime Speaker of the House Rep. Steve Harshman, R-Casper, said, adding he had been “7-0” for voting Medicaid expansion down, but after this week he would be 7-1.
“I voted no multiple times on this issue,” said current House Speaker Eric Barlow, R-Gillette. “I’m going to vote yes this time, because I haven’t seen any other solution. No one has brought anything forward, and I’ve looked myself.”
“I have to admit that although I’ve been one of the ones that have been resisting this, I have really given this some thought and I think it’s time.” said Rep. Mark Kinner, R-Sheridan.
The House passed the bill, first on a 35-23 margin, then two days later on third reading with a 32-28 vote.
In an interview after the House moved his bill to the Senate, Romero-Martinez called the chain of events “surreal and timely.”
“I think the main thing is that I believe it gives the opportunity to help a percentage of the population which has been forgotten, have been in the doughnut hole,” he said of his bill. “We have two years and the White House has a chance to meet us where we are at. And if not, we go back to the drawing board.”
A debate to come?
Passage of the bill now hinges on lawmakers in the Senate.
Senate President Dan Dockstader, R-Afton, assigned the bill to the Senate Labor, Health and Social Services Committee on Friday.
Senate Vice President Larry Hicks, R-Baggs, told reporters on Friday the Senate would give the bill a “fair hearing.”
If advanced from committee, the proposal would then be in the hands of Senate Majority Floor Leader Ogden Driskill, who decides what bills the Senate will consider each day and in what order.
Driskill, R-Devils Tower, did not bring Rothfuss’ Medicaid bill up for a debate before the first reading deadline Monday, which makes some advocates uneasy about expansion’s future. But Boley, of the hospital association, said he’s hopeful the support from high-profile lawmakers in the House will move the debate forward.
“I think that the lawmakers ... need to hear from their constituents in their community,” Boley said. “Their inboxes need to be flooded with emails and support and with stories of why.”
“From a financial perspective … this is the year. The math makes sense,” he added.
If the bill does get a Senate floor hearing, it will need to pass three readings in that chamber and receive approval from the governor before becoming law.
Spokesperson Michael Pearlman told the Star-Tribune the governor “will be engaging” with senators about Medicaid expansion. While he didn’t say where the governor might land on the issue, he did say Gordon wants to see the Senate debate the bill.
“Out of consideration for the work the House did in passing the bill, the Governor would like the bill to be debated by Senators,” Pearlman said in a written statement. “The Governor is still considering the long-term implications of Medicaid Expansion, however he understands the opportunities before us.”
Star-Tribune staff writer Camille Erickson contributed to this story