New Medicaid expansion bills replace familiar failed ones

By Ron Feemster
— February 14, 2014

After Wyoming lawmakers voted not to introduce three Medicaid expansion bills debated in interim committees during the past year into either the House or Senate, the best chances to cover 17,600 of Wyoming’s poorest residents rest with two new compromise bills.

“We’re not dead yet,” said Rep. Mary Throne (D-Laramie), whose “Medicaid Fit” bill fell short by 33-27 of the two-thirds majority required to introduce a bill in the House. “I was excited when I heard the voting in the beginning. I thought we had it. But we can still get a bill through.”

Throne’s bill was the last one standing Thursday after Sen. Charles Scott’s “Insurance Pool” bill failed in the Senate and the 1115 waiver for the Wind River Indian Reservation failed in the House by the same 33-27 margin.

“I think we still have a lot of work to do,” Throne said. “People are still concerned about taking federal money. We need to listen and learn from local communities. Expansion creates jobs. It cuts the community’s costs for charity care. It has a lot of benefits to the state.”

After the bills that came through Labor Health and Tribal Relations were defeated, Rep. Eric Barlow (R-Gillette) and Chris Rothfuss (D-Cheyenne) submitted bills they hope will appeal to the diverse constituencies that have supported some kind of expansion. Both bills come up for introduction today (Friday).

“I wrote this as a compromise,” Rothfuss said. “I put in everybody’s ideas so that everybody could have something to like and talk about. I’m hoping that people can get behind it.”

To mitigate the fears of expansion opponents who believe the federal government may not follow through on its funding obligations, Rothfuss built two sunsets into his bill, which he titled “Medicaid staged expansion.”

Rothfuss’s bill would expand Medicaid in the traditional sense until March 30, 2015. Rothfuss has several reasons for leaping into expansion immediately, including providing healthcare to the needy. He also wants the state to reap the fiscal benefits of expansion. The state would get the full benefit of 100-percent federal reimbursements.

But the longer term goal would be to customize the plan in ways that satisfy the conservative desiderata of Wyoming lawmakers, so that straight Medicaid could be replaced by a more nuanced plan. During that first year, the governor, the director of the Health Department and the insurance commissioner would devise a “Wyoming” system for providing Medicaid coverage to poor people in the state.

That new system would be required to have three tiers of coverage, Rothfuss said. The least poor recipients would receive premium assistance, similar to Senate File 88, which Charles Scott wrote. The middle tier would pay small premiums to receive Medicaid, much like Medicaid Fit, the bill that Mary Throne authored. And the very poor would continue to get straight Medicaid, which is likely to be the only option that the Centers for Medicare and Medicaid Services would approve for that population.

“The details of the income levels would be negotiated with CMS,” Rothfuss said. Coverage under the new system could start on April 1, 2015, and also has a hard sunset. “It can last a maximum of three years without further legislative action,” Rothfuss said.

Under the staged expansion bill, people whose earnings change enough to move between income levels would enjoy the option of staying with the coverage they have, at least in the short term. This is an advantage touted by supporters of the now defeated “Premium Assistance” plan. In addition, the plan would have to be negotiated to create incentives for people to earn more money.

“You want every dollar they earn to be a good dollar,” Rothfuss said. “Everyone should want to get ahead and be rewarded if they do.”

Finally, Rothfuss’s bill has a feature that is likely to appeal to the many Wyoming lawmakers who value savings. None of the money saved by “offsets,” eliminating General Fund programs and replacing them with Medicaid, can be spent under Rothfuss’s bill.

All offset savings go into a special fund that will remain available to the state in case the federal government fails to meet its payment obligations or the legislature decides not to renew the program.

“If you did this for two years, that money would remain in the fund,” Rothfuss said. “That’s $40 million dollars that you would still have available.”

Both Rothfuss’s and Barlow’s bill envision scenarios in which Medicaid money from CMS could be used for premium assistance for an employer plan.

“Many of the people who need coverage are working but still not getting coverage,” said Barlow. He wrote his bill to help low-income workers and their employers.

As in the Rothfuss plan, Barlow sees negotiating with CMS as the key to progress. “If an employer said that he just couldn’t afford to provide insurance, I’m guessing we could give 50 percent to supplement employer insurance costs,” Barlow said. “But that could be 60 percent or 40 percent, depending on the negotiations with CMS.”

After spending a year hearing testimony on the joint interim Labor Health Committee, Barlow looked across the nation at waivers that were approved — and sometimes not approved — by CMS. He tried to incorporate elements of other plans that would provide solutions to Wyoming problems.

Among several options he suggests is a “comprehensive care” system in which the health department looks for leadership to different groups in a community, including insurance companies, hospitals, providers and managed care organizations, to get people signed up and covered.

“Lawmakers are starting to recognize different reasons to support a bill like this,” Barlow said. “Fiscal reasons. Looking out for the less fortunate. But also the need to stand up for the rights of Wyoming citizens, who are United States citizens, to access the health care the country is providing them. Article 1, Sec. 38 of the Wyoming constitution says that we have the right to make our own health care decisions. Are we standing in the way of an opportunity for U.S. citizens to access health care that should be freely available?”

Both bills are dark horses. Neither lawmaker thinks he necessarily has enough votes to clear the two-thirds hurdle. But they are the only bills left.

“They both have potential,” said Elaine Harvey (R-Lovell), who chairs the House Labor Health committee. “I’m not in favor of straight Medicaid expansion. I’ve been straight up about that all along. But I am in favor of doing something for the people who need health care.”

The “Obamacare Relief” bill that Sen. Charles Scott wrote as a stopgap measure to help bridge the gap he saw between this year and a future date when the federal government “straightened out Obamacare” also failed to win introduction, falling a single vote short of two thirds at 19-11.

Should these two bills fail to reach a two-thirds majority, the last option will be to try and introduce Medicaid expansion as an amendment to the budget, which only requires a simple majority.

“If both houses have already rejected two options for expansion, the most we can hope for is a study,” Harvey said. “We won’t get expansion in an amendment.”

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