Reinsurance, association health plans, Medicaid waivers.
Recent health care actions in Wisconsin, some of which require federal approval, can be difficult to follow for anyone without a Ph.D. in health policy.
Most of the developments directly affect only a small fraction of the population. But together, they could have a significant impact on the health care system, influencing coverage for many and the premiums and taxes everyone pays.
“All of these policies that are being promoted right now address some element of both coverage and the price of premiums," said Donna Friedsam, health policy director for UW-Madison's Population Health Institute. "They touch every person in our state."
Several moves are tied to this year’s gubernatorial campaign, with Gov. Scott Walker touting some ideas and his Democratic challengers supporting others.
To help you sort through the issues, the Wisconsin State Journal has created this at-a-glance guide to the state's health policy:
What is it? A reinsurance fund helps insurance companies pay high-cost medical claims, to try to reduce premiums for everyone. In 2014 to 2016, the Affordable Care Act marketplace had temporary federal reinsurance, designed to stabilize premiums in the early years of the marketplace.
What’s the problem? The end of federal reinsurance — along with low enrollment by healthy people, the termination of other federal payments to insurers and other factors — caused marketplace premiums to rise. This year, premiums went up an average of 38 percent for the 225,000 Wisconsin residents who signed up for plans on the marketplace. The vast majority get federal subsidies that mask the increase, but those with higher incomes are paying more.
What’s new? Gov. Scott Walker and the Legislature, with some bipartisan support, last month approved a state reinsurance program. The $200 million annual fund — roughly $150 million in federal money and $50 million from the state — would pay 50 percent to 80 percent of claims between $50,000 and $250,000. With the program, premiums would go up 2 percent next year instead of 15 percent, and decrease 2 percent in 2020 instead of increasing 10 percent, state consultants say. Alaska, Minnesota and Oregon have similar programs.
What’s next? The state plans to submit its reinsurance request next month to the federal government, which can take six months to decide. If approved, reinsurance would start in 2019. The state might seek other changes to stabilize the marketplace in 2020, such as health savings accounts or the return of a high-risk pool.
What are they? They’re health conditions — such as AIDS, cancer, severe obesity and Parkinson's disease — that people develop before signing up for or switching insurance. The Affordable Care Act bans insurance companies from denying coverage to people with pre-existing conditions or charging them more, which insurers could do before the law. Congress has looked at rolling back the rules, saying they make insurance more expensive for others.
What’s new? Gov. Scott Walker, as part of his election-year health care plan, asked the state Senate to pass a pre-existing conditions bill approved by the Assembly in June amid some political maneuvering.
What’s the debate? The original bill, introduced by Democrats, banned lifetime caps on health insurance, which the Affordable Care Act also prohibits. Republicans stripped out that wording and inserted their own language. The new bill requires insurers to cover people with pre-existing conditions but allows the state insurance commissioner to alter protections, possibly by re-establishing a high-risk pool for such people. The bill is now in the Senate, where Sen. Jon Erpenbach, D-Middleton, introduced an amendment to remove the insurance commissioner provision.
What’s next? The Senate plans to return for a final day in session on March 20. It’s not clear when Congress, which failed to fully repeal the Affordable Care Act last year, might take up pre-existing conditions again.
What is it? It’s a state Medicaid prescription drug program that helps about 93,000 people age 65 and older pay for medications. Started in 2002, SeniorCare costs $30 a year, plus deductibles, co-pays and other expenses depending on income level.
What’s new? Gov. Scott Walker, as part of his election-year health care plan, said he would seek permanent approval for SeniorCare from the federal government instead of having to ask every few years to let it continue.
What’s the debate? Walker has previously proposed requiring people on SeniorCare to enroll in Medicare Part D, a federal program that started in 2006. It costs an average of $43 per month this year. The proposal, opposed by groups representing the elderly, has failed amid bipartisan opposition. Now Walker says he wants to make SeniorCare permanent. But health policy experts say the federal government has never let such a Medicaid program be permanent, and likely can’t.
What’s next? The state plans to hold public meetings before submitting its request by July.
Association health plans
What are they? Association health plans allow small employers and sole proprietors to join together through chambers of commerce or trade associations to buy insurance on the large-group market.
What’s new? The Assembly passed a bill last month allowing association health plans in Wisconsin, after amending the bill to say the plans must meet state mandates — such as covering mammograms, autism treatment and chiropractic care. In October, President Donald Trump issued an executive order supporting association health plans. In January, his administration issued proposed rules for such plans.
What’s the debate? Supporters of the Wisconsin bill, including lead sponsor Rep. Shannon Zimmerman, R-River Falls, say the plans can bring savings and flexibility to small businesses through economies of scale. Opponents, such as Rep. Deb Kolste, D-Janesville, say the plans could destabilize the Affordable Care Act marketplace by offering fewer benefits and drawing healthier people away from the marketplace.
What’s next? The bill is in the Senate, which plans to return for a final day in session on March 20. At the federal level, public comments were due last week on Trump’s proposed rules, which likely won’t become final until June.
What is it? Nearly 1.2 million Wisconsin residents, a fifth of the population, receive some form of Medicaid, the state-federal health program primarily for the poor. States, which pay about 40 percent of the cost, can ask the federal government, which pays about 60 percent, for waivers of federal rules to expand or limit benefits.
What’s new? In June, Gov. Scott Walker asked for a waiver to require adults without dependent children to undergo drug screening and limit their coverage to four years unless they work or train for a job if they are able. Childless adults would also have to pay $8 per emergency room visit, and some would face $8 monthly premiums.
What’s the debate? Walker said the proposal “is about helping people transition from public assistance into Wisconsin’s workforce.” He and other Republicans say Medicaid should be limited to those who truly need it and the coverage should be more like private insurance. Democrats and health care advocates say the 149,000 childless adults on Medicaid, who make $12,140 a year or less, already face administrative challenges to keeping their coverage. They say the new requirements would make it even more difficult.
What’s next? It’s not clear when the federal government, which recently approved similar proposals in Arkansas, Indiana and Kentucky, might rule on Wisconsin’s request. The changes can’t start until a year after approval. A lawsuit is challenging Kentucky’s changes, including its work requirement.
What is it? Under the Affordable Care Act, states could expand Medicaid to people who make up to 133 percent of the federal poverty level, with the federal government paying 100 percent at first and later 90 percent. Walker and the Republican-controlled Legislature opted instead to limit coverage to people at or below the poverty line. That shifted about 63,000 adults with higher incomes off Medicaid. It also allowed about 130,000 childless adults onto the program, with the state paying its regular 40 percent share for them.
What’s new? The Democratic challengers in the governor’s race say they would take federal funding for Medicaid expansion. They also support BadgerCare for All, which would let people with incomes above the poverty line purchase the state’s main Medicaid coverage at full price, about $7,200 a year for an adult. The federal government would have to approve such a “public option.”
What’s the debate? Wisconsin is one of 18 states that didn't adopt the Medicaid expansion. Among them, it's the only one with no gap in coverage for residents below the poverty level. Medicaid programs in the other states, including Florida, Georgia and Texas, don’t cover adults up to the poverty line. But Wisconsin shifted people with incomes just above the poverty level to the Affordable Care Act marketplace, which wasn’t designed for them. According to the Legislative Fiscal Bureau, the state could have saved $1.1 billion in 2014 to 2019 by taking the Medicaid expansion. This year, the savings would be $187 million.
What’s next? Medicaid expansion likely will be discussed during the gubernatorial campaign. If Walker wins, he likely won’t change his stance, though some Republican governors have supported Medicaid expansion.