Medicaid states encircle Wyo.

November 22, 2018 GMT

Wyoming is now nearly surrounded by states that have expanded or are expanding Medicaid, the nation’s public health insurance program for people with low income.

In November’s election voters in the traditionally conservative states of Idaho, Utah and Nebraska approved ballot initiatives to expand the health insurance program to an estimated 363,000 low-income people.

Health care doesn’t stay confined within state lines. Some Teton Valley, Idaho, residents seek care at St. John’s Medical Center, while some Jacksonites get more special treatments in Salt Lake City.

“It’s a move in the right direction for the people of Idaho,” said Barbara Herz, an economist and former St. John’s board trustee. “And isn’t it a shame that the people of Wyoming don’t have the same opportunity.”

Wyoming and South Dakota are the only two states in the region — and two of 14 in the country — resisting Medicaid expansion.

To the north, Montana is in flux. A ballot initiative failed that would have funded Montana’s Medicaid expansion past June 2019 using a tobacco tax. Now the state legislature must decide how to fund the expansion, done in 2015, that now covers more than 96,000 people, or let it expire. That would be the first time a state has undone Medicaid expansion made possible under the Affordable Care Act.

Following a June 2012 Supreme Court decision, states faced a decision about whether to adopt a Medicaid expansion under the Affordable Care Act, extending coverage to most low-income adults to 138 percent of the federal poverty level. There is no deadline for states to implement the expansion.

Because Wyoming has not expanded Medicaid, parents in a family of three have an eligibility limit at 55 percent of the poverty level. For an individual the limit is 0 percent of the poverty level.

How might Idaho’s Medicaid expansion affect St. John’s?

Not much, administrators said.

Chief Financial Officer John Kren said through spokeswoman Karen Connelly that “We don’t anticipate a significant effect on patient volumes because, overall, Medicaid as a payor source represents a very low percentage of our patient volumes.”

Theoretically, more patients covered under Medicaid in Idaho could mean fewer patients who can’t afford to pay their bills.

Those patients’ costs fall under charity care, health care provided for free or at reduced prices to low income patients. Hospitals don’t expect to ever be reimbursed for such care. So far this fiscal year, St. John’s has spent $75,000 on charity care.

But the number of patients who will now be covered under Medicaid and go to St. John’s for care is minimal.

“I don’t expect a big boost to our financial situation based on this, but it’s not going to be a negative,” said Joe Albright, speaking more as a health care navigator and less as a hospital board trustee. As a navigator Albright helps people research what health insurance they’re eligible for on the marketplace created under the Affordable Care Act.

Anyone, now or in the future, covered under Medicaid in Idaho but seeking treatment in Wyoming is good to go — as long as the doctor they’re seeing is registered with Idaho Medicaid.

“You can only get Medicaid for the state in which you are a resident,” said Niki Forbing-Orr, Idaho Department of Health and Welfare communications and media relations manager. “The Medicaid expansion in Idaho only affects Idahoans, however, you can get care from an out-of-state provider as long as that provider is an Idaho Medicaid provider. You would only bill Idaho Medicaid for the services you provide to Idaho residents that are eligible for Idaho Medicaid.”

Both St. John’s Medical Center and St. John’s Physician Practices are in-network for Idaho Medicaid. So are the vast majority of Wyoming doctors, Wyoming Department of Health spokeswoman Kim Deti said.

And of course, Idaho — and Utah and Nebraska’s — Medicaid expansion won’t happen overnight.

“We started getting calls from people the day after it passed,” Forbing-Orr said. “We wish we could make it go faster.”

There’s a process to be followed. Teton Valley residents can expect the department to get the funding it needs starting July 1, 2019, but then there’s still work to be done with the governor’s office and state Legislature — especially if any changes are made to the language in Proposition 2, the ballot initiative.

“We’re anticipating being able to implement Medicaid expansion by January 2020,” Forbing-Orr said.

Talk of political ramifications

Will the move to Medicaid by rural, red states influence Wyoming? That remains to be seen.

Some say yes. In Idaho the Medicaid Expansion Initiative passed 60 percent to 40 percent. It was a tighter race in Utah and Nebraska, with roughly 53 percent in favor and 47 percent against in both states.

“My take on what might be the greatest benefit for Wyoming residents is that with two very, very conservative states, Idaho and Utah, passing Medicaid expansion, that the legislators in Cheyenne might feel it’s safe to adopt a program that they’ve avoided because it’s too Democratic, too much related to the Obama administration,” said hospital board trustee Mike Tennican.

Albright also said he didn’t think it was “out of the question” that Wyoming might consider a Medicaid expansion.

But after his election, Gov.-elect Mark Gordon told reporters: “I just don’t think it’s necessarily the right solution for Wyoming at this time.”

That is contrary to outgoing Gov. Matt Mead’s stance on the health care program. Mead, who originally was against expansion, told the Casper Star-Tribune he regretted not supporting it.

Maybe 30,000 in Wyoming

The Wyoming Department of Health has refined enrollment projections related to potential Medicaid expansion over the years. They keep a close eye on other states where enrollment varies, with some states over-projecting and others under-projecting.

“Based on recent experiences in other states, WDH currently projects 20,000 to 30,000 Wyoming residents would enroll in Wyoming Medicaid if the program was expanded here,” said Kim Deti, public information officer.

Enrollment projections have grown since the department started offering estimates.

Staff is working to update Medicaid expansion cost projections, but figures aren’t available yet, Deti said.

“Medicaid expansion costs depend heavily on take-up rates and enrollment, as well as the medical needs and use of the expansion population,” she wrote in an email. “Remember, the federal government will pay 90 percent of medical costs associated with Medicaid expansion. Previous estimates have indicated the amount of federal reimbursement for Medicaid expansion in Wyoming would be more than $100 million per year.”

Opponents say that even though the federal government is footing the bill now, the state could end up paying later.

In the meantime, health insurance costs remain high in Wyoming. The state Legislature’s Labor, Health and Social Services Interim Committee is sponsoring a bill that could help bring down rates by subsidizing insurance companies’ coverage of high-cost patients, according to the Wyoming Tribune Eagle.

“The study of the state’s insurance market estimated a Wyoming reinsurance program could bring premiums down 17 percent from where they could be in 2020 without a reinsurance program,” the Wyoming Tribune Eagle reported.

According to Wyoming Public Radio, what’s called a 1332 waiver would include putting sicker and higher risk people into a separate reinsurance pool and use a combination of state and federal dollars to pay for it.