Thread by @IAmNickReynolds

The abortion bill has passed unanimously and we are now starting the debate on Medicaid expansion.

You can stream the meeting here:

https://twitter.com/IAmNickReynolds/status/1377251869421015040

Rep. Romero-Martinez -- the sponsor -- says he wanted to "speak from the heart" as a Republican working to expand Medicaid.

"I'm probably the first person elected to the House [who] lives in dire poverty. but I do know how to take a shower and put on a tie."

Franz Fuchs, of the Dept. of Health, says our traditional Medicaid program is largely made up of low income kids, typically those at around 356% of the poverty level.

Wyoming is projected to see about 25,000 enrollees should we expand Medicaid. health.wyo.gov/wp-content/upl…

Other states have exceeded their projections, so Wyoming has projected a range of around 13,000 to 38,000 new enrollees.

Bouchard asking about tax increases, impacts to private rates, and the fiscal impact of expansion other states have seen as a "reaction" to having to offset care for the expansion population.

Fuchs says they tried to estimate people shifting from the exchange + rates.

However, he noted that providers would come out "ahead on average," citing evidence from other states.

"What you're doing is you're taking the lowest income people on the exchange -- who tend to have more health care problems and that's the highest health care costs. So in some ways, Medicaid expansion acts as a bit of a high risk pool. You're shifting that risk to Medicaid."

Bouchard pressing, asking about potential tax increases and work requirements. Said that the Biden administration is "actively" working to roll back work programs in other states, so that may not be the route to go.

Fuchs said there are a variety of ways to pay for expansion if they overstep their projections, but would be a topic for the Revenue Committee.

Jesse Springer noted that the DoH already provides a lot of this care through their existing budget. Medicaid could offset those.

McKeown now railing against Medicaid expansion. Disputes that people on Obamacare would switch over to Medicaid expansion, because they're "already there." But Fuchs notes that lots of people can't get insured now, and that many of those plans are already heavily subsidized.

McKeown says it "doesn't take much effort" to reach 100% of the poverty line (in this case $12,000 or so a year, a minimum wage job) and that this is "building more dependency."

But Fuchs notes it gets harder to qualify when you have a family, and that most recipients work.

"There are a lot of people working there just working at relatively low wage jobs or not getting 40 hour workweeks," said Springer. "So, I just hope we know that most people [who would be eligible for Medicaid] are working."

Hutchings now raising concerns over the federal debt.

"Where are we gonna get the money buying this program?" she asked. "Even in our state, we're asking people to cut back over and over and over, and we're now saying 'let's jump on this program.'"

Fuchs notes Medicaid is funded by debt, but a good portion comes from general revenue as well.

As far as what happens after initial incentive, that's an open question. We'd still have a federal match of less than 60%, and a lot of Reps have said we'll try to negotiate that up.

There's the 90-10 match that the feds give Wyoming initially, and the FMAP increase is quite helpful, but the idea I've gotten from lawmakers is that the state cannot raise enough revenue to support its own share of the program, hence the issue.

Lawmakers in the room: Rothfuss, Sweeney, Harshman, Clifford, Nieman, Jennings.

Public comment started.

First up is Raymond Ward, a Republican member of the UT House of Representatives. (Who was quoted in this piece by @m0rgan_hughes: trib.com/news/state-and…)

UT passed expansion by ballot initiative there and the Legislature tried to fix it. But since then, he said, it's worked.

Notes numerous other states have elected to expand.

"All 38, when they looked at the benefit it gave to their constituents to their citizens who live there, and they looked at the cost and cost from their budget, all 38 of them said this is worth it," he notes.

Utah funds its program through a sales tax, he said. But the backup plan -- an increase on assessments on hospitals -- has not been deployed.

But he said that making people healthy enough to work has helped the economy enough to boost the revenues needed to pay those taxes.

I'm gonna have something brief on all this later on (I'm better at the machinery of legislation) but Morgan is your better bet for the policy of #MedEx

https://twitter.com/m0rgan_hughes/status/1377269832526094343

Danielle Amoux talks about her struggle with depression during COVID, and was "not sure" whether she'd make it through that time.

The state tried to get her on Medicaid so she could get care and, because of the CARES Act, she could.

If I wouldn't have been able to get Medicaid, I don't know that I would be here testifying right now," she said.

She works -- has a "masters" level education -- and "resents" the arguments Medicaid would make her become "dependent" on the govt.

"I work, I have a son, and I'm barely making ends meet," she said.

"We live in the wealthiest country in the world and I have to beg to get some kind of healthcare," she added.

Adrian Gerrits, of the Campbell County Hospital, says Medicaid expansion would help offset uncompensated costs on rural hospitals, where uninsured often receive care in the E.R.

"These people are receiving care," he said. "It's just in the most inefficient way possible."

As their mill levy declines (in Campbell County, that's coal) the pressure has gotten even greater for them, he said.

(Reps. John Bear, Clarence Styvar, also here btw.)

Now we're onto opponents of the bill.

First up, Hayden Dubois with the Opportunity Solutions Program, a group who favors "public policies based on principles of free enterprise, individual liberty, and a limited, accountable government" and known for railing against "liberals" on their blog. solutionsproject.org

He's also focusing very closely on the example of what was seen in Montana, and argues employers would shift their Medicaid-eligible employees off of their insurance and onto Medicaid.

Here's what the state said about that: health.wyo.gov/wp-content/upl…

Dubois also uses the "Hotel California" metaphor. Maybe the fourth time I've heard that this session, all from different people.

Karl Allred, an Uinta County GOP official, also against the bill. Argues against the Wyoming DoH projections, and says that upwards of 45,000 people might enroll.

Says he didn't have insurance and couldn't afford insurance, and that he paid for it out of pocket.

Said that this is "socialized government," and is now expected to pay for "able-bodied people's" insurance after he took care of himself without help from the federal government.

"Our state is already short on money and people cannot afford these taxes," he said.

He said he paid for both of his son's delivery -- $10,000 each -- in cash over a number of years.

I would be remiss if I did not mention that the Wyoming Republican Party -- with whom Allred is closely affiliated -- is opposing this bill.

This Facebook post is also a half-truth. Yes: per the state's estimates, providers would lose revenues.

But... they still come out on top, and are theoretically providing less costly care in their emergency rooms. health.wyo.gov/wp-content/upl…

John Mansell, a dr in Gillette, argues counter to what the trustee from his hospital said. This would accelerate the decline in fiscal health of the hospital and decrease their already slim profit margins.

Say they receive patients from out-of-state who have fled their own.

Jordan Dresser, chairman of the Northern Arapaho Business Council, says tribal leadership is in support of the bill. Says there are numerous healthcare disparities between indigenous peoples and the rest of the population.

Notes Wind River Cares is only funded at 35% of its budget. Medicaid expansion would help. They've attempted this before in absence of action by the state but not sure how that ended up. trib.com/news/state-and…

Rep. Andi Clifford sharing her own experience on Medicaid and later, the type of training she had to do in the human resources department at the casino in Wind River, where she helped train people how to budget and handle their insurance plans.

"If there was ever a time to expand Medicaid, it is now," said Clifford.

Said 7,500 members of her tribe are currently uninsured.

Bouchard argues her tribe's issues are emblematic of a "broken system" that impacts everyone. But Clifford notes the disparities on the reservation are due to broken treaties.

"My people are dying," Clifford said.

Just caught Clifford and Dresser in the hallway -- they do have an 1115 Waiver program in-place on the reservation, but it is very specific and targeted, and is nowhere near-enough to meet the unmet need they have on the WRIR.

Marcie Kindred -- a former statehouse candidate -- sharing her own Medicaid "success story."

She's been in the Capitol personally lobbying lawmakers. Yesterday, she delivered 20+ letters from constituents to her Senator, Lynn Hutchings.

Notes that her grandfather is now in a long-term facility in Colorado -- which he hates -- only because they expanded Medicaid. He worked his entire life, she said, well past retirement age. Her grandmother died in a hospital there as well, from COVID-19.

Adds that many of the proponents of the bill are sitting in this room and that many of the opponents of the bill -- in the words of the hit film 'Mean Girls' -- "don't even go here."

Hutchings quoting Thomas Jefferson's thoughts on debt but, as @richardmgarrett noted to me, Jefferson died penniless, and his family needed to liquidate all of his assets to pay his debts.

"Thomas Jefferson would have qualified for Medicaid expansion."

"I don't see any other options," Kindred said.

Hutchings asked why people don't just engage with religious cost-sharing programs like Medishare. But Kindred notes that there are roughly 25,000 people who fall in this gap currently.

Wyoming Liberty Group's @CassieCraven1 argues this is not a fiscally sustainable policy decision, and that Wyoming could be sued if it ever tries to "yank away someone's government-funded healthcare."

Says red state waivers in the past have been denied, and are unlikely to be approved now.

"We don't even know how we're going to pay for the 10%," she said. "In times when we're cutting programs for truly vulnerable populations, does this body really want to have a vote on providing free healthcare to able-bodied, working adults? Because that's what this is."

Also says that 1/5 Medicaid expenditures nationwide are fraud. "That's a fact," she said.

Here's a GAO report on that topic with a little more detail. gao.gov/products/gao-2…

Michael Leman, with the Catholic Diocese of Cheyenne, lobbying in support. "Life has become a partisan issue for us," he said.

Bouchard asks whether the whole church agrees on this subject. Leman responds if he can find two Catholics who agree on anything, to let him know.

One of Hutchings' constituents -- who is insulin-dependent -- says he has great health insurance. But many people with his condition do not, and need to pay out-of-pocket.

A two week supply of insulin? $200 every two weeks, or more than $21,000 a year.

Said that the "cost of staying alive" serves to keep many people from meaningfully participating in the economy.

Adds family members had to sell their ranch in Gillette in an effort to cover the cost of their healthcare.

"No one should have to leave Wyoming so he or she could stay alive," he (Joe Wotawa) said.

Cindy Delancey, of the Wyoming Business Alliance, encouraging this bill to pass. That's pretty significant... you don't have many "free market" groups on this issue.

Delancey says it's a "business issue," and encourages them to heed the word of subject matter experts.

Ryan Jackson, of the Wyoming Business Coalition On Health, notes most fraud comes from providers -- not individuals.

And as that GAO report I cited above notes... while it is a problem, a lot of those costs are recovered.

"This is for people who cannot afford healthcare."

Hutchings criticizes the ACA, notes it's not affordable, as Jackson said.

"Part of the problem is that it is so politicized, that it's hard to talk about it without offending people who thinks that is sacrosanct, or the ones who think that it is all garbage," he says.

"So, what we need to do is get the people in the middle to talk about what is good about insuring our people and what is flawed about the existing system," he said.

McKeown now rehashing his own qualms with the ACA.

"I am very concerned about all the free money being thrown around," Jackson said. "... but I worry about people of our state. And I really want to see what's best for them. And I don't trust the federal government, but we haven't come up with a better option."

Note: We are now 23 minutes past the time we were scheduled to adjourn. Some didn't get to comment, but Chairman Baldwin giving this bill a pretty thorough vetting in committee.

McKeown: "Montana has shut down 20 rural clinics, and they're trying to get out of it."

People whispering around me: "That's not true."

A representative for the Wyoming Health Care Association now arguing it's "too soon" to pass the bill because of the numerous unknowns from the federal government. Sounds like she's encouraging an interim study on Medicaid expansion with the new federal money.

Baldwin says there already is a task force that has been working on this -- he's a part of it.

Also a pretty extensive public outreach and awareness campaign happening by groups like @BetterWyoming whose policy guy, Nate Martin, is testifying now.

He's sharing her experience where her appendix ruptured during graduate school while she was uninsured.

"The legislature has looked at this problem for a decade and hasn't found a solution," he said. "And like a shooting pain in your stomach, it's not going away."

Says last time, this same committee "did the right thing."

"I understand that there were some powerful people were upset about that decision," he said. "But I promise you, for every person that was upset about it, there were many more who are grateful."

[He's also of @healthywyo, my bad.]

The Wyoming Mining Association is also in favor of this, saying it would help to "ease the burden on the industry."

Eric Boley, of the Wyoming Hospital Association, says there has been lots of incorrect information shared today. Particularly regarding Montana's experience with expansion. Josh Hannes, also of the association, getting into that now.

"The talk about Montana wanting to get out is inconsistent with our conversations with our partners in Montana," said Hannes.

Notes they've actually seen budget savings, and there is no desire to leave the expansion group.

Notes the state itself has projected a positive revenue impact on providers, and a lowering of rates for insurers due to the loss of high-risk patients.

Would also reduce the state's high uninsured rates. "If you're not okay with that." he said, this is the solution.

Apologies, Wyoming Mining Association is neutral on the bill -- only saying some members believe it could have positive benefits.

https://twitter.com/tdeti/status/1377298923329515521

Boley also says the line about a 40% loss in revenue for hospitals in Montana is false and that states that have expanded Medicaid have actually seen boosts in revenue.

"If not this what? And if not now, when?" asked Boley. They've discussed this for a decade, and no result.

"I'm an Eagles fan," he said. "And so I like Hotel California. But I like AC/DC better. And I challenge you to pass this out of committee and debate it on the floor, and AC/DC will say 'for those about to rock, we salute you.'"

Rep. Pat Sweeney says he wants to have a bill to work in the interim for them to negotiate our FMAP rate with the federal government.

Said we don't need to study this anymore -- it's been studied to death. And now is the time to get into it.

"We failed as the Republican Party," Sweeney said. "We controlled the Congress, we controlled the Senate, we controlled the White House. Why did we fail on repeal and replace?" Said the Freedom Caucus didn't negotiate in good faith.

Bouchard offended he blamed Republicans.

Harshman -- who's voted against expansion every year until now -- now running through all of the potential solutions Republicans here looked into, and decided against. He voted for Medicaid expansion this time.

The biggest change, as we've covered, is the change in the FMAP. The federal government establishes the matching rates on a state's median income and with high-paying energy jobs -- plus ultra millionaires in Teton County -- our rates are skewed. We hope we can negotiate up.

Adds he's called numerous red state representatives on their experiences, including some in Montana.

It didn't bankrupt their states, and Harshman said that a current Biden administration official has said that they will work with Wyoming to make the program work.

Harshman and Rothfuss arguing that this issue deserves a debate on the floor of the Senate.

"If you have a better idea, I want to join you in supporting it," he said. But there hasn't been another one for him to debate.

"It's not insurance people want," said Rothfuss. "It's access to affordable healthcare. They don't care how to get it. They just want to not die."

Public testimony closed and Furphy moves the bill.

Hutchings asks whether it's the proper role of government to provide healthcare for people.

"I ask myself is this found in our constitution? And I can't find it there." she said.

Said that everything she'd heard was all emotional and circumstantial.

"Should we send this to the floor to hear the same thing over and over again? That's what I'm hearing," she said.

Baldwin said he'd gotten more than 200 emails this morning -- mostly form letters -- lobbying this bill. Urging it to go to the floor so that members who have never had opportunities to debate Medicaid expansion on the floor are able to.