Assessing Concepts and Theories of Healthcare Leadership

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An Advocacy Report: The Wisconsin Medicaid Program

Dr. Zachary Miller

Rasmussen University

HSA5200CBE Healthcare Policy, Ethics, and Laws

Dr. Merle Point-Johnson

6/14/2024

An Advocacy Report: The Wisconsin Medicaid Program

The Affordable Care Act (ACA) was signed into law in 2010 to provide health coverage to all uninsured Americans in the United States. The primary focus of the ACA was to prioritize the needs of uninsured Americans. In the US, a public health insurance program, Medicaid, is available to low-income, disabled, and/or elderly individuals. The ACA authorized the expansion of Medicaid and mandated states to enroll uninsured adults with an income below 138% of the federal poverty line (Cha & Escarce, 2022). The expansion of Medicaid has enabled specific subpopulations to access quality healthcare, making it more affordable and, at the same time, reducing the initial financial burden on the states. With the signing of the ACA into law in 2010, there have been noticeable improvements in self-reported health, a decrease in hospital readmissions, and a reduction in mortality rates throughout the United States (Cha & Escarce, 2022).

Following the signing of the Affordable Care Act (ACA), several states filed a lawsuit against it, eventually reaching the Supreme Court. The Supreme Court ruled that the mandated Medicaid Expansion could not be enforced on all states but instead must be an optional provision for states to choose whether to adopt. In 2014, 25 states and the District of Columbia (D.C.) decided to implement the expansion. As of December 2023, 41 states have followed suit (KFF, 2023).

Medicaid Expansion with the Affordable Care Act

Beginning January 1, 2014, Medicaid programs or private insurance plans would be offered via an exchange marketplace to all Americans who meet the following eligibility criteria: under 65 with incomes within the 138% federal poverty level (FPL). For example, a family of 4 would need a household income of $43,056 to qualify in 2024. Under the new expansion, the government will fund 100% of the costs for the newly eligible recipients until 2017. After 2017, the government will cover 90% of the costs until 2020, and it currently continues to fund at 90% (KFF, 2023).

Expanding Medicaid through the Affordable Care Act (ACA) has several benefits. States that have implemented the ACA expansion of Medicaid have noted improved health outcomes and fiscal benefits. The expansion has led to improved healthcare access, quality of care, and hospital financial performance. Vulnerable populations such as young adults, prescription drug users, veterans, newly diagnosed cancer patients, and uneducated adults have access to health coverage, which was not present before the Affordable Care Act became law (KFF, 2023).

Medicaid Program Expansion Utilizing Waivers

It is crucial to keep in mind that a few states have yet to implement the expansion of Medicaid through the Affordable Care Act. For these states, it is essential to understand the available waivers to them if they are willing to adopt some form of the Medicaid Expansion program. An example of such a waiver is the Section 1115 demonstration waiver, which enables states to impose work and reporting requirements as a condition for Medicaid eligibility. There are also 1915 waivers to cover children’s long-term support, family care, and IRIS (Include, Respect, I Self-Direct) services in Wisconsin (CMS, 2023).

The 1915 Section waiver is a provision under the Social Security Act that grants the Secretary of Health and Human Services the power to sanction projects that are experimental, pilot, or demonstration in nature to advance the goals of Medicaid and other healthcare programs (CMS, 2023).

There are four 1915(b) waivers that affect Medicaid enrollees. These include (a) Freedom of Choice Waiver, which limits Medicaid recipients from receiving services outside of their care network; (b) Enrollment Broker Waiver, which uses a central broker to assist Medicaid enrollees in choosing healthcare services; (c) Non-Medicaid Services Waiver, this waiver provides additional services and utilizes cost savings to benefit Medicaid recipients. (d) Selective Contracting Waiver, this waiver restricts the provider from whom Medicaid beneficiaries can obtain services. (CMS, 2023).

States can use the Section 1915(c) waiver to cover Home and Community-Based Services under the Social Security Act. The waiver allows States to waive Medicaid regulations for institutional care (CMS, 2023).

The Current Wisconsin Medicaid Program

Eligibility for Medicaid in Wisconsin is determined by the Department of Health Services or the Disability Determination Bureau. The eligibility criteria for Wisconsin Medicaid include the following: a resident of the state of Wisconsin and a U.S. citizen or qualifying immigrant, an annual household income before taxes of $39,900 for a four-person household, as well as aged 65 plus, disabled, or blind (Benefits.Gov, 2024). For the 2023-2025 biennial budget, Wisconsin budgeted $9.5 billion for its Medicaid program, including operations, medical assistance, long-term care, medications, and training (WI DHHS, 2023). Expanding Medicaid through the Affordable Care Act could save the state budget about $1.6 billion. The money from the federal government would replace state money for primary care, physician services, outpatient services, and uncompensated care at hospitals (WI DHHS, 2023). The state of Wisconsin has not expanded federal Medicaid funding through the Affordable Care Act (CMS, 2023).

Michigan Implementation of Medicaid Expansion Through Waivers

Wisconsin has a neighboring state, Michigan, with a comparable political climate. Analyzing Michigan's acceptance of Medicaid expansion through waivers could provide valuable insights. In December 2012, the state of Michigan received approval from CMS to amend its 1115 program waiver to implement the Affordable Care Act’s Medicaid expansion. The waiver and state plan amendments would include cost-sharing, contributions to a health savings plan, healthy behavior protocols, and prohibit Medicaid eligibility denial for the new beneficiary group (CMS, 2023).

The Medicaid expansion program has proved to be financially beneficial since its inception. Updated data as of 2020 shows that the program has helped to reduce unpaid medical bills, over-limit credit card spending, evictions, judgments, and bankruptcies. These improvements have been observed across several population groups, with the most significant impact being on those with chronic illnesses. In the first three months of the expansion, over 300,000 Michigan residents (representing 3.3% of the total population) enrolled in the program (Miller et al., 2020). The Michigan Medicaid expansion has been beneficial to both the state and those who need healthcare. This program has saved money while increasing access to healthcare.

Recommendation for Wisconsin Medicaid Expansion

I recommended that Wisconsin adopt and implement Medicaid Expansion through a waiver like the state of Michigan's. If the expansion is adopted and the eligibility is updated to reflect the 138% federal poverty level for household income, up to 40,000 additional Wisconsinites could become insured, resulting in reduced uncompensated care for healthcare providers (Ohm, 2019). It can help regulate health insurance premiums by enhancing the risk pool in the ACA individual market. This will also attract hundreds of millions of dollars in federal funds to pay for state budget items currently supported by state tax revenues.

In 2023, Governor Tony Evers introduced his biennial budget proposal for State Fiscal Years 2023-2025, which included allocations for Medicaid expansion and accounts for additional federal Medicaid matching funds due to the American Rescue Plan Act (ARPA) incentive for states to adopt expansion newly. The budget provided 46.5 million over the biennium to benefit doulas, community health workers, and community health benefits. However, the Wisconsin Legislature’s Joint Finance Committee voted to remove Medicaid expansion funding from the budget proposal. Evers has proposed expansion through previous budgets and legislation since the start of his term in 2019, though the Republican-controlled legislature has passed none (KFF, 2023)

References

Benefits.Gov. (2024). Wisconsin Medicaid. Retrieved April 13, 2024, from https://www.benefits.gov/benefit/1646

Cha, P., & Escarce, J. J. (2022). The Affordable Care Act Medicaid expansion: A difference-in-differences study of spillover participation in SNAP.  PLOS ONE,  17(5), e0267244.

CMS. (2023, September). State Medicaid Plans and Waivers. Retrieved April 13, 2024, from https://www.cms.gov/training-education/partner-outreach-resources/american-indian-alaska-native/ltss-ta-center/information/state-medicaid-plans-and-waivers

CMS. (2023). Michigan waiver factsheet. Retrieved April 13, 2024, from https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/Waiver-Descript-Factsheet/MI#4119

CMS. (2023). Wisconsin waiver factsheet. Retrieved April 13, 2024, from https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/Waiver-Descript-Factsheet/WI#0414

KFF. (2023, December). Status of state action on the Medicaid expansion decision. Retrieved April 12, 2024, from https://www.kff.org/affordable-care-act/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

Miller, S., Hu, L., Kaestner, R., Mazumder, B., & Wong, A. (2020, March).  The ACA Medicaid expansion in Michigan and financial health (w25053; p. w25053). National Bureau of Economic Research

Olm, B. (2019, August 7). Medicaid expansion in Wisconsin and possible impacts for employers. The Alliance. https://the-alliance.org/blog/on-my-mind-medicaid-expansion-in-wisconsin-and-possible-impacts-for-employers/

WI DHHS. (2023, February 23). Proposed budget: Expanding Medicaid. Retrieved April 12, 2024, from https://www.dhs.wisconsin.gov/budget/medicaid-expansion.htm