Wyoming, with an economy marked by farming, ranching and small businesses, has a disproportionate number of people without medical insurance. And by that measure and others, its people are among the likely winners if Congress approves a healthcare overhaul.

But if Republican Sen. Michael B. Enzi was expecting a pat on the back from his constituents for working with some of his fellow senators to seek bipartisan agreement on the issue, he was disappointed.

Last week, Enzi held a town hall meeting in his hometown of Gillette. And when he told the 500 people in the audience that he believed both sides could eventually strike a deal, it turned out that wasn’t a popular thing to say.

A state legislator even stood up and demanded that Enzi pull out of the congressional talks altogether, and was widely applauded by the audience.


The scene in Gillette was replicated in towns across the U.S. last month, as screaming taxpayers filled TV screens with criticism of healthcare proposals. The clashes dramatized a conundrum faced by lawmakers such as Enzi who are seeking compromises.

Some of the most vociferous opposition to the proposals before the House and Senate comes from residents of rural states that could benefit most if the present system is revamped.

“The states that tend to be more conservative have a higher rate of people who are uninsured,” said Ron Pollack, executive director of FamiliesUSA, which backs a healthcare overhaul. “As a result, healthcare reform is going to provide a disproportionate amount of resources to those states.”

In Wyoming, for example, nearly 1 in 3 people younger than 65 went without health insurance at some point during the last two years, according to Pollack’s group. A huge majority of the uninsured have jobs, but work for employers who don’t provide coverage.


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Fewer options

The problem pervades other rural states as well, where a high percentage of employers are small businesses. Although there is a consensus in Congress for keeping the current employer-based system of medical insurance, that system is riddled with holes in coverage that disproportionately affect rural states.

In addition, both in the West and South, such states tend to set higher thresholds for Medicaid eligibility, leaving few options for low-income earners who can’t afford individual insurance coverage.


Moreover, residents of rural states often have lower incomes than those in other parts of the country. It’s more difficult to find healthcare providers. And they have little, if any, choice in the private insurance market, which is typically dominated by one or two companies in a region.

Given that reality, it may not be surprising that senators from these states have been the most active in the effort to salvage a bipartisan compromise on healthcare. Sens. Max Baucus (D-Mont.) and Charles E. Grassley (R-Iowa), who hold top posts on the Senate Finance Committee, are part of a group of senators still talking about a deal, along with Enzi, Kent Conrad (D-N.D.), Jeff Bingaman (D-N.M.) and Olympia J. Snowe (R-Maine).

If they fail, the Democratic leadership in the Senate has threatened to ram a bill through without GOP backers.

Although Enzi has said that he wants to find common ground on healthcare, his public remarks have become more polarized during the congressional recess.


“The Democrats are trying to rush a bill through the process that will actually make our nation’s finances sicker without saving you money,” Enzi said in the GOP’s weekly radio address Saturday.

Eric Wedell, a Wyoming physician and governor of the state chapter of the American College of Physicians, applauded Enzi’s efforts to broker a compromise. Enzi “is continuing to work hard on healthcare reform because he knows we need it,” Wedell said.

But another Wyoming physician, Timothy Hallinan, disagreed, saying it would be better to have no bill than to have the kind Enzi is negotiating.

It was Hallinan, a state representative, who demanded at the meeting in Gillette that Enzi stop working with Democrats.


“Perhaps Sen. Enzi will get the most egregious -- in his and my view -- items dropped through compromise. Nonetheless, the compromised bill will be going in the wrong direction and must be seen as a down payment on where the current majority plans to go -- a complete takeover of medical practice by the federal government,” Hallinan said.

“I would rather see no bill than that. I suspect that a large percentage of the American population agrees,” he added. “I know that a big majority here in my district agrees with me.”

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Potential benefits


Although much attention has been focused on whether the ultimate legislation will provide for a government-run insurer or a series of private health cooperatives to help cover the uninsured, the bill is also expected to increase eligibility for Medicare and Medicaid, which could provide a lift to states like Wyoming.

“Things that are enormously important are getting less attention,” lamented Pollack of FamiliesUSA. Rural, conservative states, he said, “are going to get the influx of new federal dollars.”

But those opposed to the proposals, such as Hallinan, point to the cost. Even at current coverage levels, Medicare and Medicaid spending is expected to vastly increase the country’s debt.

Others are simply nervous about more government involvement in healthcare. Although centralized government can often deliver healthcare services more efficiently, “it runs counter to perhaps the rugged individualism on which America is built -- where everything is available for everybody,” said Diane Rowland, executive vice president of the nonprofit Henry J. Kaiser Family Foundation.


In Iowa, where almost 70% of those who are uninsured have jobs, Grassley has faced combative audiences in a series of town halls, to the extent that speculation has risen that he will pull out of negotiations.

But Jack Hatch, a Democratic state senator from Des Moines, said that much of the anger and uncertainty in Iowa was directed at Wall Street bailouts, the stimulus and other government spending.

“I’ve been to a half a dozen of these,” Hatch said. “There are maybe 15 to 20% of the people who are just angry with everything. They’re angry with their economic situation.

“They’re afraid of any kind of deficit spending,” said Hatch, part of a White House-led effort to enlist state lawmakers to promote the legislation. “When we shift to healthcare, there’s a lot less noise and a lot more questions.”


But he admitted that opponents of the plans had succeeded in making Iowans nervous -- and that supporters would have to sharpen their message in states such as his.

“All we have to do is get the people to listen through the screams of this small minority,” he said. “We have to be more vocal and fight back.”

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j oliphant@latimes.com