Subsidies, insurance market no longer in danger
Since Wisconsin has a federally-run exchange, the Supreme Court’s decision in King v. Burwell was of critical importance in the state. The plaintiffs argued that the ACA only allowed subsidies to be provided in state-run exchanges, and 34 states – including Wisconsin – have federally-run exchanges (Healthcare.gov) instead. But on June 25, the Court ruled that subsidies are legal in every state, including those that use Healthcare.gov.
At ACAsignups, Charles Gaba estimated that 159,000 people in Wisconsin would have lost their subsidies if the court had ruled that subsidies were only available in state-run exchanges. Coverage would have become unaffordable for them, but also for tens of thousands of other Wisconsin residents who purchase their own health insurance without subsidies.
The American Academy of Actuaries estimates that premiums market-wide would increase by at least 35 percent in states where subsidies are eliminated, and the Urban Institute pegged the potential rate increase at 55 percent. Either way, it would have been catastrophic for the individual insurance market and people who purchase their own coverage.
But fortunately for the residents, medical providers, and insurance carriers in Wisconsin, subsidies were upheld by the Supreme Court, and will continue to be available for current and future enrollees.
Gov. Walker and the King case
In January, ThinkProgress put forth a video from 2013 of Wisconsin Governor Scott Walker saying that there’s “no real substantive difference between a federal exchange or a state exchange…” ACA supporters who wanted the Supreme Court to rule that subsidies are available in every state jumped on Walker’s comments as proof that nobody who was implementing the ACA was aware of the fact that subsidies might be in jeopardy in federally-run exchanges.
Indeed, Walker’s unique solution to Medicaid expansion (details below) indicates that he clearly believed that subsidies would be available in federally-run exchanges, since Wisconsin shifted about 83,000 people from Medicaid to subsidized plans in the exchanges as of 2014 (they are enrollees with incomes between the poverty level and 138 percent of the poverty level, so they are currently eligible for subsidies in the exchange).
But Vox’s Sarah Kliff explained that Walker’s comments didn’t really dismantle the King case, as he was simply talking about who would really be running the show in the exchange, and was pointing out that the state would have to comply with the federal government’s requirements, even if it were technically a state-run exchange.
And to be clear, Walker is no fan of Obamacare. He’s repeatedly called for repeal of the law, and following the Supreme Court’s ruling, Walker said that lawmakers should “redouble their efforts to repeal and replace” the ACA.
Rates have been submitted for 2016, and are currently under review. Five individual exchange plans in Wisconsin from three carriers (All Savers, Unity Health Plans, and WPS Health Plan) have proposed rate increases of ten percent or more for 2016 (in the small group market, Mercy Care and WPS Health Plan have both proposed double digit rate hikes for their exchange plans).
In 2015, there were 15 carriers in the Wisconsin exchange. So although some of the proposed rate hikes are steep, it’s important to remember that they have not yet been approved, and that many other alternatives will be available when enrollees shop around during the 2016 open enrollment period (November 1, 2015 to January 3, 2016).
2015 enrollment numbers
As of February 22 – after the second open enrollment period had ended – 207,349 people in Wisconsin had finalized their 2015 private plan enrollments through the exchange. Of those enrollees, 90 percent qualified for premium subsidies. More than half of the enrollees (115,755) were renewing plans from 2014, and of those renewals, more than half (66,759) were “active” renewals as opposed to auto-renewals. Of the active renewals, 40,303 switched to a new plan for 2015.
In addition to the private plan enrollments, another 27,628 exchange enrollees in Wisconsin were eligible for Medicaid or CHIP during the 2015 open enrollment period. Medicaid enrollment continues year-round, but tends to increase during the general open enrollment due to additional outreach and advertising.
Open enrollment for 2015 has ended, and most people can only purchase a new plan at this point (including off-exchange) if they have a qualifying event. However, enrollment is year-round for Native Americans and for enrollees who qualify for Medicaid or CHIP.
Average 2015 rate increase of just 3 percent
In late September, the Wisconsin Office of the Commissioner of Insurance released rate filings for 2015 health plans. The average rate increase in Wisconsin’s individual market (including on and off-exchange plans) is just 3.2 percent for 2015. And two carriers – Medica Health Plans of Wisconsin and Molina Healthcare of Wisconsin – have reduced their premiums by 17 and 11 percent, respectively. Anthem’s rates have increased an average of 9 percent, but that includes exchange plans as well as plans sold outside the exchange.
For a 40 year-old non-smoker, a Commonwealth Fund analysis calculated an average rate increase of 7 percent in the exchange in Wisconsin for 2015, across all metal levels. For people who are enrolled in the benchmark plan (second lowest-cost silver plan) from 2014, The NY Times Upshot found that they could see rate decreases across much of the southern and western portions of Wisconsin, as long as they’re willing to switch to the new benchmark plan for 2015.
There is significant disparity in rate changes from one area of the state to another though. The northeast part of Wisconsin has had the highest rate of health insurance inflation in the state over the last 14 years, although people enrolled in the benchmark plan there should see average rates increases under 6 percent for 2015.
In the Milwaukee area, the benchmark plan is offered by a different carrier in 2015, and so are the lowest-cost silver and bronze plans. People who are on a plan that was auto-renewed on December 15 are still eligible to shop for a new plan anytime until February 15, and Wisconsin is a market where it’s definitely worth shopping around during open enrollment.
New carriers joining the exchange
Open enrollment for 2015 started on November 15, 2014 and runs through February 15, 2015. The federally-facilitated (ie, through HealthCare.gov) Wisconsin exchange had 13 carriers in 2014, but has 15 for 2015. Two new carriers – United Healthcare and Managed Health Services Insurance Corporation – have joined the exchange for 2015, and their entry is one of the factors holding down rate increases.
Wisconsin was one of only seven states with a federally facilitated marketplace that had at least ten carriers in 2014. But despite the robust competition, Wisconsin’s exchange rates were relatively high in 2014. The average premium for the lowest-cost bronze plan in Wisconsin in 2014 is $287, compared with $249 nationally.
In late October 2013, Citizen Action of Wisconsin created a report highlighting the very different ACA paths taken by Minnesota and Wisconsin, and placed some of the blame for Wisconsin’s high rates on the fact that the state ultimately took a hands-off approach to the exchange and also refused to accept federal funds to expand Medicaid. 2014 rates in Wisconsin are double the rates of neighboring Minnesota. But the rate increase for 2015 – an average of just three percent – is significantly lower than the 5.4 percent national average rate increase.
Despite the small increase for 2015, Citizen Action of Wisconsin released a new report in October that highlighted the ongoing differences between the neighboring states, and the expectation that rates will still be higher in Wisconsin than in Minnesota in 2015.
How many people enrolled in 2014?
The 2014 Obamacare open enrollment period ended in April. 139,815 people had purchased private plans in the Wisconsin exchange by April 19 – nearly a 96 percent increase over the number who had done so by March 1.
In addition to the private plan Obamacare enrollments, Wisconsin’s exchange has also enrolled 97,509 residents in the state’s BadgerCare Medicaid program by the end of June.
According to a Gallup poll, 11.6 percent of Wisconsin’s population lacked health insurance in 2013. The poll found that the rate had dropped to 9.6 percent by the middle of 2014.
Wisconsin Medicaid – a unique approach…
Wisconsin has not expanded Medicaid under the ACA, but has taken a more proactive approach than most non-expansion states in providing coverage for people living in poverty. Wisconsin dropped the existing BadgerCare Medicaid eligibility to 100% of poverty level, which resulted in 72,000 people losing BadgerCare eligibility. Since subsidies for private Obamacare plans purchased in the exchange begin at 100% of poverty level, the residents who lost BadgerCare eligibility were able to purchase heavily subsidized plans in the exchange instead.
However, critics have noted that a lot of those 72,000 people (with incomes just over 100% of poverty) were probably unable to afford a private plan, even with the available cost-sharing and premium subsidies.
As of the beginning of September, the state estimated that 25,800 former BadgerCare members had not yet enrolled in a subsidized plan through the exchange. They initially had until June 30 to do so, but HHS has granted them another special enrollment period – September 4 through November 2 – during which they could apply for a subsidized plan in the federally-facilitated Wisconsin exchange. The Wisconsin Department of Health Services sent letters to the former BadgerCare enrollees who had not yet obtained new coverage, informing them of the special enrollment period.
But an additional 83,000 childless adults with incomes below 100% of poverty level are newly eligible for BadgerCare in 2014. Wisconsin created their own version of Medicaid reform without using the federal funds allocated by the ACA. As a result, the state was able to make its own rules, and people in Wisconsin with household incomes between 100% and 138% of poverty level are expected to purchase subsidized private plans – they are not eligible for Medicaid.
…but not fully expanded Medicaid
Technically, this means Wisconsin has not expanded Medicaid under the ACA (if it did, people with incomes up to 138 percent of poverty would be eligible for Medicaid and the state would receive federal funding for Medicaid expansion). Although Governor Scott Walker has received criticism from consumer advocates, among states that have not expanded Medicaid, Wisconsin is the only one without a coverage gap, since BadgerCare was expanded to cover everyone up to 100% of poverty level (in most states that did not expand Medicaid, eligibility limits are far lower than that).
Nevertheless, 19 Wisconsin counties and the city of Kenosha added referendum questions to their ballots in November, asking citizens to weigh in on Gov. Walker’s decision to not fully expand Medicaid under the ACA. Voters passed all 20 of the ballot initiatives, but they are essentially just a way of communicating resident wishes to lawmakers, as the final decision on expanding Medicaid is up to the Governor and the state’s lawmakers.
Wisconsin’s go-it-alone approach to modified Medicaid expansion could end up being financially challenging, as the state has incurred significantly higher Medicaid spending in 2014 and does not have the federal government funding Medicaid expansion as they would do if the state followed the guidelines laid out in the ACA (federal funding in that case would cover 100 percent of newly-eligible enrollees through 2016, and then the state would gradually pay a small portion of the new expenses, capping out at 10 percent by 2020).
Over four years, it’s estimated that the total cost to state and federal taxpayers for Wisconsin’s unique approach to Medicaid will be $2 billion more than it would have been under straight Medicaid expansion as called for in the ACA.
Wisconsin exchange history
Gov. Walker had previously expressed a preference for a state-run exchange rather than a “one size fits all” federally operated exchange. In 2011, Walker used an executive order to create the Office of Free Market Health Care to plan for a Wisconsin exchange. Walker’s plan for a “free-market, consumer driven approach” leaned heavily on an insurance marketplace implemented by former Gov. Jim Doyle. According to one state insurance expert, the only notable change proposed by Walker was to put the exchange online.
However, Walker showed a changed mindset in 2012, returning a $38 million federal grant and closing the Office of Free Market Health Care. In announcing his November 2012 decision to accept a federally operated exchange, Walker said the state would have no real control and much higher financial risk with a state-run exchange.
Legal challenge to the ACA in Wisconsin
The fight against Obamacare is on-going in Wisconsin. US Senator Ron Johnson, a Wisconsin Republican, has brought a lawsuit against the federal government over the issue of congress and congressional staffers receiving subsidies to purchase health insurance through the exchanges.
The federal government believed that the case should be thrown out, as they claim that Johnson has no legal standing since he’s not being harmed by the rule that allows congress and staffers to receive subsidies in the exchange. In September, Johnson began an appeals process with the 7th Circuit Court of Appeals after a lower court sided with the federal government and ruled that he lacked standing to challenge the law.
The oral arguments for the appeal are scheduled for January 21 in Chicago, and Johnson plans to attend the hearing. He and his attorney will be arguing that he does have legal standing to challenge the ruling that allows members of congress and their staffers to receive subsidies in the exchanges.
The whole issue stems from language that Chuck Grassley (R – Iowa) added to the ACA when it was being drafted. His addition requires that congress and congressional staffers lose their employer-sponsored health insurance and switch instead to exchange plans. But those who earn too much to qualify for subsidies would be taking a significant financial hit. They would have gone from having 75 percent of their premiums subsidized (under their government group plan) to paying 100 percent of their own premiums. As such, the Office of Personnel Management intervened and said that congress and staffers could keep their existing subsidies and apply them to the exchange plan premiums. Sen. Johnson is attempting to repeal that ruling.
Wisconsin health insurance exchange links
Wisconsin Office of the Commissioner of Insurance
Assists consumers who have purchased insurance on the individual market or who have insurance through an employer who only does business in Wisconsin.
(800) 236-8517 / email@example.com
State Exchange Profile: Wisconsin
The Henry J. Kaiser Family Foundation overview of Wisconsin’s progress toward creating a state health insurance exchange.