Bill to expand Medicaid on Wind River reservation fails

by Ron Feemster
— February 12, 2014

Wyoming House members voted this morning not to introduce a bill that would have allowed the tribes and the Wyoming Department of Health to investigate ways to use federal money to pay for health care on the Wind River Indian Reservation.

House Bill 80, titled “Medicaid waiver-tribal health programs-2,” was sponsored by the Select Committee on Tribal Relations. It received 33 favorable votes but failed to receive 40 of the 60 House members’ votes. A two-thirds majority is needed to introduce a non-budget bill in the budget session.

“I’m disappointed,” said Patrick Goggles (D-Ethete), who introduced the bill. “But it’s not the end. When you don’t win, you go back and look at a different avenue forward.”

The bill was very modest in scope. Rather than authorize the state health department to implement what is called an 1115 demonstration project on the reservation, it merely created an exception to the legislature’s ban on the health department discussing or in any way moving forward on Medicaid expansion without the consent of the legislature.

“It is a good bill,” said Sen. Cale Case (R-Lander), who is Goggles’ co-chair on the select committee. Case spoke to WyoFile outside the Senate chambers this morning, several hours before the vote in the House. “It merely authorizes them to investigate it. The Health Department can’t actually apply for a waiver under the bill. We need more information about the 1115 waiver. I’m not sure anyone has all the information.”

Case has gone on record before against the 1115 demonstration project on the reservation, calling it “socialism.” But he said he favored the bill in order to gather more information. “I think you know that I’m not inclined to support it. But there is so little information out there. A lot of the information was bad. We need answers.”

Goggles also noted that the governor’s opposition to Medicaid expansion in his State of the State address contributed to the “atmosphere” that made it difficult to advance the bill. In the past, the governor has left the door open for Medicaid expansion on the reservation.

Glen Fowler, an enrolled member of the Northern Arapaho tribe who works as a health care consultant for the tribe, described the House vote in harsher terms than Goggles.

“From my side, they missed a chance to honor the federal trust responsibility to the tribes,” Fowler said. “And it died. The result for the reservation is a tremendous loss — $4 million to $5 million that would have been spent directly on health care delivery.”

Fowler noted, as Goggles did in his introductory remarks in the House chamber, that under any 1115 demonstration project, the state acts merely as a pass-through for  federal money. Such a program does not require the state to spend any money on the reservation.

The lawmakers reaction may have been more of a knee jerk reaction to the word “Medicaid” than a reasoned response, according to Rep. Ken Esquibel (D-Laramie). “They hear the word ‘Medicaid’ and they freak out,” Esquibel said. “They should study it and research it and read the bill instead of relying on a preconceived notion.”

The main restriction on any 1115 waiver is the requirement to be “budget neutral” for the federal government. If the feds put money in at one point, they have to get the money back somewhere else.

Wyoming is in the sixth year of a budget neutral 1115 waiver for mothers whose first deliveries were paid for by Medicaid. Under the “Pregnant by Choice” program, the state offers optional contraception services to the mother after her Medicaid birth, in order to help her plan the next one.

The federal government and the state save money because paying for contraception is cheaper than paying for deliveries.

“The fertility rate for participants on the waiver in a recent quarter was 3 births per 1,000 women,” said Kim Deti, spokeswoman for the Wyoming Department of Health. “The baseline fertility rate among all other Medicaid women was 227 births per 1,000 women.”

At $20,934 per birth, including prenatal care, delivery, and infant care for the first 12 months, the waiver saved $3,161,034 on 151 averted births in the quarter, according to figures provided by Deti. The cost of family planning services for women on the waiver was $69,862 including two births by women in that group.

The reservation is infinitely more complicated than “Pregnant by Choice,” which enrolls fewer than 700 women. The failed bill would have begun a discussion between tribal leaders and health department officials. In addition, it would have enabled epidemiologists from the Department of Health to look at data collected by Indian Health Services and others in Fremont County to identify health care needs and ways the federal government could recoup the money it spent on Medicaid coverage.

“We’ll continue to get the tribal liaisons to talk to the Wyoming Department of Health in ways that don’t violate state statutes,” said Goggles. “I’m optimistic that when we introduce it next year and it goes right to committee. We did have the vote of Elaine Harvey, the Labor Health committee chair this year. I’m grateful for that vote.”

— Ron Feemster covers the Wind River Indian Reservation for WyoFile in addition to his duties as a general reporter.

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