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Wisconsin and Health Reform

As a red state, at least during the implementation of Obamacare, Wisconsin lawmakers voiced their disapproval of the Patient Protection and Affordable Care Act since the beginning. The law’s most substantial regulations have taken effect, and Wisconsin has been required to reshape many aspects of health insurance and the administration of care. All states have been required to adapt to gradually implemented, and often times delayed, laws established by the PPACA since 2010. These regulations are primarily designed to increase the nation’s overall health and access to coverage, and also reduce national healthcare spending in a country of many health disparities.

Wisconsin opted not to expand BadgerCare, the state’s Medicaid program, under health reform, and also didn’t create it’s own health insurance exchange. These decisions were the only state-level options provided by this federal law. Initially, these weren’t optional, but after the Supreme Court ruling in June 2012, the White House had to tweak the law so that Medicaid expansion and exchange implementation were up to the states. This unfortunately denies a large number of Wisconsin residents access to coverage if they don’t earn little enough for Medicaid or poverty-level income to qualify for the exchange. This experiment with national health care has provided a number of protections and benefits for insured Americans, and is making an impact on Wisconsinites. Below are the highlights of implementation during the ACA’s transitional period (2010-2013) and the full implementation period (2014 and later).


Health Reforms in Wisconsin: 2010-2013

Various changes have been made to alter health care laws in Wisconsin, including the elimination of rescissions, an insurer’s ability to terminate benefits just because a policyholder gets sick. Insurers can only cancel policies if you lie on your application or are otherwise being a fraud. Additionally, there are no more lifetime maximums established in health insurance policies, and annual maximums were increased every year until phased out entirely in 2014. Wisconsin insurers also must adhere to the medical loss ratio, which regulates a company’s premium income and results in annual rebate checks if an insurer has spent less than 80 percent of those premiums on patient-focused improvements.

Laws have also been adjusted for Wisconsin underwriting since 2010, as children up to age 19 who qualify as having a pre-existing condition cannot be declined coverage. Elimination riders, rate-ups, and exclusion periods were allowed until 2014. From 2011 to early 2014, adults with conditions could enroll in the federal risk pool to obtain coverage until the laws changed. Helping provide more insurance to the uninsurable, the federal Pre-Existing Condition Insurance Plan was provided as an additional option from the state risk pool, HIRSP.

Coverage for dependent children was extended to age 26 for young adults without employer-based insurance under a parent’s group or individual plan in Wisconsin. This continuation of benefits provided 43,000 more Wisconsin residents with coverage, as of December 2011.¹ Insurers in Wisconsin are also required to offer preventive care for free with in-network doctors under each health plan. More preventive services were also added to the list of those approved since the law became effective, now providing more necessary screenings and services to reduce the health risks of women.


Wisconsin Health Reform: 2014 and Later

The greatest changes of health reform were schedule for 2014-2015, though some provisions have been delayed. Beginning in 2014, Wisconsin residents are required to obtain coverage or pay a penalty tax for being uninsured. If you’re enrolled in Medicaid, Medicare, the marketplace, group coverage, or another form of comprehensive coverage, you don’t have to pay the tax. This regulation helps raise awareness of Medicaid programs and the exchange, where people can enroll in subsidized coverage. Health plans sold on the marketplace include coverage for ten categories of essential health benefits (EHBs), including prevention, office visits and emergency care. Less common services covered by marketplace plans include maternity care and mental health benefits. In addition to the marketplace, many non-marketplace plans must cover EHBs

In the implementation process, exchanges were misunderstood and red states mostly thought the law had zero financial backing. As taxes have been raised in several areas, the government has made sure it will be able to afford reforming the health care system. According to Governor Walker, “No matter which option is chosen, Wisconsin taxpayers will not have meaningful control over the health care policies and services sold to Wisconsin residents… If the state option is chosen, however, Wisconsinites face risk from a federal mandate lacking long-term guaranteed funding.”²

However, the marketplace is now open and provides strong coverage opportunities for low-to-moderate income households that would otherwise struggle to pay for insurance.Medicaid expansion is not taking place in Wisconsin, or at least not yet. If the state agreed to increase its Medicaid rolls, the program would admit adults without children who were once covered by BadgerCare.  While substantial federal funding was offered to the state to insure its needy residents, the money was turned down. Those who are not eligible for Medicaid can apply for the marketplace, though financial assistance is available to those with poverty-level income up to 400 percent of FPL. Anyone who makes less than the current FPL but doesn’t qualify for Medicaid is left without coverage.

The traditional individual market (non-marketplace plans) will also shift immensely, as underwriting receives a friendlier face through the health law. Pre-existing conditions are no longer subject to rejection or rate increases, and insurers cannot impose condition-related exclusions or elimination riders. Rates can only increase based on age and tobacco use as risk factors, meaning Wisconsin women will have the ability to buy a health plan for the same cost as a male in the same age group, and professional skiiers won’t have higher premiums than office workers.

Private insurers also have a few more guidelines regarding covered benefits. Every insurer is required to offer at least the ten categories of Essential Health Benefits (EHBs), which include emergency care, maternity and newborn coverage, prescription drugs, and others that are already typical of a comprehensive plan. Not all plans are required to contain EHBs, so review the types of coverage being offered in your area prior to making a decision. Additionally, individual plans on and off the exchange must pay at least 60 percent of your total covered costs so that cost sharing is no greater than 40 percent. This is known as “minimum essential coverage”, or the requirements a health plan must meet in order to help you avoid the penalty tax.






1. Healthcare.gov. “How the Health Care Law is Making a Difference for the People of Wisconsin.” http://www.healthcare.gov/law/resources/wi.html.

2. 16 Nov. 2012. Huffington Post. “Scott Walker, Wisconsin Governor, Rejects Key Health Care Reform.” http://www.huffingtonpost.com/2012/11/16/scott-walker-health-care_n_2144605.html.