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Tania Malone tried to avoid trips to the doctor. It wasn’t that she didn’t want to — Malone said she needs regular checkups to stay on top of an autoimmune disorder, small fiber neuropathy and other health issues — but she felt she couldn’t afford the visits.
The single mother and social worker had no insurance and limited income to cover the bills. So she tried to endure the pain and visit urgent care only when necessary.
“I would just try to battle,” Malone recalled.
But the approach didn’t work: One weekend last year, the Douglas resident suffered an episode that landed her in the Memorial Hospital of Converse County emergency room; she still owes the hospital for the visit.
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Malone has since been able to acquire health insurance from her employer. But as someone who’s yo-yoed between insurance, no insurance and Medicaid and who’s spent years struggling with the high cost of health care, she believes the state can do better: She’s an advocate for Wyoming to expand its Medicaid program to cover more low-income residents.
There are many Wyomingites who are similarly going without insurance and winding up with big bills, she said, “and it’s just not fair to them, that they don’t have a reliable option.”
For more than a decade, Wyoming’s overwhelmingly Republican statehouse has batted away attempts to expand Medicaid here. State studies indicate expansion would provide coverage for roughly 19,000 people and help with the tens of millions of dollars worth of uncompensated care that hospitals provide to the uninsured and write off each year. But opponents remain wary of expanding a federal insurance program in general and Medicaid in particular.
Ahead of this winter’s legislative session, Sen. Cale Case (R-Lander) said some of his colleagues who voted against expansion in the past have privately told him they want to support it.
“But they’re afraid of being primaried, of being painted as being, you know, a liberal, Obamacare, whatever, and they’ve been afraid,” he said. “And they need to have strength.”
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Case made an impassioned pitch for expansion last week on the Senate floor, bringing a pair of budget amendments that would have started the process of extending Medicaid coverage to those earning up to 138% of the federal poverty level. For a family of four, that’s about $41,000 annually.
Ultimately, the amendments met the same fate as all past expansion attempts. One measure that would have used lodging tax dollars to help pay for the program failed on a 7-23 vote on Feb. 19, while another version was shot down 5-26 on Feb. 22.
Low expectations
Expansion supporters began the session recognizing they faced long odds.
On the Legislature’s first day, Wyoming Hospital Association President Eric Boley said Case’s effort “doesn’t have much of a chance, unfortunately.” And Jan Cartwright, a board member of the pro-expansion coalition Healthy Wyoming, had indicated her group’s focus in this election year is on educating lawmakers, candidates and voters.
“I think that it is a bitter pill, maybe, to say, ‘Well, we can’t do anything this session,’” Cartwright said before the Legislature convened. “But … we’ve been working on this for a long time, so we just go for where the winds are.”
Where the Legislature will go next is unclear. More than a decade ago, lawmakers discussed crafting a “Wyoming solution” to expand coverage — for example, by helping low-income residents get on private insurance instead of Medicaid. But those conversations have fallen by the wayside in recent years while the Legislature has moved farther to the right, reducing the likelihood that expansion will pass.
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During the Feb. 22 floor debate, freshman Sen. Bob Ide (R-Casper) described Medicaid as “essentially socialized medicine” and said partnering with the federal government “hasn’t worked out.”
“We need to work on helping the people in other ways other than this,” Ide said.
In response, Sen. Chris Rothfuss (D-Laramie) questioned how the state would find a better solution. He said Wyoming would not only help thousands of people who have limited or no access to health care, but also stand to save $33 million over the first two years of expansion.
“If not this, then what?” Rothfuss asked during the Feb. 19 floor debate, describing it as a question he’s posed for over a decade.
He argued the state has been treating the expansion population as “a statistic that’s too small to write policy for.”
An estimated 40% of those who would be added to Medicaid’s rolls — those earning 100-138% of the federal poverty level — can currently get private insurance on the federal Health Insurance Marketplace at little or no cost and about 45% of the potential enrollees currently have some form of insurance coverage, according to Wyoming Department of Health figures.
However, the majority of the affected Wyomingites — roughly 11,400 people — are living below the federal poverty level and remain in the “coverage gap” without insurance. They don’t qualify for the existing Medicaid program, but also don’t make enough money to qualify for subsidized insurance via the marketplace.
The Wyoming Department of Health refers people in need to other sources of support, said department spokeswoman Kim Deti, but “no doubt, the people in this group are in a tough spot.”
Debating ‘the neediest among us’
The coverage gap was supposed to have been eliminated in 2010. As passed by the Democratic-controlled Congress and signed by then-President Barack Obama, the Patient Protection and Affordable Care Act required states to offer Medicaid coverage to everyone earning less than 138% of the federal poverty level.
However, the requirement was struck down by the U.S. Supreme Court in 2012 — a ruling that has allowed Wyoming and nine other states to continue to reject expansion.
On behalf of a divided court, Chief Justice John Roberts wrote that Congress needed to give states “a genuine choice” on a change that “dramatically” increases their obligations to the Medicaid program.
Roberts noted that Medicaid was created to meet the health care needs of the elderly, the disabled and low-income families with children. By including it in a broader plan to provide universal health insurance, “it is no longer a program to care for the neediest among us,” Roberts wrote.
Variations of the chief justice’s critique echo in the chambers of the Wyoming Capitol each time expansion is debated.
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Sen. Charles Scott (R-Casper), a former chair of the Legislature’s Labor, Health and Human Services Committee, contends only a small number of people truly need the expanded coverage.
“There are very few people who go without health care because we don’t have Medicaid expansion,” Scott said.
He argues the vast majority of the adults in the gap could earn enough money to get above the poverty level and qualify for insurance subsidies, but some “choose not to work hard enough to do it.”
During the Feb. 19 floor debate, Scott said a number of people in the gap opted to retire early, and “I have a limited sympathy for that.”
For a single person, it takes working a full-time job at minimum wage ($7.25 an hour) to clear the federal poverty level of $15,060, while a single parent with four children would need to earn upwards of $17.50 an hour to get to $36,580.
For adults with multiple children, “you could have a real problem there,” Scott said, “but it’s quite rare.”
Working for coverage
Of the 19,000 people projected to join Medicaid if it expands, the Wyoming Department of Health estimates 56% of them are now working.
Case sees expansion as a way to boost working people who are trying to stay off the welfare system.
“If you’re poor, and you’re in America, and you actually are in Wyoming, then your health care choices are as limited as anywhere in the modern world,” he said. “And if you have a chronic disease, and you’re poor, and you have children, and you’re trying to hold jobs, it’s not a pretty situation. And it’s not your fault.”
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Angie Dax had long worked in home health care when her own health fell apart. In 2020, the Casper resident was diagnosed with pulmonary hypertension, she said, followed by emphysema, COPD, congestive heart failure and cardiomyopathy.
Climbing the stairs at client’s homes became a struggle, and ultimately, Dax was unable to keep working as a CNA, she said. “It just seemed like it went downhill so quickly.”
Things sunk further last year, when her doctor found a mass on her lungs. With no insurance and no income, Dax said she couldn’t get an appointment for a PET scan, instead spending months at home, wondering if cancer was growing in her lungs and sinking into depression.
“I felt like I was screaming at the top of my lungs,” she said, “but nobody was listening to me.”
Dax was eventually able to borrow some money for the scan; she’s also since qualified for Medicare and, because of her medical disability, Wyoming Medicaid. But her prognosis isn’t good: Dax has been told she has roughly a year to live, she said.
With the time she has left, Dax has joined the American Cancer Society Cancer Action Network’s push for Medicaid expansion. Dax traveled to Cheyenne last week as part of those efforts, attending the premiere of a short film that features Dax, Malone and Zina Regan of Riverton. The organization also lobbied lawmakers at the capitol on Feb. 22 — the same day the Senate nixed Case’s final attempt at expansion.
Many Wyomingites are going without coverage and need health care, Dax said, calling it “shameful.”
Other options
With lawmakers showing little appetite for expanding Medicaid, thousands of residents need to find other options for health care. For those unsure of what’s available, Enroll Wyoming is one place they can turn.
Via an in-person appointment or phone call, the nonprofit organization can help people double-check their eligibility for marketplace coverage and direct them to other resources, all at no charge.
Even if a person thinks they don’t qualify for marketplace subsidies, Enroll Wyoming encourages making an appointment to explore options.
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“There are a lot of people who are surprised [at] what they qualify for,” said Caleb Smith, Enroll Wyoming’s marketing director.
The organization can also refer people to discounted health clinics, hospital charity care programs, soup kitchens, food banks or organizations that lend out medical equipment. Conversations typically end with the caller having more options than they had before, Smith said.
However, some areas of the state have fewer resources than others, he said, and “there are some times where I find myself saying, ‘I wish we had more options for you.’”
The official HealthCare.gov website offers a sparse list of alternatives for those in the coverage gap: A person can reapply for marketplace insurance if they start earning more money, the site notes, or they can consider purchasing a cheaper catastrophic plan that only covers the priciest medical bills.
There are other lower-cost options out there — like short-term insurance and health care sharing ministries — but they come with significant limitations. While marketplace plans must cover “10 essential health benefits,” like prescription drugs, birth control and mental health services, short-term plans and sharing ministries do not, often limiting what they’ll cover and how much money they’ll pay per member.
While it’s not insurance, HealthCare.gov does suggest one way for those in the gap to get affordable care: community health centers.
Standing in the gap
For those who are truly the most impoverished, health centers are the only place to get regular care at a price they can afford, said One Health Executive Vice President Colette Mild.
One Health is among eight centers that operate in 12 communities around the state. The nonprofit facilities offer a range of services, regardless of a patient’s ability to pay; they also provide discounts to those earning 200% or less of the federal poverty level. Six of Wyoming’s centers participated in an analysis that found 75% of the 36,303 patients they treated in 2022 had low incomes, and more than half were below the poverty line.
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One Health serves much of northern Wyoming, with clinics in Powell, Greybull, Lovell, Sheridan and, soon, Cody. The organization has 67 employees based in the state with additional providers in Montana available for telehealth appointments.
Services include urgent care, wellness checkups, mental health counseling, substance abuse disorder treatment, vaccinations, prescriptions and management of chronic conditions like diabetes and high blood pressure. Once the center moves into bigger quarters in Powell, they’ll add in-house dental care.
Like other community health centers, One Health also seeks to go beyond traditional care and address other needs that might underlie a patient’s health problems. For example, the organization employs a patient resource specialist who can help anyone in the community apply for the Supplemental Nutrition Assistance Program (SNAP), work through Medicaid paperwork, look for low-income housing or find medical equipment.
Dr. Sarah Sowerwine-Fitzgerald, One Health’s associate vice president of medicine and behavioral health, said complicated paperwork can be a barrier for obtaining care — as can patients’ reluctance to talk about their finances.
“But if we break that down and are just like, ‘Health care is expensive, how can we do this the best for you?’ … I feel like it’s easier for people to speak up,” she said.
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When patients are referred to other facilities for specialized care, One Health offers gas cards to help cover travel costs. Staff also search for the best deals on prescriptions — sourcing drugs from in-house pharmacies, considering less costly alternatives, using free coupons at GoodRx or even checking prices in Canada. For some patients, saving $30 on a prescription “is a huge difference,” Sowerwine-Fitzgerald said.
Calling on volunteers
In Laramie, Jackson and Lander, patients in poverty can also turn to donor-supported free clinics.
The Lander Free Medical Clinic just celebrated its first year of operations, in which it used over 5,000 volunteer hours to stretch an $80,000 budget into $400,000 worth of medical services, delivering care to over 100 patients.
But volunteers can only do so much.
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The Heart Mountain Volunteer Medical Clinic in Cody recently announced it was closing its doors after more than a decade of service.
The nonprofit organization aimed to host at least one clinic a week, but toward the end of last year, “that was just not feasible,” said Amanda Brengle, the clinic’s outgoing executive director.
The Heart Mountain clinic had “some of the best doctors that really were committed and showed up once a month no matter what,” Brengle said, but getting enough providers was a long-running challenge. The clinic also wasn’t immune from the staffing shortages that have stretched medical facilities across the state.
“[For] our volunteer providers, ever since COVID, it’s been a little bit of a challenge,” Brengle said, “because a lot of them don’t have the time and the energy to volunteer outside their normal working hours.”
The organization is transitioning into a foundation and referring its former patients to One Health, which expects to open a Cody clinic by late summer. With the shift, the Heart Mountain Volunteer Free Clinic hopes to provide more assistance to needy patients: Instead of spending its limited dollars on clinic overhead, its funds will help cover patients’ care at One Health.
“With One Health expanding and having more services that we can offer, we really felt like it was the best thing for our patients,” Brengle said.
In a typical year, the Heart Mountain clinic provided free care to roughly 100 patients, ranging from disabled individuals who were unable to work to full-time employees earning close to the clinic’s upper limit of 200% of the poverty level. Many were restaurant workers, others held supporting roles at local hospitals and many summer patients were seasonal hospitality workers, Brengle said. About half fell below 100% of the poverty level, she estimated.
“A lot of them do work at least part time,” Brengle said, “but it’s just not enough.”
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Wages haven’t necessarily kept up with rising housing costs, and that’s squeezing the budgets of low-income earners, said Jayson Nicholson, program coordinator of the Heart Mountain-linked First Stop Park County Help Center.
In the same way that Malone put off care, the Heart Mountain clinic’s uninsured patients tended to wait until they absolutely had to see a doctor, Nicholson said, which could result in more serious, costlier problems.
Prediabetes could progress from a manageable or reversible condition to a permanent one requiring checkups and expensive insulin, he said, while in the absence of cleanings, routine dental problems could turn into lost teeth and pricey dentures.
At One Health, Dr. Sowerwine-Fitzgerald said they’ve similarly seen more and more patients pinched by rising costs.
“We have all these people who can hardly afford to live here, let alone engage in things like primary care,” she said. “And so the choice of not partaking in this Medicaid expansion has really forced a lot of families to choose.”
And that, she believes, results in an unhealthier community.
A growing safety net
Wyoming currently offers Medicaid benefits to disabled adults, pregnant women, elderly residents receiving long-term care and extremely low-income adults (earning less than $12,000 a year for a four-person household) who are serving as caretakers for children or other family members. Children, by far, make up the largest chunk of Medicaid enrollment, as the state offers coverage to youth in households earning up to 200% of the federal poverty level, or about $62,000 for a family of four.
In total, 79,159 adults and children — or nearly one of every seven Wyomingites — were covered by Medicaid or the associated Kid Care Children’s Health Insurance Program (CHIP) as of December.
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Enrollment swelled during the COVID-19 pandemic. December’s figure was up 38% from an average of 57,330 monthly members in the 2018-19 fiscal year. The prolonged surge was driven by federal policy, which prohibited states from removing anyone from Medicaid’s rolls until the end of the public health emergency last year. Between May and January, the Department of Health removed 11,162 clients from the program.
The federal government generally picks up 50% of the costs of Medicaid coverage in Wyoming, though it’s higher for CHIP and some other expenditures. In the fiscal year that ran from July 2021 to June 2022, Wyoming Medicaid reported spending $756.5 million, with $476.6 million covered by the feds.
If the state expanded Medicaid and 19,000 more people gained coverage, the Department of Health estimates it would cost around $100 million a year. However, the federal government would pick up 90% of that tab, potentially putting the state’s obligation at around $11 million annually.
The American Rescue Plan of 2021 sweetened the deal even further: If Wyoming agreed to expand Medicaid coverage, the federal government offered to temporarily up its match on the pre-existing programs (boosting its match from roughly 50% to about 55%). The Department of Health figured the state would receive an additional $54 million from the change and actually come out $32 million ahead over the first two years of expansion.
But that didn’t sway critics like Rep. Sarah Penn (R-Lander), who said during the 2023 legislative session that “we cannot be enticed to allow this into our state.”
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The opposition is in part on principle. Penn said in a recent email that she doesn’t think government should provide health care or encourage government dependency; Scott similarly described it as an issue of small government versus big government.
“It is an expansion of the whole federal welfare system, and that’s partisan,” he said, adding, “national Democrats appear to have a strategy of making as many people dependent on federal welfare as possible.”
Other concerns are financial — including long-standing fears that the federal government will eventually back off its 90% match and stick the state with a bigger bill, or cut its reimbursement rates and further stretch medical providers.
Paying a pittance
During his four decades in medicine, Dr. John Mansell has watched Congress cut Medicaid and Medicare reimbursement rates well below the cost of care. And as a pain management specialist, Mansell has felt the effects more acutely than most. While Medicaid and Medicare generally pay 50-75% of the commercial rate for doctor’s services, Mansell said the programs pay just 20-25% when it comes to anesthesia services.
While previously working for a large anesthesia group in Rockford, Illinois, he said 55-60% of patients were on Medicare or Medicaid, but they made up only about 8-9% of the group’s annual revenue.
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“Two-thirds of our work was paying 1/12th of our income,” he said, which resulted in shifting more costs to privately insured patients.
Now in Gillette, Mansell said an hour’s worth of visits with Medicaid patients yields about $200, barely running ahead of the $160-$175 it costs to run the clinic on an hourly basis.
That’s one reason Mansell opposes putting another group of people on Medicaid, “because providers just can’t live on that,” he said, “or they just elect not to take [Medicaid] anymore and … it’s what we call ‘coverage without care.’”
Mansell also has frustrations with what he sees as federal managers’ arbitrary refusals to cover certain procedures, unpredictable rate cuts and time-consuming red tape. And like Sen. Scott, he also thinks the little-cost care provided by Medicaid leads to overutilization and “a tendency to disregard the value of the benefit.” Mansell said more than 90% of his clinic’s no-shows are Medicaid patients.
Ultimately, he expects Medicaid to draw more people and grow faster than state officials expect. And with a ballooning national debt and rising interest rates, Mansell is convinced it’s only a matter of time before the federal government reduces reimbursement rates to cut costs.
“Our biggest worry is if you expand Medicaid, you’ll break it,” Mansell said, “and then all those people who really really need it won’t have it.”
Boosting providers
While the financial impact varies from provider to provider, the Department of Health projects that, on the whole, expansion should give providers a net gain in revenue.
In the case of hospitals, they’re now eating the costs when uninsured patients can’t afford the bill, so getting reimbursed at Medicaid’s lower rate would be better than nothing.
Uncompensated care at Wyoming’s hospitals has grown exponentially in recent years, the hospital association’s Boley said, jumping from an average of roughly $120 million a year to $151 million in 2021. Based on the experience of other states, he expects expansion would reduce that figure by at least 30%, lifting the facilities and patients.
As for community health centers, there’s no question that expansion would offer a boost. Although Medicaid generally pays much less than private insurance, it pays more for a standard doctor’s visit and comes the closest to covering One Health’s costs, said CEO Dr. David Mark.
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Health centers receive some federal funding to help care for low-income patients, but it’s a flat amount that only covers about 20% of One Health’s operating costs, Mark said. Making ends meet currently requires creativity — including a mix of some 60 different grants — which is one reason why Medicaid expansion is at the top of Mark’s list of policy priorities.
“It would allow us to take care of more people, offer more services, have a much more robust system of care,” he said.
He speaks from experience, as One Health also operates in Montana, which expanded Medicaid in 2016. Mark said the change had a noticeable impact: The percentage of uninsured patients dropped at One Health’s clinics, while critical access hospitals and local communities got an economic boost.
“To deny that kind of a benefit [in Wyoming] based on the theoretical possibility that someday the federal match rate may decrease is a little short-sighted, in my opinion,” he said.
Floating alternatives
Wyoming lawmakers did narrowly approve a more modest expansion of Medicaid services last year, allowing mothers to remain on the program for 12 months after giving birth instead of 60 days. The change, which is scheduled to sunset in 2027, is expected to benefit about 1,200 women at any given time, at a cost of about $3.87 million a year.
However, a bill that would have fully expanded Medicaid never made it to the House floor that session.
At a January 2023 legislative committee meeting, Penn agreed with expansion advocates that people are struggling.
“We have a problem that we need to fix,” she said, but “there are other options.”
In a recent email, the nurse practitioner said the state should impose more strict work-search requirements for Medicaid eligibility and generally reduce regulations to increase job opportunities.
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But Penn also expressed some openness to exploring a Wyoming-tailored version of expansion, specifically praising Indiana’s approach. The Hoosier State’s plan, which launched in 2015 under then-Gov. Mike Pence, requires enrollees to make monthly contributions to a health savings account in order to qualify for full benefits.
Penn also supports an idea forwarded by Mansell to prohibit fixed pricing within a patient’s insurance deductible. Under the physician’s concept, a patient would be allowed to haggle on the price of a procedure or appointment when they’re paying for it out of their own pocket. Currently, insurance patients must pay the much higher network rate if they want the expenditure to count toward their deductible.
Mansell acknowledges that not everyone will like the idea, but “we have to rein in pricing into something that’s more realistic,” he said.
To cover the cost of uncompensated care, Mansell would also prefer the state simply cover hospitals’ budget shortfalls, though at least on paper, that would be significantly more costly to the state than Medicaid expansion.
The elusive ‘Wyoming solution’
Lawmakers spent years discussing the possibility of crafting a Wyoming-tailored version of expansion, but those conversations fizzled out.
“I think the reality is that’s easy talk,” said Boley. “But when you actually put pencil to paper, it’s pretty hard to come up with a Wyoming solution when we’re in such an ultra-conservative state, and there’s going to be a price tag attached to it.”
For instance, he suspects the federal government would only offer a 50-50 match on a Wyoming plan instead of a 90-10 split.
Scott thinks it’s too late to create a state solution — “that ship has sailed,” he said — but Boley hopes the recent budget amendment restarts the conversation.
Last year, Rep. Steve Harshman (R-Casper) floated the idea of limiting the state’s expansion to the true “gap” — only offering Medicaid to those under the poverty level and excluding those in the 100-138% range who can get subsidized insurance. However, “the current administration at the federal level continues to signal a lack of support for such an option,” said Deti, the Department of Health spokeswoman.
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Tracy Woodhouse Brosius, the interim leader of the Wyoming Primary Care Association and the CEO of HealthWorks in Cheyenne, said participants in the health care system tend to pass the blame around when it comes to high costs.
“And everybody’s like, ‘Oh, I can’t fix it,’ and we stop,” Brosius said.
However, she believes there are many things Wyoming could do — including doing more with primary care and leveraging federal funds to expand community health centers — but she said the discussions always come back to the lack of universal insurance.
If lawmakers dislike Medicaid, she suggests they consider Arkansas’s plan, in which residents below the poverty line receive subsidized marketplace coverage instead.
“But if we’re resistant to doing anything, then … we just need to accept that this is who we are,” Brosius said. “And I don’t like to accept that.”
In the hands of the Legislature
For those in the gap, the Healthcare.gov webpage ends with a note that could be interpreted as a call to action: a reminder that citizens can register to vote.
Voters in seven states — including neighboring South Dakota, Nebraska and Utah — bypassed their legislators and expanded Medicaid via ballot initiatives. Polling commissioned by advocates suggests a majority of Wyomingites support expansion, but an initiative is off the table here, as state law prohibits voter proposals that spend state money.
That leaves the decision squarely in the hands of the Wyoming Legislature.
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Malone, who briefly ran for the Legislature herself, said last week that she figured the Senate would reject expansion this session. She believes some lawmakers may change their minds if they learn more about the impacts of Medicaid expansion, “but there are definitely some that I don’t think ever will,” she said. “And the only way to really get things to change is to get out and vote.”
While the defeat of the budget amendments was “disheartening,” Malone said it won’t stop her advocacy.
“I always have hope … always, always,” she said, “because I mean, if we don’t have hope, we don’t have anything.”
This story is part of “The Holdouts,” a reporting collaborative focused on the 10 states that have not expanded Medicaid, which the Affordable Care Act authorized in 2010. The collaborative is a project of Public Health Watch.
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