Physician Edition


June 14, 2017

Volume 5-Issue 11

AHCA Medicaid Funding Disparity For Wisconsin: $36.9 Billion Less

New report shows nonexpansion states at significant funding disadvantage

A new report ( released this week documents significant funding disparities between Medicaid so-called "expansion" states when compared to "nonexpansion" states over the next decade under the current version of the American Health Care Act (AHCA). The 19 states that opted out of the Affordable Care Act’s full expansion for Medicaid, including Wisconsin, will receive $680 billion less than expansion states. Wisconsin’s portion of that total is estimated at almost $37 billion over 10 years.

"The report is eye-opening and should be of concern to anyone in a nonexpansion state," said Eric Borgerding, president/CEO, Wisconsin Hospital Association. "While the AHCA did attempt to provide a measure of relief to nonexpansion states like ours, clearly it is insufficient and must be addressed by the U.S. Senate during their deliberations."

The report released by the Missouri Hospital Association takes into account the various structural Medicaid funding provisions in the AHCA over the next decade—such as the move to per capita spending caps—and other provisions meant to lessen the disparity for nonexpansion states. The latter includes eliminating Medicaid Disproportionate Share Hospital payments cuts two years earlier for nonexpansion states than for expansion states as well as a $10 billion safety net fund.

The report details that even with all of these provisions in mind, expansion states will see an average of $1,936 per beneficiary compared to $1,158 per Medicaid beneficiary in nonexpansion states over the next 10 years. The disparity is a result of using 2016 as a base year when establishing the AHCA’s per capita cap rates, which locks in the significantly enhanced federal Medicaid matching funds for expansion states. This means enhanced funding continues forward at those higher rates while nonexpansion states will not recover from their disadvantaged financial position.

"The unique Wisconsin model has worked to significantly reduce our uninsured rate, and we can be proud to say that everyone in poverty is covered under Medicaid," said Borgerding. "Unfortunately, this report shows that Medicaid funding disparities are baked into the AHCA and will place our state at a significant disadvantage long-term. Ironically, nonexpansion states are essentially being penalized for rejecting ObamaCare in a bill that is repealing ObamaCare."

Borgerding’s comments are similar to those made by Sen. Alberta Darling and Rep. John Nygren, Co-Chairs state Legislature’s Joint Committee on Finance, in a February 24, 2017 letter they penned to members of the Wisconsin Congressional delegation ( And earlier this week, Rep. Nygren reiterated his concerns with unfair treatment nonexpansion states like Wisconsin are receiving in nation’s capital.

"One of the frustrations I have had with the proposal coming out of Washington is that it didn’t reward states like Wisconsin that did it the right way and basically continues to reward the states that went a different course," Nygren said this week at a Wisconsin Health News panel discussion (see related story below). "To me, that is continuing this inequity moving forward, rather than addressing the states that have everybody in poverty covered."

WHA continues to urge Wisconsin’s two U.S. Senators, Ron Johnson and Tammy Baldwin, to fight for Wisconsin and ensure Medicaid funding equity under any proposals acted upon by the Senate.

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Wisconsin Hospitals State PAC & Conduit Approaches $150,000

See full contributor listing

Fundraising graphicAs of June 8, the Wisconsin Hospitals State PAC & Conduit is just under the half-way mark of its aggressive $312,500 fundraising goal for 2017. A total of $149,000 has been contributed to date by 137 individuals. Take a look at the full 2017 contributor listing at to see who is on the list.

First quarter contributions were $70,000 and have since picked up with $79,000 contributed so far in the second quarter of the year. The average contribution per individual is $1,088, and since the first of the year, an average of almost $6,500 has been contributed each week.

The Wisconsin Hospitals State PAC & Conduit has three contributor levels beginning at $1,500 and going up: Leaders Circle ($5,000+), Platinum Club ($3,000-$4,999) and the Gold Club ($1,500-$2,999). There are 54 individuals who have contributed at one of these levels already in 2017. All contributions large or small are appreciated.

To make your 2017 contribution, log onto or contact WHA’s Jenny Boese at 608-268-1816 or Nora Statsick at 608-239-4535.

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DHS Submits Waiver for Medicaid Childless Adults

The Department of Health Services (DHS) submitted their proposed waiver request June 7 to the Centers for Medicare and Medicaid Services for changes impacting childless adults enrolled in the state’s Medicaid program. If approved, the waiver would allow Wisconsin to impose premiums, copayments for emergency services, drug screening and drug testing, and work requirements on those enrolled in Medicaid as "childless adults." The proposal would also expand opportunities for treatment for substance use disorder and seek relief from Medicaid’s current policy to limit reimbursement to institutes for mental disease (IMD). (See related article.)

WHA had submitted its comments on the proposal May 19, (See previous story  and comment letter.) WHA expressed support for the state’s commitment to increasing treatment options for individuals with substance use disorder and for the intention of the overall proposal to engage participants in maintaining and improving their overall health and incenting the efficient use of health care resources.

WHA also made several recommendations to ease the administrative burden as well as the financial burden on hospitals. Further, WHA had encouraged DHS to seek enhanced federal funding for the waiver population. The original waiver was considered a partial expansion under the previous administration and was not eligible for the enhanced funds that other states received for full expansions. WHA describes Wisconsin as a model for avoiding gaps in coverage and notes other states are now considering changes to their programs that align with Wisconsin. In Arkansas, for example, recently passed legislation requires the state to modify its current Medicaid waiver to reduce the income threshold for coverage from 133 percent FPL to 100 percent FPL, like Wisconsin’s program. Arkansas is an expansion state and has asked the federal government to maintain the higher match it currently receives.

In the end, DHS did not include the funding issue in its final proposal, but did make some modifications to the proposal in alignment with WHA’s comments.

With respect to premiums, the final proposal applies premiums only to those with income above 50 percent of the Federal Poverty Level (FPL), with one premium amount of $8. The previous proposal would have applied premiums to anyone with income above 20 percent FPL, and there were four different levels and premium amounts. Further, in the final submission, DHS said it agrees with commenters that a grace period is necessary, and the agency is considering a grace period of 12 months for members who miss a payment. Both of these changes align with WHA comments on the draft proposal.

Of particular note for hospitals is the application of an emergency room copayment. Under the original proposal, DHS would have imposed an emergency room copayment of $8 for a first visit and $25 for each subsequent visit to the emergency room. The final proposal decreases the higher copay for the subsequent visits, which is a positive step. However, the copay would still apply to all emergency room visits and providers would be required to collect the copayment. WHA continues to encourage DHS to narrow the scope to non-emergent use only and to collect the copayment directly.

The waiver proposal now moves to CMS, where there is a 30-day review period. Waivers submitted to CMS typically can still take months to receive approval, although the Trump administration has stated its intention to move more quickly than past administrations on state proposals.

The waiver has also been the subject of review during the state Legislature’s Joint Finance Committee (JFC) deliberations on the state budget. The JFC approved a change to the state budget that would require the waiver amendment to get approval by the JFC after it is approved by CMS and before it is implemented. Once approved, DHS has indicated it would take at least a year to make all of the changes necessary to implement the provisions

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Medicaid Coverage More Important in Rural Wisconsin than Metropolitan Areas

More people living in small towns and rural WI rely on Medicaid than in cities

Children living in rural areas of Wisconsin are more dependent on the Medicaid program than those living in larger metropolitan areas, according to a new study, "Medicaid in Small Towns and Rural America: A Lifeline for Children, Families and Communities," released by Georgetown University Health Policy Institute. Statewide, 34 percent of children with Medicaid coverage live in a rural areas, compared to 31 percent in metropolitan areas of the state.

Slightly more adults are covered by Medicaid (14 percent compared to 13 percent) in non-metropolitan areas than in metro areas of the state, as well.

In seven Wisconsin counties, nearly half of the children are in the Medicaid program. Only one of those--Milwaukee County—is classified as a metropolitan area. See chart below.

Percent of Children with Medicaid by County"Medicaid is vitally important and in fact disproportionately important for families living in rural America," Joan Alker, executive director of Georgetown’s Center for Children and Families, told reporters on a press call, as reported in Wisconsin Health News (WHN) June 7, 2017.

The report shows the national uninsured rate for children and adults in rural areas has fallen in recent years due to the combination of Medicaid coverage and access to subsidies in the exchange. Wisconsin did not take the federal Medicaid expansion dollars (which to date would have totaled $1.75 billion in federal dollars and expenditures of $680 million less in GPR), but did expand Medicaid to cover all with income below 100 percent of the federal poverty level, adding some 130,000 people who are "in poverty" to Medicaid.

WHA President/CEO Eric Borgerding said the report is a timely reminder of the critical importance of the Medicaid program to the health of children living in rural areas of the state.

"More than 400,000 Wisconsin children are in the Medicaid program. That coverage means they are more likely to receive preventive care and live healthier, more productive lives into adulthood," Borgerding said.

According to the report, people who live in rural areas are more likely to live in poverty, have poorer health and less ability to access health care due to transportation issues.

"A quarter of Wisconsin’s non-elderly population reside in our small towns and rural areas. We must address the very real issues they face, many of which are tied to their ability to access health care," said Borgerding. "When people have coverage, they are more likely to see a physician and receive care. Any changes to the Medicaid program that reduce or remove that access will have a disproportionate impact on the health of our young people and clearly not move us in the direction of becoming a healthier state in the future."

The report noted that the importance of Medicaid for families in small towns and rural areas has grown over time. However, the number of kids who are uninsured is high in some parts of the state. The percent of children who are uninsured in Wisconsin is highest in Clark County, where 35 percent of the kids lack coverage; Milwaukee has the second highest uninsured rate among children at 27 percent.

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HSHS appoints Johnson as new System VP and Chief Physician Executive

Kenneth JohnsonSpringfield-based Hospital Sisters Health System (HSHS) announced the appointment of Kenneth M. Johnson, MD, as HSHS vice president and chief physician executive. Johnson currently serves as chief physician executive for HSHS Eastern Wisconsin Division (EWD), which includes HSHS St. Vincent Hospital and HSHS St. Mary’s Hospital Medical Center in Green Bay; HSHS St. Nicholas Hospital in Sheboygan; and HSHS St. Clare Memorial Hospital in Oconto Falls.

"In his new role, Dr. Johnson will lead System initiatives around quality, patient safety, and clinical integration," said HSHS President/CEO Mary Starmann-Harrison. "We look forward to having Dr. Johnson bring the leadership he has shown in our Eastern Wisconsin Division to our entire system."

Johnson received his Bachelor of Science from Louisiana State University A&M; his Doctor of Medicine from Louisiana State University Medical School; and his Masters of Public Health from the University of Illinois – Chicago, where he also completed his residency. Prior to joining HSHS, Johnson served as an emergency room physician at Columbia Hospital in Milwaukee, WI; and at St. Francis Hospital in Evanston, IL.

He will begin serving in his new role July 10.

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Hartberg Testifies in Senate Committee on Advanced Practice Clinician Legislation

David Hartberg testifyingWHA-backed policy would create advanced practitioner training grant program for hospitals, clinics

WHA Board member and Gundersen Boscobel Area Hospital and Clinics CEO David Hartberg testified before the Senate Revenue, Financial Institutions and Rural Issues Committee on legislation creating a grant program in Wisconsin to incentivize the creation of new clinical rotation opportunities for advanced practice clinicians in rural communities. Hartberg was joined by George Quinn, executive director of the Wisconsin Council on Medical Education and Workforce, on May 24 for the hearing on Senate Bill 161.

“Advanced practice clinicians are playing increasingly important roles on our patient care teams, especially in rural Wisconsin where our workforce shortages can be more acute,” said Hartberg. “With limited financial resources and staff that have several roles in our organization, it can be difficult to find the time and money to support this type of clinical training. Senate Bill 161 provides incentivize funding that encourages facilities like mine to take on the additional cost of training a student in a rural rotation.”

Sen. Patrick Testin (R-Stevens Point), the lead author of Senate Bill 161, discussed during his testimony how this bill is modeled after the state’s widely successful graduate medical education (GME) grant program, with a matching contribution from Wisconsin hospitals to address an important workforce need that exists in rural communities. He said Senate Bill 161 would replicate the model we have built for GME to attract and expose more advanced practice clinicians to rural communities, because significant needs exist for these providers in rural Wisconsin.

“In those counties that have a hospital’s vacancy rate for advanced practice clinicians, 80 percent have a vacancy rate greater than 10 percent. It should come as no surprise to anyone of us that many of those counties are in rural Wisconsin,” said Testin.

“Creating these training opportunities in rural hospitals takes time, money and a significant buy-in from hospital leadership and the community,” said Rep. Deb Kolste (D-Janesville), a lead co-author of Senate Bill 161. “The unique opportunity with this bill is that the applicants can tailor training programs to meet the needs of their community.” Rep. Romaine Quinn (R-Rice Lake) is the other lead co-author of Senate Bill 161 in the Assembly.

“WHA was proud to partner with the authors of Senate Bill 161 to craft this legislation, designed to leverage a ‘grown our own’ model that has been successful in attracting and retaining more physicians to Wisconsin and apply that same concept to the needs that exist for advanced practice nurses and physician assistants in Wisconsin’s hospitals and clinics,” said WHA President/CEO Eric Borgerding.

“This is just one more way to encourage people that may not otherwise be interested in going to some of our rural communities to take a look at rural Wisconsin,” said Sen. Howard Marklein (R-Spring Green), chair of the Committee. “Once we have them in—in our case—southwest Wisconsin, they find it’s not a bad place to live, raise a family and have a good career.”

“I want to thank you for bringing this forward,” said Sen. Janis Ringhand (D-Evansville), a member of the Committee. “I served on a rural hospital board for eight years, and the majority of our time we spent recruiting doctors. It’s a very difficult job when you are in a rural area, and I think this could be a real incentive to get people to come and stay in rural areas. I think people are recognizing the real value of advanced practice nurses and physician assistants.”

The bill, which has received broad bipartisan support, also has received support from several other individual provider organizations including the Wisconsin Academy of Physician Assistants, Wisconsin Association of Nurse Anesthetists and the Wisconsin Nurses Association.

In related news, on May 25 the Joint Finance Committee adopted the policy provisions in Senate Bill 161 into the state budget and authorized $1 million in funding for the program over a two-year budget period. The budget bill still needs approval from the full Assembly, Senate and Gov. Scott Walker before the provisions would be enacted into law. (See the related story at

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Healthy Wisconsin Initiative to Focus Statewide Efforts on Key Health Issues

New state health priorities align with hospitals’ community health needs assessment

Building on a year of collaboration with organizations from around the state, health officials launched Healthy Wisconsin ( this week aimed at improving the health of Wisconsin residents by 2020. The plan highlights five priority areas for improving health: Alcohol, nutrition and physical activity, opioids, suicide and tobacco.

Healthy Wisconsin includes a state health assessment and improvement plan to help communities identify strategies to make Wisconsin healthier.

“Healthy Wisconsin builds on the great work already underway in Wisconsin to address these five priority health issues,” said Department of Health Services Secretary Linda Seemeyer. “The goal of this effort is to improve the health of those who live here in the next three to five years by collaborating with partners throughout the state to address issues that are having a real impact on our communities.”

Hospitals and health systems are working with community partners to develop and implement programs aimed at improving population health. According to WHA President/CEO Eric Borgerding, the Healthy Wisconsin initiative will leverage those local efforts and help build statewide support for improving the health of our citizens.

“When everyone in the state is pulling together toward the goal of keeping our citizens healthier so they can enjoy a higher quality of life, we have a much greater opportunity to make real improvements in our overall health status,” Borgerding said. “We are excited about the opportunities this new health initiative opens for hospitals and health systems across the state to support the overall goal of creating a healthier Wisconsin.”

WHA participated on a statewide steering committee that included representatives from community organizations, which helped in the development of the plan by reviewing health data and information on evidence-based practices. The committee then selected the five priority health issues. The plan also incorporates the concept of adverse childhood experiences (ACEs) and resilience and how these can affect health.

A new Healthy Wisconsin website highlights goals, data and strategies to encourage public involvement in making progress on the five priority health areas. The website will also highlight local and statewide success stories that show communities working to make a difference in each focus area.

“We know that improving health in Wisconsin will take all of us working together,” said State Health Officer Karen McKeown. “We are excited about the opportunity Healthy Wisconsin offers to energize people and communities around these shared goals.”

Learn more about Healthy Wisconsin and the priority health issues at Access additional information about the Wisconsin Health Improvement Planning Process (WI-HIPP), the process used to develop Healthy Wisconsin, at

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