The debate over expanding Medicaid in Wyoming took a small step forward Monday, when the Senate Labor committee heard nearly two hours of public testimony. That marked the first significant time spent on Medicaid this session.
So far there is one bill for Medicaid expansion, while two other draft bills wait in the wings. Support for expansion is strong among interested groups, who showed up in force at Monday’s meeting.
Groups who oppose expansion are not as organized or vocal in the Capitol so far this session. Yet many legislators oppose Medicaid expansion in any form, following through with campaign promises made to their constituents.
A few lawmakers, including some on the Joint Labor, Health, and Social Services Committee, remain undecided on how they will vote on expansion.
“Many of us, I believe, are conflicted over that particular policy decision,” said Sen. Bill Landen (R-Casper). “From my standpoint I just want to listen and learn, and try to make the best vote possible for my district.”
Committee chairman Sen. Charlie Scott (R-Casper) set up Monday’s meeting to take testimony without working a bill or voting on it. He aimed to gather input on Senate File 66, his favored bill, which would expand Medicaid using health savings accounts.
“Frankly, we wanted the testimony before we started working the bill because there are some rough spots in the bill, and we wanted some guidance,” he said. “We are looking for ideas. We want to hear the public as a baseline.”
Wyoming lawmakers have grappled with Medicaid expansion for years, first opposing expansion altogether, then studying alternatives. In 2014, lawmakers gave permission to Gov. Matt Mead (R) to begin discussions with the Center for Medicaid and Medicare services to see what kind of state-based Medicaid plan the federal government might approve.
Those discussions resulted in the Department of Health drafting the SHARE Plan. The acronym stands for “Strategy for Health, Access, Responsibility, and Employment.” The Joint Labor Committee declined to sponsor a bill modeled after the SHARE Plan in a 7-7 vote in December.
That leaves Sen. Scott’s SF 66 as the only committee-sponsored bill for Medicaid expansion on the table. Meanwhile, supporters of expansion still favor the SHARE Plan or its variations.
Sen. John Hastert (R-Green River) has drafted a bill modeled after the SHARE Plan. Rep. Sue Wilson (R-Cheyenne) also provided a draft bill. Neither one has introduced a bill, so far.
The prospect for Medicaid expansion remains murky at this early stage. Yet the number of interests involved, and the past history of the issue, indicate Medicaid will likely be one of the most intensely debated topics of the 2015 session.
Supporters of expansion
Twenty-two people testified before the Senate Labor and Health committee in favor of expanding Medicaid during public testimony Monday, including lobbyists representing hospitals, churches, health clinics, and other organizations.
“We don’t mind asking (the federal government) for road funds, and agricultural funds, and funds for everything else you can think of,” said Dale Steenbergen, CEO of the Greater Cheyenne Chamber of Commerce.
“Why are these (Medicaid) funds any different? It is about going and reclaiming the tax money that we all pay, and bringing it back to this state so medical costs don’t continue to skyrocket.”
Opposition to expansion
The only opposition to expansion during Monday’s public comment came from two members of the House: Rep. Allen Jaggi (R-Lyman) and Rep. Marti Halverson (R-Etna). Both questioned the wisdom of expanding Medicaid given the federal government’s fiscal problems and the increasing national debt.
Halverson quoted Louisiana Republican Gov. Bobby Jindal’s opposition to expansion:
“Every dollar we refuse to spend on Medicaid expansion is one dollar less that we have to borrow from China, not one dollar more that goes to another state. Our refusal to expand Medicaid does in fact help to reduce the growth in federal spending, which is yet another reason why every state should do the same.”
Halverson presented information from the Florida-based political group Foundation for Government Accountability that argues Medicaid expansion requires a large reduction in payments to senior-citizens enrolled in the Medicare Advantage program. The group asserts that Wyoming Medicare Advantage recipients would lose $784 million in benefits before 2022.
Mike Fierberg, spokesman from the Denver office of the Center for Medicaid and Medicare Services said the actual reduction in benefits is likely a much smaller amount. Congress intended for the reduction in benefits to bring Medicare Advantage in line with what is offered by the Medicare A and Medicare B benefits. Fierberg also noted the study quoted by the Foundation for Government Accountability is likely out of date.
How expansion would help the reservation
More than a dozen members of the Northern Arapaho tribe attended the meeting to discuss SF 66. They spoke in favor of the expansion, saying it would provide important services to a community where life expectancy is 51 years.
They noted that the expansion would benefit them and their families personally because many make less than 138 percent of the federal poverty level.
“I fit into the category,” said Micah Lott, a Northern Arapaho who has scoliosis and an epilepsy disorder. He recently turned 18. “I am the scenario. It would help me.”
Medicaid expansion would allow low-income tribal members living anywhere in the state to receive covered health care at hospitals. For example, reservation residents could go to hospitals in Riverton or Lander for care, rather than visiting the local Indian Health Service clinics. Those clinics are funded at less than 50 percent of need, and often provide care only in serious emergencies.
Whether low-income tribal members live on or off the reservation, expanded Medicaid would also enable them to seek care or specialized procedures in Casper, Cheyenne, or other places, and have their costs covered by Medicaid.
Tribal members are also pushing a separate measure to increase Medicaid funding to Indian Health Service clinics. Last week the Select Committee on Tribal Relations voted to ask Gov. Mead to write a letter recommending Wyoming accept a pass-through of additional federal funds for IHS clinics. Both the Joint Appropriations Committee and the Legislature would have to approve the pass-through in the budget bill. Update: The Center for Medicaid and Medicare Services may require a 4 percent administrative match from the state, which the Northern Arapaho and Eastern Shoshone tribal councils have agreed to pay. The waiver for the pass-through would last five years, but would have to be reapproved by the state every year. The funds would total $17 million over five years initially. Funding would bump up to $11.7 million annually when the Fort Washakie clinic expands its square footage, which would qualify it for a higher level of federal funding.
Would Scott’s bill pass?
Scott believes he has enough votes in the Senate Labor Committee to advance SF 66 to the Senate floor. He pledges to put his full support behind the measure. That’s a reversal from his own past efforts to reject Medicaid expansion.
Scott believes SF 66 will face stiff opposition among his fellow Senators. He predicts that some of his colleagues in the Senate will see Medicaid expansion as a risk to future education funding, but nobody knows until the measure is debated on the floor.
In Scott’s view, the federal government will likely decrease funding for Medicaid expansion in the future, perhaps in as little as two years. He estimates that would leave the state to pick up a tab of $50 million to $70 million, based on a 50-50 federal-state cost share of the $100 million to $140 million expansion program. That would require diverting money from higher education, or raising taxes, he argues.
“If we have to put that much more money into Medicaid, we are going to have to cut the hell out of higher education, and that is not a wise thing to do,” Scott said. “That’s a hard one to counter, because I think it reflects what really might happen.”
It’s unclear why Scott thinks such a shortfall would cut education funding. Other deficits, such as the estimated $222 million deficit projected for this year, would likely be covered by shifting money from savings, not higher education, according to lawmakers. Scott did not mention whether other large-spending agencies, like the Department of Corrections, or the Department of Family Services, might end up on the chopping block.
Yet others argue against Scott’s SF 66 for its own potential costs. While the SHARE Plan is revenue neutral, Scott’s plan would cost the state $19.6 million in 2017 to manage it, and nearly $30 million in 2018. That’s according to a fiscal note prepared by legislative staff, which Scott believes is incorrect.
“There is a fiscal note attached to the bill, but it is blatantly wrong,” he said. “Don’t pay much attention to that.” Scott did not give evidence during Monday’s meeting to back up his claim.
Another question regarding Scott’s bill is whether CMS would approve it. Indiana has proposed an expansion plan that uses health savings accounts — similar to Scott’s SF 66 — but it has been stalled for months awaiting federal approval.
SF 66 also faces opposition from lawmakers who oppose any form of Medicaid expansion whatsoever. Should a Medicaid expansion bill pass the Senate, it would face a close vote in the House. Last year 33 of 60 Representatives supported hearing bills aimed at expanding the program, a narrow majority that fell short of the 40 votes needed for introduction in a budget session. This year is a regular session, which means bills don’t need a supermajority to win introduction.
More detail on draft bills
Sen. Hastert’s SHARE Plan draft bill adopts the plan created by the Department of Health and endorsed by Gov. Mead last fall. The plan allows for two benefit tiers. The first would expand coverage to those below 100 percent of the federal poverty level, and a second tier from 100 to 138 percent of the federal poverty level.
Those in the lower tier would make copayments for procedures, while those in the upper tier would pay a copayment and a small premium, not to exceed 5 percent of their annual income. Hastert’s draft bill would have the state administer the expanded Medicaid program, which would include health assessments, case management, and a work assistance benefit.
Scott has said he would not support the SHARE Plan as written, and would do his best to see that it does not pass. It’s unlikely the bill could pass the Senate Labor Committee, given Scott’s opposition.
The Wilson bill
House Labor Committee member Rep. Sue Wilson (R-Cheyenne) drafted a bill to expand Medicaid according to the SHARE Plan. It would also create a task force to develop a state-funded program for providing health care for the poor should the federal government renege on its financial commitment to expanded Medicaid. It would also create an account to collect Department of Health funds saved by the elimination of programs no longer needed under expanded Medicaid.
Wilson said she believes the Affordable Care Act was a terrible bill. Even so, she supports a short-term expansion of Medicaid because people would benefit from having insurance even if it is only for a few years. She has heard from people who would prefer having insurance for only three years over having none at all. That could enable them to get procedures like hip replacements, which would allow them to go back to work and potentially exit the Medicaid program.
Wilson disagreed that the federal government’s poor fiscal condition is reason to oppose expansion. “I don’t know that we can solve the nation’s fiscal problems using 17,600 people as the tip of the spear,” she said.
Later this week Department of Health director Tom Forslund will provide an informational session explaining the policy issues at play in the various draft legislation.
For further reading:
Lawmakers dump vetted SHARE plan, adopt Scott’s Medicaid plan, December 17, 2014.
Can lawmakers agree on path toward Medicaid expansion?, December 16, 2014.
Wyoming Medicaid expansion plan faces headwinds, December 9, 2014.
Florida group takes aim at Wyoming Medicaid expansion, December 9, 2014.
‘Medicaid expansion still very important’ on reservation, August 3, 2014.