JANESVILLE, WIS.—A man standing outside the Rock County Job Center in House Speaker Paul Ryan's hometown last month expressed worry and frustration over not having health insurance.
Christopher, 28, who didn't want to give his last name, said he was dropped from BadgerCare Plus, the state's Medicaid program, in July. He had found a job without health benefits paying $1,300 a month, a little over the state's minimum hourly wage of $7.25. BadgerCare limits coverage for single adults to income of $990 a month, the federal poverty level.
Christopher explored buying an Affordable Care Act exchange plan but found it would cost him $117 a month plus a high deductible and copayments, which he said he can't afford. To save money, he takes his psychiatric and other medications every other day rather than daily, even though this puts him at increased risk of suffering another psychotic episode.
If Wisconsin had expanded Medicaid under the ACA to adults with incomes up to 138% of poverty, Christopher could have kept his BadgerCare coverage. But Republican Gov. Scott Walker rejected the federally funded expansion because he wants the ACA repealed.
Ryan is pushing a conservative ACA repeal-and-replace package. Although the speaker remains popular in his sprawling southern Wisconsin district—he won more than 80% of the vote in the Republican primary last month and 63% in his 2014 re-election contest—interviews with constituents and healthcare providers there indicate wariness about his proposals, which likely would drive healthcare policy if Republican Donald Trump is elected president.
While hospital and clinic leaders were leery about directly criticizing Ryan's plans—one said talking about Ryan and ACA issues would anger conservative donors—they said the ACA coverage expansions have helped them serve patients better, even if the law could stand improvement.
“We've told the speaker that if we're going to transition to a very different model, we have to limit disruption and continue expanding coverage,” said Rachel Roller, senior vice president of government relations for Milwaukee-based Aurora Health Care, Wisconsin's largest hospital system, with 15 facilities. Charity care at Aurora Health Care declined from $56.4 million in 2013 to $29.8 million in 2015. Roller expressed particular concern about preserving the ACA's payment and delivery system reform initiatives.
Statewide, hospital charity care declined from $328 million in 2013 to $164 million in 2015, while bad debt dropped from $276 million to $188 million during that period, according to the Wisconsin Hospital Association.
Ryan spearheaded a recent House GOP leadership white paper that would ax the ACA and its Medicaid expansion and substitute refundable, age-based tax credits to help people buy coverage, which would offer less financial help to younger people. He wants to convert Medicaid to a system of capped federal grants to the states, cutting federal spending and giving states much greater flexibility to set eligibility and benefits. He would cover individuals with pre-existing medical conditions in state high-risk pools, which in pre-ACA days had high premiums, limited benefits and long waiting lists.