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Wyoming and the ACA’s Medicaid expansion

March 01, 2018 , , ,

Wyoming Senate passes bill to impose work requirements, despite lack of expansion

Wyoming has not expanded Medicaid under the ACA, which leaves an estimated 6,000 people in the coverage gap, and a total of about 20,000 people ineligible for Medicaid, 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 60,010 people as of November 2017, which was a drop of 11 percent since 2013. Nebraska is the only other state where enrollment declined in that time, and it was only a 1 percent drop in Nebraska.

The majority of Wyoming residents support Medicaid expansion, and Democratic state lawmakers, along with Republican Governor, Matt Mead, 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.

Instead, 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 is now with the House, but 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).

If S.F.97 is enacted, the state would submit a waiver proposal to the federal government, seeking permission (likely to be granted by the Trump Administration) to impose a work requirement for the existing Medicaid program. There would be a variety of exemptions: People 18 and younger or 65 and older would not be 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 be subject to the work requirement.

But for people not exempt, there would be 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 lose eligibility for Medicaid for 12 months. Amendments to soften the requirement by making the ineligibility period shorter than 12 months did not pass.

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 $11,429 in 2018.

In general, the Medicaid work requirement would only apply to that last category, of very low-income parents. Low-income parents whose child is over the age of six would be subject to the work requirement. The state estimates that about 2,500 to 3,500 people would be 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 be exempt from the work requirement or are already working.

But those 2,500 to 3,500 very low-income parents would need 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 is enacted and the federal government approves the state’s waiver proposal.

Efforts to expand Medicaid, but no progress

Although the vast majority – 70 percent – of Wyoming residents are opposed to the Affordable Care Act (ACA) in general, by the end of 2014, 56 percent of the state’s residents support the idea of expanding Medicaid to cover more of Wyoming’s low-income population. In in 2016, after the legislature passed a budget that didn’t include Medicaid expansion, only 41 percent of survey respondents approved of the budget. But when the budget in the survey was altered to include Medicaid expansion, 52 percent of respondents approved of it.

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, as Governor Matt Mead has 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 2018, due to strong Republican opposition. If a work requirement is added to the program, it could garner more Republican support for Medicaid expansion, but it’s unclear whether there would be enough support for an expansion bill to pass.

Previous expansion discussions

The legislature in Wyoming voted in 2014 to block Medicaid expansion, but they directed Governor Mead and the state Health Department to continue negotiations with the federal government.  In November 2014, Governor Mead announced in a press conference that federal officials appeared to be “more open” to his proposals for a state-specific Medicaid expansion plan than they were in the past.

Later in November, 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 be 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 was not 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.

Lawmakers considered expansion in early 2015…

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 has 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.

… but ultimately rejected it

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.

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 – 2017: overall enrollment declines 11%

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 program actually decreased by 3,900 people – a 6 percent decline. And by the end of 2017, enrollment had fallen even more, for a total decrease of about 11 percent since 2013. Wyoming and Nebraska are the only states where total Medicaid/CHIP enrollment decreased during that time period, and Nebraska’s decrese was much more modest, at just 1 percent.

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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