Heading into the start of the legislative session last week, there was cautious optimism that Medicaid expansion could make inroads this year.
The bill proposed a slow road to expansion: It required study and the approval of the governor before it could move forward. It had received the backing of the Joint Revenue Committee in the fall, a boost that expansion had never received before. A fresh state Department of Health report showed that Wyoming would pay $18 million versus the federal government’s $136 million to cover 19,000 people in the first two years. Three neighboring states had recently expanded Medicaid through ballot initiatives. A group of progressive and health-related organizations came together to publicly lobby for the legislation.
This session — a 20-day budget session that requires a high vote threshold for bills to even get introduced — provided sizable obstacles. But still: guarded optimism.
“We were hopeful,” said the Wyoming Hospital Association’s Eric Boley. “The fact that the bill came out of the Revenue Committee as opposed to Labor, Health and Social Services — they’re taking a look at the economic impact expansion could’ve possibly had on the state. ... We were hopeful that maybe at least we’d get a look, a better look.”
Even critics were concerned that the Revenue Committee’s stamp of approval would be influential.
“We were (concerned) because it came out of the Revenue Committee, which is really troubling,” said Cassie Craven, who works for the conservative Wyoming Liberty Group.
Within a few hours of the session starting Monday, the bill was dead, falling nearly two-to-one as the House worked through its consent agenda. Supporters were deflated.
“We were all surprised how it was killed in this really kind of insider baseball, political way, with no debate, not allowing for any debate, not allowing for any testimony in a single committee,” said Chris Merrill, the executive director of the Equality State Policy Center. “Not even allowing for that hearing to take place. It’s disappointing, but it’s also a failure of this body to do due diligence on an issue that a committee passed in the interim.”
The Republican Speaker of the House, Casper’s Steve Harshman, said the bill was partially doomed by the “undemocratic” high threshold that it had to meet out of the gate.
“Sometimes on those bills, you get up to 34, 35 votes, and even if you have a majority, you see it’s going to go down,” he said. The bill would’ve required 40 aye votes to move forward. “When people realize what’s happening, they flip their vote. That never goes on the record.”
On Thursday, Republican Rep. Pat Sweeney tried again: He proposed a constitutional amendment to expand Medicaid. That was dead before the sun went down Friday.
Another year in the Wyoming Legislature, another doomed attempt to expand Medicaid. Craven and others said that the state’s budgets and revenue were not in a place to commit to new ongoing costs (though Craven said she would’ve opposed expansion even if the budget outlook was stable).
“We’ve gone over it in the past so many times,” said Rep. Tyler Lindholm, a Sundance Republican. “And honestly, if we’re going to look at Medicaid, we’re going to need to do so much more than just turn it over to the governor and hope for the best. I think that was everybody else’s thinking.”
So what now? There are undeniable problems in Wyoming that expansion would’ve addressed; 19,000 people would’ve been covered, for one. The Health Department report estimated that people would likely pay less for exchange plans. Uncompensated care — costs that hospitals write off because patients can’t pay for it — was also projected to drop.
If not expansion, then what?
“It’s outrageously frustrating,” said Dr. David Wheeler, the president of the state medical society and a Casper neurologist who helps provide stroke care to parts of rural Wyoming. “To me, it’s just empty posturing. I work really, really hard every single day trying to figure out creative ways to get good health care to people all over this state. I’m not getting any support from the state to do that. It’s all on my dime and time. The state’s done nothing for us.”
‘A Wyoming solution’
For years, critics of expansion have called for the state to explore a solution specifically tailored to the Equality State. Gov. Mark Gordon has opposed expansion; he’s repeatedly told the Star-Tribune that he advocates looking for a Wyoming-specific solution, rather than expansion.
To date, no such plan has been presented. In response to a question sent Tuesday about whether Gordon had a plan, the governor’s spokesman said Thursday he wouldn’t be able to provide an answer by deadline. A message left for Sen. Charlie Scott, a Natrona County Republican and chair of the Senate’s health committee, was not returned last week.
Supporters of expansion say there is no “Wyoming-specific solution” that could replace expansion. An inherent difficulty in finding an expansion stand-in is the broad range of what the program can do. Expansion broadens the qualifications for Medicaid to include those making 138 percent of the federal poverty line, which is about $36,000 for a family of four. The federal government pays 90 percent of the costs going forward, while the state pays for the remaining 10 percent.
By the state’s projections, expansion could lower costs, provide coverage to those who can’t afford it and help cut hospital losses. National research shows it improves health outcomes, helps the labor force and slows financial distress faced by poorer patients.
Does a plan exist that can do those things?
“I don’t think it does,” said Jen Simon, the founder of the Wyoming Women’s Action Network. “I think you’d have to make it out of whole cloth. Any time you’re starting something brand, brand new, it’s more labor intensive, more expensive, more experimental. Why reinvent the wheel?”
“I think there is some interest to look for a Wyoming solution,” said Jan Cartwright, the executive director of the state primary care association. “But a Wyoming solution — are we going to get 90 percent from the feds to do it? It looks like we’re going to use state funds to do it, and I just don’t think that’s very smart from a fiscal standpoint.”
Craven, of the liberty group, said expansion was not a silver bullet for the state’s health care troubles — a point upon which she and expansion supporters can agree. She advocated that the Legislature undertake a holistic study of health care access in the state, with an emphasis on transparency and competition. Craven is not alone in supporting this effort; other lawmakers and Gordon have talked about transparency.
The theory goes that if Wyoming’s hospitals and providers had to show prices, and if there were more hospitals and providers to drive competition, then patients could shop around, and the free market would drive down costs.
“If our goal is really to help people, then we need to find the basket of solutions for health care in Wyoming,” Craven said. “I don’t think it’s a silver bullet from the federal government. I think that’s been easy.”
There are problems with that theory and approach, both in Wyoming and as a stand-in for expansion. For one, Craven’s plan wouldn’t seem to address coverage; access does not translate to affordability, particularly in a state with some of the highest health care costs in the nation.
For another, there is a fundamental lack of competition in the state because of the low population. Most counties have just one hospital. Many of those facilities are sustainable in large part because they’re critical access hospitals; because of their isolation, they receive federal reimbursement boosts. But if another hospital were to open in Douglas or Powell or Thermopolis, that designation would disappear, placing renewed financial distress on facilities that Boley says are already cash-strapped.
Then there’s of course the question of whether communities in Wyoming could even support multiple hospitals to drive that competition. Health Department data shows nearly half of the state’s hospitals operated on negative margins in 2018.
Supporters of expansion have pointed to the program’s success in other states, including those neighboring Wyoming (all of which but South Dakota have expanded). Indeed, the research is resoundingly positive.
The Kaiser Family Foundation, one of the largest health care think tanks in the country, reviewed 324 studies of expansion published from 2014-19.
“Research indicates that the expansion is linked to gains in coverage; improvements in access, financial security, and some measures of health status/outcomes; and economic benefit for states and providers,” Kaiser researchers wrote.
Craven said that cost projections for expansion have often been inaccurate in other states, where enrollment projections have been significantly lower than the reality. She pointed to Colorado, which expanded Medicaid several years ago.
She said that people had moved to states like Colorado to take advantage of expansion; the same, she said, would happen in Wyoming. Expansion in states like New York have had significant overruns on costs. New York is facing a deficit of more than $2 billion on its program, which is rich in services.
Marc Williams, a spokesman for the Colorado Department of Health Care Financing and Policy, said that the state had experienced more Medicaid enrollees than anticipated. Data he provided to the Star-Tribune showed that there were more than 221,000 enrollees in the second year of expansion there, compared to a projection of 144,000. That meant Medicaid costs — which, in that year, were borne entirely by the federal government — were $113 million off. In fiscal year 2016, expansion in Colorado cost $228 million more than expected.
Williams said the vast majority of the unexpected enrollees weren’t newcomers to the state. He said they were primarily people who were already eligible for Medicaid — even before expansion — and hadn’t enrolled. He said that when those people signed up for insurance to avoid the Affordable Care Act’s individual mandate — which required all Americans have insurance or pay a penalty — they were told they could actually receive Medicaid.
“They just never bothered to apply because they didn’t want to accept a government handout or it was embarrassing or they just never thought about it,” Williams said.
The Wyoming Health Department said its latest projections take underestimates from elsewhere into account.
Craven and lawmakers who have been critical of expansion highlight people who will stop working or take fewer hours so they continue to meet the threshold for expansion. Rather than make a little more money, this argument goes, people would take fewer hours to stay on Medicaid.
The Kaiser foundation’s research does not support such a claim.
“Single-state studies in Ohio and Michigan showed that large percentages of expansion beneficiaries reported that Medicaid enrollment made it easier to seek employment (among those who were unemployed but looking for work) or continue working (among those who were employed),” researchers found, adding that there was an increase of employment among individuals with disabilities.
“Some studies found no effects of expansion on some measures of employment or employee behavior; no studies have found negative effects of expansion on these measures,” the researchers concluded.
Merrill said the cliff effect — when a person or family makes more money and is dropped from social programs like Medicaid — wasn’t even a factor when it comes to expansion. Once a person earns enough to move off the program, he said, they will be rolled onto income-based subsidies for health plans on the federal exchanges. People will move from one to the other and won’t need to make less money to keep health care. He said the “academic point” of the cliff effect was “infuriating.”
Craven said that the state shouldn’t rush into expansion and that it was an “expensive Band-Aid.” She urged the Legislature to do the “hard work” of finding another solution to the state’s myriad health care problems. Expansion supporters say the state has studied and talked about expansion for years and there hasn’t been a push to rush — indeed, the bill rejected last week would’ve given the governor time and approval to move forward.
There’s little legislation being considered by lawmakers now that would do that. While lawmakers, particularly those on the Labor, Health and Social Services Committee, are very familiar with the problems, there’s little beyond studies and discussions that’s yet been proposed to address them.
It’s unclear if expansion has a future in the Equality State. Because of Wyoming’s Constitution, it’s unlikely that supporters would be able to kick-start a ballot initiative like the ones that passed in Nebraska, Utah and Idaho.
Its advocates maintain that it’s a no-brainer.
“I would just say, ‘Does Medicaid expansion fix all of the problems with our incredibly screwed up health care market?’ No, no it does not. And it will not,” Merrill said. “A ton of work needs to be done. But what it does do is it helps a very specific population. It helps fill in a gap for people who work at jobs that don’t provide health insurance and they can’t afford to purchase it on their own.”
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