Wisconsin: Congratulations, Scott Walker! Your request to kick thousands of your constituents off their healthcare was approved!

In the pile-on among Republican-controlled states to impose work requirements on ACA Medicaid expansion enrollees earlier this year, I somehow missed this one:

Wisconsin waiting to hear about requiring work, drug screening for Medicaid recipients

Wisconsin is still waiting to see if the federal government will let it require childless adults on Medicaid to be screened for drugs and work if they are able.

Gov. Scott Walker’s administration also asked in June to add premiums and co-pays for some adults without dependent children on Medicaid, which the federal government also must authorize.

The changes, which Walker said would help people move from public assistance to the workforce, can’t start until a year after approval by the Centers for Medicare and Medicaid Services, or CMS.

...Under Walker’s proposal, childless adults on Medicaid would have to submit to a drug test or enter drug treatment if drug screening called for it.

Able-bodied people under 50 would lose coverage after four years if they didn’t work or do similar activities.

Nearly 148,000 of the 784,000 people on BadgerCare, Wisconsin’s main Medicaid program, are childless adults, who must make $12,140 a year or less to qualify. Nearly 1.2 million residents are on some form of Medicaid.

Huh. Here's the thing...unlike every other state which has had work requirements approved, Wisconsin never expanded Medicaid under the ACA.

They did, however, expand "traditional" Medicaid to a number (apparently around 148,000 of them) of childless adults. There are two main differences:

First, Wisconsin's "traditional" expansion only extends up to 100% of the Federal Poverty Line, while ACA Medicaid expansion would've covered childless adults up to 138% FPL, which would've covered up to 32,000 more people.

Second, under "traditional" Medicaid, Wisconsin has to pay about 40% of the cost, with the federal government paying the other 60%. Under ACA expansion, the state wouldn't have to pay any more than 10% at most. Why on earth Walker didn't opt for ACA expansion instead of doing it this way I have no idea...other than the fact that he was planning on running for President at the time and wanted to be able to honestly say that he "didn't accept Obamacare" or whatever.

In any event, back in February Walker was very gung-ho about putting the screws to low income adults in his state: Work requirements, premiums, co-pays and even mandatory drug testing! That'll show those lazy good-for-nothings!

However, a funny thing happened between February and today: Walker suddenly realized that the Affordable Care Act (aka Obamacare) is now popular...including Medicaid expansion...and he's up for re-election six days from now. Announcing that you're launching a program which will kick thousands of your own constituents off their healthcare program while forcing the rest of them to submit to humiliating drug screenings if they don't want to die doesn't look good on election day.

What's a shameless opportunist to do? Why that's easy! Wait until after the election to make the announcement!

Scott Walker, in fight for political life, slow-walks Medicaid work rules
The delay comes as many Republicans have retreated from health care on the campaign trail.

Wisconsin Gov. Scott Walker sought for years to put Medicaid recipients to work. Now federal officials have given him most of what he wanted, but he's delaying the process for fear the changes will doom his flailing reelection bid, say three federal officials familiar with the deliberations.

“Wisconsin's been stalling,” said one official, adding the Trump administration has been ready to formally approve and announce the state’s new work requirements for weeks. “It’s ended up being a lot of hurry-up-and-wait.”

...Those who criticize Walker for hesitating contend that focusing voters’ attentions on health care is likely to hurt him with independents who are expected to decide the election. The two-term governor is effectively tied with or trailing Democratic candidate Tony Evers in multiple polls ahead of the Nov. 6 election.

Unfortunately for Gov. Walker, it appears that CMS Administrator Seema Verma decided to give him a little October Surprise of her own:

CMS Approves Innovative Wisconsin Plan to Improve Health and Lift Individuals from Poverty

(Of course she uses propagandistic buzzwords to describe the approval, but yeah, she just approved Walker's work requirement waiver.)

...Today, I signed and delivered our approval of Wisconsin’s request to amend and extend the BadgerCare Medicaid reform demonstration for the next five years. This means that this important program will continue to provide health coverage to more than 178,000 childless adults with incomes below the poverty level, while allowing the state to make a number of locally designed enhancements to strengthen the program.

NY Times reporter Margot Sanger-Katz has an excellent thread which goes into the details about the waiver itself, which parts were approved and, most interestingly, which parts weren't approved:

But it is a lot more forgiving than some of the other plans. In Arkansas, beneficiaries lose coverage for the year if they miss work targets in three months.

in Wisconsin, community engagement requirements will only apply to non-exempt adults under 50 without children. These working-age adults will be required to participate in at least 80 hours per calendar month – that’s 20 hours per week- of qualifying activities like employment, job training, volunteer community service, or enrollment in a qualified work program. Additionally, Wisconsin beneficiaries will have 48 aggregate months – a total of four years - to come into compliance with the requirement before they will be subject to a six-month period of non-eligibility, after which they will be free to re-enroll and start a new 48-month clock.

— Margot Sanger-Katz (@sangerkatz) October 31, 2018

I agree, that is considerably less draconian than Kentucky or, say, my own state of Michigan's...but it also just serves to underscore how pointless this whole idea is. There's only two reasons to do this: First, to save money by kicking some people off the program...which is pretty much cancelled out by having to establish an elaborate new bureaucratic infrastructure to administer the program, which is the exact sort of thing Republicans supposedly can't stand. That leaves the second reason: To try and hunt down the mythical "lazy moocher" type who could work but prefers to sit on his lazy butt, soaking up all that free healthcare goodness.

In particular, the four-year cut-off makes the whole thing just plain silly. The first article says around 148,000 childless adults are enrolled today. I'm not sure how many of them are under 50, but let's say it's an even 100,000. That means 100,000 people--the vast bulk of whom are already working, going to school, caring for other sick relatives, etc--will have to fill out a bunch of paperwork every month for the next four years to prove they're doing so in order for the state to prove that a small percentage of them...aren't.

Don't get me wrong, I'm sure there are a few of those types out there, but this really seems to be using a cannonball to swat a fly.

The waiver also will allow the state to charge premiums to some Medicaid beneficiaries and lock out those who fail to pay.

CMS also is providing authority to allow the state to implement additional features, including:

  • Implementing premiums on childless adults with incomes from 50 percent up to and including 100 percent of the FPL as a condition of eligibility;
  • Allowing termination and a period of non-eligibility as a childless adult for up to six months for childless adults who do not pay the required premium, with on-ramps to reactivate coverage during the non-eligibility period;
  • Allowing the state to vary premiums for childless adults based on the responses on a health risk assessment (HRA) and avoiding health risk behaviors;
  • Charging childless adults an $8 co-payment for non-emergency use of the emergency department (ED), consistent with 42 CFR § 447.54(b); and
  • Requiring full completion of an HRA as a condition of eligibility, as a part of the application for childless adults, in order to identify healthy behaviors.

— Margot Sanger-Katz (@sangerkatz) October 31, 2018

Wisconsin has tried premiums before. Research showed they depressed enrollment. https://t.co/iGhYqyTrCj pic.twitter.com/8YB3UgPFLm

— Margot Sanger-Katz (@sangerkatz) October 31, 2018

The state wanted to require drug testing for Medicaid beneficiaries. That did not get approved. pic.twitter.com/oDwNp6rCWT

— Margot Sanger-Katz (@sangerkatz) October 31, 2018

That's right...drug testing all Medicaid enrollees was a bridge too far for the Trump Administration, which tells you something about how absurd Scott Walker is.

More details on the “health risk assessment.” Beneficiaries can be charged higher premiums if they drink, smoke, don’t wear their seatbelt, or “fail to engage in dietary, exercise, and other lifestyle…behaviors in an attempt to maintain a healthy body weight.”

— Margot Sanger-Katz (@sangerkatz) October 31, 2018

The evidence that these sorts of wellness incentives change health behavior is…. not strong. Here’s @aaronecarroll on an RCT studying such incentives. https://t.co/jBiQ6F1IBH pic.twitter.com/zSm0xLxXr9

— Margot Sanger-Katz (@sangerkatz) October 31, 2018

Anyway, I'm sure Tony Evers, Walker's Democratic opponent, will find this development noteworthy...