We're talking Medicaid expansion this morning. (Again.)

Watch live here.
Rep. Gray says that the current Biden Administration policy to expand Medicaid to red states is "coercive." Asking if there are any legal challenges pending, but DOH staff say that most of the legal issues out there have "been resolved."
This is how our current environment as a non-expansion state compares to states that have expanded. Note the populations carved out here.
This DOH brief says the savings could be significant. Under the American Rescue Plan Act, the Department of Health estimates overall net savings of $34 million State General Funds over the first biennium of expansion.
This is what the uncovered population looks like. Parents and caretakers 47-99% of the federal poverty level and all non-disabled adults below the FPL can't get covered under the status quo.
Gray said he's "perplexed" about having to make a decision using data that covers only one biennium. "I find that very problematic."

But Steffan Johannson, of the DOH, said there is more uncertainty in out years. Said the $20m in biennial savings could be replicated.
Under the ARP, our 90-10 match with the federal government to expand would stick. But we'd also see a 5% increase in our match for the traditional Medicaid population, saving $34m over first biennium. This is temporary, just two years, but some think we could make that permanent.
There have been some concerns that we could exceed our estimates, which is currently about 24,000 based on enrollment increases in other, recent expansion states. But the range is pretty big.
Some have thought that would have had an adverse impact on providers, but DOH estimates that their revenues would actually increase. Would also effectively reduce rates for others.
A lot of this, notably, is old news. We got the exact same presentation during the Legislative session and, despite this, narratives about Medicaid expansion that either lacked evidence or context persisted all the way to the Senate.
Hallinan asked if this would be "discrimination" against Wyoming for increasing the FMAP by just 5%.

"That would be a decision above my pay grade," Johannson said.

Yin asked if it should be a question for a Congressional candidate to see if they would increase the FMAP. Same.
Johannson keeps saying Wyoming only has one provider on the ACA exchange right now. But as @m0rgan_hughes points out, we now have two. trib.com/news/state-and…
Gray says he's "perplexed" by assertions providers will see revenues increase when many are troubled by debt based on reimbursement rates for Medicaid.

However, Johannson notes that we will see a decrease in uncompensated care, allowing them to come out on-balance.
If you're interested in the DOH methodology, here's how they estimated impacts from Medicaid expansion. wyoleg.gov/InterimCommitt…

They analyzed experiences from all expansion states.
It's interesting that roughly two-thirds of this 36 page presentation covers the DOH's methodology in compiling these estimates. There was a lot of doubt during session stemming from lawmakers focusing on individual states' experiences and occasional falsehoods.
Sen. Troy McKeown, a swing vote who helped defeat Medicaid expansion during the session, argued at one point during testimony that rural hospitals in Montana closed after the state expanded Medicaid. That's demonstrably false.

Johannson says that expansion "would almost certainly increase ambulance revenue" amid growing concern for ambulance services in rural reaches of the state.

However, this would not be enough to save those problems completely. wyofile.com/ambulance-serv…
Any help counts though.

"Anything that is having a positive impact is kinda big out there," Sen. Case said.
Medicaid "costs" typically go to providers, money which groups like the Wyoming Hospital Association have noted circulates back into communities.
Johannson also said that expansion would help to take more expensive individuals off of the exchange, potentially lowering premiums for the general healthcare population.

Gray asks what the DOH is doing to get more than one provider on the exchange. (There are two).
This is what that shift would potentially look like. That big gray box in gray? That population would be removed from the general population, having a "marginal impact" on rates for the rest of the exchange pool.
Please note this is "potential." This is not a guaranteed thing. Wyoming is unique in that a large share of the population is self-insured, and we likely won't see a dramatic decrease in rates across-the-board.
Jennings notes hearing is happening in Revenue -- not in health -- and that it was "bizarre" it showed up here. Asked if there are health aspects they need to hear.

The presentation is the exact same health committee got. MedEx has also traditionally been covered in revenue.
Gray also says that they're possibly on the "15th or 16th" attempt to expand Medicaid in his five years in office. "It seems like they want us to trust that all the projections are right" and after being told things would get worse, they got better.
Johannson says new administrations can change conditions and while this benefit is temporary, there are bills in Congress right now to guarantee a 100% match for the first three years of expansion.

"The deal, at least temporarily, has changed," he said.
But Gray said this calls into question the estimates. Asked if Wyoming could decide to pull out of the deal if it wants to -- something lawmakers argued we wouldn't be able to do this winter.

Prior to the Trump administration, we received a guarantee in writing we could.
"The legal ability to withdraw from Medicaid expansion and the political and policy decision are two different things," Johannson said. "In the current context of the law... Wyoming does have the legal authority to withdraw at any time."
More, unreported false information from session: Harshman said he got form letters saying Medicaid expansion would increase federal funding for abortions.

"But we operate under the Hyde Amendment," he said. "And this Legislature is pro-life."
There's a possibility the Hyde Amendment could go away under Biden, Johannson said, but Wyoming could set terms for its own funding share. "We do not see a possible increase in elective abortions in Wyoming.
To-date, we've had just one similar procedure covered under Medicaid in the last decade, Johannson said.
Harshman also said he's gotten emails that this would lead to a single-payer system, and eliminate choice in the marketplace.

Johannson said there's a yes and no here. Anything public sector matches that criteria.
But single payer is a greater policy decision, and Medicaid expansion is still a multicare system. "That certainly isn't going away until it comes, and that's a federal conversation. I don't see that in the near-future."
Wyoming is easy to see what is shippable and what isn't. OBGYNs, Ambulance Services, things that people need and want vs. elective procedures or services you could shop for. We see that in economies of scale. Not so much here. And rn, we've lost a lot of those essential services.
"The expansion of Medicaid does not dramatically alter that landscape in Wyoming," Johannson said.
Harshman asks about the 25% increase in elective abortions seen in Alaska after expansion. The Hyde Amendment covers their law too, but Johannson said their program allows state funds to cover those procedures.
(Does anyone have a source? Having trouble finding one.) I found a source from Oregon. sciencedirect.com/science/articl…
Jennings now asking another Hyde Amendment question, and the possibility of the federal government changing the conditions of the federal dollars to require the coverage of abortions, for example.
Johannson said there could be a possible court challenge but again, all hypothetical.
Case saying he can't imagine the federal government forcing states to cover abortions with their money.

"But if they did, this is an optional program. We withdraw from the program at that point... this is not the obstacle to implementing Medicaid some would like us to believe."
Plus as @itsmikeyin already noted, it would be illegal for Wyoming to participate in Medicaid expansion should the federal government compel us to cover abortions with our own funds, per the Wyoming Constitution.

Jennings still hung up on this.
Said that there must be a clear lack of political will to withdraw from Medicaid expansion given 38 states have gotten in and not withdrawn.

I guess it depends... pull insurance for tens of thousands of people over the potential for abortions you can't get in Wyoming? Tough.
Rep. Gray raising the question of profit margins falling by 10% in some instances per the FGA. Which the DOH has acknowledged (Johannson said he has taken issue with FGA analysis), but he also noted net revenues went up overall. Added that providers have not gone out of business.
Harshman says that there is a lot of public comment lined up, and we'll have a hard, 3 p.m. cut-off time.

Sen. Anthony Bouchard is up first. Says some providers don't serve Medicaid patients because the reimbursements are so low. Could run them out of state.
"Moving to single payer... what's happening in this state right now is people are getting their entitlement checks and not going to work," he said.

"More entitlements will create that problem in our govt."
"The consequence is people move to Wyoming to get the benefit, and we'll create a problem where the brick and mortars can't take care of it." Said we'd need to expand hospitals to meet the need.

We're surrounded by expansion states. All have grown faster than WY.
Said it's up to Wyoming lawmakers to "take the carrot" from the federal government, and that expansion will dilute the pool and cause people's premiums to go up -- counter to testimony by DOH.

Asks how many will fall off the ACA for Medicaid.
There are certain qualifications for Medicaid expansion though. Case asks if Bouchard was in the room for the DOH testimony.

"I don't know if you were in here about the discussion about single payer but... the answer was no," Case said.
Bouchard says we're "tearing down" the free market. Says he currently does not have health insurance, that we only have two providers.

"We're a capitalist system. We're talking about an entitlement system."
"Show me in the U.S. Constitution where Congress should even be dealing with healthcare," he said.

"There's nothing free in life. Is there free things? Doesn't someone have to pay for it?" Bouchard asks.

Harshman notes we're looking at people around or below the FPL.
Harshman also notes Bouchard voted to expand Medicaid for school-based services.

"Now we're looking to expand Medicaid for women around 45 years of age... these poor people are deserving and these aren't. We'll have to decide who is deserving of these benefits."
"Federal overreach? No doubt about it. We live it... But I don't want to get into this. None of us are pure in this thing. We're all going to draw Social Security one day. And I don't think any of us are going to turn this down."

Said we're trying to do what we can for that 24k.
Rep. Wharff now testifying. Says he's concerned about the federal debt. Says there has been an effort to say we're "not passionate" to not extend healthcare to those populations.

"If you don't think there's not a hard push to make us more socialist, you're not paying attention."
Says it opens the door to where the population becomes dependent on the government for healthcare.

Talked about an instance where he was uninsured and his son faced a life-threatening illness. Goes to a local children's hospital, and they held "numerous fundraisers" to cover it
"We'd have half a dozen fundraisers on behalf of my family. And I can tell you people rallied around us in our community. One of my biggest concerns is... the things we used to do as a nation will contract, and they will go away."
Said if it's given away, "you're not going to appreciate it as much as you worked for it." Says we've lost sight of that.
"If we get more and more people dependent on the government for assistance, sooner or later this system is going to break. We can't keep giving away trillions of dollars as a nation."
Said he's "concerned" about the medical community coming to the state and saying they need it. But says there can be a better way.

Said Medicaid is now the "biggest issue" in Utah's budget. Later says he's seen no data, and that the evidence he has is anecdotal.
Also cites research from the Foundation for Government Accountability (whom the DOH said has had issues with research) and claimed that federal law restricts states from leaving: something the DOH already said was not accurate.
Anyone have details about Utah's experience? Their governor put additional money in the Medicaid program in his latest budget abc4.com/news/local-new…

But it looks like their assumptions also come from heightened federal buy-in. GF expenditures increased, yes, but fed funding up.
Source for those numbers, btw: ibis.health.utah.gov/ibisph-view/re…
Rep. Lloyd Larsen (R-Lander) said his view on Medicaid expansion has changed, and now urging lawmakers to advance a bill to "at least have a discussion."
Sorry to get hung up on Utah, but they also ended the last fiscal year with a budget surplus, per this release from February. governor.utah.gov/2021/02/19/upd…

While Wyoming cut spending this session, Utah was able to increase spending. And they will continue to. sltrib.com/news/politics/…
And from this @m0rgan_hughes story, where she asked about this with a Utah lawmaker: trib.com/news/state-and…
Jennings said they have not been given alternatives to Medicaid expansion, and they haven't looked at any. Asks if it's concerning that we keep coming back "to this one thing," and if they hadn't done proper diligence in vetting alternative approaches.
"I think we have to continue to look," Larsen says. "But is this also not an option? I think it's important we consider our options... If we're fully going to vet out options, then the expansion of Medicaid has to be included."
Sen. James asks about capturing waste fraud and abuse. Larsen notes we already have a fraud division to investigate these cases, and that they have made arrests related to Medicaid fraud in the past.

In fact, here's one from a year ago. justice.gov/usao-wy/pr/med…
After a break, Harshman stipulates that today's meeting is informational only, and addresses a concern stemming from yesterday where Sen. James felt excluded while trying to participate remotely.

"I don't want any 20 minute campaign speeches," he said. "Life is too short."
Jordan Dresser, of the Northern Arapaho Tribe, encouraging the Legislature to adopt Medicaid Expansion. Said it's part of their tribe's culture to take care of one another, and that it's part of Wyoming's culture too.
"It should be something automatically given to all of us, considered at the top of the priorities for us here in Wyoming," he said.
After shares from IHS for healthcare were too low, Northern Arapaho Tribe entered into a 638 Contract (which allows them to self-determine healthcare outside the realm of IHS) to expand Medicaid on their own, providing needed HC to tribal members while saving the state funding.
Richard Brannan, of Wind River Cares, estimates that this move save the state about $38 million.
"It's people's lives," Brannan said. Says his effort to get the tribe on that program was inspired by divine influence.

"He loves poor people. He loves people in pain. He is a god of restoration. That's what Medicaid expansion is."
Nina Webber, a Cody resident with close ties to the Wyoming GOP, railing against Medicaid expansion. Named off the talking points from earlier -- that Alaska's abortion rate rose by 25%.

Said this is only for disabled and needy people, and that this disincentivizes work.
Also critical of the Biden administration pushing back on work requirements. But most Medicaid recipients were working before the pandemic. kff.org/coronavirus-co…
One woman citing a UVA study from 2010 saying Medicaid patients were 13% more likely to die than non-Medicaid patients. This had nothing to do with Medicaid though. politifact.com/factchecks/201…
Of course, there's also this study from the same university seven years later. news.virginia.edu/content/study-…
Sheila Rambur, a business owner, said that one of her employees didn't want to make more money, because she would lose her Medicaid. Said that expansion would add "more people like her to the pile." Said expansion will lead to socialism.
Mark Gaskill now testifying on his experience running the state's Medicaid fraud program. He accused the AG of obstruction in that case, in which Wyoming was defrauded for "millions" of dollars.

Wants measures to ensure fraud is addressed.
We're still working through the opposition. Cathy Ide, of Casper, concerned about the "expansion of socialism in Wyoming." Said this is a bribe that masquerades as a string that will tie us together, but is actually a rope to hang us with.
"We have become a nanny state that looks to government to support our needs, rather than god and hard work," she said.
Hayden Dublois, a research analyst at the FGA (a conservative think tank), argues reduction in uncompensated care costs were swamped by the poor Medicaid reimbursement rates.

Some have challenged FGA research over the years. cbpp.org/research/healt…
Instead of expansion, they're advocating for offering telehealth services across state lines and programs like Farm Bureau Plans, which he said offers robust benefits at lower rates.

These have been criticized for their lack of regulatory oversight. brookings.edu/wp-content/upl…
Jimmy Dee Lees, of the Sheridan County League of Republican Woman, said expansion could lead to a "poor self esteem cycle" and discourage people to work. She's a Medicare recipient, and said the rates have gone up yearly and they now need supplemental insurance costin $700/month.
Karl Allred calls this socialized medicine and that we can't afford it. Said Medicaid expansion almost bankrupted Indiana.

That plan -- developed by Mike Pence -- was heavily criticized for its "personal responsibility provisions." khn.org/news/article/i…
The Wyoming Liberty Group's Cassie Craven says hospitals in Montana saw a 40% drop in profit margins due to cost-shifting. beckershospitalreview.com/finance/montan…

However, that same source noted revenues increased, while outcomes improved. greatfallstribune.com/story/news/201…
She's also warning of a potential repeal of the Hyde Amendment, tying their hands.

But it's a little more complicated. kff.org/womens-health-…
The Catholic Diocese of Cheyenne's Deacon/lobbyist, Mike Leman, testifying in-favor of Medicaid Expansion alongside the Wyoming Hospital Association's Eric Boley.

"Healthcare is not welfare," said Leman.
Boley said the state's rural hospitals are "struggling," and this influx of cash will allow them to sustain themselves. Referring to the same Navigant study Craven did, says Medicaid expansion has actually been a major success in Montana. guidehouse.com/insights/healt…
Harshman asking about Montana, and the negatives they've heard about.

Boley says overall, hospitals are doing well. Josh Hannes, another WHA official, said that the waiting lists referred to by a previous speaker was only true for a section of the population not on Medicaid.
Boley said that while Medicaid is not the best payer, it still pays. And right now, hospitals eat $120m in uncompensated care per year. Expansion will cut that cost by about $30m. Volume will drive staffing as well.
Case asks about Indiana -- which we mentioned earlier.

Boley said they adopted early, and that their program is structurally different than the one Wyoming was considering. Their hospitals' financial strength is better than ours as well, Hannes said.
Rep. @itsmikeyin also notes that most critics have cited data from the very early stages of expansion, and that finances for hospitals have actually improved substantially under expansion, including Montana.
Boley said that a bigger issue than waiting lists right now is that they're actually in need of physicians and that Medicaid expansion would actually help to attract those healthcare professionals, who are actively looking to go to expansion states.
Everyone keeps asking if Wyoming can drop out of the program. The answer is yes. medicaid.gov/sites/default/…
via @CassieCraven1, details on the Hyde Amendment stipulation. Couldn't find a good explainer if this would preempt state statute, but this quote sums it up.
Sheila Bush of the Wyoming Medical Society said that there have been some doubts cast on the numbers. But our population has been stable, she notes, and that this is "not the first time" the majority of the medical community has decided this was the best path forward.
"We don't have unanimous consent on anything, but we do hold this as a firm position," she said.
Adds this will help with physician recruitment, and give hospitals more predictability in assessing their bottom lines. To the overruns of demand, she argues these are not new patients -- we just aren't giving them access to the best and most efficient means.
"We make them so sick, we can't deny them care. And the only option is the emergency room."
Mountain Health Co-Op, a health insurance provider on the exchange neglected in earlier testimony, says they're supportive of Medicaid expansion. Says that in ID and MT, where they operate, it's better for providers and communities. No comment on rates.
Lots of emotional testimony in-favor of expansion. One woman, from Sheridan, argued that if "45% of the state budget" is federal funding, then it's good enough for Wyoming's most vulnerable.
Another woman speaking on behalf of a quadriplegic friend, who is unable to speak. Sold their trailer in order to pay off medical bills. Said if she didn't have a disability, she would be working.

"We shouldn't be made to feel shame for asking for help," she said.
Comment over. Case now moving to take up HB-162 -- the Medicaid Expansion bill from session -- as a "starting point."

This version died in the Senate, but passed the House 32-28.
Gray said he is opposing, this is "not in his values."

Cites an FGA study saying we can't get out (this is not what the feds have said) and maintains his concerns about Montana, though... officials from Montana have refuted those were not accurate talking points.
Said there is a "credibility gap" between those who want this to happen and officials on the ground. (Hospitals and doctors have testified today expressing support for expansion.)

Said he also doesn't believe this should be in the Revenue Committee.
Sen. Case said that the narratives peddled about Montana and Utah have been inaccurate, as have the false talking points from the FGA. Also notes two of the largest organizations of medical officials coming out to support it, contrary to what some have argued.
There's also the abortion issue, particularly the Alaska example. But Alaska made a policy decision to allow abortion access with their funding. Wyoming most certainly would not and if it did, Wyoming performs very few already, due to a lack of providers.
"It is disappointing to me as a member of the Legislature to hear the same falsehoods over and over," he said. "I have never experienced it.
Oh wow, I forgot Sen. Baldwin (Chair of Labor/Health) was also on Revenue Committee.

Said that this is the right thing for Wyoming, its hospitals, and its citizens most in need right now. Said that when they improve their healthcare, they improve the state and the economy.
Rep. Jennings says that his belief this isn't the right vehicle doesn't mean opponents don't care about the people about Wyoming. They think there are alternatives that should be looked at, and that there are "special interests" pushing expansion.
Yin says that providers are going to see a benefit, and that it's confusing there is still insistence by members that this is not the case.

"Now is the time. It was the time seven years ago. Might as well do it now."
James concerned about waste, fraud and abuse, that we can't get out of Medicaid (there is a guidance document I've cited several times, it's here again: medicaid.gov/sites/default/…)

Says he is going to vote no.
We're now voting to revive 2021's HB-162 and send this on to the special session. If this vote fails, it will be taken up in the 2022 budget session. Until we get to a session, it remains in the purview of the committee for amendments, Case said.

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More from @IAmNickReynolds

10 May
An official for the University of Wyoming's Center for Business and Economic Analysis walking through their version of the tax capacity study, with estimated from the minimum rate to if we went "full socialist" and maxed everything out.

Quite a bit.
Based off median income, we have room to raise taxes.
Here's us compared to states with no income tax... we could earn $2.3 billion if we adopted the median of their tax policies.

However, Texas and Washington have major metros. We don't. S. Dakota is the best match, which would net us about $1.1b extra per year.
Read 17 tweets
10 May
Knapp, who now lives in California but is moving back to Gillette, said he’s wanted to go into public service since high school and that “now is a good time to do it.”

According to his LinkedIn, he works in Orange County and has been heavily involved in the O&G industry.
Did anyone else get a heads-up he was running? Nobody contacted me about him running until about 6 a.m. today and though I heard rumors someone was announcing in Campbell County last week, nobody knew who it was.
With more than a year until the Republican primaries, we now have seven challengers, including

1. Bouchard
2. Gray
3. Keller
4. Selvig
5. Knapp
6. Smith
7. Belinskey

Several possibles, including Bryan Miller, Ed Buchanan, William Perry Pendley.
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10 May
The Legislature's Revenue Committee discussing the state's tax structure this morning.

Revenue Director Dan Noble says the state's tax structure is a regressive one: "Our tax structure is unstable. We base... more than half of our economy on price of commodities."
We also have the "second lowest" tax burden for a family of four in the United States, he said, and that our current tax structure could actually hinder the state's growth, due to the high cost of services and a thin tax base.

Watch live here:
Notes state and county officials are limited in their taxing authority. And tax administration is confusing.

"We spend probably more time than anything else appearing before the State Board of Equalization and the Supreme Court associated with mineral issues."
Read 26 tweets
7 May
Getting a lot of questions on what this actually does! So a quick thread...
Lawmakers are allowed to participate remotely and won't be docked pay for it.

Lawmakers can only hold meetings at sites able to facilitate full remote meetings.
Much better than the policy they originally proposed.
The drawback is that we won't have meetings in rural areas that occasionally require field visits. If you look at the list, all the sites are places like Laramie, Rawlins, Jackson, Rock Springs, Casper, Cheyenne...
Read 5 tweets
7 May
Management Council is discussing this policy change right now. Live stream here:
Interesting quote by Albert Sommers: "I think the public participation piece is probably going to be the most hotly debated [we have]." (1/2)
"One of the things that I've heard repeatedly from some of the chairs on the House side is the concern that if we don't have some throttle on who comes in when they come in, then we can get all manner of out of state people coming in at one, you know, kind of flooding in."
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7 May
Darin Smith is officially in, just one day after he told me and @Victoria_Eavis he was only considering it. cowboystatedaily.com/2021/05/07/che…
CST, yesterday: Image
And us: Image
Read 5 tweets

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