County ambulance prospects keep an eye on Medicaid expansion in state

RIVERTON — Prospective ambulance contractors for Fremont County might be waiting to see if Wyoming adopts Medicaid expansion under the Affordable Care Act. Expansion could make ambulance service attractive financially for an ambulance provider. 

“In my talks (with possible bidders), there’s been hope that we’d have Medicaid expansion in Wyoming,” said Fremont County Commissioner Larry Allen, who is the ambulance liaison for the county. “The prospective bidders were very interested in it because their pay stream would be more predictable.” 

While Medicare is federal insurance for the elderly, Medicaid is geared more toward disabilities, pregnancies, poverty, and other hardships. Medicaid is a federal program, but it is administered individually by each state. 

Under the Affordable Care Act, the federal government has agreed to provide funding for states to expand eligibility. Most U.S. states have embraced expansion, but Wyoming remains one of a dozen holdouts. 

The enhanced federal funding for expansion has been available since 2014. Recent revenue declines in Wyoming amid a persistent slump in the state’s key energy industries have elevated the possibility of Medicaid expansion here. A Medicaid expansion bill in the Wyoming legislature, now revived ahead of a possible July special legislative session or next year’s February budget session, would expand Medicaid eligibility to any non-disabled, childless adult under 138 percent of the federal poverty level. 

The state would accept nothing less than a 90 percent payout by the federal government to meet state expenditures on those newly accepted enrollees, according to the bill text. The expansion, if adopted, also would be contingent upon the federal government upping its payout on pre-existing Medicaid costs from 50 percent to 55 percent. 

The Joint Revenue Committee advanced the bill after a 9-5 vote during its meeting last week in Riverton. 

Allen told The Ranger that a worry with Medicaid expansion is that as the years advance and the federal landscape changes, the mandate to cover could remain, even once the federal incentives are gone. 

“That was the fear of the legislators in the past, that the Medicaid participation would be good at first, the federal government would be a good partner to the state… but then the federal government would start pulling funding away from them,” he said.

Because of that, Allen said, the wording of the final bill will be vital to the movement’s success. 

In a final speech to the committee he chairs, state Sen. Cale Case, R-Lander, said the Centers for Medicaid have stipulated publicly that states may withdraw from the program at any time. 

Case, in an interview with The Ranger, said the ambulance providers may be more content with the flat rate paid by Medicaid than with the threat of nonpayment from uninsured or underinsured patients. 

Noting the ambulance crisis in Fremont County and elsewhere in Wyoming, Case also said his committee may explore an option to increase reimbursements to ambulance services specifically. 

“We can mess with those rates and we could improve reimbursements for rural ambulance... Medicaid expansion – it alone won’t save ambulances – but it’ll help.” American Medical Response Regional Director Matt Strauss declined to comment after several requests. 

AMR is Fremont County’s current ground ambulance provider, but it is pulling out once its June 30 contract expires. 

Wyoming Hospital Association Director Eric Boley told the committee that about $120 million in uncompensated hospital care would be met with about $30 million enabled by expansion to people in the insurance gap — who currently don’t qualify for the Affordable Care Act insurance exchange and can’t afford private insurance. 

“If you’re a business owner,” said Boley, “would you rather get paid something or nothing?” 

Presenters at the same meeting feared that people already covered under private insurance or the federal insurance exchange would drop their insurance once granted Medicaid under the expansion, and therefore would drive hospital reimbursement totals down. 

State Rep. Chuck Gray, R-Casper, said hospitals often demonstrate that “Medicaid reimbursement is not adequate, and it’s a huge part of the net income problem in hospitals in Wyoming. 

“Yeah, there’s an influx of cash, but it’s not fully meeting the cost of the care provided,” Gray said, adding that conversely, those same hospital associations ask for the Medicaid expansion. “How can those two things go together?”