In 2006, Dina Mishev of Jackson was diagnosed with multiple sclerosis. Her medications cost $4,000 per month. She’s had one problem after another with her health insurance company: rising deductible (it reached $10,000 before she was diagnosed), attempts to drop her coverage after the diagnosis (which she successfully appealed), and denied claims.
Finally, in 2010, her insurer dropped her for good, saying she’d missed a payment even though the payments were made by automatic withdrawal from her checking account. This time she didn’t appeal. For the first time since her diagnosis she had another option: a new federal health insurance meant to cover people with pre-existing health conditions.
“I have to say, I love my insurance company now. I never thought I would say that,” Mishev, 36, says of the new pre-existing condition insurance plan.
Jane Ifland, 61 of Casper, has been without health insurance for 15 years. In the early 1990s she left the employer-based insurance she had in order to start her own business. She “tried like a dog” to buy private health insurance, but each company she approached turned her down because of a past diagnosis of depression. She also looked into buying insurance from the Wyoming state high-risk pool, but found the $1,600-per-month premium more than she could afford.
Her circumstances made her a perfect candidate for the new federal pre-existing condition insurance program. “When I first looked at it, I could not believe that I was understanding it. It was so simple,” says Ifland, who easily enrolled.
For the first time in 15 years, she now has health insurance, but unfortunately none of the Casper doctors and hospitals she goes to is “in-network” for the plan. That means she can either pay extra — twice the co-pay under a separate deductible that’s $1,000 more — to use an out-of-network doctor in Casper, or drive to Wheatland or Rawlins to use an in-network care provider.
“There is no way that it is fair for me to have to pay twice as much to have medical care in my town as they do in Wheatland. It pisses me off, frankly,” she says, mentioning both the inconvenience of the long drive and research showing people who get care closer to home respond better than those who travel to find care.
People involved with health policy in Wyoming report other residents have traveled to Billings or Denver rather than Casper to find care providers who would accept the federal insurance.
Insurance for people with pre-existing health conditions is a crucial piece of federal health care reform meant to reach people in 2010 and start boosting public support for the new law.
But the program has been very slow in implementation. Few people know about it; even fewer are benefiting from it.
The U.S. Department of Health and Human Services (HHS) has dragged its feet on marketing the new insurance, according to a Congressional study requested by U.S. Sen. Mike Enzi (R-Wyoming). The agency was concerned that the program would be so popular that hundreds of thousands of people would quickly enroll and use up all the funding allocated for the program.
Meanwhile, experience thus far shows the new program is most successful if state governments, who can tailor the program to their circumstances and needs, implement it rather than leaving it up to the federal government.
The program is one of the few parts of federal health care reform that Republican leaders would like to keep. Both of Wyoming’s two Republican U.S. Senators support the program.
But in Wyoming, both Wyoming’s past Democratic and current Republican governor declined to have the state take on implementation of the program. They left implementation to the agency in Washington, which not surprisingly adopted a “one size fits all” approach, which has not benefited rural states like Wyoming.
As a result, some Wyoming citizens like Mishev have seen the benefits of the insurance program, but others like Ifland are simply frustrated, unable to access its promise. Compared to other states, enrollment in Wyoming been relatively high. But figures indicate that sign-up in Wyoming could be higher — and Wyoming people could more easily access its benefits — if state government had taken on implementation.
That’s a lesson that could be significant for new health care debates in Wyoming, as more of the federal health care program comes into effect and state leaders must decide whether to administer them. In some states, that choice not to administer the federal insurance for people with pre-existing conditions, “there was an element of this being a political decision,” says one close observer.
“This was a creature of a Democratic administration and there are Republican counterparts who don’t like the health care reform that was passed,” notes Cecil Bykerk, who directs the state-administered version of the federal program in Montana and two other states. In some states where Republican leaders opposed the entire federal health care law, Bykerk says, “Clearly in some cases they felt it wasn’t correct, and said fine, let the feds do it.”
Wyoming’s leadership has opposed the federal health care reform law, and Wyoming is among 26 states that have filed suit challenging the constitutionality of the law. Federal courts have been split over the issue so far, and the U.S. Supreme Court is expected to take on review of the law next year.
The states that chose not to administer the federal pre-existing conditions insurance are not all the same states that have challenged the entire federal health care act in court. The experience with national health care reform thus far seems to indicate that — ideology aside — if the national law remains the law of the land, implementation by state governments will benefit local citizens more than if states leave implementation by default to the federal government.
The federal law meets a few stumbling blocks
The controversial federal health care reform act passed in 2010 is titled the Patient Protection and Affordable Care Act. It’s often known as the Affordable Care Act (ACA).
Both Enzi and his colleague, U.S. Sen. John Barrasso (R-Wyoming), support the portion of the Affordable Care Act called the Pre-existing Condition Insurance Plan or PCIP.
They have been concerned since 2010, however, that PCIP is underfunded, enrollment requirements are too difficult to meet, and benefits have remained inaccessible for too many people who should be eligible.
PCIP was included in the 2010 health reform act with a funding cap of $5 billion. Many, including Enzi, were concerned that the cap was too low. Before PCIP started, the Center for Medicare and Medicaid Services estimated that the program would be so popular that 375,000 people would enroll within the first year and the program would run out of money by the end of 2013.
Enzi has kept a close eye on PCIP. Before passage of the bill, he requested an analysis of the program from the Congressional Budget Office, which estimated that if the $5 billion funding cap for the program were lifted, up to 700,000 people would enroll at a cost of $10 to $15 billion by 2014. In Wyoming, about 150 people have enrolled so far.
Also before the act was passed, Enzi joined 30 other senators in writing a letter of concern to the Secretary of Health and Human Services. Enzi’s statement at the time said, “Given the importance of the high-risk pool program and the reliance on this program of millions of Americans with pre-existing conditions and life-threatening diseases, it is crucial that this program be fixed and fully funded.”
Last winter, Enzi requested an investigation of the program from the Government Accountability Office (GAO) — an independent nonpartisan agency sometimes called the “congressional watchdog” — which attributed the low enrollment to several factors:
First, the statutory requirement that applicants be uninsured for six months — designed to prevent private insurers from “dumping” high-risk people into the federal insurance program — makes it hard for some to enroll. Enzi told administration officials his constituents told him they “can’t afford to go without insurance for six months.”
Second, the premiums are too expensive for many uninsured people. That is the case despite the fact that the premiums are the same that healthy individuals pay for insurance on the private market in each state. In Wyoming, the cost per month ranges from $126 to $542 depending on age and which of three plans is selected.
Third, HHS, “intentionally limited initial marketing activities in order to avoid enrolling more people than the plan could support,” the GAO report stated.
This summer, HHS increased its marketing efforts and lowered premiums in some states to recruit more enrollees. Enrollment has been slowly and steadily climbing. By the end of August, 33,958 people — still only about 9 percent of the level predicted to enroll within the first year — had signed up. The program shows no indication of running out of money to help cover health care for individuals who are enrolled — only 2 percent of the funds had been spent within the first 10 months of the program, the GAO found.
While states have enrolled more participants in PCIP than federal health officials have, the GAO also found that premiums for state-run programs were 19 percent more expensive than for the federally-administered PCIP — $440 per month for a 50-year-old person compared to $370, respectively.
In 2010, Barrasso joined Sen. Tom Coburn (R-Oklahoma) to lament that more people do not have access to PCIP. They wrote, “Sadly for thousands of Americans with pre-existing conditions like cancer, diabetes, and lupus, who are already enrolled in [state] high-risk pools, they have discovered they will be denied access to a new system of [federal] high-risk pools that could offer better benefits at lower costs.” The comment came in an overall critique the two senators wrote of the federal health care reform: “Bad Medicine: A check up on the new federal health care law.”
Senators Enzi and Barrasso declined to comment to WyoFile for this story.
Wyoming leaves it to the feds
One analysis from the Commonwealth Fund — a private foundation that analyzes health care policy — suggests over 9,000 Wyoming citizens have pre-existing health problems and no health insurance.
Some people with pre-existing conditions do have insurance. The legislature instituted the Wyoming Health Insurance Pool or WHIP in 1990 to cover high-risk health care consumers. About 750 Wyoming people purchase that insurance. The numbers of customers are kept down, observers of the system say, because WHIP premiums can reach as much as $2,000 per month for enrollees in their sixties. For catastrophic coverage, enrollees have to accept $25,000 in out-of-pocket expenses.
The federal PCIP program, with premiums one-quarter that high but a requirement that applicants be uninsured for six months prior to enrolling, covers only about 150 people so far. And some, like Ifland, are enrolled and paying but haven’t yet seen any benefits.
One reason PCIP is not benefiting more people in Wyoming is the state’s decision not to implement the program. The result has been that Wyoming’s PCIP participants have been left in the hands of an insurance company chosen nationally that has little activity here, and therefore few doctors, clinics or hospitals signed up to accept that insurance.
President Barack Obama signed the Affordable Care Act in March 2010, and in April 2010, states were allowed to decide whether to administer the program in-state or leave it to the HHS.
In Wyoming, Gov. Dave Freudenthal (a Democrat) decided to leave administration of the program to HHS, writing that he believed the guidelines weren’t clear and that the $8 million grant that would accompany the three and a half years of the program to Wyoming was not enough. In addition, the state already had its own high-risk insurance plan (funded by the legislature at $3 million a year).
Freudenthal wrote to HHS, “the state’s involvement would be an unnecessary addition to the process that would result in redundant administrative costs and unnecessary delays.”
Freudenthal did not choose to have the state challenge the entire new federal health care reform act in court.
Republican Gov. Matt Mead, by contrast, made joining that court challenge one of his first acts as governor when he was sworn in, in January 2011. He continued Freudenthal’s decision to have Wyoming not implement the PCIP provision of the federal law. Mead said he has not heard complaints from constituents about the difficulties of accessing PCIP. Instead, his administration is focusing on issues of implementation of other components of federal health reform that have upcoming deadlines.
HHS therefore has implemented the PCIP portion of the law in Wyoming since 2010. For the 23 states that chose to let the federal government run PCIP, HHS invited private insurance companies to bid on the opportunity to administer the program. Fourteen companies made bids, but several of them did not meet the basic statutory requirement that they be not-for-profit.
HHS ended up selecting the Government Employees Health Association (GEHA) to administer the program from Delaware to Texas and from Florida to Wyoming. GEHA, the second-largest insurer of federal employees nationwide, is a private, not-for-profit insurance company. Some Wyoming providers, such as the hospital in Rawlins, already accepted GEHA insurance – they were “in-network” with the company, as the insurance industry says. Other areas of Wyoming, including many communities in the 12 counties served by the Wyoming Medical Center in Casper, have few providers in-network for GEHA.
Nonetheless, Wyoming has done better than most states where the federal government is in charge of implementing the PCIP program. More of Wyoming’s uninsured are enrolled in PCIP than in any other state where HHS administers the program.
A case study: Montana v. Wyoming
Despite the funding concerns up front, 27 states did elect to administer their own versions of the program, including four of Wyoming’s neighbors — Colorado, Utah, Montana and South Dakota.
So far, across the country, the 27 states that administer PCIP on their own have enrolled more than twice as many applicants (23,370) as HHS has in 21 states (10,588). (Two states — Vermont and Massachusetts — have no enrollees because residents of those states with pre-existing conditions already had access to insurance.)
People who enroll in PCIP in the 27 state-administered states have much better access to providers. States that administered PCIP themselves contracted with familiar, active insurers in their states, rather than relying on GEHA.
Montana is one of the states that decided to administer its own version of PCIP. The decision was made by the state’s insurance commissioner. She had the authority to so because she is elected, unlike Wyoming’s commissioner who is appointed by the governor.
Like Wyoming, Montana is a “medically underserved area,” meaning there is a shortage of doctors. (In 2008, Wyoming had 19 doctors per 10,000 people and Montana had 22. The national average was 26.) And like Wyoming, Montana already had its own state-run high-risk pool created by the state legislature and administered by Blue Cross Blue Shield. Like Wyoming, Montana was concerned about funding for the program. Montana, with a population almost twice that of Wyoming, got twice as much federal money for the program: $16 million.
Insurance and consumer representatives in Montana wondered, “What happens if the $16 million runs out?” says Bykerk, executive director of the state-administered federal high-risk pools in Montana, Iowa and Alaska. The state brought its concern to HHS, which assured Montana officials that it would shut down enrollment, find more funding or otherwise make certain Montana would not have to pay for the program if funds ran short.
So Montana created its own version of PCIP, following the federal guidelines, which they call the Montana Affordable Care Plan. The insurance company for the plan is Blue Cross Blue Shield of Montana, which has been building its network of providers in the state for more than 25 years.
In Montana, both the state’s own high-risk pool and the new federal high-risk pool are in the hands of Blue Cross Blue Shield. The same board of directors and executive director oversee both.
But the funding sources remain separate and they fulfill slightly different needs.
People who have just lost coverage from an employer or other source are eligible for the state’s high-risk pool in Montana, just as they are in Wyoming. People who enroll in the state’s program, however, can’t get coverage for treatment of pre-existing conditions for a year, in either Montana or Wyoming, unless they’ve had continuous insurance provided by their employer for the previous 18 months or longer. This is meant to avoid having people wait until they get sick before enrolling.
People with pre-existing conditions can get immediate coverage for treatment of that condition under the federal program, but they can’t enroll in the program unless they’ve been without insurance for 6 months. This is meant to avoid insurance companies “dumping” customers into the federal plan when they get sick.
“If we get a call and somebody says, ‘How do I get a hold of this thing?’ we’ll give them information,” says Wyoming Insurance Commissioner Ken Vines of the federal high-risk insurance. “There is a link on our website, but we have no responsibility or oversight on how it’s run.”
Montana’s insurance commissioner has spread the word about PCIP through public talks and radio advertisements. Montana has enrolled a greater percentage of its uninsured in PCIP than any other state except Pennsylvania.
Improving the Wyoming picture
Last April, Ifland nominated her doctor at the Sage Medical Group in Casper as a PCIP provider and asked an administrator at the Wyoming Medical Center to enroll the hospital in the network for PCIP. Seven months later, neither provider has joined.
Mary Lynn Shickich, chief strategy officer for the Wyoming Medical Center, says there is no particular reason for the delay. “It’s a circumstance of a large hospital looking at all potential contracts,” she says. The process has started, but it’s taking months for GEHA to negotiate rates with the Wyoming Medical Center.
According to GEHA’s contract to administer PCIP, the company “must have the ability to immediately contract with state-wide provider networks.” But GEHA doesn’t expect providers in medically underserved areas like Wyoming to enroll in their network for a temporary program like this, according to a customer service agent at who answered GEHA’s PCIP provider network hotline.
Wyoming Insurance Commissioner Ken Vines says care providers in places like Wyoming won’t easily give a discount to an insurance company for letting them join the network, and that discourages the insurance company from trying.
Instead, GEHA set up a care management department within the PCIP program to review appeals. People in rural areas can go to an out-of-network provider if no in-network providers are available. In Wyoming, because the network is so sparse, GEHA reviews appeals of every claim, a lengthy process.
In Jackson, Mishev’s care providers are not in-network. “When I needed an MRI a couple of months ago, they wanted me to drive to Riverton when I literally live right next door to St. John’s Hospital and can get the MRI there,” she says. With plenty of experience dealing with troublesome health insurance companies, Mishev has been appealing her claims. “My appeal has always gone through and they treat the people I have seen as in-network.”
Meanwhile at the Wyoming Medical Center, Shickich says negotiations with GEHA have been going well. “I think they’re very fair,” she says of the company. “We actually feel it’s very important as the primary care giver for folks in Natrona County to make sure that we provide care to individuals with pre-existing conditions. We see that as part of our community responsibility.”
The target date for the hospital to finalize its contract with GEHA is mid- to late-October. The plan won’t be available to patients until January 1, 2012, according to the hospital.
In the meantime, Ifland is still paying her $403 monthly insurance premiums and waiting. She has still not seen a doctor for tests she was told ten months ago that she should get.
Wyoming’s health coverage debate
When Gov. Mead in January 2011 had Wyoming join 25 other states in a lawsuit seeking to strike down the Affordable Care Act, the governor said, “If it [the federal health reform law] is all thrown out and they start over, I think that would be an improvement.” Six district courts and three federal courts of appeals have come to differing conclusions about the constitutionality of provisions in the Affordable Care Act.
Mead has stated, “I think the better course of action is for [health care reform] to be state-led rather than from the federal government.”
But Barb Rea, a healthcare consumer advocate based in Casper, says Wyoming has, “been trying for decades to expand coverage and change the reimbursement system and collect more data and do all the things we need to do to reform our system, but it’s politically too contentious because someone is going to make less money in a reformed system. Their lobbyists get out there and wreck whatever it is you put in front of our legislators. It’s a political football.”
Mead wrote to WyoFile in an email: “It is my belief that the ACA is not only unconstitutional, but it takes a cookie-cutter approach to health care. Essentially the law is too big and ignores the fact that what works in California does not work in Wyoming. This is why I think states are in the best position to formulate health care policy changes. I do not think it is enough to say no to the federal government, we have to seriously engage in state-led efforts. My commitment is to work on solutions in Wyoming that provide greater access to high quality, affordable care for every citizen of the state.”
As early as 1994 the Wyoming Health Reform Commission, chaired by former Natrona County Republican state Sen. Tom Stroock, recommended that Wyoming establish universal health coverage, including coverage for high-risk individuals, by 2002. That 18-year-old vision has never been realized in Wyoming. At a health reform forum in Casper, Gov. Mead’s health policy advisor told the audience she and the governor have never discussed universal health coverage for Wyoming citizens.
In 2003 a federally-funded Wyoming task force published their report, “Covering Wyoming’s Uninsured: A Strategic Plan for Improving Health Insurance Access” in which they made seven recommendations for providing health care coverage to Wyoming’s uninsured. Since that time, the number of uninsured in Wyoming has increased from about 70,000 to more than 78,000.
The lawsuit over the constitutionality of the Affordable Care Act to which Wyoming is party is expected to go before the U.S. Supreme Court in the next year. “If the entire bill is thrown out, we haven’t really been advised what to do,” says Bykerk, director of Montana’s federal high-risk pool. “I suppose programs could shut down immediately.”
If that happens, people like Mishev and Ifland will go back to being uninsured and uninsurable.
— Emilene Ostlind grew up in Big Horn. She earned her degree in creative nonfiction writing and environment and natural resources at the University of Wyoming.
— If you enjoyed this article and would like to see more quality Wyoming journalism, please consider supporting WyoFile: a non-partisan, non-profit news organization dedicated to in-depth reporting on Wyoming’s people, places and policy.
For more information:
- Overview of PCIP with links to programs in each state.
- Page for states that elected to let the Department of Health and Human Services administer PCIP (including Wyoming), where you can enroll for PCIP coverage, find providers, nominate providers for the network and learn more about how PCIP works for Wyoming citizens.
- Wyoming’s consumer advocate organization providing facts, data, information and resources explaining the Affordable Care Act.
- Kaiser Family Foundation provides data on healthcare in all 50 states. For facts about Wyoming, click on the state at www.statehealthfacts.org.
- Information about implementation of the federal health reform law from the George Washington University’s Hirsh Health Law and Policy Program and the Robert Wood Johnson Foundation.