Wyoming and the ACA’s Medicaid expansion

Joint Revenue Committee voted 8-5 in favor of Medicaid expansion bill, but the bill died in committee as soon as the 2020 session got underway

Medicaid expansion in Wyoming

Wyoming is among the minority of states refusing federal funding to expand Medicaid

Wyoming is among the minority of the states where Medicaid still has not been expanded, and the state continues to refuse federal funding that would allow it to expand coverage to about 19,000 low-income residents. An estimated 6,000 of those individuals are in the coverage gap (ie, they essentially have no access to coverage at all), despite federal rules that would allow them to have coverage if Wyoming were to accept federal funding to expand Medicaid.

Total enrollment in Medicaid/CHIP in Wyoming stood at 53,843 people as of November 2019, which was a drop of 20 percent since 2013. Nationwide, Medicaid/CHIP enrollment is up 26 percent since 2013; only nine other states have seen a decrease in enrollment, and their decreases are in the range of 1 to 9 percent.

Legislative committee voted in support of Medicaid expansion, but bill was killed in committee as soon as the 2020 session got underway

The majority of Wyoming residents support Medicaid expansion, and Democratic state lawmakers, along with former Governor, Matt Mead, (a Republican), have spent years pushing for Medicaid expansion. But Republican lawmakers, who hold an overwhelming majority in both legislative chambers, have steadfastly refused to expand Medicaid eligibility. There were hopes that might change in 2020, but that did not come to pass.

In November 2019, lawmakers on Wyoming’s Joint Interim Revenue Committee voted in favor of a Medicaid expansion bill that was to be sent to the full legislature once it convened in February 2020. The vote was 8-5 in support of the measure, raising hopes that it might garner enough support in the full legislature to pass in 2020 (since the state’s budget would have been involved, the bill will needed two-thirds support in its originating chamber in order to advance).

A group of medical students from the University of Wyoming testified in front of the committee in favor of Medicaid expansion, noting that when patients are unable to afford their care it affects their doctors as well, leading to high rates of burnout and potentially driving doctors out of the state. The Wyoming Hospital Association also testified, explaining how the state’s uncompensated care costs would be mitigated by Medicaid expansion.

Some GOP committee members who had previously opposed Medicaid expansion voted in favor of the measure in late 2019, but some remained steadfast in their opposition, including one who noted that he believes the federal government’s 90 percent funding rate for Medicaid expansion will not last (the federal government has been paying more than 90 percent of the cost of Medicaid expansion in every state that has expanded thus far, and will pay 90 percent starting in 2020 and in all future years, assuming the ACA remains intact).

Ultimately, the bill died in committee on the first day of the 2020 legislative session. Wyoming will now go at least another year without Medicaid expansion, leaving rural hospitals without enough funding and thousands of low-income residents without any realistic access to health coverage.

Lawmakers considered Medicaid expansion (with a work requirement) in 2019, but it didn’t pass

In 2019, lawmakers in Wyoming considered SF 146, which called for a study of the effects of Medicaid expansion if Wyoming were to expand coverage as of 2021. The measure passed with strong support in the Senate, but narrowly failed in the House.

Lawmakers also considered HB 244, which would have directed the state to work with HHS to expand Medicaid, albeit with a work requirement. But that bill failed in February in the House, by a vote of 23 to 36.

Wyoming Senate passed a bill in 2018 to impose work requirements, but it died in the House

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 Instead of working towards Medicaid expansion in 2018, Senate Republicans passed S.F.97 in February 2018, by a vote of 25 to 5, in an effort to impose work requirements on the state’s existing Medicaid population. The measure moved to the House, where an identical bill (H.B.148) failed on introduction in the House in mid-February, by a vote of 34-24 (it needed a two-thirds majority to advance). Ultimately, S.F.97 failed in the House, where the Labor, Health, & Social Services Committee killed it with a 4-4 tie vote, not allowing it to advance.

If S.F.97 had been enacted, the state would have submitted a waiver proposal to the federal government, seeking permission to impose a work requirement for the existing Medicaid program. There would have been a variety of exemptions: People 18 and younger or 65 and older would not have been subject to the work requirement, nor would people medically unable to work. Pregnant women, people in drug/alcohol treatment programs, and parents caring for a child who is either under the age of six or seriously ill and/or disabled would not have been subject to the work requirement.

But for people not exempt, there would have been a requirement to either work, volunteer, attend school, or participate in a job training program for at least 20 hours per week. If they failed to do so, they would have lost eligibility for Medicaid for 12 months. Amendments to soften the requirement by making the ineligibility period shorter than 12 months did not pass in the Senate.

Wyoming currently only provides Medicaid to low-income elderly residents who need long-term care, low-income disabled residents (those two populations account for about 60 percent of the state’s Medicaid spending), low-income children and pregnant women, and very low-income parents who are caring for a dependent child. In Wyoming, those parents are only eligible if their household income doesn’t exceed 55 percent of the federal poverty level. For a family of three, that’s $11,731 in 2019.

In general, the Medicaid work requirement would only have applied to that last category, of very low-income parents. Low-income parents whose child is over the age of six would have been subject to the work requirement. The state estimated that about 2,500 to 3,500 people would have been subject to the work requirement—the Wyoming Department of Health confirmed that the rest of the state’s Medicaid population (roughly 57,000 more people) would either have been exempt from the work requirement or are already working.

But those 2,500 to 3,500 very low-income parents would have had to start working (or volunteering or participating in a job-training program) at least 20 hours per week in order to keep their Medicaid coverage if S.F.97 had been enacted and the federal government had approved a waiver proposal. For the time being, the work requirement is no longer on the table, as it did not advance in the Wyoming House.

Prior efforts to expand Medicaid, but no progress

Although Wyoming’s lawmakers have been reluctant to expand Medicaid thus far, a downturn in oil and gas revenues and the resulting shortfall in Wyoming’s budget may eventually make them reconsider; former Governor Matt Mead estimated that expanding Medicaid would bring $268 million in federal dollars into Wyoming.

Governor Mead was initially opposed to Medicaid expansion when he took office in 2011, but by 2013, he had begun exploring options for expansion of coverage, and by the end of 2014, he was a proponent of expanding Wyoming’s Medicaid program using a Section 1115 waiver to implement a state-specific version of expansion.

In the fall of 2015, Governor Mead’s administration was working to obtain estimates from CMS regarding federal spending for Medicaid expansion in Wyoming, and Mead provided two versions of his 2016 budget to lawmakers. One version included Medicaid expansion, and the other didn’t, so that lawmakers could see the financial ramifications of continuing to reject Medicaid expansion. But lawmakers continued to reject Medicaid expansion.

In 2016, Governor Mead tried again, including Medicaid expansion in his budget proposal. The Joint Appropriations Committee removed it, but Medicaid expansion supporters attempted to put it back in via a budget amendment. That effort failed, however, with only 10 senators voting in favor and 20 voting against it. Opposition in the House was even stronger, so Medicaid expansion proponents in the House didn’t attempt a budget amendment of their own.

Hospitals in the state have thrown their weight behind the efforts to expand Medicaid, noting that their budgets are already tight, and that they face considerable uncompensated care losses unless the state accepts federal funding to expand Medicaid. In just three months in 2015, Wyoming hospitals had already used up more than half of a small fund set aside by the state to offset uncompensated care losses.

In 2017, Mead noted that he regretted the fact that the state hadn’t expanded Medicaid, and pointed out that Wyoming was missing out on $100 million per year in federal funding by rejecting Medicaid expansion. But Medicaid expansion still has not gained traction in the Wyoming legislature as of 2019, due to strong Republican opposition. Even when a work requirement was added to the expansion legislation (2019’s HB 244), the measure failed to pass.

Early expansion discussions

In November 2014, Governor Mead’s administration released the details of their SHARE (Strategy for Health, Access, Responsibility and Employment) proposal for modified Medicaid expansion.

The governor’s proposal included having newly-eligible enrollees pay a small premium ($20 to $50 per month for most households) if their income was between 100 percent and 138 percent of poverty level, and there would also have been small copays for most newly-eligible enrollees. Mead’s proposal also included access to vocational rehabilitation and job search services to encourage unemployed enrollees to enter the job market. Officials noted that the job training and placement portion of the program would not have been a requirement for participation (which would have been a hard sell in terms of winning federal approval under the Obama Administration, which flatly rejected work requirements and similar provisions), but rather a benefit for enrollees.

Governor Mead’s proposal had not yet been officially approved by HHS, but Mead and his administration were reasonably certain that HHS would ultimately approve their plan for Medicaid expansion, as it had been thoroughly vetted by the federal government and approved as budget neutral for the state.

But it also had to be approved by Wyoming lawmakers, which didn’t happen. Mead noted that if the legislature didn’t approve his plan, he “would ask and expect them to have an alternative for the 17,000 people” who have no realistic access to coverage in Wyoming due to the state’s failure to expand Medicaid.

In December 2014, the Joint Interim Labor, Health, and Social Services Committee approved a different Medicaid expansion bill, created by the committee’s chairman, Charles Scott, a Republican from Casper.  This alternative passed the committee by a 10 – 4 vote, but it hadn’t been vetted by the feds, and nobody knew how it would perform from the perspective of the state’s budget. The committee also voted on the SHARE proposal, but it didn’t pass (7-7).

Scott’s alternative proposal — loosely modeled on Indiana’s plan — called for having the Medicaid expansion population put funds into health savings accounts (HSAs), supplemented by additional government funds (since this proposal had not been approved by the federal government, it remained unclear whether the state would have to fund the HSAs rather than relying on federal Medicaid funds). Scott had long advocated for HSAs as a measure of healthcare reform, but they’re rarely useful for people who are living in poverty.

Initially, after the committee vote, it appeared that Wyoming lawmakers would use Scott’s plan as the focus of their Medicaid expansion discussions during the 2015 legislative session. A concern was that the plan has not been approved or even reviewed by HHS, and similar proposals had been rejected by HHS. But then in late January, Indiana announced that their Medicaid expansion waiver had been approved by HHS, creating hope that perhaps Scott’s plan could also get approval.

On January 29, 2015 the Senate Labor and Health Committee approved a Medicaid expansion bill (SF 129) that was essentially a combination of the SHARE proposal and Scott’s HSA proposal. The committee voted 4-1 to approve the bill and send it to the Senate floor. But on February 6, the Senate rejected the bill on a 19 – 11 vote.

A House committee had been scheduled to consider another Medicaid expansion proposal on the same day, but the committee abandoned their efforts after seeing the results of the SF 129 vote in the Senate. As a result, Medicaid expansion was off the table for the 2015 legislative session in Wyoming. And efforts to expand coverage in subsequent sessions have also failed, even when a work requirement provision was added to the legislation.

Wyoming Medicaid can seek recovery of birth costs from unmarried fathers

Wyoming enacted legislation in 2018 (HB 86) that allows the state to seek to recover a portion of the cost of Medicaid-funded births in certain situations. As of July 2018, when a baby is born to a mother who is on Medicaid and not married to the baby’s father, the state can work to determine paternity and then bill the father for a portion of the cost of the birth.

The amount billed depends on the father’s income. Fathers with income below 200 percent of the poverty level do not have to pay the state for the cost of their baby’s birth. But fathers with income above that level have to pay a percentage of the cost, ranging from 10 percent to 50 percent, depending on how high the father’s income is.

The legislation doesn’t apply to fathers who are married to the mother of the child, since Medicaid eligibility is based on household income. In other words, those fathers’ incomes are already taken into consideration when determining whether the mother is eligible for Medicaid to cover her pregnancy costs. But when the mother and father have separate tax households, the mother can qualify for Medicaid without the father’s income being taken into consideration. So the intent of the legislation is to ensure that fathers with financial means are accountable, at least to some extent, for the cost of their baby’s birth.

Legislation like this is controversial, however, and consumer advocates worry that it is a counterproductive approach in terms of the overall health of the mother and baby.

Who is currently eligible?

Eligibility is unchanged for now, and remains as it was in 2013.  Non-disabled, non-pregnant adults without dependent children are not eligible, regardless of income.  The following legally-present Wyoming residents are eligible for Medicaid:

  • Parents with dependent children, if their household income is up to 56 percent of poverty (about $11,080 annually for a family of three).
  • Pregnant women and children age 0 – 5 with household incomes up to 154 percent of poverty.
  • Children 6 – 18 are eligible for Medicaid with household incomes up to 133 percent of poverty.
  • All children are eligible for separate CHIP with household incomes up to 200 percent of poverty.
  • The Pregnant by Choice program provides no-cost family planning services to women who enroll within 60 days postpartum and have household incomes that do not exceed 159 percent of poverty.

How do I enroll?

2013 – 2019: overall enrollment declines 20%

Medicaid enrollment runs year-round, but tends to spike during open enrollment because of outreach efforts on the part of enrollment assisters. 2,216 people enrolled in Wyoming Medicaid from October 2013 through April 2014, through HealthCare.gov. Another 847 people enrolled in Medicaid through Healthcare.gov during the second open enrollment period. All of them were already eligible under the existing rules, but had not enrolled prior to October 2013.

People cycle in and out of Medicaid eligibility though, and from the fall of 2013 to July 2016, the net total enrollment in Wyoming’s Medicaid/CHIP program actually decreased by 3,900 people – a 6 percent decline. By the end of 2017, enrollment had fallen even more, and was down about 11 percent since 2013. By November 2019, enrollment was 20 percent lower than it had been six years earlier. There were nine other states where enrollment had declined, but only by 1 to 9 percent (nationwide, Medicaid/CHIP enrollment was 26 percent higher at the end of 2019 than it had been six years earlier).

If Medicaid is not expanded in Wyoming, there are several thousand people who will remain in the coverage gap and have no realistic access to health insurance.  They do not qualify for Medicaid, and they are not eligible for subsidies in the exchange because their incomes are too low. In addition, rural hospitals in Wyoming are increasingly under a budget crunch, as they still face uncompensated care costs for people who are uninsured, but for whom federal Medicaid funds would be available to reimburse the hospitals if Medicaid were to be expanded.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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How to apply in WY

You can enroll through HealthCare.gov or the state Department of Health website.

Eligibility: Pregnant women and children are eligible with household incomes up to 154% of poverty (children are eligible for CHIP with household incomes up to 200% of poverty).  Parents with dependent children are eligible with household incomes up to 56% of poverty.

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