At the August 24 WHA Public Policy Council meeting in Madison, WHA President/CEO Eric Borgerding led a discussion about the status of the federal efforts to repeal and replace the ACA, and what might come next as states are seeing trends of increased uncertainty and potential market instability.
Borgerding emphasized sustaining coverage is of paramount importance, noting that Wisconsin expanded Medicaid to all with income below 100 percent of the federal poverty level, and moved people with higher incomes off Medicaid when affordable coverage in the exchange became available. As Wisconsin has reduced the number of uninsured by 38 percent, ensuring functioning markets and seeking equity in Medicaid funding on par with expansion states have become priorities for WHA.
Borgerding said he believes the states will play a greater role as efforts at the federal level have stalled. Kathleen Nolan, managing principal with Health Management Associates (HMA), couldn’t agree more. Invited as a special guest to the Council, Nolan has been closely monitoring the work of the Trump Administration and helping states and health care stakeholders navigate policy changes.
Nolan emphasized states now have an opportunity to craft proposals using what are known as “waivers.” Noting the exchange marketplace is “less secure,” she described 1332 “state innovation” waivers that can be used to make changes to health coverage through the insurance exchange. Alaska is the only state with an approved 1332 waiver, although other states, such as Iowa and Minnesota, have submitted applications or are in the process of submitting applications.
Nolan also mentioned the section 1115 waiver process, which has been used for years in the state Medicaid program. Arkansas, for example, is pursuing a waiver to reduce eligibility to 100 percent FPL, yet maintain the level of enhanced federal funding they received for full Medicaid expansion. This, she said, could be a model although we may not know for several months if that waiver is approved.
Nolan also noted states could consider combining the 1332 waivers and 1115 waivers to provide coverage for low income populations in new ways. Nolan said what CMS would accept under these waivers has yet to be fully defined. She identified that as an opportunity.
“It’s on the state’s shoulders to decide what is innovative, what they want and what will work for their state,” said Nolan. “Pursuing an effort to make sure that Wisconsin is doing everything they can to keep the exchange as vibrant as possible is really important,” she added.
WHA makes progress on 2017 priorities
WHA Senior Vice President Kyle O’Brien updated the Council on WHA’s accomplishments in the state budget—including a $62 million all funds increase in the Medicaid Disproportionate Share Hospital (DSH) program. O’Brien also discussed the increases in graduate medical education (GME), investments in rural health care workforce training grants and a Medicaid care coordination pilot program for high utilizers of hospital emergency departments that were also included in the Joint Finance Committee version of the state budget. O’Brien said the Committee, after taking a break over the summer to negotiate the final budget deal, has come back to the table to vote on the budget and WHA expects the budget to move forward in the coming weeks.
Matthew Stanford, WHA general counsel, provided the Council with several additional updates regarding legislation to reform Wisconsin’s emergency detention process and progress on WHA’s team-based care regulatory reform package. Stanford also discussed the July Court of Appeals decision finding Wisconsin’s caps on noneconomic damages in medical malpractice cases unconstitutional, and WHA’s efforts and strategies to have the Court of Appeals decision reversed by the Wisconsin Supreme Court.
Ann Zenk, WHA vice president, workforce and clinical practice, provided an update on significant progress made to enact the enhanced Nurse Licensure Compact (eNLC) in Wisconsin. Sen. Howard Marklein and Rep. Nancy VanderMeer have been working with stakeholders, including WHA and the state Department of Safety and Professional Services (DSPS), to draft legislation enacting the updated compact in Wisconsin, and on August 2 the lawmakers asked their peers to support this legislation. The lawmaker’s efforts are well-timed, because enactment of the eNLC, and formation of the new Interstate Commission, was triggered on July 20, 2017 when the 26th state joined the new compact, so as Zenk noted, “There is definitely a sense of urgency.”
On August 17 the commission chose January 19, 2018 as the implementation date for eNCL; Zenk explained, “The implementation date is when states party to the eNLC begin to issue and recognize eNLC licenses between eNLC states.”
“If Wisconsin does not join the eNLC, nurses currently enjoying the benefit of a multi-state license—especially those near our state border with Iowa, or serving patients through telemedicine, or through a multi-state agency—will be forced to apply for a duplicative single state license in multiple states,” according to Zenk.
Council members noted that Wisconsin’s participation in a nurse licensure compact since 2000 “makes not joining the eNLC feel like a takeaway for our Wisconsin nurses and health care organizations.” Zenk shared that HEAT members, chief nursing officers, and human resource leaders, have all received a heads up that this legislation is on the way, to prepare them to contact legislators to sign on when legislation is introduced. Council members were asked to do the same. As the August 18 HEAT update noted: “Enacting this legislation by year’s end will help ensure a seamless transition for Wisconsin nurses holding a multi-state license under the current compact.”