Whether the 87,000 parents who would lose Medicaid coverage under Gov. Scott Walker’s budget can afford private insurance in a government-subsidized exchange might be summed up by Jessica Jaglowski’s uncertainty.
“We can afford to pay some kind of premium,” said Jaglowski, a stay-at-home mother of three whose husband earns about $38,000 a year. “But if it turns out the deductibles and co-pays are high and things aren’t covered, that could be a big problem for us.”
The affordability of the exchange is one of several Medicaid-related questions being raised after Walker introduced his 2013-15 budget proposal last week.
Other questions involve reduced coverage for pregnant women and state benefits for 82,000 childless adults.
“There’s a lot we don’t know yet,” said Bobby Peterson, executive director of ABC for Health, a Madison nonprofit that helps people get health care.
Jaglowski’s family has been on BadgerCare, the state’s main Medicaid program, for five years. Walker’s plan would shift her and her husband, but not their children, to the exchange.
They’d likely face a combined premium of about $95 a month — plus out-of-pocket costs of up to $4,200 a year when seeking care.
“I hope there’s something affordable on the exchange, but I don’t feel certain about that,” said Jaglowski, of Milwaukee.
About 82,000 childless adults who make less than the poverty level — $11,490 for an individual and $27,570 for a family of five — would gain BadgerCare coverage through a partial Medicaid expansion.
But Walker plans to shift 87,000 parents with incomes above the poverty level from BadgerCare to the federal exchange. Enrollment is to begin Oct. 1, with coverage starting Jan. 1.
The state assumes about 80,000 of the affected parents would enroll in the exchange, said Claire Smith, spokeswoman for the state Department of Health Services.
But after the state added exchange-like premiums in July for 48,835 BadgerCare members who make more than 133 percent of the poverty level, 15,819 people affected dropped out by December, Smith said.
It was not known how many of them got other coverage or were uninsured, she said.
Democrats and health care advocates say a significant portion of the 87,000 parents losing BadgerCare won’t be able to afford the exchange, leaving them uninsured and relying on expensive emergency rooms for care.
They also want the state to accept the 100 percent federal funding available to fully expand Medicaid to about 175,000 adults who make up to 133 percent of the poverty level, as allowed under the health reform law. But Walker and many Republicans say the full Medicaid expansion is too risky because federal funding might fall through, forcing the state to pay its usual 40 percent share for the new enrollees.
Walker said he’s returning Medicaid to its “intended purpose as a safety net for the neediest.”
Above poverty, but still poor
Jaglowski, 40, said her family isn’t among the very neediest. They make a little over 133 percent of the poverty level.
But the insurance offered by her husband’s workplace, an educational nonprofit, would cost them more than $14,000 a year in premiums.
“There’s no way we could afford it,” she said.
The family, including three children ages 2 to 7, hasn’t had to pay a premium for BadgerCare.
Jaglowski said she’s glad the exchange will be available, but she worries about out-of-pocket costs.
“We may be above poverty level, but we’re still pretty low income for five people,” she said.
Peterson said it will also be confusing for parents to have one kind of insurance on the exchange and for their children to remain on BadgerCare.
“It’s important to keep parents and kids in the same health care if they can,” he said. “This puts a big wedge in.”
Change in pregnancy coverage
Another concern is reduced BadgerCare coverage for pregnant women.
Currently, pregnant women with incomes up to 300 percent of the poverty level get full BadgerCare coverage.
Walker’s budget would give those making more than 133 percent of the poverty level only prenatal services, including labor and delivery care, Smith said.
The women no longer would be covered for postpartum care or dental care, said Sara Eskrich, health care policy analyst for the Wisconsin Council on Children and Families.
“This is a disappointing change,” Eskrich said. “The whole health of the mother, pre- and post-natal, has a direct impact on the health of the unborn child.”
It’s not clear what benefits the 82,000 childless adults would get under the state’s partial Medicaid expansion, said Jon Peacock, research director for WCCF.
Smith said they would get “full” benefits, including mental health services. But childless adults covered now receive partial benefits through the BadgerCare Core Plan, which expires this year.
The federal government has to approve the state’s changes, and “it’s far from certain that Wisconsin’s waiver for a partial expansion would be approved,” Peacock said.
Smith said the state expects the changes to be approved.
Need to build infrastructure
Some wonder if the exchange will be ready to enroll people by October and start coverage in January, as required by the health reform law.
Insurance companies will offer various levels of coverage for individuals and small groups, with government tax credits available for people with incomes between 100 percent and 400 percent of the poverty level.
Insurance plans wanting to participate must be certified by the end of July, said J.P. Wieske, spokesman for the state Office of the Commissioner of Insurance. They’ll likely start applying in April, he said.
The federal government is setting up exchanges in Wisconsin and 25 other states that decided not to establish their own.
The government is preparing a website and hotline for people to enroll, said Kenneth Munson, regional director for the U.S. Department of Health and Human Services. People also will be able to sign up in person, he said.
By June, grants will be awarded to “navigators” to help consumers use the exchange, Munson said.
Participating plans will be reviewed to make sure they provide “essential health benefits,” he said, and it’s likely many plans will be available in Wisconsin.
“We’re talking about insurers competing for business,” Munson said. “It’s hard to imagine insurers not offering policies for sale on the exchanges.”