Published June 2017
Wyoming has a comparatively small population spread across a large land area. In 2010, 35.2% of the state’s population lived in areas defined as rural by the U.S. Census Bureau1. Individuals living in rural areas face unique obstacles to health care that may not apply to those living in urban areas; those individuals living in rural areas tend to be older and less healthy, have fewer available doctors and other health care providers, and must travel longer distances for health care. In addition, a smaller proportion of the population living in rural areas tend to be covered by medical insurance (Meit, et al., 2014).
Beginning in second quarter 2015 (2015Q2), Wyoming experienced an economic downturn caused by “a substantial decline in the prices of oil, and extended period of low natural gas prices, and the erosion in the price of coal” (Gallagher, 2016). This downturn continued through 2016Q3, the most recent period for which data were available at the time of publication. During this period of economic downturn, Wyoming experienced a decrease both in the number of jobs worked and in the number of persons working, particularly in the mining industry (Moore, 2017). However, even as other industries were experiencing job losses, Wyoming’s health care & social assistance industry experienced job growth.
The purpose of this chapter is to examine the reasons behind the growth in health care & social assistance, particularly increased medical care consumption by an aging population and increased health care spending due to increases in insurance coverage from the Affordable Care Act and increased federal spending on programs such as Medicare. This chapter also includes a discussion about the implications of continued employment growth within health care & social assistance.
Wyoming is the least populated state in the nation. In 2015, there were approximately 91.0 people per square mile living in the United States, but only 6.0 people per square mile living in Wyoming (see Table 2.1). By comparison, Montana was home to approximately 7.1 people per square mile, Colorado had approximately 52.6 people per square mile, and an estimated 20 people per square mile lived in Utah.
As shown in Figure 2.1, Wyoming’s population has continued to age since 2010, despite a decline in the state’s baby boomer population (see Table 2.2). Baby boomers include people born between 1946 and 1964 (Vincent & Velkoff, 2010), and currently constitute the second largest living generation of people in the country behind millennials, who were born between 1981 and 1997 (Fry, 2016). In 2015, baby boomers were between the ages of 51 and 69. Nationally, according to the U.S. Census Bureau (Colby & Ortman, 2014), baby boomers will comprise approximately 20% of the country’s population by 2029, and a similar proportion of Wyoming’s population as well.
In both 2010 and 2015, the median age of Wyoming residents was 36.9 years of age; the median age in 2016 may have been higher due to job losses in the mining industry and the out-migration of jobseekers during the current economic downturn, which will be discussed later in this chapter.
In 2015, 28.3% of the state’s population was age 55 or older (see Table 2.3), and at least one-fifth of the population in each county was age 55 and older. However, not all counties are aging at the same rate. The proportion of older adults was larger in some counties in 2015, such as Hot Springs (41.3%), Platte (39.3%), and Johnson (37.5%). In comparison, counties such as Albany (20.3%), Campbell (20.4%), Sweetwater (23.4%), and Uinta (25.7%) had smaller proportions of older people.
Figure 2.2 shows a comparison of the proportion of the population age 55 or older in 2010 and 2015. By 2015, those people who were age 55 or older comprised 4.7% more of the total population in Lincoln County and 4.5% more of the population in Sublette and Uinta counties. In contrast, by 2015 the proportion of those age 55 or older increased only 1.6 percentage points in Albany County and 1.4 percentage points in Natrona County.
In terms of total change (see Table 2.4), the number of people ages 55 and older grew at a much greater rate than other age groups from 2010 to 2015 in most counties. The number of people ages 55 and older increased by 31.4% in Campbell County, 24.8% in Teton County, and 22.3% in Lincoln County. In comparison, the increase of people ages 55 and older was relatively low in some counties, including Niobrara County (2.5%). This is possibly because a larger proportion of the population was already in that age group in 2010.
Migration also has an effect on Wyoming’s population. Table 2.5 shows the number and proportion of people who moved into the state during selected years by state of origin. These data are compiled by the Internal Revenue Service (IRS), based on yearly tax returns. During the 2011/2012 tax year, the IRS changed the way it calculated migrants (Pierce, 2015), so data from 2011/2012 is included in this table as well as data for 2009/2010 and 2014/2015 to show any major differences before and after the implementation of the new methodology. In 2011/2012 there were 30,222 in-migrants and 26,936 out-migrants, leaving a net in-migration of 3,286 people. The largest proportions of in-migrants in 2011/12 moved to Wyoming from Colorado (12.6%), Florida (10.9%), and Utah (7.3%).
In comparison, during 2014/2015, there were 18,277 in-migrants and 18,079 out-migrants, leaving a net in-migration of 198 people. That year, the largest proportions of in-migrants moved to Wyoming from Colorado (14.9%), California (8.1%), and Utah (8.3%).
As previously noted, Wyoming’s population is aging in part because of a large baby boom population, but also perhaps because of migration patterns that take younger individuals out of the state for higher education or employment opportunities. Several studies conducted by R&P have found evidence of an exodus of younger workers over time (Holmes, 2015; Glover, 2012; Bullard, et. al., 2009; Jones, 2005). Additionally, there is evidence that workers of all ages have left the state, probably in search of employment due to the state’s most recent economic downturn, which occurred between 2015Q2 and 2016Q3 (Moore, 2017).
Individuals age 55 or older have a greater likelihood of having chronic health conditions requiring medical attention compared to the younger population (National Center for Health Statistics, 2014). In fact, more than 90% of older adults reported having at least one chronic disease in 2008 (Dall, et al., 2013). Chronic ailments include cancers, heart disease, stroke, diabetes, and Alzheimer’s disease (U.S. Department of Health and Human Services, n.d.). Older adults are also more likely to suffer medical emergencies such as falls (U.S. Department of Health and Human Services, n.d.). An increase in the number of older adults puts pressure on the health care delivery system both because of the need for more trained professionals to provide care, and because a substantial proportion of the current health care workforce is also aging and nearing traditional retirement age (National Center for Health Workforce Analysis, 2006; Harrington & Heidkamp, 2013).
Older individuals use medical services such as ambulatory care, hospitals, skilled nursing facilities, and home health care at a much greater rate than younger people (Center for Health Workforce Studies, 2006). Primary care physicians tend to be the initial point of care for this population, but the number of primary care physicians in the United States has been declining as medical students choose to specialize in areas of medicine with higher wages (Alliance for Health Reform, 2011). Also, the number of physicians with experience and training in geriatrics is much smaller than will be needed for an aging population (Population Reference Bureau, 2010).
A shortage of nurses, particularly those trained in geriatric medicine, is projected within the next decade. Although there is a substantial supply of nursing applicants, nursing schools do not have the space or faculty to educate them all (Population Reference Bureau, 2010). Similarly, the demand for direct care workers such as home health aides, certified nursing assistants, and medical assistants is expected to increase in the near future as older populations increase their use of home health care, assisted living facilities, and skilled nursing facilities (Population Reference Bureau, 2010).
As shown in Figure 2.3, the total number of people working in Wyoming generally increased between 2000 and 2008, but decreased substantially during the previous economic downturn (2009Q1-2010Q1) before starting to increase again. Employment dropped again after 2014 during the most recent economic downturn (2015Q2-2016Q3). However, as shown in Figure 2.4, employment in the health care and social assistance industry (NAICS 62) has increased every year since 2000. This sector includes ambulatory care, hospitals, skilled nursing facilities, individual and family services, vocational rehabilitation, and child day care services. The continued employment growth in this industry, especially compared to the history of job losses related to economic downturns in other industries, indicates that the need for health care workers continues to grow.
Tables 2.6 and 2.7 contain the number and percent of Wyoming workers by selected age group, county, and substate region in 2010 and 2015. Figure 2.5 is a map of Wyoming’s substate regions. In Tables 2.6 and 2.7, workers are split into two groups: those younger than age 55 and those who were age 55 or older, in order to show the number and proportion of the population that will need to be replaced by younger workers as they retire and leave the workforce. Overall, the proportion of workers age 55 or older increased from 15.6% in 2010 to 17.3% in 2015. All counties except Platte County experienced growth in the proportion of workers age 55 or older. Weston County had the largest increase (20.3% to 24.2%), which is expected considering the average age of Weston County’s population was among the oldest in the state in 2010 at 43.6 years (Glover, et al., 2011); the population of Weston County has continued to age over the past five years. In comparison, counties like Albany County (14.5% to 14.9%) and Teton County (9.3% to 10.1%) had very little growth in the proportion of older workers from 2010 to 2015.
Moore (2017) found that, during the most recent economic downturn, the mining industry lost jobs at a much higher rate than other industries, and there was a corresponding drop in the number of persons in Wyoming’s resident labor force2. This decline may indicate that people may have left the state when they were unable to find work. Counties with high concentrations of mining employment lost the largest number of total workers between 2010 and 2015, including Sublette County (-1,273) and Campbell County (-837; see Tables 2.6 and 2.7). Both of these counties also had the largest increase in proportion of workers age 55 or older, probably due to younger workers migrating away in search of better employment opportunities. This departure of younger workers leaves behind the older workers who may retire in the next decade and will also require more health care. The proportion of workers age 55 and older in Sublette County increased from 13.1% in 2010 to 16.5% in 2015; in Campbell County, the proportion of older workers increased from 13.5% to 16.7%.
Although employment in the health care industry continued to increase between 2010 and 2015, the age of workers within that industry also increased. As shown in Table 2.8, the percentage of those age 55 or older increased by 12.0% from 2010 to 2015, while the percentage of workers ages 19 and younger decreased by 19.3%, those ages 20-24 only increased by 0.6%, and those ages 25-34 increased by 7.6%. Research & Planning has access to data from the state’s licensing boards and is therefore able to calculate the average age for workers in several health care occupations. See Chapter 3 of this publication for the results of that analysis.
People ages 65 and older, and those with permanent disabilities, are eligible for Medicare, a federal insurance program that covers hospital and physician care, as well as prescription drugs and other services (Cubanski & Neuman, 2016). In 2015, Medicare spending constituted 15% of the federal budget (Cubanski & Neuman, 2016), and 20% of the National Health Expenditure budget (U.S. Centers for Medicare and Medicaid, 2016). Medicare coverage is broken into several parts; Part A covers services such as hospitals, skilled nursing care, hospice, and home health care, and Part B covers medically necessary services and preventative care. People who are enrolled in Medicare Parts A and B are also eligible for Medicare Advantage programs, also referred to as Medicare fee for service programs, which are private insurance plans that offer further medical, vision, dental, and hearing coverage (U.S. Centers for Medicare and Medicaid Services, N.D.).
Between 2010 and 2014 (the most current data available) the number of people in Wyoming who were enrolled in Medicare Parts A and B increased by 14.2% (see Table 2.9). This is a slightly larger increase than the national average, where the number of enrollees increased by 13.4%. The number of people in the state who also enrolled in a fee for service plan increased by 17.9% compared to an increase of 3.2% nationally. The total standardized cost for Medicare services increased by 16.0% in Wyoming during this period, but the standardized per capita costs decreased by 1.6%. In comparison, nationally the total costs increased by 2.9% and per capita costs decreased by 0.3%.
In addition to Medicare, federal funding also helps provide programs such as Medicaid and Children’s Health Insurance Program (CHIP). Medicaid is a program designed to provide health care to several mandatory eligibility groups, including low income families, qualified pregnant women, and people receiving Supplemental Security Income (U.S. Centers for Medicare and Medicaid). Although the ACA provided a means to expand Medicaid coverage, the state of Wyoming chose not to do so. CHIP is a program funded by both state and federal monies and provides affordable health care coverage to children in families whose income is within 200% of the federal poverty line but are not eligible for Medicaid (Wyoming Department of Health, n.d.). Until October 2016, CHIP was 65% funded by the federal government and 35% funded by the state. After October 2016, this changed to 88% federal funding and 12% state funding, but this could change in the future (Scott, 2017a).
Between 2010 and 2015, Medicaid enrollment increased by 4.5% (see Table 2.10). Total Medicaid expenditures during this time increased by 2.5%. More than half of all Medicaid expenditures in 2015 were medical costs (56.0%) and 40.0% were long term care costs (see Figure 2.6). In comparison, CHIP participation dropped between 2010 and 2015. As shown in Table 2.11, the average number of children continuously enrolled in CHIP each month decreased by 44.7% between 2010 and 2015 and the total annual unique enrollments decreased by 16.4% (Scott, 2017b). This drop is due to both changes in the way the CHIP program was implemented as the state streamlined the CHIP and Medicaid application systems, and a mandatory transfer of 1,250 children to Medicaid based on adjusted income guidelines (Scott, 2017a).
People who are younger than age 65 and not eligible for Medicaid generally rely on either employer-provided insurance or privately purchased insurance to cover the costs of their health care needs. Access to health insurance has a significant effect on an individual’s ability to obtain medical care in the United States. Without some form of insurance, costs can quickly become prohibitive depending on the type of medical care being sought (Institute of Medicine, 2009). Individuals who do not have some form of medical insurance generally have less access to health care and are more likely to go without care, even when they need it (Kaiser Family Foundation, 2016).
In 2010, the Patient Protection and Affordable Care Act (ACA) was enacted. In addition to increasing patient protections, this legislation expanded access to insurance through mandated employer coverage, statewide insurance exchanges, and income based subsidies to make insurance options more affordable to a larger proportion of the population (National Conference of State Legislatures, 2011). Nationally, the proportion of uninsured persons decreased from 18.2% in 2010 to 10.5% in 2015 (Kaiser Family Foundation, 2016). In Wyoming, the number of people who enrolled in a plan from the ACA marketplace increased every year since the legislation took effect (Chilton, 2015), and by 2016 23,770 people had enrolled, with the majority living in non-metropolitan areas (Barker, et al., 2017). However, laws regarding the ACA and health care access could change in the next years with the new federal administration.
R&P collects survey data on a quarterly basis from state employers regarding whether or not they offer selected benefits. The survey methodology and past issues of the yearly data analysis can be found at http://doe.state.wy.us/LMI/benefits.htm. As shown in Figure 2.7, the proportion of total jobs that offered selected types of health insurance remained stable between 2010Q1 and 2015Q4. Approximately two-thirds of jobs offered medical insurance. Slightly fewer jobs were offered dependent medical insurance, although that proportion was still more than 60% each quarter. More than half of all jobs were offered dental insurance and at least 40% of all jobs were offered vision insurance.
A larger proportion of full-time jobs were offered selected benefits during this period compared to part-time jobs. As shown in Figure 2.8, four out of every five full-time jobs offered medical insurance, although that proportion began to decrease after 2013Q4. More than 75% of full-time jobs offered dependent medical insurance and nearly as many were offered dental insurance. Around half of all full-time jobs offered vision insurance, but that proportion increased over time so that two-thirds of those jobs offered the benefit after 2014Q1.
As shown in Figure 2.9, a much smaller proportion of part-time jobs offered selected benefits between 2010Q1 and 2015Q4, and that proportion generally decreased over time for all benefits. In 2010Q1, approximately one in five part-time jobs offered medical insurance but that dropped to 15.2% in 2015Q4. This decline happened for the proportion offered dependent medical insurance and dental insurance as well.
Compared to employment in all industries, employment in Wyoming’s health care industry has steadily increased since 2000. The reasons for this are two-fold: Wyoming’s population is aging and medical spending has increased, especially public-funded medical spending.
Evidence shows that older people generally need more medical care than younger individuals. Among other things, older populations are more likely to suffer from one or more chronic health conditions, such as cancer, Alzheimer’s disease, heart disease, and diabetes, which need regular medical supervision or intervention. Wyoming’s population has continued to age since 2010, due in part to a large baby boom population and in part to an out-migration of younger workers looking for better economic opportunities after the most recent economic downturn. The distribution of this aging population, however, varies by county. Some counties have a much larger population of people age 55 or older than others, and some counties have experienced larger increases in the proportion of older people over the last five years. This overall aging of the state’s population will continue to have an effect on health care employment in the future as more and more people need specialized attention.
Health insurance, especially from publically-funded sources, is also driving health care employment in Wyoming. Medicare spending, which is tied to age, has increased substantially in the past five years, and will continue to do so as more people become old enough to enroll. People who are not old enough to qualify for Medicare often rely on employer-provided insurance or private insurance. The ACA was passed in order to make private insurance affordable to a greater number of people; while the future of the ACA is in question, the proportion of jobs offering health insurance by their employers has remained stable over time. Studies have shown that people who do not have health care insurance do not always seek medical care when they need it, so it stands to reason that those with health insurance would utilize medical services more often.
An aging health care workforce will lead to some issues in the near future. Similar to the general population, health care workers in Wyoming are aging and many will reach typical retirement age in the next decade. Because of this, there will be increased need for trained replacement workers. Also, there is a shortage nationally, and most likely locally, of health care professionals who are trained specifically in the needs of geriatric populations. This type of training will become increasingly important as larger numbers of older individuals seek medical care.
Lack of state or federal funding may impede health care employment growth Seventy percent of Wyoming’s revenue comes from severance taxes and royalty fees on mineral extraction, and with the most recent economic downturn affecting primarily the mining industry, tax revenues have also been impacted (Richardson, 2017). Due to diminished tax revenues, large funding cuts have already been made to state agencies that are dependent on state money (as opposed to federal funds), including the Wyoming Department of Health. Funding cuts to this department in 2016 were expected to impact more than 600 private sector jobs, including health care jobs (Murphy, 2016). Similarly, in terms of federal monies, it is possible that programs such as the ACA, Medicare, Medicaid, and CHIP could be cut or modified, which could affect the amount of money flowing into the state’s health care industry and the people employed there.
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1The U.S. Census Bureau defines rural as what is not urban — that is, after defining individual urban areas, rural is what is left. For an in-depth explanation of this issue, see http://www2.census.gov/geo/pdfs/reference/ua/Defining_Rural.pdf.