Note from Pete Simpson: Medicaid expansion remains one of the most politically-charged issues in Wyoming in recent years. While opposing sides seem so far apart you could drop Wyoming through the gap, Medicaid expansion has also coalesced in favor of expansion a large group of stakeholders who rarely agree on political issues. And the issue remains unresolved.
We need more discussion, and more facts behind the discussion. So this week we’re asking readers to dive back into the Medicaid issues with two Wyoming people who are not politicians but are what I might call policy wonks: Charles Katebi of the Wyoming Liberty Group and Sarah Gorin, formerly of the Equality State Policy Center, and most recently director of the low-income healthcare clinic in Laramie. Both make impassioned arguments, and both cite detailed studies to support their positions.
We hope readers can use these columns to start to learn about the issues in detail for themselves — getting beyond the short sound bites that occupies most of the political debates on this issue. Read these columns, check out the studies they cite, and come back to us with your comments. Make sure those candidates out there have studied up on it too! — PS
— by Sarah Gorin
The majority of Wyoming legislators chose to turn their backs on Medicaid expansion from its first offering. Since January 2014, nearly $300 million that would have created an estimated 800 jobs in our state, enabled uninsured Wyomingites to get the health care they need to go back to work, and strengthened our rural hospitals has gone to other states that chose Medicaid expansion.
Budgeting data prepared for the 2016 Legislature showed that accepting Medicaid expansion would save money for the state because the funds accompanying expansion would replace state monies now being spent on “safety net” programs. Recent budget cuts that eliminated the safety net programs also eliminated the savings — and, of course, mean that less health care now is available in our state.
Is Medicaid expansion still worth doing? Yes. Why? One: It saves lives. Two: It’s a badly needed job generator. Three: It will strengthen access to health care for all Wyomingites. Four: It’s still a bargain, as the federal government will pick up 95 percent of the cost in 2017, dropping to 90 percent by 2020.
Many assume that Medicaid already covers all low-income people. It does not. In Wyoming, for example, Medicaid eligibility is “categorical” — that is, a low-income individual must also fit in a specified category to obtain Medicaid coverage. The largest category is children; the most expensive one is individuals in nursing homes.
Who’s missing? Thousands of adults with debilitating conditions such as uncontrolled diabetes, asthma, and high blood pressure do not qualify for Wyoming’s limited Medicaid coverage. They are left to fend on their own or in our hospitals’ emergency rooms — the most expensive and ineffective way to deliver primary health care, and one that raises health care costs for the insured and uninsured alike.
The most spectacular untruth of those opposing Medicaid expansion is their constant chant that Wyoming’s uninsured simply need to get off their butts and work. These opponents never explain how an employer could expect an uncontrolled diabetic or asthmatic to reliably perform a full-time job, especially jobs requiring physical labor such as lifting materials on a construction site or mopping floors and making beds. Employers, on the other hand, have this figured out. They don’t hire sick people.
Nor do opponents of Medicaid expansion acknowledge that many uninsured Wyomingites are, in fact, working — but they don’t make enough money to qualify for subsidized insurance on the federally-established Wyoming health insurance exchange. Opponents of expansion claim that Wyoming workers with low incomes can and do receive subsidies under the exchange, and so argue further that serving those workers with expanded Medicaid would hurt the private insurance company now allegedly covering them, with the aid of subsidies, under the exchange.
But the fact is that workers with incomes below 100 percent of the federal poverty level cannot receive subsidies. (For reference, the 2016 FPL for one individual in the continental United States is $11,880/year; for a family of two, $16,020/year; for three, $20,160; for four, $24,300.) The law works that way because the original law expected Medicaid expansion to occur nationwide.
Low-income workers frequently work only part-time due to personal illness, caring for an elderly parent or children or grandchildren, or lack of transportation that limits their job opportunities to those within walking distance. Denial of Medicaid expansion in Wyoming means that these low-income workers, making less than 100 percent of the federal poverty level, can get health insurance only if they pay its full cost — with no help from the exchange. Paying full freight for a health insurance policy at these income levels is laughable; there would be no money for anything else. These workers have no choice but to try to find employment that accommodates their situations and hope they can get to the emergency room if things get really bad.
To look at this issue in more detail: Subsidies on the health insurance exchange begin at incomes equal to 100 percent of the FPL. For the purposes of the following illustration, this works out to a 40-hour week at an hourly wage of $7.70/hour for a family of two — say, an adult and a preschooler — more than the federal minimum wage of $7.25/hour, and therefore more than Wyoming’s six thousand workers at minimum-wage or below receive.
What it takes to be self-sufficient in Wyoming.
Meanwhile, the recently updated Self-Sufficiency Standard for our state, issued by the Wyoming Women’s Foundation, utilizing Wyoming data on a county-by-county basis, shows that an adult and a preschooler need an hourly wage of at least $14-$15/hour, with a 40-hour work week, to cover necessary household expenses. In most counties, the hourly wage needs to be more than $15-$18/hour (up to nearly $26/hour in Teton County). The study assumed access to employer-sponsored health insurance or the most heavily-subsidized health insurance policy on the exchange.
In short, yes, a fraction of Wyoming’s uninsured technically qualify for subsidized health insurance policies, but the Self-Sufficiency Standard data demonstrate that to utilize these policies, something else has to go. The rent and the child care have to be paid so the adult can work. In some Wyoming towns the family can go to a food pantry and get something to eat, but that $150 new-patient visit has to be put off, and please, hope to high heaven, make it a mild winter so the heating bills aren’t so high.
The Self-Sufficiency Standard also demonstrates the sheer fantasy of claims by Medicaid expansion opponents such as State Sen. Charles Scott (R-Casper), who says people will reduce their incomes to qualify for an expanded Medicaid program. It will be difficult for these Wyomingites to get the most out of their new health care without heat, adequate food, or perhaps even a place to sleep safely.
In sum: Those with incomes below 100 percent of FPL have no access to health insurance, and in most cases no access to health care except in the emergency room. For those making a bit more, in the words of the Self-Sufficiency Standard, “Nevertheless … are far below what is needed to meet families’ basic needs.”
Medicaid expansion helps strengthen families’ economic security. In Oregon, which implemented a lottery to offer a state-funded Medicaid expansion before the federal government paid for it, people with Medicaid were 40 percent less likely (than those without insurance) to go into medical debt or default on other bills to pay medical expenses. A study of this randomized expansion found that Medicaid coverage “nearly eliminated catastrophic out-of-pocket medical expenditures.”
This same study often is cited by legislators as a reason not to expand Medicaid, because it also found that clinical outcomes (e.g., high blood pressure) were not significantly improved among the expansion population after two years of program implementation. However, besides the positive effect on family finances, the study showed that expansion produced substantial improvements in other health outcomes: mental health, raised rates of diabetes detection and management, and increased use of preventive services.
In Ohio, where Medicaid expansion began in January 2014, more than 50 percent of those enrolled were treated for mental health and drug addiction problems, and more than one in 10 was diagnosed with severe mental illness. The societal and fiscal advantages of mental health treatment before the individual has to be institutionalized — or jailed — are obvious.
Several legislators opposed Medicaid expansion on the premise it would hurt the “private insurance market.” As noted earlier, the only health insurance policies even remotely affordable for low-income Wyomingites are the subsidized policies offered through the federally established exchange. This is hardly a private insurance market, and the only company offering policies through the exchange — Blue Cross Blue Shield of Wyoming — supports Medicaid expansion.
Opponents wring their hands about greater-than-anticipated enrollment in other states’ expanded Medicaid programs – as though that was a bad thing! Consider our neighbor, Montana. Since Montana expanded Medicaid seven months ago, enrollment is nearly double initial projections and the number of uninsured has dropped by half. Since the federal government is picking up the cost of most of the newly insured, this is great news for Montana’s hospitals, which already have experienced a significant reduction in unpaid-for care (which, let’s remember, drives up costs for the insured). Montana also has reported substantial improvements in access to care for tribal members.
Wyoming’s governor and legislators have chosen to double down on the bust by cutting state expenditures, choking what little economic lifeblood remains. By slashing healthcare expenditures, education, and other key services, lawmakers guarantee the need for even more spending in the future (prisons come to mind).
But the state has money and the majority of Wyomingites support Medicaid expansion. Economic development funds would be an appropriate use for the needed Medicaid match (estimated at $7 million to $17 million) because Wyoming’s high cost of health care — the highest in the country, per capita — is an economic development problem. Legislators could bond the state capitol renovation rather than pay cash, as suggested by State Sen. Chris Rothfuss (D-Laramie). There are rainy day savings and unused water development funds available. Tax exemptions that never have been shown to accomplish anything could be repealed. A good choice for repeal would be the sales tax exemption for the purchase of manufacturing equipment, which cost the state some $18 million last year, as reported by the Wyoming Department of Revenue.
The Medicaid expansion match would be a tiny investment to bring a much greater return for all of Wyoming’s people. The leaders who have advocated Medicaid expansion deserve our thanks, and we constituents should demand answers from the lawmakers who have opposed it.
— Sarah Gorin has lived in Wyoming more than 35 years and has worked in various public-interest and advocacy positions. She recently retired as director of the Downtown Clinic in Laramie, a free clinic for low-income uninsured.
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