Wyoming: Medicaid expansion may not be dead yet after all!

Wyoming

March 31st, 2021:

Senate committee kills Medicaid expansion bill, by Morgan Hughes

Medicaid expansion will not happen in Wyoming this year.

The state’s Senate Labor, Health and Social Services Committee killed a bill Wednesday morning to expand the federal insurance program, which would have insured an estimated 25,000 additional Wyomingites.

Lawmakers have defeated similar proposals for nearly a decade. Advocates hoped this year might be different. Many House Republicans voiced a change of heart after the COVID-19 pandemic and the decline of fossil fuels rocked the state’s economy, leaving many without health coverage. This session was the first in which a bill to expand the program passed a legislative chamber.

The bill, proposed by Rep. John Romero-Martinez, R-Cheyenne, would have expanded the federal program in the state only so long as an improved federal match was maintained. Estimates from the Wyoming Department of Health suggested the state could save $34 million over two years because of a federal increase in the match for the state’s traditional Medicaid program.

Opponents of the proposal primarily landed in two camps: those with a philosophical opposition to “socialized medicine,” and those concerned the state’s savings would dry up after two years with the increased match.

Not so fast, it turns out:

May 11, 2021:

RIVERTON, Wyo. -- Wyoming lawmakers are giving Medicaid expansion a second look at today's Joint Revenue Committee meeting in Riverton, after proposals failed to clear the Senate in this year's legislative session.

Jan Cartwright, executive director of the Wyoming Primary Care Association, said the pandemic and downturns in the fossil-fuel sector exposed gaps in the state's health-care system when Wyoming workers lost job-related health insurance.

She contended expanding Medicaid would help fill those gaps.

"There are people who are not able to access health care other than through the emergency room, where it's the most high-cost and least effective," Cartwright explained. "And these would be funds that would help to stabilize our health care system for everyone in Wyoming."

As it happens, I was able to live-tweet most of the public comment during the committee hearing, of both those opposed to expansion and those supporting it:

  • The first Zoom speaker is claiming that if they expand Medicaid, it will somehow cause people to WANT to earn less so that they'll qualify for it. Which might make some sense if the rest of the ACA didn't exist for those who earn more, or if they could afford ANY coverage NOW. 
  • The second Zoom speaker claims that Wyoming has crappy oversight over Medicaid waste/fraud/abuse, therefore they shouldn't expand it. Here's an idea: Expand it *and* improve your oversight process? Just spitballing here. 
  • Also, he talks about "throwing billions of dollars more at it"...except that KFF estimates that expanding Medicaid would only cost Wyoming about $20 million per year. It would take 50 years for the state to hit even $1 billion in costs (OK, call it 30-40 years with inflation). 
  • The third Zoom speaker cut out. The fourth is speaking now. She opposes expanding Medicaid because "SOCIALISM!!" and claims it's "A ROPE WHICH WILL STRANGLE OUR STATE!" NANNY STATE! WE DON'T LOOK TO GOD ANYMORE! STOP THE ADVANCEMENT OF SOCIALISM!!
  • The third guy is back. Oh, Christ...he's from FGA. Their schtick is that expanding Medicaid to "able-bodied" people means that they states won't have enough money to pay for Medicaid for "non-able-bodied" people. Which would be a self-inflicted decision.
  • Now he's arguing that Wyoming should instead stick with the $0-premium #SecretPlatinum plans allowed for by the #AmRescuePlan.
  • He then calls Medicaid expansion "welfare" but he's totally fine with the federal government picking up 100% of the tab for private ACA plans. 
  • Also, none of these people seem to grasp the concept of HOW FEEDBACK WORKS. TURN OFF THE SECOND MICROPHONE, PEOPLE. 
  • Somehow the "7 minute public comment" period has turned into an open Q&A forum for the FGA guy to spout talking points about "farm bureau" plans, #ShortAssPlans, association plans and other types of #junkplans. Lovely. 
  • He's also talking about a 1332 reinsurance program, which wouldn't do a damned thing to help those in the Medicaid Gap and are mostly useless if the #SubsidyCliff is killed off permanently anyway. 
  • Now the head of a Republican Women's group is talking about a baby born at the Ronald McDonald House. She thinks people who can't afford insurance should just "make arrangements" with their doctor to pay what they can. OK, then.
  • Reminded of Sue Lowden's "Pay with a chicken". 
  • SHE AND HER HUSBAND ARE ON MEDICARE. BUT SHE DOESN'T WANT ANYONE ELSE TO HAVE PUBLICLY-FUNDED INSURANCE BECAUSE IT MIGHT MAKE HER PERSONAL COSTS GO UP. She says she was "forced" to go on Medicare because of her age. 
  • The next dude says that "IT'S SOCIALIZED MEDICINE!" and "WE CAN'T AFFORD IT!" and that "IT ALMOST BANKRUPTED INDIANA!" and "YOU CAN'T GET OUT!" (actually, they could easily add a provision that if the FMAP threshold ever falls below 90% the program ends). 
  • Now he's pushing for other options suggested by the FGA guy like reinsurance, farm bureau plans, #ShortAssPlans, etc...which are pretty useless for those in the Medicaid Gap.
  • He claims IT WILL BANKRUPT WYOMING...at $20M/year? 
  • The next lady wants to "STAND WITH" states like South Dakota and Texas instead of "STANDING WITH" states like Washington.
  • She starts using bullet points with: "FACT!" which is always a bad sign. 
  • She likes to say "BILLION WITH A B!" a lot. She says "you need the people with the most money to pay for the people with the least money" which is kind of how taxes work. She notes that Hillary Clinton says "EVERYONE HAS A RIGHT TO HEALTHCARE" and that this is a bad thing. 
  • Now she's on to how Medicaid expansion will absolutely lead to Medicare for All, and free abortions for all, and this is a bad thing. I think she said every woman would HAVE to have an abortion. 
  • Now she's talking about transgender surgery. I think she just said that an "abortion-inducing drug" would require you to abort a transgender child named Hyde and Helms. I've kind of lost the thread. 
  • She lost her audio, thank God. Now they're on to the PRO-expansion speakers. Looks like 14 pro-expansion speakers (6 in person, 7 online). 
  • I will say that Wyoming only having half a million people does make for a less formal hearing experience.
  • Interesting--the first guy speaking in FAVOR of Medicaid expansion appears to be a staunch anti-choicer...let's see where he's going with this... 
  • This anti-choice guy notes that denying access to healthcare for the working poor/etc. IS NOT CONSISTENT with his "pro-life" stance. BRAVO!
  • He notes that he can't say "gov't should stay out of healthcare" given that THE VA IS SOCIALIZED MEDICINE. BRAVO! 
  • As an aside, I'll also note that, as I've said before, the biggest barriers to *any* universal healthcare program (whether M4All or Med4America or anything else) are NOT just the cost or the "option" but the Hyde Amendment and whether it includes undocumented immigrants. 
  • The next PRO-expansion speakers appear to be from a hospital association, I think. Talking about how Medicaid expansion in Montana proves that it will help save rural hospitals, healthcare service jobs, etc. throughout small communities. 
  • Now he's using Colorado as an example--noting that CO is kicking ass with their Medicaid expansion program. Says Utah (which just expanded last year) hospitals are seeing a "boon" thanks to Medicaid expansion. 
  • They're answering questions about the alleged "waiting list problem" in Montana. Turns out it's bullshit anyway--that "waiting list" is for people who would otherwise be institutionalized, NOT for the Expansion population. 
  • They note that it COSTS hospitals in WY $120 million per year in uncompensated care and that a big chunk of that would be eliminated thanks to Medicaid expansion; Medicaid may reimburse at too low a rate, but getting paid something is a lot better than getting paid nothing. 
  • One of the committee members just threw one of the anti-expansion speakers under the bus by noting that there's no evidence that Indiana has been "bankrupted" by Medicaid expansion. They also state outright that the claims re. Montana and Utah have both been debunked. 
  • This isn't really "Public Comment" anymore...it's unofficial Witness/Q&A. Which I'm actually fine with; the questions so far have been perfectly reasonable. 
  • Q about "healthcare professionals who are opposed to expansion"...hospital guy notes that it's a royal pain in the ass to get providers in Wyoming...in part because a lot of providers refuse to go to a state which HASN'T expanded Medicaid. 
  • ROFL he's asked about one of the anti-expansion speakers and he flatly says that he doesn't remember a thing she said because he tuned it out. 
  • Points out that a primary care physician would rather be in a state where they'll at least be guaranteed SOME pay than one where they might face not getting paid at all. 
  • Next up: A couple more pro-expansion guys. One is a retired physician. Sounds like he knows everyone on the panel. Says every healthcare provider he knows supports it. Personal experience with those caught in the Medicaid Gap. "Not deadbeats...they need a hand up" 
  • Talking about the loss of rural hospitals. "IN EXPANDING MEDICAID, YOU'RE SUPPORTING A RURAL HEALTHCARE SYSTEM IN DIRE NEED OF SUPPORT!" 
  • Next guy...CEO of some healthcare system (?)...talking again about uncompensated costs...6% of their expenses are uncompensated care; that could be put into wages, equipment, new services, etc. Accidentally calls it "Medicaid Advantage". 
  • Says that uncompensated care goes from 6% to 0.5% in states which have expanded the program.
  • Woman from the WY Medical Society is up next. 
  • She's talking about a big report from 1994 which said the #1 recommendation was for WY to move towards universal healthcare coverage.
  • Starts tackling the BS claims...notes that at the time it was 19K; today it's 24K...which is right in line with 27 years of population growth. 
  • She addresses the "cash pay patients" and notes it's a tiny part of the expansion population because almost no one can afford to pay cash.
  • "Medicaid expansion continues to serve as the best option." 
  • Notes that 99% of WY doctors participate in Medicaid; 93% of WY dentists; more predictable business/payments would be helpful.
  • Addresses the "increase in patients" by noting THOSE PEOPLE ALREADY EXIST, they've just been shut out until they need emergency care or are terminal. 
  • Addresses the claims of "increasing government" and "socialism!" by noting it was EMTALA, SIGNED BY RONALD REAGAN IN THE 80'S, WHICH REQUIRED HOSPITALS TO TREAT EVERYONE whether they can pay or not.
  • Q about whether her org would support an independent review board/etc for better oversight of waste/fraud/abuse; she says of course, if that's proven to be necessary. 
  • Now they're moving to the Zoom speakers supporting expansion.
  • Dude from the Montana Health Co-Op, which also operates in Wyoming (they've been in MT & ID for years). Doesn't have a lot to say beyond they support it. 
  • Next up is a young woman whose mother went through cancer twice. She wants the committee to pass expansion to save the lives of people like her mother. 
  • Next is a physician assistant. 35 yrs as a PCP. His wife is a medical assistant. They've cared for 40,000 patients at his clinic; mostly low-income folks. "These people are forced between medical care and rent, food, gas, etc...they're much sicker as a result of not getting care" 
  • He notes that there's no longer any financial argument against the startup costs (thanks to the federal ARP offer). It would help 19K - 30K WY residents, most of whom are the so-called "essential workers" we claim to have praised over the past year. 
  • Next up is a woman who's first word was "CRAP!" (she's having computer problems...she apologizes).
  • Her dad "doesn't want his hard-earned dollars going to everyone" but she has MS and has been on disability. If she didn't have the care she received she'd be in a wheelchair today. 
  • Her meds are $80K/year to start...and she sees people who need the same treatment and can't afford it because they don't have coverage. 
  • Next up is a single mom of 2, one with disabilities; she had a single mom and was on Medicaid herself as a kid.
  • Her son is developmentally delayed...medical bills kept piling up...they stopped going to specialists since they couldn't afford it with their private insurance 
  • Her son was approved for Medicaid 4 years ago; it took a long time but has made a world of difference; goes on to praise how awesome her son is doing today.
  • She wants her fam/friends/neighbors who don't currently qualify to be able to...including herself now that she's single. 
  • Next up is a farmer who had no insurance & was caught in the Medicaid Gap. She considered moving to Colorado purely because they have Medicaid expansion. She's lucky that this year #ACA HC.gov coverage is free for her thanks to the #AmRescuePlan... 
  • It sounds like she earns between 100 - 138% FPL; that population is eligible for a $0-premium #SecretPlatinum plan...but only for 2021 - 2022 right now...
  • Next up is a cancer patient who's 40th birthday is today; she's lucky to be here/etc. Very emotional telling her story...she was 24 yrs old, tubes & wires...left on her own... "When I was 24 it was before the ACA. I have many friends who were uninsured or underinsured" 
  • She notes that yes, the U.S. does have some of the best healthcare experts in the world...but if you don't have access to them they're not terribly helpful.
  • Notes that 111 of WY residents die every year due to not having Medicaid expansion in place...that's nearly 1,100 to date. 
  • "If federal dollars are good enough for the very poor, and they're good enough for the middle-class, they should be good enough for us" 
  • Next up is a woman speaking on behalf of her sister (I think) who is non-verbal/requires substantial personal home care.
  • She's on SSDI, but current WY Medicaid rules require a long process to double-check every penny she has to make sure she qualifies. 
  • "If I wasn't a person w/a physical disability I'd be working full-time...we shouldn't be made to feel ashamed for needing help just to survive"
  • "Please pass expansion so Sarah & others who are disabled have the healthcare they need." 
  • Next up is another woman telling her story...has a son...she was struggling & couldn't afford private coverage, her son qualified for Medicaid. Started a housecleaning business, did well until COVID. Suffered from depression, tried to enroll in Medicaid to get help... 
  • ...apparently she was able to qualify thanks to last year's CARES Act, and it was a lifesaver for her. She notes that no, it didn't make her "dependent"...it's actually MADE HER LIFE WORTH LIVING and she's back in business, doing much better now. 
  • "This "handout" is NOT going to make me work less"...if you DON'T pass expansion, whose grandson will get to live?" 
  • Another woman is telling her personal story. She became disabled at 35; it took 3 years to be diagnosed, no income, no Medicaid or Medicare for that time. She lost her employer-based coverage when she lost her job. 
  • OK, I'm afraid I have to cut out now. EXPAND MEDICAID, DAMMIT. /END 

UPDATE: Hey, look at that!

MedEx in Wyoming advances by a vote of 9-5! Great to see possible consideration for the special session this year. https://t.co/7FS3eeWU45

— Lucy C. Dagneau (@thelucygoose) May 12, 2021