Medicaid expansion discussed in forum

CHEYENNE — With a little more than a week until the Legislature convenes, lawmakers and health care experts got a chance to talk about the nuances of Medicaid expansion Thursday during a panel discussion organized by the Wyoming Liberty Group.

Following the federal adoption of the Affordable Care Act in 2010, 36 states have either fully expanded or are in the process of expanding Medicaid. Expansion would cover people whose incomes are at or below 138% of the federal poverty level – roughly $17,500 for a single person.

In Wyoming, the state Legislature has considered Medicaid expansion for several years. Last November, the Joint Revenue Interim Committee voted to sponsor a bill authorizing Gov. Mark Gordon to form a plan for Medicaid expansion in Wyoming.

During Thursday’s forum, three panelists – Wyoming Primary Care Association Executive Director Jan Cartwright, Wyoming Hospital Association Vice President Josh Hannes and Rep. Dan Zwonitzer, R-Cheyenne – said they were in favor of expansion.

Three other members of the panel – Sen. Bo Biteman, R-Ranchester; Goldwater Institute Healthcare Policy Director Naomi Lopez, and John Mansell, an anesthesiologist with more than 25 years of medical experience – were opposed to expanding Medicaid.

The seventh member, Rep. Sue Wilson, R-Cheyenne, described herself as being somewhere in the middle of the two camps.

An estimated 19,000 people in Wyoming would gain coverage within 24 months of the expansion, according to a report released last month by the state Department of Health.

One of the big questions up for discussion during the forum was how Wyoming would pay for its share of the program. Projections show the state would throw in $18 million in the first biennium of implementation, while the federal government would provide $135 million.

Wilson, who serves as chairwoman of the House Labor, Health and Social Services Committee, said it’s obvious expansion would provide a benefit to people who don’t currently have insurance.

“But I won’t vote for it unless I can see a clear, new revenue stream, because $20 million is $20 million that we don’t have,” Wilson said.

Wilson added she worries the funding for Medicaid expansion could only be carved out through cuts to other programs in the Department of Health.

Yet for others on the panel, Medicaid expansion was seen as an ineffective way to address gaps in health care coverage, regardless of how it’s paid for. Biteman said he sees Medicaid expansion as the state starting down the road to a single-payer system.

“I support the free-market approach,” Biteman said. “I think (Medicaid expansion) is just doubling down on more government.”

Others agreed with Biteman that expansion can lead to ballooning costs. Lopez, bringing a more national perspective from her work at the Goldwater Institute, pointed to New York, which is facing a budget deficit of more than $6 million in coming years, as an example of how Medicaid costs can get out of control.

Hannes and Cartwright both noted that none of the 36 states that have expanded Medicaid have attempted to reverse the implementation. While they saw that as evidence of the program’s efficacy, Lopez argued it’s unclear whether states are legally permitted to roll back their program after expanding Medicaid.

She said even states with trigger legislation to exit the program if the federal government were to reduce its reimbursement below 90% are unsure whether those triggers are legal.

“There are a lot of smart people who have done a lot of work on this who don’t think that’s actually legal,” Lopez added.

Cartwright disagreed. She said while the ACA has changed, one of the legislation’s fundamental aspects allows states to get out of the program.

“The bedrock is that (the Centers for Medicare and Medicaid Services) says we can get out if we go in,” Cartwright said.

Another point of discussion was on how effectively Medicaid expansion would provide coverage to the population that would be eligible for it. Hannes noted the Department of Health study shows an estimated three to four deaths would be avoided annually.

Lopez, on the other hand, argued Wyoming shouldn’t view Medicaid expansion as a “silver bullet” to its health care issues.

“Do the hard work on the supply side and in the insurance market,” Lopez said. “Drill down and figure out what kind of system is going to best meet the needs and preferences of those individuals who need care the most, and I think you’ll find it looks nothing like Medicaid expansion.”

Some who have served in the state Legislature for years, however, couldn’t see any other route to address health care gaps. Zwonitzer, who co-chairs the joint committee that sponsored the legislation, said he’s looked at a ton of studies on Medicaid expansion, and almost all of them show health care costs staying steady or slightly decreasing.

“For Wyoming, we’re out of options at this point,” Zwonitzer said.

Zwonitzer noted Wyoming has continued to see its population decline in recent years, pointing to projections of what the state’s population will look like in 2040.

“Our population goes up 40,000 people to about 600,000,” Zwonitzer said. “The number of working-age adults, 25 to 54, stays the exact same. We’re going to gain 40,000 people the next 15 years, and the number of people in our workforce stays the exact same.”

With the state also projected to lose more energy jobs in the next five years, Zwonitzer said Medicaid expansion promotes a more stable situation for people until they can find other employment.

“Once they leave, we’re not getting them back,” he added. “We’ve seen some studies in Montana and Kansas that expansion does fill the gaps for some people (to keep them) from leaving the state when they lose their jobs.”

While this year doesn’t mark the first time Medicaid expansion has been on the table, there seems to be substantial momentum building for expansion that hasn’t materialized in past years.

Earlier this week, a wide-ranging coalition called Healthy Wyoming announced its support for expansion. The coalition includes the Wyoming Hospital Association, the Wyoming Primary Care Association, Wyoming Medical Society, the Wyoming chapter of the American Heart Association, the American Cancer Society, AARP Wyoming, the Equality State Policy Center and others.

In coming weeks, the topic of Medicaid expansion is sure to be analyzed and debated further. Last session, a bill to expand Medicaid failed in the House by a 36-23 vote. Whether this year’s bill faces the same fate will be determined during the upcoming budget session, which begins Feb. 10.