Note from Pete Simpson: Medicaid expansion remains one of the most politically-charged issues in Wyoming in recent years. While opposing sides seem so far apart you could drop Wyoming through the gap, Medicaid expansion has also coalesced in favor of expansion a large group of stakeholders who rarely agree on political issues. And the issue remains unresolved.

We need more discussion, and more facts behind the discussion. So this week we’re asking readers to dive back into the Medicaid issues with two Wyoming people who are not politicians but are what I might call policy wonks: Charles Katebi of the Wyoming Liberty Group and Sarah Gorin, formerly of the Equality State Policy Center, and most recently director of the low-income healthcare clinic in Laramie. Both make impassioned arguments, and both cite detailed studies to support their positions.

We hope readers can use these columns to start to learn about the issues in detail  for themselves — getting beyond the short sound bites that occupies most of the political debates on this issue. Read these columns, check out the studies they cite, and come back to us with your comments. Make sure those candidates out there have studied up on it too! — PS

— by Sarah Gorin

Sarah Gorin

The majority of Wyoming legislators chose to turn their backs on Medicaid expansion from its first offering. Since January 2014, nearly $300 million that would have created an estimated 800 jobs in our state, enabled uninsured Wyomingites to get the health care they need to go back to work, and strengthened our rural hospitals has gone to other states that chose Medicaid expansion.

Budgeting data prepared for the 2016 Legislature showed that accepting Medicaid expansion would save money for the state because the funds accompanying expansion would replace state monies now being spent on “safety net” programs. Recent budget cuts that eliminated the safety net programs also eliminated the savings — and, of course, mean that less health care now is available in our state.

Is Medicaid expansion still worth doing? Yes. Why? One: It saves lives. Two: It’s a badly needed job generator. Three: It will strengthen access to health care for all Wyomingites. Four: It’s still a bargain, as the federal government will pick up 95 percent of the cost in 2017, dropping to 90 percent by 2020.

Read the companion piece to this Pete Simpson Forum — “Medicaid expansion’s hidden cruelty,” by Charles Katebi

Many assume that Medicaid already covers all low-income people. It does not. In Wyoming, for example, Medicaid eligibility is “categorical” — that is, a low-income individual must also fit in a specified category to obtain Medicaid coverage. The largest category is children; the most expensive one is individuals in nursing homes.

Who’s missing? Thousands of adults with debilitating conditions such as uncontrolled diabetes, asthma, and high blood pressure do not qualify for Wyoming’s limited Medicaid coverage. They are left to fend on their own or in our hospitals’ emergency rooms — the most expensive and ineffective way to deliver primary health care, and one that raises health care costs for the insured and uninsured alike.

The most spectacular untruth of those opposing Medicaid expansion is their constant chant that Wyoming’s uninsured simply need to get off their butts and work. These opponents never explain how an employer could expect an uncontrolled diabetic or asthmatic to reliably perform a full-time job, especially jobs requiring physical labor such as lifting materials on a construction site or mopping floors and making beds. Employers, on the other hand, have this figured out. They don’t hire sick people.

Nor do opponents of Medicaid expansion acknowledge that many uninsured Wyomingites are, in fact, working — but they don’t make enough money to qualify for subsidized insurance on the federally-established Wyoming health insurance exchange. Opponents of expansion claim that Wyoming workers with low incomes can and do receive subsidies under the exchange, and so argue further that serving those workers with expanded Medicaid would hurt the private insurance company now allegedly covering them, with the aid of subsidies, under the exchange.

But the fact is that workers with incomes below 100 percent of the federal poverty level cannot receive subsidies. (For reference, the 2016 FPL for one individual in the continental United States is $11,880/year; for a family of two, $16,020/year; for three, $20,160; for four, $24,300.) The law works that way because the original law expected Medicaid expansion to occur nationwide.

Low-income workers frequently work only part-time due to personal illness, caring for an elderly parent or children or grandchildren, or lack of transportation that limits their job opportunities to those within walking distance. Denial of Medicaid expansion in Wyoming means that these low-income workers, making less than 100 percent of the federal poverty level, can get health insurance only if they pay its full cost — with no help from the exchange. Paying full freight for a health insurance policy at these income levels is laughable; there would be no money for anything else. These workers have no choice but to try to find employment that accommodates their situations and hope they can get to the emergency room if things get really bad.

To look at this issue in more detail: Subsidies on the health insurance exchange begin at incomes equal to 100 percent of the FPL. For the purposes of the following illustration, this works out to a 40-hour week at an hourly wage of $7.70/hour for a family of two — say, an adult and a preschooler — more than the federal minimum wage of $7.25/hour, and therefore more than Wyoming’s six thousand workers at minimum-wage or below receive.

What it takes to be self-sufficient in Wyoming.

Meanwhile, the recently updated Self-Sufficiency Standard for our state, issued by the Wyoming Women’s Foundation, utilizing Wyoming data on a county-by-county basis, shows that an adult and a preschooler need an hourly wage of at least $14-$15/hour, with a 40-hour work week, to cover necessary household expenses. In most counties, the hourly wage needs to be more than $15-$18/hour (up to nearly $26/hour in Teton County). The study assumed access to employer-sponsored health insurance or the most heavily-subsidized health insurance policy on the exchange.

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In short, yes, a fraction of Wyoming’s uninsured technically qualify for subsidized health insurance policies, but the Self-Sufficiency Standard data demonstrate that to utilize these policies, something else has to go. The rent and the child care have to be paid so the adult can work. In some Wyoming towns the family can go to a food pantry and get something to eat, but that $150 new-patient visit has to be put off, and please, hope to high heaven, make it a mild winter so the heating bills aren’t so high.

The Self-Sufficiency Standard also demonstrates the sheer fantasy of claims by Medicaid expansion opponents such as State Sen. Charles Scott (R-Casper), who says people will reduce their incomes to qualify for an expanded Medicaid program. It will be difficult for these Wyomingites to get the most out of their new health care without heat, adequate food, or perhaps even a place to sleep safely.

In sum: Those with incomes below 100 percent of FPL have no access to health insurance, and in most cases no access to health care except in the emergency room. For those making a bit more, in the words of the Self-Sufficiency Standard, “Nevertheless … are far below what is needed to meet families’ basic needs.”

Medicaid expansion helps strengthen families’ economic security. In Oregon, which implemented a lottery to offer a state-funded Medicaid expansion before the federal government paid for it, people with Medicaid were 40 percent less likely (than those without insurance) to go into medical debt or default on other bills to pay medical expenses. A study of this randomized expansion found that Medicaid coverage “nearly eliminated catastrophic out-of-pocket medical expenditures.”

This same study often is cited by legislators as a reason not to expand Medicaid, because it also found that clinical outcomes (e.g., high blood pressure) were not significantly improved among the expansion population after two years of program implementation. However, besides the positive effect on family finances, the study showed that expansion produced substantial improvements in other health outcomes: mental health, raised rates of diabetes detection and management, and increased use of preventive services.

In Ohio, where Medicaid expansion began in January 2014, more than 50 percent of those enrolled were treated for mental health and drug addiction problems, and more than one in 10 was diagnosed with severe mental illness. The societal and fiscal advantages of mental health treatment before the individual has to be institutionalized — or jailed — are obvious.

Several legislators opposed Medicaid expansion on the premise it would hurt the “private insurance market.” As noted earlier, the only health insurance policies even remotely affordable for low-income Wyomingites are the subsidized policies offered through the federally established exchange. This is hardly a private insurance market, and the only company offering policies through the exchange — Blue Cross Blue Shield of Wyoming — supports Medicaid expansion.

Opponents wring their hands about greater-than-anticipated enrollment in other states’ expanded Medicaid programs – as though that was a bad thing! Consider our neighbor, Montana. Since Montana expanded Medicaid seven months ago, enrollment is nearly double initial projections and the number of uninsured has dropped by half. Since the federal government is picking up the cost of most of the newly insured, this is great news for Montana’s hospitals, which already have experienced a significant reduction in unpaid-for care (which, let’s remember, drives up costs for the insured). Montana also has reported substantial improvements in access to care for tribal members.

Wyoming’s governor and legislators have chosen to double down on the bust by cutting state expenditures, choking what little economic lifeblood remains. By slashing healthcare expenditures, education, and other key services, lawmakers guarantee the need for even more spending in the future (prisons come to mind).

But the state has money and the majority of Wyomingites support Medicaid expansion. Economic development funds would be an appropriate use for the needed Medicaid match (estimated at $7 million to $17 million) because Wyoming’s high cost of health care — the highest in the country, per capita — is an economic development problem. Legislators could bond the state capitol renovation rather than pay cash, as suggested by State Sen. Chris Rothfuss (D-Laramie). There are rainy day savings and unused water development funds available. Tax exemptions that never have been shown to accomplish anything could be repealed. A good choice for repeal would be the sales tax exemption for the purchase of manufacturing equipment, which cost the state some $18 million last year, as reported by the Wyoming Department of Revenue.

The Medicaid expansion match would be a tiny investment to bring a much greater return for all of Wyoming’s people. The leaders who have advocated Medicaid expansion deserve our thanks, and we constituents should demand answers from the lawmakers who have opposed it.

— Sarah Gorin has lived in Wyoming more than 35 years and has worked in various public-interest and advocacy positions. She recently retired as director of the Downtown Clinic in Laramie, a free clinic for low-income uninsured.

— Columns are the signed perspective of the author, and do not necessarily reflect the views of WyoFile’s staff, board of directors or its supporters. WyoFile welcomes guest columns and op-ed pieces from all points of view. If you’d like to write a guest column for WyoFile, please contact

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  1. Glad to see the discussion going! To address some comments:

    (1) Required reporting on the sales tax exemption for purchases of manufacturing equipment has failed to demonstrate any connection between such purchases and job creation. In fact, nothing prevents a manufacturer from getting the exemption for the purchase of equipment that ELIMINATES jobs. So either the criteria for applying the exemption need to be drastically tightened, or we should repeal the exemption and use the badly-needed revenue for something beneficial like Medicaid expansion.

    (2) Here are the conclusions of the Oregon study:
    “This randomized, controlled study showed that Medicaid coverage generated no significant
    improvements in measured physical health outcomes in the first 2 years,
    but it did increase use of health care services, raise rates of diabetes detection and
    management, lower rates of depression, and reduce financial strain.” The measured physical health outcomes were limited to blood pressure, cholesterol, and blood sugar levels. Failure to get all these within the ideal range does not mean the participants were not healthier, especially in light of the other conclusions on depression and financial strain.

    (3) Charles Katebi’s suggestion to “get rid of Obamacare’s regulations that increase the cost of health insurance” means get rid of the requirements that make the insurance worth something. Let’s remember a basic problem with the health insurance market: Insurers make money only on well people. “More affordable” and “more choices” are nice catch phrases that mean the insurance doesn’t cover anything substantive (for example, prescription drugs or emergency services, or treatment for specific diseases such as cancer). Those phrases reflect the bad old days before the Affordable Care Act when insurers could refuse coverage for your pre-existing condition, like your cancer or your MS or your asthma.

    (4) Charles Katebi did not provide any cost projections for “direct financial support” for low-income patients, nor did he acknowledge that a primary care program is insufficient health care coverage. What if you need your appendix out?

    (5) I agree that Medicaid reimbursements are miserable and a disincentive for health care providers to see Medicaid patients. But rather than cite this fact as an argument against Medicaid expansion, I’d propose the obvious solution: raise the reimbursements! We don’t expect highway contractors to accept a cut rate. Yes, it will make the program cost more, and also will infuse millions into our state’s health care infrastructure and overall economy.

  2. The moral of this complex story as I see it is ” Don’t look a gift horse in the mouth.” If you’ ve ever been to an Emergency Room you know what they charge for a bandaid much less a stent. And with no insurance and no way for the patient to pay the bill gets passed on to your county. If you are among the Wyomingites who hate the federal government and wanted to secede from the union when Obama won a second term why not make the government pay through the nose for what your neighbor needs? You take it in a sec when a wolf kills a cow, for ranch subsidies and highways, don’t you? I don’t get it..

  3. Thanks for the bit more than a sound bite. I am sure the truth lies somewhere in the middle. The affordable care act is not the end all. In fact it needs to be changed. But there should be something out there. Health insurance shouldn’t be a luxury that only those who have a job that provides it or those who make over 150K can afford. I am thankful that my husband has a job that provides it for us. However he can’t leave that job because it provides it for us. My business wants to provide it for our employees but can’t afford to. The prices before ACA and after are both insane. My children had similar procedures 18 months apart and the price shot up 1500. The doctor is driving a different car everyday. The hospital remodels the waiting room every few years. We need to look at all aspects of healthcare to cut the fat. Stop worrying that someone is taking advantage of the system and look at all those who it truly helps.

  4. Sarah, you mentioned: “In Oregon, which implemented a lottery to offer a state-funded Medicaid expansion before the federal government paid for it, people with Medicaid were 40 percent less likely (than those without insurance) to go into medical debt or default on other bills to pay medical expenses.”

    You forgot to mention that this study also concluded that Medicaid “generated no significant improvement in measured physical health outcomes” for uninsured individuals who went onto the program.

    Should we expand a health program that doesn’t make recipients healthier?

    1. I’ve had Medicaid in Montana, which paid for my hip replacements without I wouldn’t be walking.

      I’m now in Arizona and have Access which hasn’t refused a the stent in a very important part of my heart. Other than this I’m healthy. I could be dead instead.

      I have Medicare which is ok I guess but it seems the other insurance covers more.

      Wyoming seems to only wants healthy people, the rest can go to hell…typical Republican treatment of low income people.

  5. There is always a better way to achieve better conditions. President Regan stated, If not now when, if not us , who? No plan is perfect even in the face of war, battle plans have change orders. Wyoming is failing is to incorporate a plan. Sure no-one likes our present medical positions in Wyoming. However we have an opportunity to incorporate funding to utilize under medicare expansion, its not perfect. Yet that money can shore-up the present positions for Wyoming people and establish time to work-up a plan.

    Well in the last four years the facts speak for themselves, we’ve turned away opportunity for Wyoming medical needs through the fear of legislative actions based on security for our earned revenues. The Gross Domestic Product of Wyoming is produced by the whole. Does it not stand to reason or common sense Wyoming people have a common plan in place by now?

    If you want a plan that achieves better conditions, then by all means get out and vote!!! Why? In the last Wyoming election only 38.7 % voted, yet after that election, yet OUR state increased spending by 13.52 %. or 1.2 billion dollars, what was the plan for medical care then– enough said. Footnote site Ballot Redia on the Web with footnotes and government census for Wyoming.

  6. On average, Medicaid expansion has cost the states that have adopted it 260% more than predicted.

    The justification for expansion is “it’s free federal money.” All of us should know by now that there is nothing in this world that’s free. All federal money comes with massive strings attached, like all those rules and regulations decided by bureaucrats 1,750 miles away without knowing the needs of Wyomingites. There is no such thing as free, and the leverage gained by bureaucrats continues to kill us.

    The federal government says it will match all money 100%, but that matching is tier based, later decreasing to 95%, then 90% and so on leaving Wyoming taxpayers with a heavier burden every year.
    And how does the Federal government pay anything when they are approaching 20 trillion in debt? It means they must print more money which devalues our dollar and makes us all poorer.

    The largest concern, beside the fact the money doesn’t exist, is that expansion is to 18-35 year old non-disabled working adults who will take from the programs we do need. This age group is the healthiest and one of the largest taxpayer groups. Because there is only so much money to go into programs, this group will be competing with Medicare recipients (seniors) and mentally or physically disabled citizens. Such as those who are retired and have paid their dues to society, and those who can’t feed themselves, bathe themselves, or dress themselves. In other words, those who truly can’t work.

    We have a duty to our seniors. As a society we should make sure someone that’s a quadriplegic, is mentally incapable of supporting themselves, or has cerebral palsy has the care they need. It’s the 18-35 year old non-disabled people that are supposed to provide those programs, not take from them. If you are mentally or physically disabled or retired on Medicare, you shouldn’t have to compete with this demographic. If you end up having to, everyone will lose and the people who truly deserve the care won’t get it.

    We can be part of the State and Federal financial solution, or the problem. Personally, I believe in the tough choices that are part of the solution.

    Nicholas De Laat

  7. The pro con discussion is very welcome and informative It is ironic, however, that the sales tax exemption for the purchase of manufacturing equipment was suggested as a potential source of revenue to fund expansion. Wyoming needs to expand the manufacturing sector not contract it. Manufacturing jobs and potential new products and markets should be encouraged not discouraged. The concept of this economic policy is to not tax the purchase of equipment used to manufacture a product that is then subject to sales and use tax. The end product is taxed when purchased by the consumer. At a time when Wyoming is losing jobs it does not seem to be good idea to remove an incentive to diversify the economy into other manufacturing areas.

  8. Thank you Pete, Sarah and Charles for participating in a much needed discussion. While Sarah’s humane commentary seems more substantiated by numbers and factual data, Charles has a point about caregivers’ view of Medicaid patients.

    My question is: where do we go from here to get past ideology and onto decent health care for our entire Wyoming community (remember we have one long Main St. in our state)? Rather than who’s right and who’s wrong, is there a way to achieve a better condition and what will it take to secure it?

    1. Sandy, there many way we can provide better healthcare for everyone, especially low-income Wyomingites.

      A better system would:

      Get rid of Obamacare’s regulations that increase the cost of health insurance. This will make insurance more affordable, and give individuals more choices when shopping for health coverage.

      Second, we could offer direct financial support to individuals who still lack the means to afford healthcare. They could spend it on health insurance or pay for their healthcare directly by enrolling in a concierge or direct primary care practice. Through direct support, low-income patients would be able to choose the best plan to meet their unique healthcare needs. This would serve low-income patients far better than Medicaid would.