Medicaid expansion: What a long, strange trip it’s been

After I spent nearly two hours on hold, a woman with the Health Marketplace finally came on the line. It was December 2013, and enrollment for the first year of the Affordable Care Act’s health insurance program was in full swing.

A few of my single friends had signed up and their results were certainly affordable. After the federal subsidies built into the ACA, they had monthly premiums between $12 and $119. I felt “Obamacare,” as it came to be known, would be a much-needed lifeline for my family.

It had been a rough year. I lost my job in January, and with it health insurance for my wife and myself. We had been living on savings and my unemployment check, but the former was dwindling and the latter had expired. Fortunately, we had no major medical bills in 2013, but how long would that last?

I gave the woman on the phone the information she requested and waited while she ran the numbers and looked for an insurance policy. It would be a pretty narrow search. Blue Cross Blue Shield of Wyoming was the only insurance provider for the state.

She politely informed me that I didn’t qualify for either Medicaid or a government subsidy for health insurance. “You would qualify for Medicaid, but you live in Wyoming, which hasn’t expanded the program,” she said. “I’m afraid you are in what’s called the Medicaid gap.” 

A quick review of how the basics of Obamacare worked, before the GOP gutted it: Each state set up its own online marketplace for private insurance companies to compete for customers. The program ensured a level playing field and a fair shake by requiring all policies to have certain fundamental elements and explaining costs and benefits upfront in plain language. 

The federal government then picked up some of the tab for customers. How much exactly depended on income, but for most Americans it was significant — thus the $12 and $119 monthly premiums mentioned above. Voila! Affordable healthcare for the first time in generations.

But the feds only chipped in to subsidize premiums for customers within a certain income range. Above that range, and you were well off enough to pay full price. Below that range, the solution was Medicaid.

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The problem was that many state Medicaid programs — federal insurance, administered by the states, subject to each state’s rules and requiring state cost-sharing — excluded a lot of people. 

So they built a solution into the ACA: The feds agreed to pick up a much larger share of the Medicaid cost — essentially to pay the states — if states agreed to expand their programs to include those folks like me who fell between the two safety nets.

Wyoming refused, turning down hundreds of millions of dollars in the process, and creating a yawning gap that swallowed up tens of thousands of Wyoming residents like me — all to spite Barack Obama. 

I was stunned. “So what am I supposed to do?” I asked the healthcare navigator.

“Well, the only option you have is to get private insurance,” she said.

I asked how much that would be, and the answer was $1,369 a month. If I paid that one bill, it would wipe out my monthly income. 

It was at that moment I discovered how big the Medicaid gap was: precisely the size of the hole in the pit of my stomach.

So, I was overjoyed last week when the House passed a Medicaid expansion bill with a 32-28 vote. House Bill 162 – Medical treatment opportunity act still has sizable hurdles ahead; it must be approved by the Senate, and then signed by Gov. Mark Gordon, to become law. But passage by even one chamber is historic, and proof that momentum has finally shifted.

It’s been a profoundly slow process.

In January 2014, I nervously testified at a Joint Labor, Health and Social Services Committee hearing on Medicaid expansion. Public speaking isn’t my forte, but this was an important message. I was only one of 19,000 residents in the same sinking boat, but if legislators approved expansion, we could all be pulled ashore.

Several others testified, but our collective words fell on deaf ears. Three expansion bills failed during the budget session.

Getting a job that May lifted me out of the gap, but I’ve never stopped fighting for Medicaid expansion. Even casual readers know it’s an issue I won’t drop. 

I’d be lying if I said my experience hasn’t partly driven my effort; of course it has. I know what it’s like to be denied insurance coverage solely because conservative legislators who rail against the federal government — but never refuse any other federal funds — have turned it into a partisan issue.

What’s in the best interests of their constituents, the state’s fiscal profile and Wyoming’s economy are what should determine how legislators vote. By all three measures, Medicaid expansion wins.

The Department of Health estimates 25,000 eligible residents would sign up for an expanded program.

Without insurance, this population can’t afford to regularly see a doctor. When they are sick, they turn to emergency rooms, because it’s the only place that can’t say no.

But care is costly, and the bills are paid by others. Uncompensated care totals an estimated $100 million at Wyoming hospitals, which reduce those crippling costs by charging people with health insurance more for medical services. Insurance companies then raise their premiums, even for healthy customers.

These negative factors hurt both the state and local economies. But there’s also an important human element to consider: Healthy workers are more productive.

Yes, I said workers. Almost all House members who spoke against HB 162 talked about how “able-bodied adults” shouldn’t have government-paid health insurance. It’s their code phrase for shiftless free-loaders who won’t work.

The concept is dogma based on fiction. More than 60% of those who would qualify under Medicaid expansion work. Many who would benefit are single mothers who can’t afford childcare or transportation. Others are too sick to work and need healthcare to rejoin the labor force.

I worked when I was in the gap, just not at a job that paid a living wage or offered health insurance. People who have one, two or three part-time, low-wage jobs are not lazy; they’re employed at convenience stores, fast-food chains, grocery stores, gas stations and other service-sector jobs that help drive the economy.

Expansion opponents claim it will bankrupt the state. In reality, Wyoming would get $54 million over the next two years, while spending $20 million to cover its 10% of the cost. That’s a net $34 million that the state can spend on anything. Had we expanded at the earliest opportunity, that surplus would have been an estimated $500 million.

Opponents say Wyoming will never be able to end the program. But HB 162 has two provisions that state just the opposite. If the feds ever fail to pay less than 90% of the expanded program’s cost, or less than 55% for “regular” Medicaid, Wyoming can simply walk away.

HB 162 goes to the Senate Labor, Health and Social Services Committee on Wednesday. The panel passed an identical Senate bill earlier this session, but it died when Senate Majority Floor Leader Ogden Driskill (R-Devils Tower) didn’t bring it to the full Senate for a vote.

The right wing of the Wyoming Republican Party has mounted a fierce campaign against Medicaid expansion. But several groups, including the Healthy Wyoming coalition, have countered with an aggressive effort of their own. [Full disclosure: I belong to Healthy Wyoming.]

That helping hand lawmakers like to say they’re willing to extend to the needy? HB 162 will aid 25,000 friends and neighbors, making them healthier, more productive workers, while padding the state’s needy coffers.

It will help hospitals — especially rural, critical-access facilities — keep their doors open. And as uncompensated care at hospitals goes down, lower insurance premiums for everyone should follow.

Many Wyoming lawmakers initially opposed Obamacare because they didn’t want to hand its namesake a victory. Since then, the rationale has been two-fold: the federal government can’t be trusted to keep its word, and many expansion states have bailed out.

But Medicaid expansion is alive and well in every state that’s adopted it, and the feds have never reneged on their commitments.

A few minutes before voting no on HB 162, freshman Rep. John Bear (R-Gillette) cluelessly said, “No one is going to go without needed healthcare. We are committed to providing that to our fellow human beings.”

The Legislature has long failed to make those words true. Now it has a chance to do the right thing.