Callous politicians who have refused to expand Medicaid are the primary threat to access to quality health care in rural states.
I’ve been making that case about Wyoming in this column since 2013, when the state Legislature first rejected expansion under the Affordable Care Act and left nearly 18,000 low-income residents without access to health insurance.
Paul Krugman, New York Times columnist and winner of the Nobel Prize for Economic Sciences in 2008, has now drawn the same conclusion on a national level.
“Much of the collapse of rural health care could have been avoided, and could be easily reversed, if so many state governments hadn’t chosen to impose misery on their own rural constituents,” Krugman wrote in a June 24 column.
Wyoming is one of only 14 states — all controlled by Republicans — that have not expanded Medicaid.
Krugman compared the health care situations in Kentucky and Tennessee to make his point. Kentucky expanded Medicaid and did everything it could to make the ACA work for its residents.
The result was a two-thirds drop in the uninsured rate in Kentucky. But in Tennessee, which bypassed Medicaid expansion, adults are now twice as likely to be uninsured as their neighbor.
The results in Wyoming are even more indicative of the high cost the state has paid by failing to insure low-income, childless adults under Medicaid. For adults age 18-64, Wyoming’s uninsured rate ranks 42nd in the country, according to the Commonwealth Fund Scorecard on State Health System Performance issued last month.
Another statistic that jumps out in the scorecard directly related to the Medicaid expansion issue: Wyoming ranks 48th for its age 18 and older population without a usual source of care.
People who work two or three part-time jobs in Wyoming almost never receive employer-paid health insurance benefits. The vast majority don’t regularly see a doctor, so they don’t have access to preventative health care. When they do get sick, their only option is treatment at hospital emergency rooms, where they can’t afford to pay.
That drives up the cost of hospitals’ uncompensated care, which the Wyoming Hospital Association estimates at more than $100 million per year. Hospitals make up that growing expense by increasing their rates for patients who have insurance and can afford to pay.
What do insurance companies do in response to the higher costs? Jack up their health premiums, of course.
Voters who think they’re not affected by the Legislature’s decision to not expand Medicaid — which the Department of Health now estimates could bring health insurance to 23,000 low-income residents — are impacted by higher insurance rates.
So how have conservative legislators responded to the demonstrably abject failure of their six-year-old policy? They’ve responded by doing nothing positive. And why wouldn’t they: They keep getting re-elected despite hurting sick people, hamstringing our hospitals and other health care providers and costing the state about $120 million annually in federal Medicaid funds.
Over six years, that’s nearly a quarter of a billion dollars.
No, they continue to portray the population that would be eligible for the federal program under the ACA expansion as shiftless, lazy bums who want to take advantage of hard-working taxpayers. The reality is that more than two-thirds work at low-paying jobs, and the vast majority of those remaining can’t work because of medical conditions.
Instead of helping these needy people, conservatives like Sen. Larry Hicks (R-Baggs) have sponsored bills to go after those who already get “regular” Medicaid by trying to impose work requirements to get benefits. That ruthless effort was passed by the Senate but failed in the House earlier this year, after groups like the Equality State Policy Center shamed enough legislators into rejecting Hicks’ bill.
Those hard-working taxpayers, by the way, see that $120 million a year the federal government collected from them being distributed to other states who were smart and compassionate enough to expand Medicaid.
Actually, they don’t see it because it’s an invisible, hidden cost of the way the Legislature has chosen to do business as usual when it comes to health care.
Krugman noted that rural America is facing a health care crisis in large part because of “gratuitous political cruelty [that] has denied health insurance to millions who could have had it with a stroke of a pen.”
Or if the conservative U.S. Supreme Court hadn’t ruled that states have the option to reject Medicaid, which would have been required nationally under the original ACA rules.
“Some of it may reflect the general mean-spiritedness, the embrace of cruelty, that was already infecting the GOP even before Donald Trump, and has now become one of the party’s defining traits,” Krugman wrote. “Yes, that’s harsh, but you know it’s true.”
It is true. I admit I’m sometimes guilty of ascribing every social ill in the country to the president, but Wyoming and other GOP-led states rejected Medicaid expansion long before Trump announced his campaign in 2015. To be sure, he has exacerbated problems with the nation’s health care system by trying to repeal Obamacare, but he did not create them.
I’ve spent a lot of time wondering why Wyoming voters have been caught in the trap of supporting politicians who continually vote against their best interests on many issues, especially health care. Frankly, such contemplation usually just gives me a headache because I find no solutions.
Across America, but particularly in rural states, Krugman chalked up the situation to “cynical calculation.”
“Rural voters often complain that national elites don’t care about their needs,” Krugman believes. “Well, one way to make people feel hostile toward those elites is to block their access to federal benefits and hope they don’t realize who’s actually causing their misery.”
Politicians like Sen. Charles Scott (R-Casper), who railed against Medicaid expansion and predicted that the federal government would renege on its promise to pay for most of Medicaid expansion (all of it, actually, for the first three years) have been proven wrong. It didn’t happen, and so many states have now expanded, it won’t happen.
I don’t expect Wyoming to ever expand Medicaid, despite the fact that many of the key interests that state lawmakers generally listen to the most — including business, industry, health care professionals, educators and the clergy — have all called for them to do so.
Unfortunately, that ship has sailed. Gov. Matt Mead, who changed his mind and eventually supported Medicaid expansion, told lawmakers they had no choice but to pass it because of all the benefits that would be accrued. His own party’s leadership thumbed their nose at him, which is likely why the new Republican governor, Mark Gordon, opposes expansion.
But Wyoming voters should know this: You’ve been lied to for years about this vital health care issue. Some of you have seen your own health deteriorate, and according to the Wyoming Department of Health, 111 of your fellow residents have died prematurely each year without Medicaid expansion.
The rest of us have been hit in our wallets, through higher hospital bills and insurance premiums. Hospitals that could have used federal Medicaid expansion funds to improve and expand services have instead been forced to scramble for ways to keep their doors open in the face of the skyrocketing costs of uncompensated care.
And if you don’t believe me, ask the economist with the Nobel Prize on his mantle. That guy knows what he’s talking about.