Wisconsin Union Battle Masks Medicaid Tensions
Topics: States, Medicaid
By Christopher Weaver
KHN Staff Writer
Feb 25, 2011
This story was done in collaboration with POLITICO
Hiding out at a secret location in Illinois, Wisconsin state Sen. Kathleen
Vinehout ends every media interview with the same warning: Republican Gov. Scott
Walker's attack on public employee unions is overshadowing another part of his
budget plan that could shred the state's health care safety net.
The governor's proposal, a "budget
repair" bill that would strip most public employees of their collective
bargaining rights, would also allow the Walker administration to make
potentially drastic changes in health programs with little legislative
oversight. Officials say it could help tackle a looming two-year $3.6 billion deficit. But, the result, Vinehout
predicts, is that glarge numbers of people will lose BadgerCare," a component of Wisconsinfs Medicaid
program.
Taking the lead in revamping health programs for the poor would be Dennis
Smith, Wisconsin's new health secretary. A mild-mannered bureaucrat and head
of the federal Medicaid program under President George W. Bush, he's known
within policy circles for staunchly conservative views and stinging critiques of
President Barack Obama's health care law.
Under Walker's plan, Smith could reshape critical aspects of Wisconsin
Medicaid and potentially strip tens of thousands of people from the rolls. He'd
also be directed to ask the federal government for permission to go further.
In the process, Smith could chart a course for other Republican-led states
seeking to reduce deficits by paring Medicaid. And he could emerge as a national
leader in the right's resistance to the new health law, an increasingly
important issue in the lead-up to the 2012 elections.
Still, Smith faces some hurdles. The health law makes an additional 16 million people eligible for Medicaid, a joint state-federal
program, beginning in 2014 and bans states from dumping most people who are now
covered.
Nonetheless, an analysis by the independent state Legislative Fiscal Bureau
says Wisconsin could drop about 70,000 higher-earning adults from Medicaid
without getting permission from Washington.
Smith is already edging into the national spotlight – in part thanks to House
Budget Committee Chairman Paul Ryan of Wisconsin. A day after Smith was
confirmed as health secretary, he was called before the panel to testify on how
the health law will hurt the state's residents.
"Expanding Medicaid under the current framework doesn't make sense," he told
Kaiser Health News in late 2009 as the law was being debated. "You've got to
give states flexibility." (Smith couldn't be reached for comment for this
story.)
Just over a million people in Wisconsin are enrolled in Medicaid, at a cost
of more than $6.5 billion in 2009, the latest year available. That year, the federal government
picked up almost 70 percent of the cost, but the share will decline when
stimulus funds dry up this summer. Walker says Medicaid costs are at the root of
half of the projected deficit.
Currently, most major Medicaid changes must be cleared by the full Wisconsin
legislature. But, under Walker's bill, Smith's health department could make
those changes through an emergency rule-making process without legislative
approval. The Joint Committee on Finance would have 14 days to veto the changes.
But critics say the new rules mean Smith and Walker wouldn't have to present
detailed plans to the public.
What Smith comes up with "may be brilliant," says David Reimer, a former
state budget official who is now director of Community Advocates Public Policy
Institute in Milwaukee. "It may be awful. But we don't know."
Smith, an Illinois native, was head of the federal Center for Medicaid and
State Operations from 2001 to 2008. He also worked on Capitol Hill and ran
Virginia's Medicaid program. Before becoming Wisconsin's health secretary, he
was a senior fellow at the conservative Heritage Foundation and also worked for Utah-based Leavitt Partners, a consulting firm set
up by Michael O. Leavitt, former secretary of the Department of Health and Human
Services.
Leavitt says Smith left the consulting firm because "he wanted to use his
experience in a laboratory where his vision could be demonstrated. There's no
question that if he's able to put it together and make it work, others will
follow him."
Still, while it's clear that Walker and Smith want to tackle Medicaid, the
question is: What's their plan? The budget bill outlines some likely changes,
but also gives Smith leeway to make broader ones that aren't yet clear.
In the past, Smith has consistently argued that Medicaid should focus only on
the poorest people (Wisconsin covers individual adults earning nearly $22,000),
and should rely on private managed-care programs to restrain costs. He also has
promoted charging recipients higher co-pays to try to dissuade them from seeking
unnecessary treatments.
Critics, such as Judith Solomon, an analyst with the liberal Center on Budget
and Policy Priorities, say Smith has long advocated policies that could hurt the
poor and undermine the intent of Medicaid. Opponents also cite a 2009 paper published by Heritage that seemed to advise states to
drop out of Medicaid altogether.
But Robert Moffit, a senior fellow at Heritage who brought Smith to the think
tank in 2008, says while "there's no question Smith is a real conservative,"
he's thoughtful and open to new ideas.
As head of the federal Medicaid program, Smith issued a record number of
waivers that allowed states to experiment — including increasing the use of
managed care and allowing states to find new ways to pay doctors and
hospitals.
"How many newly insured individuals gained health insurance under the Bush
administration because of our waivers?" Smith said in the 2009 interview.
"Instead of getting credit for that, we got criticism" from liberals who wanted
Washington to control the programs more tightly, he said.
The Obama administration is likely to resist the kind of changes Smith will
likely want to make in Wisconsin. Though federal Medicaid officials would not
specifically comment on Wisconsin, they indicated that the types of policies
suggested in Walker's bill — such as barring people who are likely eligible
for Medicaid from receiving services before being formally enrolled — could
pose problems.
But Leavitt, Smith's old boss, says economic problems have become so severe
that something has to give. "Health care policy has always been driven by human
compassion," he says. "We can't lose it, but we are now dealing with a new
factor."