What Ryan's healthcare proposals look like from Janesville

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 Scott Walker rejected the federally funded expansion because he wants the ACA repealed.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.

“If I could talk to Paul Ryan, I'd say 'I respect you, but what are you going to offer someone like me who makes minimum wage to help me get health coverage?'” Christopher said.

In a written statement, Ryan's office said, “Obamacare has made healthcare even more bureaucratic and expensive. … By putting the patient-doctor relationship first and applying free-market principles, House Republicans have offered a better way to fix America's healthcare system.”

Most of Ryan's district is not affluent. His hometown suffered a major economic blow when a big General Motors assembly plant, along with affiliated supply firms, shut down in 2008, costing more than 5,000 jobs. It's never fully recovered, though a big Dollar General distribution center is opening in Janesville, bringing more than 500 mostly lower-wage jobs.

Since the ACA took effect, Wisconsin's uninsured rate has dropped from 11.6% to 10% in 2015. That ranged last year from 6% to 13% in the six counties in Ryan's district, with 11% uninsured in his home Rock County and 12% in adjacent Walworth County, according to the Robert Wood Johnson Foundation. Those rates are higher than the 8.6% national uninsured rate in early 2016 reported by the federal government last week.

Competition on the ACA exchange markets in Ryan's district has been strong, with between four and eight insurers selling plans this year in the district's six counties, according to the state insurance commissioner's office. The number of plans may shrink in 2017, with at least two insurers signaling they'll stop selling on the exchange.

A key factor in driving down Wisconsin's uninsured rate was Gov. Walker's state-funded expansion of BadgerCare to adults without dependent children and incomes up to 100% of poverty. At the same time, he eliminated coverage for those parents and caretaker adults at 100% to 200% of poverty who previously qualified for BadgerCare, directing them to buy insurance on the ACA exchange. About 150,000 childless adults gained Medicaid coverage, while about 70,000 parents and caretakers lost it, said Donna Friedsam, a University of Wisconsin health policy expert. No one knows how many of those cut from BadgerCare bought Obamacare coverage.

Walker's plan wouldn't have been possible without the ACA because he wouldn't have been able to move people off BadgerCare without having “a place to send people he was disenrolling,” Friedsam said. But, she noted, the governor's model could be undermined by Ryan's plan because “there will be quite a substantial change in the ability of low-income people to acquire coverage.”

Roller said the combination of the ACA and BadgerCare has helped Aurora Health Care's patients. “Many childless adults who previously didn't have access to coverage are now better able to manage their chronic health conditions,” she said.

A significant share of the people who gained ACA or BadgerCare coverage work in low-wage jobs that don't offer insurance. Nearly 180,000 working Wisconsonites employed by companies such as Walmart, McDonald's, Menards, the University of Wisconsin, and Aurora Health Care received BadgerCare coverage in the third quarter of 2015, according to data from the Wisconsin Department of Health Services.

But under Ryan's Medicaid block grant approach, states likely would receive reduced federal funding over time and would face budget pressure to reduce eligibility, said Deborah Bachrach, a partner at Manatt, Phelps & Phillips who is a former New York State Medicaid director. Republicans in some states that have expanded Medicaid already are arguing for nudging childless, non-disabled adults off Medicaid.

Democratic state Sen. Janis Ringhand, who represents Janesville, said Ryan's popularity doesn't mean the people who vote for him support his policy positions, or even know about them. “A lot of folks in the district are on Social Security, Medicaid and Medicare, and they would be upset if they were aware that Congressman Ryan is trying to cut those programs,” she said.

That's true for John Erickson, a 59-year-old Kenosha resident who retired for health reasons from his factory production manager job last year. He was delighted when he found a subsidized exchange plan this spring that cost him just $232 a month.

Erickson, who said he doesn't get involved in politics and has never voted, didn't know his congressman wants to abolish the ACA. “I think it's wrong to repeal Obamacare,” he said. “A lot of people would be without insurance because they can't afford it.”