Wyoming is a pretty good place to be a kid, and the 2019 Kids Count Data Book agrees. Their report released this week gave the Equality State high marks for education, economic well-being, and family and community. But when it comes to health Wyoming is second to last in the nation.
One big reason children's health in Wyoming is weak compared to the rest of the nation, is 10 percent of kids in the state are without health insurance. According to the Kids Count Data Book from the Annie E. Casey Foundation, that's twice the national average.
And while most states have improved over the last 10 years, the situation in Wyoming has gotten slightly worse.
Katie Doherty said that's a problem because no matter where kids live they get sick.
"They get stomach bugs, they get colds, they get high temperatures, they fall, things happen to kids," said Doherty. She is the nurse manager for the Albany Community Health Clinic in Laramie, and she said without insurance kids are at risk.
"Not having adequate health care and proper vaccinations, they end up with more chronic diseases," Doherty said.
She sees a lot of uninsured kids because the clinic is a federally qualified health center. Its mission is to care for underserved populations. No one is turned away even if they can't pay upfront and the clinic offers a sliding scale fee option for uninsured families who have to pay out of pocket.
But the clinic's office manager Jamie Nippgen said even at a reduced cost, families will hold off on scheduling visits for sick kids until they absolutely need care.
"Had it been me I would have called day one and they wait several days because it's a money issue. It's heartbreaking to know that families wait those extra two days to see if it passes. And I'm lucky enough to call my pediatrician on day one," she said.
If the issue escalates over the weekend, Doherty said kids end up at acute care facilities or an emergency room.
"But then they are faced with this overwhelming bill," said Doherty.
Part of the problem is jobs with health benefits have been on the decline in Wyoming.
"In 2010, 68.7 percent of all jobs were offered medical insurance. By 2017, only 60 percent of all jobs were offered medical insurance," said Lisa Knapp, a Senior Research Analyst with the Wyoming Department of Workforce Services.
She said under the Affordable Care Act (ACA) businesses with less than 50 full-time employees are not required to provide benefits. But Knapp said the decline in employer-based insurance hit part-time workers the hardest.
"Among part-time workers, this has dropped by more than half. So in 2010 quarter 1, 23.7 percent were offered medical insurance but by 2017 quarter 3, only 10.4 percent were offered the benefit," said Knapp.
Under the ACA employers also aren't required to provide insurance for workers who clock less than 30 hours, and when finances get tight that's an easy place to cut.
Rebekah Smith said when part-time jobs don't offer health benefits that can be hard on working moms. Smith directs the Wyoming Women's Foundation, which supports research on economic self-sufficiency for families. That means families can cover basic needs like housing, food and health care without public or private assistance.
Smith said research shows, "the access that women have to jobs that have health insurance tends to be more limited." She said that could be because working moms don't have the time or money to pursue the education needed for higher paying jobs. Additionally, Smith said scheduling can be an issue.
"They are often working around the schedules of their children with respect to school activities or the limitations of child care hours," said Smith.
If the daycare facility closes at 5 pm but a full-time job requires longer days then a working mom might opt for multiple part-time jobs.
Jan Stall with the Wyoming Department of Health said for parents who don't have access to employer-based insurance, "there's actually a number of ways for children to get coverage."
Stall oversees eligibility for the Wyoming Medicaid Program and Wyoming Kid Care, also known as CHIP. These programs serve kids from families with household incomes at or below 200 percent of the federal poverty level. That's $51,500 for a family of four.
"Any children that apply for Medicaid or CHIP, if we deny that case for being over income we automatically send that application to the federally facilitated marketplace so that would be another option for families," said Stall.
The federal marketplace established by the ACA offers subsidized plans, but it's up to families to enroll and pay the premium, and Stall said sometimes they can't.
"Wyoming insurance rates tend to be on the higher side and some families just with the small amounts they are making may not be able to afford that," said Stall.
She said one way to cover more kids would be to increase the income limit for the CHIP program. But that would cost the state more money and require approval from the state legislature.
"There are states out there, many states that go up to 250, 300, some even go up to 350 percent. So I'm sure there are children that if we had a higher income limit we would be able to cover more," said Stall.
But even with the current requirements, she said there are thousands of kids who are eligible but who are not enrolled. The Wyoming Department of Health says it does outreach, puts ads in local newspapers and shows up for community events, but there are still parents out there who don't sign up their kids.
Nurse Katie Doherty from the Albany Community Health Clinic said she's heard from parents who are reluctant to get involved with government bureaucracy.
"There could be a stigma easily associated with labeling yourself as part of that lower socio-economic class because my child is on Medicaid. Those are all kind of against that western culture that we have here," said Doherty.
The clinic's office manager Jamie Nippgen said in addition to shame and stigma, the process is just overwhelming.
"It is burdensome if you look at the application it's very thick and for some people, it might be a time thing or an education thing whether or not they are able to trudge through that paperwork," said Nippgen.
So clinic staff do what they can to make it less daunting. Sometimes that's making copies or phone calls, or just sitting with someone as they fill out the 20-page form.
Nippgen would like to see Wyoming devote more resources to that kind of direct support.