We knew things would be going a little slow in the Wyoming Senate’s Great Medicaid Debate on Friday when President Phil Nicholas (R-Laramie) stood up early in the proceedings to ask, “What exactly is a waiver?”
We’ll give him the benefit of the doubt, because he’s got a bigger workload than just about everyone else in the Capitol, and he may have been asking the question to make sure newer members know what are the underlying issues for Medicaid expansion in the state.
Plus, it would be just too unnerving if the leader of the entire chamber didn’t know about the waiver process. This is the third consecutive year of the expansion effort, and waivers are a pretty basic piece of information. Nobody’s been hiding what this is all about.
For the new kids in the class, a 511 waiver is what the state of Wyoming will request from the secretary of Health and Human Services, who decides if states want to administer legitimate demonstration projects unique to their populations or just want to run the program as cheap as possible, no matter what the cost is to beneficiaries.
Under the Medicaid law, waivers can be requested from any state that wants to start “innovative or experimental state health care programs.”
Is Wyoming’s proposal either innovative or experimental? You be the judge.
The state of Wyoming has never officially asked the feds for a 511 waiver, but obtaining one is the ultimate goal. To make such a request, state lawmakers must first agree on a Medicaid expansion plan, and that has never happened. After Friday’s session, it’s starting to look doubtful they’ll reach a meeting of the minds this year.
The situation was much more hopeful last fall, after the Wyoming Department of Health (DOH) and the federal Center for Medicare and Medicaid Services (CMS) negotiated and came up with an expansion plan named SHARE.
SHARE wasn’t comparable to traditional Medicaid, because it would require the working poor to pay health insurance premiums and co-payments that many cannot afford. But it would have provided some assistance to the 17,600 people whose low incomes make them eligible for Medicaid, if state officials would just give the program a green light.
CMS would still have to decide if the plan was worthy of a waiver, but DOH Director Tom Forslund came back from the talks saying he’s 98 percent sure the feds would approve it.
The problem is the chairman of the Senate Labor, Health and Social Services Committee — Sen. Charles Scott, a Casper Republican who is the longest serving legislator in the state’s history — abhors SHARE.
Scott offered an alternative bill that his committee adopted the day it shelved SHARE. His plan is based on the “Healthy Indiana” plan and features health savings accounts (HSA), an element he’s been in love with since he created the ill-fated “Healthy Frontiers” program for Wyoming several years ago.
Healthy Frontiers had its funding from the Legislature yanked after only one year, because very few poor people signed up for it. Scott thinks the state’s Medicaid expansion program will only succeed if it has HSAs, because the accounts will combine a large amount of state funds with $50 a month put in by the poor.
Scott likes to say this gives Medicaid expansion beneficiaries “skin in the game,” and he believes making them contribute to their own HSA will give them an incentive to spend less money on health care, because if they ever leave the program they can take a portion of the funds with them.
The main problem with the plan, which Scott admits, is that the feds aren’t used to Medicaid programs that use HSAs, except Indiana, which has struggled for about a year to get approval. Scott told his Senate colleagues that the accounts would be “a sticking point” for the CMS, but he is stuck with it anyway because he believes without HSAs, Wyoming “would lose all of its bargaining power.”
Also, Scott’s plan would cost the state about $65 million in 2016, while SHARE is revenue-neutral, because it will use savings in other social services programs made possible because Medicaid recipients won’t need them anymore.
Scott thinks the feds will jump to accept his plan, because they want more states to come on board. But others aren’t so sure. After listening to Scott explain his HSA incentives and his questionable and confusing concept of using “invisible money” the first year so the state doesn’t have to put funds into the front-end of the program, Nicholas called time-out.
“I’m not prepared to accept your propositions on face value,” he told Scott.
As it turned out, neither was half of the Senate. An amendment to put HSAs into Senate File 129, which mirrors the SHARE plan, was defeated on a 15-15 tie vote.
As he headed out during the lunch break, Scott was not happy with the turn of events. He only let SF 129 out of his committee because it contained his alternative ideas, and without them in the bill, he acted kind of like a kid who took his baseball home so the game couldn’t continue.
“Unless somebody comes up with something I don’t know of that can be a real control upon utilization of costs, then I have to vote no [on SF 129],” he said.
The defeat of his amendment, he added, “turns it into just a conventional Medicaid expansion, and those are too expensive, bad for the clients, and likely to get us in trouble in a few years when the feds renege on their promise [to pay at least 90 percent of the cost of expansion].”
Scott predicted if SF 129 is approved and implemented, within three years Wyoming will have to come up with $50 million to $70 million a year, which would result in tax increases, cuts in education and reductions in money for local governments.
The Senate went in for an afternoon session that leaders hoped would result in a vote on first reading, but it quickly became apparent legislators had too many questions about the SHARE bill for it to receive a fair hearing of its pros and cons. The Senate debate will continue at 10 a.m. Monday, giving legislators three nights to sleep on it.
So what does this mean for the bill’s chances? Marguerite Herman, lobbyist for the League of Women Voters, said after Scott’s amendment failed, “He did his ‘data dump’ — saying everything he knows about Medicaid, whether it pertained or not.”
On the plus side, she said senators seemed to be engaged on the issue. “I think Charlie drops his advocacy of the bill, but whether he is unalterably opposed, I don’t know,” Herman said.
But she added that SF 129 “appears to be the only vehicle Scott can attach himself and his health savings accounts to in the foreseeable future.”
Anne Ladd, CEO of the Wyoming Business Coalition on Health, said she doesn’t know whether the defeat of the HSAs will result in more or less support for the bill. “But people are continuing to ask good questions about what this all means,” she said.
“They’re getting past the ‘We hate federal money’ piece and talking about the merits of different portions of the bill,” Ladd added. “I’m encouraged by that.”