Gov. Scott Walker makes no apologies – he brags about Wisconsin’s health care.
“In the State of the State address, we listed off the great things about Wisconsin…and we pointed out that we are literally the best state in the nation for the quality of our health care system,” Walker told the WHA Board at its February 8 meeting in Madison. “We brag about Wisconsin health care and talk about not just how it attracts economic development, but how it attracts talent and adds to the overall quality of life.”
Walker acknowledged the health care systems in the state for providing good health care, but he also recognized hospitals are an asset to the community and another reason people want to live in Wisconsin.
In a statement released following the WHA Board meeting, Walker praised the work of the state’s health care leaders and WHA in helping Wisconsin achieve and sustain its high-quality health care. “Wisconsin is a national leader in health care quality in large part because of the work of the Wisconsin Hospital Association,” Walker said in the statement.
The Governor also wants to make sure that all residents have access to affordable care by holding the line on premium increases. Walker described his proposal, which relies on a waiver process contained in the ACA, to create a reinsurance program that would help stabilize the individual market. He said about 220,000 people purchase insurance in the marketplace, which this year saw a 36 percent increase in premiums and is now down to 11 plans participating across the state.
“If you look at premiums in the group insurance market, those are increasing at around five percent,” Walker said. “I asked the Office of the Commissioner of Insurance to craft an approach to make the premium increases for individual coverage align closer with increases in the group plans.”
The Governor’s reinsurance program is estimated to cost $200 million annually, with roughly three-fourths derived from redirected Obamacare dollars already coming to Wisconsin. The rest would come from the state, generated for 2019 by savings from the suspension of the ACA’s health insurance tax. Walker believes if the program is successful, it can keep premium increases low and attract new insurers or bring those back who have left the market.
“With Congress looking increasingly unable to repeal and replace the ACA, standing by and watching it fail is not an acceptable Plan B,” said WHA President/CEO Eric Borgerding. “For some time we have advocated that the state take matters into its own hands, craft our own solutions. We commend the Governor for using the tools available under the ACA, which is still the law, to put forward a plan aimed at stabilizing premiums, increasing competition in the insurance market and sustaining coverage gains. WHA supports this proposal and will work to see it become law.”
Well before Obamacare, Wisconsin took steps to address affordability of insurance by minimizing the impact of high-cost claims, Walker noted in a reference to the state’s defunct Health Insurance Risk Sharing Program (HIRSP). While Walker’s 1332 waiver is a different approach, and avoids assessments on insurance companies or fee schedules on providers for its funding as under HIRSP, the risk mitigating concept is not new to Wisconsin.
Getting more people into the workforce has been a priority for Walker. He cited the investments that have been included in the state budget to increase training opportunities, across all occupations. He thanked hospitals and health systems for supporting the SEARCH program, which provides training and jobs to people with disabilities.
The Governor also discussed how he is using another type of waiver (a “1115 waiver”) to implement eligibility and cost-sharing changes to the Medicaid program. The waivers can be complimentary in an overall strategy aimed at moving more people into the workforce and self-sufficiency, according to the Governor.
“We think inherently most people want to work, and we are willing to try some new things to help them transition over to work, to keep them out of your ERs and reduce uncompensated care,” the Governor said. “I recognize the concerns. The goal is still to help those who are able to get into the workforce—employer-based insurance coverage or access to a better individual market—that is our game plan on workforce.”
Some of the proposals in the 1115 waiver have drawn concern from WHA, which has twice submitted comments to CMS seeking changes to the proposal.
“We understand and support the goal of promoting self-reliance. We ascribe to the notion that the best Medicaid reform is a good job with good benefits, but we also know that this is a very challenged and at-risk population,” Borgerding said. “When implementing premiums and co-pays, those challenges become most evident. The concern is both affordability for this very low-income population and how these types of cost-sharing strategies will be implemented. Hospitals must continue serving everyone who comes through their doors, even if they are disenrolled from Medicaid for not paying a premium to the state or cannot make a copayment.”
Among other things, in its comments to CMS and lawmakers, WHA has consistently advocated for copayments for Medicaid be made payable to and collected by the state rather than hospitals.
“(WHA) have been good partners. When you raised concerns about Medicaid expansion we partnered to make our approach work, and I think you would agree that it’s been a success,” the Governor said. “We want the same thing with this proposal. We want to be innovative. Washington is hungry for states that want to be innovative as long as we can deliver tangible results, they might work with us.”
On behalf of the Board and WHA’s members, Borgerding thanked the Governor for his ongoing commitment to health care access in Wisconsin, noting the $2.7 billion in new state funding that has been injected into Medicaid, creation of the Disproportionate Share Hospital Program and the millions of dollars in new state funding for medical education programs since the Governor took office.
Borgerding Presents WHA 2018 Strategic Goals and Initiatives
WHA President/CEO Eric Borgerding presented WHA’s 2018 goals. He highlighted several key advocacy items, including Medicaid, which remains a top priority. Borgerding said WHA will reconvene the Medicaid Work Group this summer, noting that this group helps set WHA’s Medicaid agenda for the next state budget. He indicated WHA again will set several reimbursement priorities that are not confined to within the walls of the hospital and that support the continuum of care.
“We are not only looking forward, but we are realigning, evolving and growing to craft and deliver an agenda that reaches far beyond the hospital walls,” Borgerding told Board members. “As one of our member leaders recently said, ‘WHA goes to where its members are.’ That was a great compliment to our team.”
Workforce will continue to be a major area of focus in 2018 on major issues related to licensure, payment, and regulation, including advanced practice clinicians and physicians. Borgerding said WHA is planning a conference for members to understand the laws and regulations that enable the better use of APCs and advanced practice registered nurses (APRNs) in health care settings, a move he said is a “good example of not only passing but implementing legislation.”
The Behavioral Health Task Force will also be reconvened in 2018 to set a broader long-term agenda. Integrated physician and clinic engagement continues to be an important space to WHA, as physician practices evolve.
“Our physician agenda is evolving in an advocacy perspective,” Borgerding said. “We want to start working to address regulatory burdens at the state and federal level that limit physicians from also practicing at the top of their license.”
The work of the Post-Acute Care group and Special Needs Dental Work Groups will both continue in 2018. Borgerding said both efforts are great examples of how WHA is “going where its members are.”
Borgerding referenced the challenge in the Supreme Court to the non-economic damage caps in the Goals. Oral arguments are April 19. WHA filed an amicus brief with the Court of Appeals and the Wisconsin Supreme Court. This is the first serious legal challenge to the current caps, and WHA is monitoring the case very closely. If the caps are struck down this year, a legislative fix would not be possible until the Legislature convenes in 2019.
The goals are aggressive and targeted, but keenly focused on advocating for WHA members to enable high-quality, high-value care for employers and the people who live in our state.
“Our agenda, our work in Madison and in Washington, our focus on quality health care, is driven by, informed by our members,” Borgerding said. “What we focus on must be meaningful, must move the needle. We have to go where our members are. That’s what keeps WHA highly relevant and what delivers value for our members across the state.”
Dan Boston: What to Expect from Washington D.C.
On the heels of the Senate announcing they had reached a budget deal, Dan Boston, president, Health Policy Source, Inc. and WHA’s lobbyist in the nation’s Capitol, discussed what Wisconsin health care leaders could expect from Washington, D.C. in 2018. The deal that was reached in the Senate, according to Boston, included several important health care provisions, including funding for CHIP, FQHCs and other key WHA priorities like the Medicare Dependent Hospital program and the Low Volume Adjustment. What remains unaddressed is restoration of cuts to the 340B drug program. Several pieces of legislation, both good and bad, are still pending as AHA continues pursuing a legal strategy to the block cuts.
Boston also said it’s uncertain whether the ACA is imploding or just slowly fizzling out, but despite the CSRs remaining unfunded, a shortened enrollment period and the individual mandate being repealed in 2019, sign ups remained nearly identical to last year. While a full repeal of the ACA remains unlikely, he said Congress could potentially revise the rules for essential benefits, enrollment periods, and age bands, while increasing the use of 1332 waivers. He indicated House Republicans are not expected to make another attempt to repeal/replace Obamacare before the 2018 election cycle.
Boston, who has been named by The Hill as one of D.C.’s top lobbyists for 14 of the last 15 years, has worked with WHA for over two years. Via teleconference from Washington, DC, he was making his first appearance at a WHA Board meeting.
“Dan and his team at HPS are a tremendous WHA partner asset for us and our members,” Borgerding told the Board. “They will be an increasingly important part of our D.C. strategy going forward.”
State advocacy update: ACA enrollment, 1332 waiver, workers comp and legislative issues
WHA’s Joanne Alig updated the Board on the status of Wisconsin’s 1332 waiver and provided the current state of the insurance exchange.
Enrollment on the insurance exchange in Wisconsin was down about seven percent, less than was anticipated, according to Alig. Nationally, enrollment was down about five percent.
While Wisconsin has more insurers participating in the exchange than other states, Alig noted there are several counties that now have only one insurer, and overall Wisconsin has fewer insurers participating across the state compared to 2017. Alig also noted the average premium increase for the individual market in 2018 was 36 percent.
“It’s not a crisis yet, but we are moving toward more market instability,” Alig said. “The individual mandate is effectively gone in 2019. Estimates are that premiums would go up about 10 percent, according to the CBO.”
Alig said states are using the 1332 waiver to stabilize the market. The state Legislature would need to pass legislation to enact the provisions in the waivers.
When the Governor introduced his reinsurance plan, WHA released a statement that supported the state in its decision to “strike its own path and take steps to stabilize the market, using the tools available to all states under the ACA.”
Alig summarized the reinsurance proposal, which if approved at the state and federal levels would be in place for benefit year 2019. Alig also noted that the Insurance Commissioner’s office is analyzing other options for stabilizing the markets for benefit year 2020 and beyond and will be working on these options through the coming calendar year.
WHA will continue to be actively engaged with OCI as it reaches out to stakeholders for feedback and comment on the 1332 waiver proposals.
WHA Senior Vice President Kyle O’Brien briefed Board members on the status of a proposed bill that will add a fee schedule for medical care provided to injured workers through the state’s worker’s compensation program. WHA, along with the Association’s members and coalition partners, have been lobbying against the change for months and have met with lawmakers across the state, asking them to oppose the proposal. O’Brien reported that the Senate Labor Committee chairman has stated this bill will not move out of his Committee if it includes a medical fee schedule and no lawmaker in the Assembly is even interested in formally introducing the bill in that house.
O’Brien said WHA has been working with Rep. Joe Sanfelippo, Sen. Alberta Darling and Rep. Jessie Rodriguez on legislation that would provide $1.5 million annually to reimburse hospitals and health systems for care coordination programs. He said floor action in both houses is expected as early as February 15 on this legislation, designed to better manage care for Medicaid enrollees who frequent hospital emergency departments. In 2016, over 10,000 Medicaid enrollees presented to a hospital emergency department seven or more times. The bills have been introduced as Assembly Bill 871 and Senate Bill 742.
Work continues on emergency detention reform legislation that would align Wisconsin’s emergency detention statutes with the obligations that currently exist for hospitals and health care providers under federal law. In addition, this legislation provides necessary clarification and liability protection to health care providers when they feel an obligation to warn about someone they believe is a harm to themselves or others. Assembly Bill 538 passed out of the state Assembly unanimously in November 2017 and was unanimously approved by the Senate Health Committee February 7, 2018. WHA expects this bill to be available for scheduling on the Senate floor as soon as February 20.
O’Brien also reported to the Board on several bills that WHA publicly opposed, including legislation mandating the use of cameras in hospital operating rooms and legislation that would prohibit hospitals from using specialty/board certification as a condition for receiving medical staff privileges. O’Brien said he expects neither bill will move forward this legislative session.