Wyoming Medicaid expansion hopes are dashed again

When the budget session wound down last March, a tiny glimmer of hope about Medicaid expansion in Wyoming emerged when lawmakers allowed state officials — if they felt like it — to negotiate with the federal government to develop a state-specific plan.

As opportunities go, it wasn’t much. I didn’t expect Gov. Matt Mead, an Obamacare opponent who repeatedly said no to expanding Medicaid to the working poor, to ever OK such a move.

But he did. Maybe it was his upcoming re-election campaign and a sudden need to try to be seen as a populist, but the governor allowed the Wyoming Department of Health to negotiate for a state waiver to operate its own Medicaid demonstration project.

 DOH Director Tom Forslund led a team that persuaded the Center for Medicare and Medicaid Services to bend on some important issues. More progress was made when several opponents said they were willing to at least reconsider expansion because of the talks. Criticism from some of their constituents was also probably a factor.

 And then last week, on the brink of a new level of success, everything went to hell.

I should have known it was coming. I foolishly allowed myself to be optimistic that legislators would finally do the right thing. After more than three decades covering them, I still act like Charlie Brown, confident that this time, Lucy won’t pull the football away as I try to kick it, and I won’t once again hit the ground with a loud thud.

 Pardon me for turning to cartoon analogies, but this latest crazy turn of events has left me pretty confused, and also cranky.

 Forslund and his team developed a plan called SHARE that would allow about 17,600 low-income state residents to receive Medicaid assistance, or at least a watered-down version of what the poor get in other states. The poverty-stricken citizens were caught in what’s become known in non-expansion states like Wyoming as the Medicaid gap — they couldn’t enroll in the program because the state refused to expand it, and their income is so low they aren’t eligible for any Obamacare subsidies. 

SHARE is a workable plan, even though it has some elements I still dislike. It requires the poorest of the poor to pay premiums and co-pays for services, which just flat doesn’t make any sense to me. Twenty-eight states that accepted traditional Medicaid didn’t feel the need to take money people don’t have or can’t afford, just so legislators can feel good about the way they are supposedly upholding “Wyoming values” by making it even more difficult for those mired in poverty to survive.

In reality, a majority of GOP state lawmakers are just gouging the poor and punishing them for not being able to afford health insurance. Federal rules keep them from making people on traditional Medicaid pay, but they can make this desperate, needy group jump through hoops for a little help.

 The only reason for Republican governors like Mead to reject traditional Medicaid expansion is to stick it to President Barack Obama. Wyoming has thrown more than $100 million in federal funds down the drain and watched community hospitals threatened with closure because they can’t afford to keep picking up the tab for the medical costs of the poor.

 Meanwhile, the low-income people eligible for expanded Medicaid still aren’t being helped. Nearly three-fourths have jobs, even though officials often treat them like lazy freeloaders.

Expansion supporters decided the SHARE co-pays and premiums are acceptable, and I agree they’re better than no help at all. The DOH dodged the Legislature’s requirement that participants work — something CMS has never approved in any state — by designing a “work benefit” program aimed at helping those in poverty learn skills to get better-paying jobs.

 Forslund reported back to a legislative committee last week that he couldn’t make any promises, but if the Legislature passes the SHARE plan at the general session that begins Jan. 13, CMS will very likely sign off on the “Wyoming solution” our officials are seeking.

 But by a 10-4 vote, the Joint Interim Labor, Health and Social Services Committee approved an alternative, much more complex bill crafted by the panel’s chairman, Sen. Charles Scott (R-Casper). He led the fight against Medicaid expansion last session, and vowed then Wyoming will never accept anything that is part of Obamacare.

 Scott’s bill would make participants put minimal amounts of money into health savings accounts, with government funds making up the vast majority of the total balance. He told his committee the accounts will encourage the poor to save and not spend all of the money on health services, since they will be entitled to keep a portion of the funds when they no longer need Medicaid.

You might be asking yourself, “Hmmm, health savings accounts — why does that sound so familiar?” It’s because in 2011 they were a centerpiece of Scott’s last attempt at health care reform in Wyoming, a demonstration project called “Healthy Frontiers.”

 Healthy Frontiers was so unpopular, the state Senate killed the project a year later. Far fewer people signed up for it than Scott anticipated, and critics also condemned it as a money sinkhole.

 This is the plan that’s now supposed to win the Legislature’s approval? Really?

 There are two problems with Scott’s concept of viable health care reform for the poor: one fiscal, and the other philosophical.

 DOH officials said because the health savings accounts are a new Medicaid waiver request, it hasn’t been determined if any federal funds can even be deposited. Scott thinks they would be, but at this time he has no guarantee that will actually happen.

 If there isn’t a quick, affirmative answer to that question, the committee’s bill will be shot down in flames. Can you imagine how traditionally penny-pinching GOP legislators will react if the health savings accounts must be totally state funded?

The other problem is Scott’s insistence that lack of health insurance coverage isn’t what’s making health care reform fail, it’s because the poor use too many unnecessary health care services. Darn those poor people, they’re always getting sick and using more than they need! He claimed they don’t have any incentive to not seek health care at expensive emergency rooms, but Scott said health savings accounts will solve that by allowing them to keep a small share of whatever money is left.

 Instead of wasting valuable time on an unproven plan, the Legislature could go with the much simpler SHARE, which has already been vetted by the feds. Barring an improbable special session, if lawmakers don’t approve expansion now, the issue will be on hold until 2016, while the state wastes millions more and the needy continue without health insurance.

 After passing Scott’s proposal, Co-chairman Rep. Elaine Harvey (R-Lovell) let committee members vote on the SHARE bill. But unlike Scott’s heavily amended measure, they couldn’t change it at all. The bill predictably failed on a 7-7 vote.

 The DOH did exactly what the Legislature directed, and its hard work was wasted. If I was Tom Forslund, I would feel blindsided.

SHARE will probably be resurrected by one or two sponsors, but it won’t have the backing of a committee. Such support generally makes a bill more likely to pass. Any optimism I used to have about this issue is gone. With hatred of Obamacare still prevalent at the Capitol, especially by the Tea Party crowd, it would be hard enough to get SHARE approved by both chambers. Even Scott isn’t sure exactly how his health savings account plan will work, so it could well be dead on arrival.