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(This is an expanded version of an item in NCSL’s ACA Newsletter. It reflects similar discussions occurring in many state legislatures over how to deal with aspects of the Affordable Care Act.)

By Megan Comlossy

An interim legislative committee is considering three possible alternatives to expanding Medicaid in Wyoming, after a proposal to expand the traditional program was overwhelmingly rejected during the last legislative session. Each option has a strong backer, though none seem completely sold on expansion.   

Elaine Harvey Wyoming blog
Representative
Elaine Harvey

Representative Elaine Harvey (R), co-chair of the Joint Labor, Health and Social Services Interim Committee, has proposed using Medicaid funds to purchase private insurance through the exchange for those newly eligible for Medicaid, using Arkansas’ “premium assistance” approach."

“So many parts of this will improve people’s lives and the way they use medical services, that are different from traditional Medicaid,” she says.

Among the benefits Harvey sees are financial incentives to encourage people to properly use health care services—for example, using the emergency room only in emergent situations. “We’ve taught three generations how to use the ER inappropriately, and they do.” But by using a standard insurance product, everyone would be subject to standard insurance rules—and cost sharing. Using the ER in a nonemergency situation, for example, would cost more than, say, visiting a primary care doctor. The plan’s health savings account, which would allow people to manage their own health  funds, and provide freedom of choice, is another plus, according to Harvey. “If someone really feels the need to go to the ER when it’s not an emergency, they can. That’s their choice.”

Other benefits she points to are potential improvement in access to care as providers are reimbursed at standard insurance rates and more willing to accept Medicaid beneficiaries; less cost shifting for hospitals; more people in health insurance exchanges—expanding the insurance pool and possibly improving rates; and product portability. “This plan doesn’t stop upward mobility,” she says. If a beneficiary’s financial situation improves, the payer changes, but the plan remains.

Charles Scott wyoming blog
Senator Charles Scott

Senator Charlie Scott (R), who also co-chairs the committee, supports expansion based on the Arkansas model, though with more stringent requirements. Health care “ought not be totally free,” says Scott. “If you have some ownership, you’re less likely to waste it.” His proposal would require recipients to work and contribute more to the cost of their care. “If we’re going to do a Medicaid expansion—and I’m not yet convinced that we ought to—I’m going to build in as much cost and utilization control as I can.”

The final option, recommended by the Wyoming Department of Health and supported by Governor Matt Mead (R), would rely on the state’s existing Medicaid  infrastructure, but offer more limited benefits and require more cost sharing than traditional Medicaid. Medicaid Fit is the only option that doesn’t require the state to seek an 1115 waiver from the federal government. Nor does it rely on a private sector approach to health insurance. The benefits package would more closely resemble a commercial plan than does traditional Medicaid.

Neither co-chair expresses much support for Medicaid Fit. Both share concern over the future’s uncertainty. Will the ACA unravel before our eyes? Will the federal government renegotiate on its financial obligations and saddle the state with higher costs? Perhaps reevaluating the situation in a year would be the more prudent option, they say.

So what will likely happen when the legislature convenes in February?

“I don’t think Medicaid expansion has much of a chance of passing,” says Harvey. “No one is excited about it. But if there is a chance, it’s with the Arkansas plan.” 

“It’s not clear to me that Obamacare is going to survive,” says Scott. “If its unraveling visibly enough, I don’t think we can pass any expansion.” And, the senator explains, maybe that’s better. If Wyoming doesn’t expand Medicaid, that leaves a group comprised primarily of childless adults with income below 100 percent of the federal poverty level, without health insurance. He suggests that a single, able-bodied adult should be able to work just over 30 hours a week at a minimum wage job to reach 100 percent FPL, making them eligible for a subsidy on the exchange. “That’s a powerful reason to go to work,” he says. Though he notes the numbers don’t add up for a family, and some may still fall through the cracks.

The committee meets one more time in January, at which point it will vote on whether to move any of the proposals forward. Depending on who you ask one, or perhaps two, bills have a chance.

For more information on state actions regarding the Affordable Care Act, see NCSL's Federal Health Reform Newsletter.

Megan Comlossy is a policy associate with NCSL's Health Program.

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This blog offers updates on the National Conference of State Legislatures' research and training, the latest on federalism and the state legislative institution, and posts about state legislators and legislative staff. The blog is edited by NCSL staff and written primarily by NCSL's experts on public policy and the state legislative institution.

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