Scenario
You are the director of community affairs for the health lobby organization, Pathways to a Healthy America. In 2010, President Barack Obama signed the Affordable Care Act into law. As a result, millions of Americans who were previously uninsured gained access to the healthcare system. One of the initial provisions of the Act required individual states to expand the eligibility criteria for Medicaid. The program’s costs would be absorbed by the federal government at a rate of 100% for the first three years of program participation which would decrease to 90% after 2020, still, considerably higher than previous funding by the federal government. However, in 2012, the Supreme Court ruled the mandate unconstitutional allowing individual states to voluntarily “opt” out of the Medicaid expansion program. As a result of the various states’ decision to “opt” out of the ACA’s Medicaid expansion, millions of adults fell into the critical coverage gap. Your organization represents a state which has decided to forego participation in the ACA expansion program. The decision was met with both praise and criticism.
It has now been a few years since the decision and your organization has gathered information on the impact of the decision in order to advocate for Medicaid reform during the next state legislative session.
You are required to write an advocacy report to state lawmakers in which you advocate for either participating in the original expansion program or participating with conditions (waivers) to address the critical gap in coverage for vulnerable adults in your state. Waivers such as Section 1115 enable for alternative implementation of Medicaid expansion and allow states to impose restrictions which may result in a denial of Medicaid eligibility for individuals who do not meet those restrictions, i.e., work requirements.
Looking to Review My submission to do better.
Instructions
Research the Medicaid expansion program offered through the Affordable Care Act (ACA) as well as Medicaid reform initiatives using waivers to increase access to Medicaid. Determine, based on your state’s profile, which process (the ACA’s expansion program or the use of waivers) is most beneficial to your state. Include a comprehensive, well-supported recommendation for participation in Medicaid reform using either the ACA’s program or a modified reform process using waivers.
Your advocacy report should describe your state’s current Medicaid program including its eligibility criteria, demographics, Medicaid spending and savings since the ACA’s implementation, and comprehensive details of current or pending waivers. You should also include a discussion (benchmark) on another state’s success with Medicaid reform using your recommended strategy (the ACA’s expansion program or the use of the specific types of waivers for which you propose).
Miller_Deliverable2_HSA5200CBE_HealthcarePolicyEthicsandLaws.docx
Del2SubmissionFeedback.docx
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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
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Criterion 1
A –
Report includes a comprehensive, coherent, well thought out recommendation, for either the ACA’s expansion of Medicaid or a modified expansion process with a justification based on comprehensive research with fully developed, well-supported reasoning.
Criterion Feedback
The justification for this recommendation needs to be more comprehensive and fully developed, with additional well-supported reasoning based on the research you have conducted. Try to build out your rationale further.
Criterion 2
A –
Report includes a comprehensive description of the state’s Medicaid program including eligibility criteria, demographics, spending, savings and the state’s current or pending waivers.
Criterion Feedback
Your submission briefly mentions the state’s Medicaid program but does not provide a comprehensive description of eligibility criteria, demographics, spending, savings, and the state’s current or pending waivers. Please add a couple of paragraphs about this.
Criterion 3
A –
Report includes a comprehensive assessment of another state’s successful reform efforts and a comprehensive, well-supported discussion on the criteria used in evaluating the implementation of successful Medicaid reform in that state
Criterion Feedback
You briefly mention another state. However, you did not provide assessment of its successful Medicaid reform efforts. Additionally, you don’t discuss the criteria used in evaluating the implementation of successful the state’s Medicaid reform. Please add this.
Criterion 4
A –
Report includes a comprehensive discussion with significant and current details on the Medicaid expansion program offered through the Affordable Care Act (ACA). Discussion includes assertions supported by credible research.
Criterion Feedback
A – No adjustments Needed
Criterion 5
A –
Report includes a comprehensive description of waivers (i.e., Section 1115). Discussion includes assertions supported by credible research.
Criterion Feedback
A – No adjustments Needed
Criterion 6
A –
Includes 3 or more credible, scholarly, current (within the past 5 years), and relevant sources. Adequate integration of information included within the report. Appropriate synthesis and analysis included in the report.
Criterion Feedback
A – No adjustments Needed
**Please Highlight Any Changes to the paper
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