No ACA Medicaid expansion, but no coverage gap either
Although Wisconsin has not expanded Medicaid under the guidelines laid out in the Affordable Care Act (ACA), the state’s Badger Care Medicaid program does cover all legally present residents with incomes under the poverty level. Wisconsin is the only non-Medicaid-expansion state that does not have a coverage gap; all low-income residents either have access to Medicaid or subsidies to help them purchase private coverage in the exchange.
Wisconsin Governor Scott Walker has long been opposed to the ACA, and one of the reasons he opted not to accept federal funding for Medicaid expansion under the ACA was because he was concerned that the federal government would not keep its promise to continue to pay at least 90 percent of the cost. That has proved somewhat prescient now that Trump is in the White House and Republicans control both chambers of Congress. The American Health Care Act (AHCA), introduced by House Republicans in March 2017, would freeze Medicaid expansion as of 2020, and would also restructure federal Medicaid funding to be a per-capita allotment, instead of the current open-ended matching system.
The AHCA and Wisconsin Medicaid: More than 200,000 could lose coverage
The American Health Care Act (AHCA), introduced by House Republicans in March 2017, would freeze Medicaid expansion as of 2020, and would cut Medicaid funding by $880 billion, according to the CBO’s analysis. Walker has cautioned Trump and Congress about the need to maintain current funding for Medicaid, saying in February “You can’t cut Medicaid. There’s just no way about it.” But if Republicans pass the AHCA or something similar to it, they will indeed cut Medicaid funding.
The CBO projects that the uninsured population in the U.S. would grow by 24 million people by 2024 if the AHCA is enacted. The Center for American Progress has broken those numbers down by Congressional District and type of coverage. They estimate that 171,500 non-elderly Wisconsin residents would lose Medicaid coverage over the next decade under the AHCA, in addition to 32,500 elderly Medicaid enrollees (dual-eligibles, who are currently enrolled in both Medicaid and Medicare).
The elderly Medicaid enrollees are not included in the CBO’s projection, but the Center for American Progress estimated that a total of 1.4 million seniors could be cut from Medicaid roles due to the funding cuts for Medicaid in the coming years, if the AHCA is enacted.
BadgerCare Plus – past and present
Prior to 2014, BadgerCare Medicaid had much more generous eligibility guidelines than programs in most other states. It was still limited to children, pregnant women, and parents with dependent children, but it covered them with incomes up to 200 percent of poverty level (300% for children and pregnant women).
Medicaid expansion under the ACA would have extended Medicaid coverage to everyone — including adults without dependent children — with incomes up to 138% of poverty. But the Supreme Court ruled in 2012 that states could not be penalized if they didn’t expand their programs, and Wisconsin Governor Scott Walker saw an opportunity to revamp the state’s Medicaid program, providing access to coverage for everyone while relying as much as possible on private coverage.
ACA subsidies to purchase private plans in the exchange are only available to people with incomes between 100 percent and 400 percent of poverty level. So Governor Walker decided to make BadgerCare available to everyone with incomes up to 100 percent of poverty level (pregnant women and children are still eligible with household incomes up to 300% of poverty level). This meant that about 83,000 adults without dependent children became newly eligible for BadgerCare on April 1, 2014.
But in trade, Walker’s plan called for switching to private coverage through the exchange for about 72,000 residents with incomes between 100 percent and 200 percent of poverty level. This group was comprised almost entirely of parents with dependent children, and they were eligible for BadgerCare Plus under the old rules. Although this group is now eligible for significant subsidies in the exchange, there are concerns among consumer advocates that the people who were previously insured through BadgerCare Plus might not be able to afford private coverage in the exchange (including the out-of-pocket costs for claims), even with subsidies.
For the people who lost eligibility for BadgerCare, the exchange provided a special enrollment period that ran through the end of June 2014. But by September 2014, the state estimated that there were still 28,500 former BadgerCare members who had not enrolled in coverage through the exchange. As a result, a new special enrollment period was enacted, running from September 4 to November 2, 2014.
An expensive choice
By not accepting federal funding to expand Medicaid under the ACA, Wisconsin has missed out on billions in federal funding since the beginning of 2014. If the state had accepted Medicaid expansion to cover adults with income up to 138 percent of the poverty level, the federal government would have paid 100 percent of the cost through the end of 2016, and would be paying 95 percent of the cost in 2017. But because Wisconsin cuts off Medicaid eligibility at 100 percent of the poverty level, they aren’t eligible for the enhanced federal match provided by the ACA. Under the Obama Administration, some states proposed expanding Medicaid to 100 percent of the poverty level with full federal funding, but HHS did not agree to that provision, insisting that in order to receive ACA Medicaid expansion funding, states had to expand coverage all the way to 138 percent of the poverty level (133 percent, with a built-in 5 percent income disregard).
Because Wisconsin has taken a unique approach to partially expanding Medicaid, they have been paying more in state funds than they would if they had expanded Medicaid as called for in the ACA. Most states that opt for Medicaid expansion will end up with a small increase in their state budget over the next ten years (starting in 2017, the states pay 5 percent of the cost, increasing to 10 percent by 2020, assuming the ACA’s Medicaid expansion remains in place). But in Wisconsin, expanding Medicaid under the ACA would save the state $248 million by 2022 (again, that’s assuming Medicaid expansion remains in place, which would not be the case if the AHCA is passed).
Who is eligible?
BadgerCare Medicaid is available for the following legally-present Wisconsin residents
- Pregnant women with household income up to 300 percent of poverty.
- Children 19 and under with household income up to 300 percent of poverty.
- Adults with household income up to 100 percent of poverty.
How do I enroll?
- You can enroll online at HealthCare.gov or the BadgerCare website.
- You can enroll by phone at 1-800-318-2596.
- You can also enroll in person or by phone at a local Wisconsin Income Maintenance Agency (this map shows the agency for each region – you can click on your region and it will show you the address and phone number of your local office).
- You can print a paper application and take it to your local Income Maintenance Agency or submit it by mail (the address to use depends on whether you live in Milwaukee County or not).
As of December 2016, there were 1,037,863 people enrolled in Wisconsin’s Medicaid program, which was a 5 percent increase since the end of 2013. States that have expanded Medicaid have seen substantial increases in their Medicaid enrollment. Although Wisconsin did allow childless adults with income up to the poverty level to enroll starting in 2014, they cut eligibility for parents with dependent children whose income was between 100 percent and 200 percent of the poverty, offsetting much of the enrollment gains.
9.1 percent of Wisconsin residents were uninsured in 2013, and that fell to just 5.7 percent by 2015, according to U.S. Census data. Both of those numbers are lower than the national average; nationwide, the uninsured rate fell from 14.5 percent to 9.4 percent.
Although Wisconsin has not expanded Medicaid under the ACA, the BadgerCare Medicaid program has much more generous eligibility rules than most non-expansion state programs. So there is no coverage gap, and relatively affordable health insurance is universally available in Wisconsin.
Public support for Medicaid expansion
In the November 2014 election, voters in several counties approved expanding Medicaid, but the vote was symbolic – it was still up to newly-reelected Governor Walker and the state’s legislature, and they have not taken any steps in the ensuing years to change the state’s Medicaid eligibility.