Health and finances are uncertain in Wyoming’s Medicaid gap

Karen King waves off an offer of help as she digs a splinter from her work-worn thumb with a needle. She can manage it on her own.

At 64 she’s strong and healthy and accustomed to meeting the challenges that come her way head-on. But there are limits to what she can fix with grit and home remedies alone.

Rheumatism, heart trouble, cancer – like most Americans, her family history is a medical minefield. Unlike most of us though, she’s navigating that minefield without the benefit of professional help. She hasn’t had any of those problems yet. But since she has no access to affordable medical insurance, regular screenings and basic preventative care are beyond her reach, to say nothing of any necessary treatments. So she tackles what she can on her own, hopes for the best, and tries not to worry about what will happen if she becomes sick or injured.

Ms. King is one of thousands of Wyomingites who have fallen into Wyoming’s “Medicaid gap” – a regulatory limbo created by the state’s refusal to expand Medicaid coverage in defiance of the Affordable Care Act (ACA).

Universal coverage – every American insured by either private carrier, Medicare or Medicaid — is the foundation of the ACA’s strategy to rein in skyrocketing healthcare costs. The legislation, as signed into law in 2010, uses multiple tools to build that foundation. It eliminates insurers’ abilities to drop customers or refuse enrollment. It requires large employers to offer coverage to their employees. It provides subsidies, in the form of tax credits, to Americans purchasing private insurance in healthcare marketplaces. And it originally required, and initially pays for, states to provide Medicaid to residents who aren’t poor enough or are otherwise categorically disqualified from Medicaid but don’t earn enough to qualify for marketplace tax credits.

In states that have expanded Medicaid, recipients can get benefits up to 138 percent of Federal Poverty Line, above which they qualify for subsidized insurance on the marketplace. Since Wyoming hasn’t expanded Medicaid under the ACA, the program’s benefits cut off before recipients’ income levels reach 138 percent of the poverty level. This creates Medicaid gap, where thousands of people qualify for neither subsidies in the marketplace nor for Medicaid. In Wyoming the people in that gap number 17,600, uninsured because state lawmakers, encouraged by Gov. Matt Mead, refused to accept Medicaid expansion.

Wyoming, along with 27 other states, challenged the law’s compulsory Medicaid expansion. In 2012 the Supreme Court ruled that states could not, in-fact, be compelled to offer Medicaid to a broader population. Twenty-eight states have thus far opted to expand Medicaid anyway, and accept the millions of federal dollars on offer to pay for it. Wyoming has remained a holdout, refusing to accept more than $75 million in federal support for the expansion. That has helped punch a big hole in universal coverage, while saddling Wyoming hospitals with an estimated $200 million in uncompensated care and stranding Karen King without realistic access to coverage.

“I’m not destitute,” says King, “but I could become so if I had to go to the hospital.”

Medicaid has, for most of its history, been thought of as a program exclusively for the destitute and disabled. Expansion and the realities of modern healthcare cost are challenging those long held assumptions.  According to a recent report issued by the Kaiser Commission on Medicaid and the Uninsured, 76 percent of the nation’s uninsured in 2011, were in households with at least one working adult. Eighty percent of the working uninsured held blue-collar jobs.

Ms. King, for example, has by most conventional measures been professionally successful. She holds a master’s degree in early childhood administration. In the course of a full and frenetic career she’s worked as a classroom teacher, educational consultant and program administrator – ultimately running Head Start and similar programs for the state of Alaska, the Wind River Indian Reservation, and at the national level. She even moonlighted as a television sports, weather and newscaster in Riverton while teaching on the reservation.

A lifetime of service has earned King the faith and respect of her community. She was elected to the Fremont County School Board, District 21 in 2006 and reelected in 2010. That life has not, however, enabled her finances to keep pace with the cost of healthcare.

When she tried to enroll in the ACA program via healthcare.gov in late 2013, the system deemed her eligible for expanded Medicaid – the revamped program that Wyoming refuses to offer. Thus categorized, she is excluded from the subsidies that would make private insurance realistic through a state or federal health exchange. Until Wyoming agrees to accept the federal money and extend Medicaid, she’s stuck in an uninsurable no-woman’s-land.

What would happen if, while walking across the rain-slick pasture behind her tidy rural Ft. Washakie home, she slipped and broke her arm?

“I’m more concerned about what I’m not going to do than what I might do,” she says. “I still go get the mammograms, and I do blood work at the health fair each year. It’s expensive. I can spend $500 just like that. But it’s the responsible thing. What I’m not doing is being responsive. If the blood work says I got high cholesterol like my father or my mother’s arthritis… well what am I going to do?”

It’s a question that might have flashed through Luke Todd’s mind in March, if a bit more urgently, as he plummeted from a Vedauwoo cliff: What am I going to do? At least he didn’t have to worry about affording treatment when, upon hitting the deck 20 feet below, his ankle broke.

Todd, a fit, active, 32-year-old Laramie resident had applied for coverage in the healthcare marketplace during the same enrollment window as Karen King, but with very different results. His estimated 2014 earnings as a retail clerk and bartender edged him over the 138 percent of poverty threshold and secured him access to tax credits and a policy that he could afford.

“I’d heard all the nightmare stories, but for me it was really easy to sign up,” says Todd. “I got great insurance really affordably. I hadn’t had that for a long time.”

He’d spent nine of the previous 10 summers fighting wildfires. Rappelling from helicopters into forest fires is hard work. But until the Forest Service recently began offering seasonal staff access to group policies, it wouldn’t buy you healthcare.

After five months of treatment for his Vedauwoo fall, Todd is still in pain. He may yet need surgery to make a full recovery. He’d have done the MRI, the orthopedic consultations and the long hours of physical therapy regardless of his insurance status, he insists. But had he fallen a year earlier it would have rewritten his financial reality and his future opportunities. As it is, he’s paid his premiums, a few hundred dollars out of pocket, and the application fee to a University of Wyoming Master’s program. Todd is studying agriculture and applied economics at UW.

In the meantime, Todd is trying to avoid another fall, this one into the Medicaid gap. Bartending and broken ankles don’t mix. He’s found alternate work as an Intern for Feeding Laramie Valley helping get fresh foods to the underserved communities that need them most. It is rewarding work, but not nearly as lucrative. His change in circumstances has called into question the income estimates he used to apply for insurance. In a bitter piece of irony, he may lose the subsidies that have afforded him health care, and be served a hefty bill at the same time, not because he makes more than he claimed on the application, but because he makes too little.

“If at the end of the year, I add it up, and I made less than I thought I would, what happens then?” he asks. “Do I have to pay it back? Do I get a huge tax bill?”

Karen King has questions of her own.

“I’m not looking for a handout,” she insists. “What I really want is an answer. We used to be able to depend on one another. What happened to the Beatitudes (a set of Christian teachings) I want someone to explain to me how this benefits Wyoming.”

Renny MacKay, Gov. Mead’s communications director responded on the governor’s behalf.

“There is general agreement that we need to find a solution for those 17,000 people. Governor Mead’s position is based on a concern that the ACA is not the best solution. With the U.S. Supreme Court’s decision, the ACA is the law of the land for now. Given that and the direction of the Legislature, the Governor is interested in negotiating with the federal government to see what the best possible option for Wyoming is. Then the Governor and Legislature can consider a detailed option and decide if Wyoming should go forward with it,” MacKay said in an email response to WyoFile.

“Governor Mead also has been looking for other solutions. In the current budget he asked for and received additional funding for opportunities including medical homes, aging and disability resource centers, the 2-1-1 program, immunization, the e-Health Partnership and the developmental disability waiver program. Those are all state programs geared towards improving access to care, prevention and more effective care. They show promise and they make a significant difference for people across Wyoming.”

State leaders continue to debate the question. Before closing the 2014 legislative session in March, lawmakers again refused to expand Medicaid, voicing continued concerns over whether the federal government will provide all the funds promised for years ahead. They did, however, authorize Gov. Mead to meet with Medicaid officials and explore options for a Wyoming-specific expansion plan.

Mead, who held the first such meeting in July, has stated that he wants to present from those negotiations the federal government’s “best possible offer” to the State Legislature in time for their consideration during the January 2015 legislative session. “If we have to go forward, like it or not, what’s the best deal the state can get?” said Mead, explaining his approach to reporters at an August 21st press conference. Meanwhile the governor continues to voice his opposition to the Affordable Care Act and maintains grave reservations about Medicaid expansion.