BEYOND THE NUMBERS
The Centers for Medicare and Medicaid Services (CMS) has approved Wisconsin’s Medicaid waiver proposal, which will significantly restrict Medicaid coverage for low-income adults in a number of significant ways.
For starters, Wisconsin is the first state allowed to take coverage away from people with incomes below the poverty line if they don’t pay $8 monthly premiums. Those with incomes as low as 50 percent of the poverty line — or about $500 per month for an adult without dependents — who don’t pay premiums will lose Medicaid for up to six months. Wisconsin also became the fifth state allowed to take Medicaid coverage away from people who aren’t working or engaged in work-related activities, which could cause many people to lose coverage. In addition, low-income adults will be required to complete a health risk assessment (HRA) in order to get or maintain their coverage.
Together, these policies are likely to significantly restrict access to Medicaid coverage for many low-income adults in Wisconsin.
Premiums. When Wisconsin first imposed premiums on adults with family incomes between 150 percent and 200 percent of the poverty level, enrollment fell — which is consistent with lots of research showing that premiums significantly reduce low-income people’s participation in health coverage programs. In Indiana, where individuals below the poverty line who don’t pay premiums receive a limited set of health benefits, 57 percent of these beneficiaries were moved to the state’s “basic” Medicaid plan for failing to pay premiums; under Wisconsin’s rules, some of those beneficiaries would lose coverage for up to six months.
Mandatory HRAs. A new requirement that adults complete a health risk assessment (HRA) before enrollment also will likely cause harm and confusion. Beneficiaries who complete the HRA and engage in specific healthy behaviors will be rewarded with lower premiums. However, research from similar incentive programs in Medicaid have shown extremely low beneficiary and provider awareness of incentive programs and, of those who were aware, beneficiaries reported confusion about the programs themselves. While no state previously conditioned Medicaid eligibility on HRA completion, Michigan is testing charging higher co-payments to newly enrolled adult beneficiaries if they don’t complete an HRA (and agree to participate in certain activities). As of March 2018, less than 19 percent of beneficiaries who had been enrolled for at least six months had received credit for completing the HRA. A 2017 survey of Michigan Medicaid beneficiaries found that of those who completed an HRA, only 0.1 percent reported that they did so to save money on co-pays — suggesting that many who completed an HRA may not have known about the incentive.
Work Requirements. Wisconsin’s waiver also lets the state take coverage away from adults aged 19 to 49 who don’t work or participate in work-related activities for at least 80 hours per month for 48 months (whether consecutive or not). About 62 percent of Wisconsin Medicaid enrollees who could face this policy already work, and 43 percent of those not working are ill or have a disability. Most people losing coverage will likely be disenrolled not because they’re not working enough or are ineligible for exemptions, but because they can’t meet the reporting requirements.
Wisconsin is the fifth state to receive approval to take coverage away from people who don’t meet a work requirement. After four months of a similar policy, Arkansas has terminated coverage for nearly 8,500 people, and the federal Medicaid and CHIP Payment and Access Commission recently urged CMS to stop approving work requirements until further oversight and evaluation of the policy could be completed.
Notably, the federal government didn’t approve the state’s proposal to require Medicaid beneficiaries without dependent children to complete a drug test as a condition of eligibility. The state, however, is allowed to ask beneficiaries about their drug use in the mandatory HRA, which could deter people with substance abuse disorders (SUDs) from enrolling, preventing them from receiving SUD treatment as well as other needed care. Moreover, Wisconsin’s premiums and work requirement will likely harm many people who need SUD treatment.