Can lawmakers agree on path toward Medicaid expansion?
By Gregory Nickerson
— December 16, 2014
Lawmakers on Monday discussed two preliminary plans that would expand Medicaid in Wyoming.
The joint interim Labor, Health and Social Services Interim Committee is drafting two separate bills: The SHARE plan, drafted by the Wyoming Department of Health under Gov. Matt Mead’s direction, and another bill championed by Sen. Charlie Scott (R-Casper) that would make a health savings account integral to an expansion.
While the committee so far has not voted on either measure, there seems to be growing consensus among lawmakers for the first time that an expansion of Medicaid is necessary.
“Whether it is SHARE or something cobbled together, I don’t’ really care, I just want to do something,” said committee member Rep. Mary Throne (D-Cheyenne). “We have been talking about this for three years now in various ways, and we really need to move forward.”
An estimated 17,600 low-income Wyoming residents could enroll in Medicaid if state leaders opt to expand the program. Right now, those who fall into the “Medicaid gap” often go without visits to primary care doctors and sometimes end up in emergency rooms, contributing to costs that are shifted to those who do have health insurance. Medical bills pile up, causing some patients to declare bankruptcy.
“Even if we don’t have the perfect Medicaid expansion plan going forward it is definitely better than what we have now,” Throne said.
Lawmakers planned to use Monday evening to draft amendments before revisiting the bills on Tuesday (today).
Public testimony
Those who provided public testimony during the meeting represented a variety of business groups, lobbying groups, and social services groups. The majority supported Medicaid expansion in general, and the SHARE plan specifically.
The arguments in favor focused on how Medicaid expansion would benefit individuals and community hospitals. Several who spoke aimed to humanize the so called “gap population” that is not currently covered by Medicaid.
“These are our neighbors,” said Bill Schilling, president of the Wyoming Business Alliance. “They might be an airline pilot or work at a convenience store. They might be a reporter, or work for a nursing home.“
Others argued in favor or expansion as a matter of public interest and economics.
“It is in the interests of public safety and welfare that we have a healthy population,” said Donna Adler, director of the Roman Catholic Diocese of Cheyenne. “It is a legitimate use of taxpayer dollars. There will always be a working poor. They occupy low wage jobs and provide an unrecognized subsidy to businesses. It is very easy to fall between the cracks. All it takes is one medical crisis.”
High health costs make it hard to build businesses in Wyoming, Adler added. “Health care costs in Wyoming are the highest in the nation. … This is a serious impediment to attracting people here.”
She said the state needs a backup plan if it includes a “trigger” to automatically end expanded Medicaid if the promised federal funding match drops below 90 percent.
John Corra, a consultant for FMC Corp., which mines soda ash in southwest Wyoming, said his company is in favor of the Medicaid expansion as laid out in the SHARE plan. Early-career employees who are at the low end of the pay scale could use the benefit, he said.
Wyoming’s rural hospitals could also use the support in order to remain financially stable. “Rural hospitals are going to be at more risk due to uncompensated care, Corra said. “It is a factor when you go out to recruit people and they ask, ‘What is the healthcare like in Wyoming?’” He said expansion could increase the size of his company’s labor pool by offering work placement assistance to those who are unemployed.
Lindi Kirkbride, a lobbyist with AARP, noted the money lost to Wyoming because lawmakers chose to reject Medicaid expansion. “Wyoming has forgone $100 million to $120 million due to its inaction,” Kirkbride said. “Medicaid expansion allows a significant amount of money to come back to Wyoming.”
One of the primary reasons Gov. Mead and lawmakers have given for resisting an expansion of Medicaid is they don’t believe the federal government will keep its commitment to provide 100 percent funding for the first few years, then 90 percent beyond 2020. Kirkbride said she believes the federal government will keep its promise.
“Since the Medicaid program was enacted in 1965, the federal government has always paid its share,” she said.
Eric Boley, past board chair with the Wyoming Hospital Association, said his group’s members endorse the SHARE plan. “We feel like it has been very well vetted and it answers a lot of the concerns that have been raised over the past few years,” he said.
Boley passed out a chart showing the amount of uncompensated care hospitals have provided over the past seven years. In 2013, hospitals provided $75 million in charity care, which was included in the full $232 million in uncompensated care seen across the state. “We take care of every patient that walks through our door whether they can pay or not,” Boley said.
Expanding Medicaid could be financially beneficial to Wyoming hospitals, just as it has in other states, Boley argued. “I worry about the longevity of our hospitals,” he said. Boley cited a study that showed Colorado hospitals have seen a drop in the level of uncompensated care and charity care since the state expanded Medicaid earlier this year.
Medicaid expansion could also increase the level of preventive care people receive, providing money for things like colonoscopies and mammography, Boley said. “It will save the state money in the long run and it will save lives.”
According to a counter on the WHA website, the state has foregone about $108 million in 2014 by not expanding Medicaid, a number that grows by $300,000 daily.
Lawmakers talk with feds
Labor Committee co-chair Rep. Elaine Harvey (R-Lovell) provided a summary of points from a recent meeting she and Rep. Sue Wilson (R-Cheyenne) had in Washington D.C with Paul Dioguardi, Director of Intergovernmental and External Affairs for the Center for Medicare & Medicaid Services (CMS).
Harvey asked Dioguardi a series of questions to find out what kinds of provisions CMS would be willing to approve in a Medicaid expansion plan. According to Harvey, Dioguardi indicated CMS may look favorably on health savings accounts for Medicaid expansion, as they are already in use in Iowa.
Similarly, CMS would approve of copayments, which are a key part of Wyoming’s SHARE plan, and a relatively new concept for Medicaid expansion across the country.
A “trigger” provision that would end an expanded Medicaid program in Wyoming if the federal funding match dropped below 90 percent would also be acceptable to CMS, Harvey said.
Dioguardi also indicated CMS is interested in an expedited approval for Medicaid expansion plan in Wyoming, according to Harvey.
“He said if we approve this in January (2015) he saw no logistical reason they couldn’t approve this in April,” Harvey said. “Every quarter they are allowing Medicaid expansions to come online.”
Dioguardi recommended that Wyoming take a close look at Medicaid plans that are already approved and pursue “copy and paste on a very large scale,” Harvey said.
While in Washington D.C. Harvey met with Wyoming’s congressional delegation, asking them to project the future of health care reform. All three members of Congress, who have opposed the Affordable Care Act, said they couldn’t predict any outcome.
Sen. Scott’s amendments
Labor Committee co-chairman Sen. Charlie Scott (R-Casper) discussed a series of amendments for the health savings account bill. He proposed a work requirement amendment that also would include a waiver to exempt people who cannot not work. He said he recognized that any work requirement is controversial. In fact, the federal government has struck down all attempts to include work requirements in Medicaid expansion programs.
“The general requirement is you have to work, but you will have individuals whose circumstances prevent them from working,” Scott said. “CMS has had a ‘We don’t like work requirements — period’ attitude.” He said he hopes that creating the work requirement waiver option would be enough to satisfy CMS during negotiations. “I think it will be easier to sell to the legislature with a work requirement,” he said.
The concept of a work requirement met resistance from other members of the committee.
“(Department of Health director Tom) Forslund and Meredith Asay have testified that if we submit an application with this the chance of passing will be nil,” said Rep. Lee Filer (D-Cheyenne). “We still have to play ball with the CMS rules. For the record, I am against the work requirements as far as this legislation would go.”
Rep. Harvey suggested the work requirement amendment should be included in the proposal to negotiate with CMS, without making it a mandate.
“I thought the language in the SHARE plan regarding the work benefits was good, and we could insert this language and state that the goal shall be all persons capable of working should be able to work at least 20 hours a week,” said Rep. Sue Wilson (R-Cheyenne).
Committee members will vote on Scott’s amendments on Tuesday (today).
Consensus on need to take action
At the closing of Monday’s meeting, Rep. Matt Greene (R-Laramie) and several other committee members favored forwarding one single bill on Medicaid expansion to the full legislature, rather than two. He argued a single bill would reduce confusion in later debates.
“We can’t just stop,” said Sen. Bernadine Craft (D-Rock Springs). “This is an issue that impacts all of our citizens in one way or another. I feel like we are much closer to coming to some kind of consensus … I will do anything to see something go forward. We need to do this. We owe it to our citizens, and not just for the uninsured. Our hospitals are facing uncompensated care. We struggle with huge issues in healthcare and we must move forward.”
Rep. Sue Wilson (R-Cheyenne) said she had doubts that Medicaid funding would remain in place for a long period, but she supports Medicaid expansion because of the immediate benefits to the low-income population. She said she would support an amendment creating a task force to seek out additional solutions for health care in the event that a “trigger” provision shuts down Medicaid expansion after a few years.
“I’m about Medicaid-ed out today, but it has been very helpful,” said Rep. Lloyd Larsen (R-Lander). “I believe that health care reform really needs to take place. … We need to move something forward to assist those in our state that currently fall in that hole that was created through a health care law that went through the courts.”
Rep. Filer and Rep. Mary Throne came out in full support of the SHARE plan, while Sen. Jim Anderson (R-Casper) said he would only support the draft bill that included personal health and wellness accounts. Rep. Norine Kasperik (R-Gillette) said she couldn’t support either bill.
Most lawmakers at the hearing agreed that it is time to do something after three years of deliberations on the issue, and they would support whatever bill the committee passes.
“Our job is to bring something to the legislature that is passable,” Harvey said. “Regardless if you feel strongly one way or another, whatever we craft, if it is not palatable for 51 percent of the legislature, then our work is pointless.”
Update: This story was updated to remove a reference to a rule that a Labor Committee bill must have a majority from both houses to pass. That rule was put in effect by the committee for the 2015-2016 session, but it was eliminated earlier in 2014.
— Gregory Nickerson is the government and policy reporter for WyoFile. He writes the Capitol Beat blog. Contact him at greg@wyofile.com or follow him on twitter @GregNickersonWY.
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