“We have the state dictating the physician’s words.” -Representative Pasch

 Assembly Bill 227 (and its counterpart in the Senate) is just one more bill in a line of women’s health legislation that has been pushed through the state legislature this week while the state budget is taking up most peoples’ attention.  These bills (including AB216, which was discussed last week) will have real and detrimental effects on the availability and access to women’s health needs in Wisconsin, and is sure to change the overall state of health over time.  Furthermore, women’s health in Wisconsin took another hit on Tuesday, when the Joint Finance Committee rejected a motion to expand BadgerCare (Medicaid) with federal dollars, and instead is choosing to spend over $100 million more in state taxpayer dollars to cover fewer people.

Key Points of AB 227:

• Mandates undergoing an ultrasound (which are offered for free at many clinics) before an abortion, for the purpose of protecting the health and safety of the woman.
• The woman choices which type of ultrasound she will undergo, either transvaginal or abdominal.
• Mandates a physician to tell the woman opting for the abortion a detailed description of the fetus, show her the ultrasound, and have her listen to the fetal heartbeat.
• A woman has a “choice”: she can decide not to have the ultrasound (and therefore not have the abortion) or bring earplugs or loud music so she does not have to listen to the doctor.
• Waivers are available for women in cases of rape or incest, but a police report must have been filed.
• The physician performing the abortion must have admitting privileges at a hospital within a 30 mile radius.

This bill offers a myriad of potential problems that will overall make it more difficult (and in some cases, more traumatic) for a woman to undergo an abortion.

First, in a theoretical situation where an abortion provider does not offer ultrasounds (note: Planned Parenthood offers the service at all three locations that provide abortions in the state) a woman must go elsewhere and come back, adding to the time before the procedure is completed and furthering her expense.

Second, the bill does offer exemptions for women in cases of rape or incest if a police report has been filed.  However, when the majority of these cases go unreported, women who have already undergone traumatic experiences and wish to end the pregnancy will be forced to endure another procedure and listen to the fetal heartbeat and descriptive details.  Doctors will not have the ability to decide on a case-by-case basis what is appropriate for their patients.

Third, this law will take away a woman’s right to make her own medical decisions.  Because ultrasounds during any pregnancy are a routine standard of care, they should not be denied to a woman.  However they should not be mandated.

Fourth, during most of the first trimester, the routine standard of care is to use a transvaginal ultrasound.  This is especially true before 6-8 weeks, because the fetus is too small to be effectively viewed through an abdominal ultrasound. While the bill mandates that a woman choose which type of ultrasound, most doctors typically perform this more invasive procedure on newer pregnancies and might therefore advise a woman to do so. Therefore, there will be cases of women who have been assaulted and have not filed a police report, and that may have to undergo an extremely invasive procedure.

Fifth, the 30 mile admitting privilege rule is an uncommon requirement for outpatient procedures.  While the justification is that a doctor should be able to bring a patient to a hospital ER in the case of an emergency, hospitals will still admit patients of doctors who do not have an agreement to perform in the facility.  However, when 40% of hospitals in Wisconsin are Catholic-affiliated, it is quite likely that this agreement to give admitting privileges may be difficult for doctors who provide abortions to obtain.

Lastly, pregnant women who are carrying fetuses to term are not forced to have mandatory ultrasounds at 20 weeks.  Even though it is a routine standard of care, the American College of Obstetricians and Gynecologists only recommends the procedure if there is a specific medical reason.  Only 75% of expecting mothers have an ultrasound during pregnancy, so it is unreasonable for 100% of women wishing to end a pregnancy to have one.  Furthermore, the purpose of an ultrasound during a pregnancy which will be brought to term is to inform the physician about the state of the pregnancy.  Therefore, mandating a woman (whether she is ending a pregnancy or carrying one to term) does not fulfill the original purpose of the procedure.

This bill is not only opposed by the Wisconsin Alliance for Women’s Health, but also Planned Parenthood Advocates of Wisconsin and the Wisconsin Medical Society, among other provider groups.  The current Wisconsin law already in place mandates that a doctor offer an ultrasound or inform her on the availability of services elsewhere.  Therefore AB227 is unnecessary.

According to the bill’s advocates, a woman has a “choice” in regards to this mandatory ultrasound: she can refuse to have an abortion to get out of having one.  Making abortions more difficult to obtain negatively affects the health and safety of women in our state, and therefore this bill does exactly the opposite of its claimed intended purpose.

Last week the Health Committee of the Wisconsin Assembly held a hearing on two proposed bills – Assembly Bills 216 and 217 (AB 216 Fact Sheet and AB 217 Fact Sheet) which threaten to come between a woman and her doctor and hinder her access to not only abortion, but all forms of contraception.

Representative Pasch concisely summarized the heart of the issue when she said “we have a subgroup deciding what is medically necessary for women”. 

However, confusion abounded in the room, especially over the contraceptive coverage mandate in the ACA, and the potential changes to the religious exemption at the federal level that are currently in place.  One of the main justifications that the writers of AB 216 used was that Wisconsin’s contraceptive equity law does not provide a conscience clause for religious entities.  Therefore, the proposed law was allegedly designed to align Wisconsin with the federal law’s religious employer exemption; however, the proposed bill is much broader than the religious exemption in the ACA, and therefore more female employees in the state will be without insurance-covered contraceptive options.

The current religious exemption in the ACA applies to religious non-profit organizations, specifically houses of worship where the majority of the employees hold the same faith.  However, Wisconsin AB 216 broadens this group to include religiously-affiliated hospitals and universities, where many employees do not hold the same beliefs.  In addition, regardless of faith, 99% of women use contraception at some point in their life, and 98% of Catholic women do so.

Furthermore, the federal Department of Human and Health Services is expected to release final regulations on the religious accommodation issue by August 1 of this year.  The federal administration understands the importance of affordable (therefore accessible) contraceptive options for women, and therefore it is crafting a compromise where religious entities won’t pay for the benefits themselves, but insurance companies will essentially absorb the costs of contraception so it is still available to those women.

Women have a right to equal coverage of affordable, accessible health care, regardless of who their employer is.

AB216 will be part of the agenda for an executive session tomorrow (Wednesday, June 4) to pass it out of committee.  After that, it likely will move quickly through the Assembly.  Call you legislator as soon as possible to voice that women’s affordable access to contraception should not depend on the beliefs of her employer.

Gov. Scott Walker’s proposed state budget contains an unfortunate surprise for pregnant women in Wisconsin. I’m personally alarmed by this as a women’s health advocate and as someone who recently gave birth to my second child.

The governor’s budget bill contains a provision that would end BadgerCare coverage of pregnant women with incomes over 133% of the federal poverty level – which for an individual is as little as $15,000 a year and for a two-person household is about $20,000 a year. Let’s celebrate this Mother’s Day and National Women’s Health Week by removing this unintended, ill-considered change from the budget.

The governor and officials in the Wisconsin Department of Health Services have stated that making this group of pregnant women ineligible for BadgerCare was included in the budget unintentionally and that the mistake would inevitably be fixed. Yet despite the budget being introduced in February, the damaging language in the bill remains even after the correction of other errors. It will remain there unless legislative leaders take action to remove it, and sadly there is no assurance that they will do so.

We simply can’t risk making it harder for pregnant women to get prenatal and postnatal care. And since Walker maintains the proposal was inadvertent, it’s crucial that lawmakers reverse this ill-advised change as soon as possible.

As currently written, the governor’s budget bill would make these pregnant women making as little as $15,000 a year only eligible for a limited benefit plan called BadgerCare + Prenatal (BC+ Prenatal). Unfortunately, this BC+ Prenatal program relies on fee-for-service care, which is generally more expensive for the state, and women in some areas of Wisconsin would have trouble finding an obstetrician who will take new Medicaid patients under this plan.

BC+ Prenatal has several other shortcomings. It has a slower eligibility determination process, which could prevent women from receiving timely prenatal care. It also causes problems with continuous eligibility since BC+ Prenatal coverage can end any time a woman’s circumstances change, leaving her without health insurance during a portion of her pregnancy. Alternatively, under BadgerCare Plus, a woman is covered throughout her entire pregnancy. The list of shortcoming with BC+ Prenatal goes on and the costs go up – both in health outcomes and associated pregnancy-related medical costs.

The prenatal care a woman receives is one of the most important factors in the health of her child. We should be thinking of ways for more pregnant women to gain access to health care services, not creating barriers that will result in fewer women seeing a doctor during pregnancy.

We take Walker at his word that this change to pregnant women coverage in our state was not intentional. But to date, he and his administration have failed to remedy the mistake, and he now has left the task of fixing his mistake in the hands of our legislators, who may not all appreciate the implications of restricting access to prenatal care. Are we willing to allow even a single preventable miscarriage or preventable premature birth to take place because of what was apparently a communications error in submitting the budget instructions?

State budget bills are large, complicated documents, bound to contain a few glitches. As we celebrate Mother’s Day and National Women’s Health Week, let’s give Wisconsin women like me a very simple but important gift: access to the critical prenatal care we need and deserve.

Our children can’t give this gift to us, but state legislators can and should. It’s time our leaders correct this glitch that could threaten the life and health of a mother’s future child and herself.

Sara Finger is executive director of the Wisconsin Alliance for Women’s Health.

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Part 1 of Enrolling in ObamaCare in Wisconsin

Challenge #3:  Wisconsin is going to be moving thousands of people between Medicaid and the Marketplace.

We are anticipating that the proposed changes to Medicaid in Governor Walker’s budget will have the effect of letting low-income individuals and families fall through the health care coverage gap as changes take place (as illustrated in a past blog post), especially because the majority of people don’t understand how the ACA works or affects them.

Additionally, because Governor Walker does not want to expand Medicaid to cover more of the lowest income Wisconsinites, many families are still not going to be able to access affordable coverage.  Families may end up falling into a hole where they are not eligible for federal subsidies in the exchange because they have an offer of employer coverage that costs less than 9.5% of their income.  However, this is a gap in affordable coverage because the 9.5% only considers the cost of individual coverage, not family coverage.

While this challenge stems from Governor Walker’s original budget proposal, our state legislators have an opportunity to fix the situation and strengthen BadgerCare as they debate and pass a final budget later this spring.

Challenge #4:   The application process is going to be complex, and there is limited federal funding to support Wisconsin Navigators.

The ACA legislation emphasizes the importance of a streamlined and simplified process for health insurance enrollment.  According to the  Guttmacher Institute, “underlying that streamlined process are several intertwined strategies: coordination among the various programs, accessibility of the application and enrollment process, simplification of that process, minimization of gaps in coverage, and proactive outreach and assistance for enrollees”.

As a state with a federally facilitated exchange (FFE), we have limited control over the creation of our Marketplace.  However, stakeholders were recently given the opportunity to give feedback on the drafted Marketplace application. The final applications were just released today – and we appreciate many of the updates HHS made to the final draft.  The new application is only three pages for an individual and seven for a family.

The federal government estimates that it will take between 30-45 minutes to complete the new application, and will likely be easier than the process we go through to purchase private insurance right now.  A benefit of the online application (in comparison to the paper application) is that it will generate real time verification of identity, income, and citizenship or immigrant status.

Depending on who you listen to, the online application for the new exchanges will range from the ease of Orbitz to the pain and confusion of filling your taxes experienced by some.  It’s likely to land somewhere in between, but this should not discredit the importance of having Navigators: a well-trained and accessible group of individuals necessary to assist individuals in enrollment.  HHS has released more info about navigators and other consumer assistance counselors, but here in Wisconsin we are unsure how such resources will be financed to meet the needs of state residents, including those transitioning from BadgerCare to the exchange.  There is only enough funding to pay a small number of Navigators for the year, and therefore other groups will need to supplement assistance once enrollment begins.

Therefore, Wisconsin organizations need to be involved in implementation. 

We agree with Nelson Lichtenstein when he writes,

“This is not a case of creating more voters who will support Obama because of Obamacare. This is a 21st century example of Alexis de Tocqueville’s 19th century observation that the health of American democracy depends on the vibrancy of numerous voluntary organizations.  In recent history, we’ve seen the way such groups feed activism and are fed by it.” (Los Angeles Times)

It will take continual efforts on the part of advocates, health care stakeholders, and individuals to ensure that the ACA does what it was intended to accomplish, and reaches those Wisconsinites who need it.  If you’re interested in being involved email us at info@wiawh.org.

Challenge #1: Too many people don’t know what the ACA is, or how it affects them.

Education about how individuals are affected by the ACA is essential to improving the rates of uninsured Americans.   However, this is proving to be a difficult step in the process; according to a recent study from the Kaiser Family Foundation, two-thirds of the uninsured and most Americans in general believe they do not have enough understanding of the ACA to know how it will affect them.  (KFF) (Want a basic understanding of the ACA in Wisconsin?  Here’s a factsheet).

From our experience as staff at the Wisconsin Alliance for Women’s Health, there is a large unmet demand for outreach and education in our state; most people want to know more about how health care reform helps them.

Enroll America is planning a media blitz this summer, but it will also take Wisconsin groups spreading awareness in order to reach uninsured Wisconsinites.  (Part 2 of this blog “Enrolling in ObamaCare in Wisconsin” will cover these actions in more depth.)

Challenge #2: There is limited and late-in-the-game support from the state government in helping plan and fund education and enrollment.

While other states (such as California with its immense “Covered California” campaign) have undertaken efforts to prepare uninsured people for enrollment in the exchange, the Wisconsin administration has not been proactive in exchange creation or enrollment education.   This preparation before October is essential to the success of the ACA and reducing rates of uninsured Wisconsinites.

Jason Stein writes in the Journal Sentinel, “everything from computer projects to consumer outreach… must be completed to expand coverage for the uninsured…. How well this implementation goes will have substantial effects on both the uninsured and state and federal taxpayers.  But at the moment, this daunting job isn’t getting much attention.”

However, advocates and stakeholders have been working to ensure that the ACA is successful and reaches those Wisconsinites who need it.  The uninsured population is difficult to reach, so it is essential that a wide range of access points are available.  The coordination and support of advocates for low-income individuals and families, health advocates, clinics, hospitals, other medical providers, and family planning providers is necessary. If you’re interested in learning more about this state-coordination, and participating in the effort, contact us at info (at) wiawh.org .

Stay tuned for Enrolling in ObamaCare in Wisconsin: Part 2!

Thanks to the Affordable Care Act, Medicaid, and CHIP, the number of uninsured Americans dropped!

Even as the country continues to feel the effects of the recession (which officially ended in 2009), the number of uninsured Americans dropped by 1.2 million in 2011, the last year for which Census data is available.  According to the Kaiser Commission on Medicaid and the Uninsured, public medical assistance programs such as Medicaid and the Children’s Health Insurance Plan (CHIP) were the main contributors to the decline from 18.5% to 18% rate of uninsured, even though the overall population increased.  Currently, around 8.8% of adults and 29.9% of children are insured through public coverage programs in the nation.

The provision in the Affordable Care Act which allows children under 26 years old to stay covered under their parents’ insurance contributed to the sharp decrease in the number of uninsured in the 19-25 age category.  In addition, the ACA also froze the eligibility levels of states’ Medicaid and CHIP plans until 2014 for adults and 2019 for children.  Therefore, even with the continued effects of the recession and economic strain, states have continued to provide additional Medicaid and CHIP coverage to residents, even as the total number of individuals covered rose greatly because their income dropped below the eligibility level.

According to the Kaiser Family Foundation, “estimates of the ACA suggest that it will have small but generally positive effects on ESI [Employer Sponsored Insurance]” and overall will make insurance coverage more stable, especially during recessions and job losses as individuals transition between ESI, private insurance, and Medicaid.

But, will the rate of uninsured Wisconsinites rise?

While Governor Walker believes his plan to renovate the eligibility for Medicaid will end up reducing our state’s uninsured population by half, it will end up creating greater gaps in care.  In his budget, Walker proposes moving 89,000 parents off of BadgerCare and into the Marketplace, and allowing 82,000 newly eligible childless adults to take those open spots.  The logistical difficulties of moving where 160,000 Wisconsinites get their health insurance will likely end up leaving individuals behind.

Yet, it could be argued that not paying for additional adults to be covered through BadgerCare saves the state money.  However, it ends up costing hospitals money in uncompensated fees when uninsured people use medical services, and even now uncompensated-care costs keep rising in Wisconsin.  This is why the Hospital Association recently suggested postponing the implementation of Governor Walker’s proposed changes to BadgerCare eligibility for 2-3 years.

The Hospital Association believes that the Marketplaces will not be an appropriate method of coverage for low-income Wisconsinites, and additionally speculates that these exchanges will not be ready by early next year for the large number of adults moved off of BadgerCare.  This would leave tens of thousands of low-income individuals without any insurance options after they’ve been removed from BadgerCare.

Expanding BadgerCare with federal funding would eliminate much of this problem.  According to the Legislative Fiscal Bureau, Wisconsin could save around $44 million in state money by preserving current BadgerCare eligibility for parents and adding childless adults up to 133% FPL just through 2015, like the Hospital Association suggests.  However, refusing to fill the gaps in BadgerCare (as Walker has done) will end up costing Wisconsin millions more in the long run than expanding the program.

We are currently waiting for the Wisconsin Legislature to solidify the budget the Governor released last week, so details on Medicaid eligibility still need clarification.  However, we do know that people will need to be educated and aware of the changes to insurance options by the end of the year – so help us do so by sharing this “What’s Happening with the Affordable Care Act in Wisconsin” fact sheet.  It’s a great way to get caught up on how the law works and where implementation is going in Wisconsin.

In his second Inaugural address, President Obama described Social Security, Medicare, and Medicaid as programs which “free us to take the risks that make this country great.”  These programs don’t hinder America’s growth, but instead allow men and women the opportunity to challenge themselves without the fear of losing the ability to take care of their health.

This is why we need Medicaid, or BadgerCare, in Wisconsin.  This medical assistance program has a disproportionately positive effect on the lives on women, as women tend to hold lower-income jobs, have higher rates of childcare responsibilities, and hold more jobs supported by Medicaid than men.

Fact Sheet: Medicaid & Wisconsin Women: How Filling the Gap in Badger Care Will Improve the Health, Well-Being, and Economic Security of Women

However, Governor Walker announced last week that he will not be requesting federal funding in order to fill the gaps in our Medicaid (BadgerCare) program as offered in the Affordable Care Act.  While he will not announce more details regarding his plans around Medicaid until this Wednesday (February 20) at his budget address, Governor Walker has described a hybrid approach whereby some current Medicaid recipients (mostly parents over 200% of the FPL) will actually be made ineligible in order to make room for non-parents up to 100% of the FPL.  Walker assumes that these newly uninsured will be able to find affordable insurance in the new health care Marketplace (exchanges) – however we believe this will merely make insurance inaccessible to more people under the guise of making them “independent.”

Raising Wisconsin Women’s Voices and Wisconsin Alliance for Women’s Health believes this decision will create a system where it is harder for low-income women and men to find affordable insurance, even though they may have access to the Marketplace.  Partial expansions of Medicaid programs as proposed by Governor Walker are not what the Affordable Care Act intended, and more gaps in care than we expected to see will likely become the reality.

How is Medicaid Affected by the Affordable Care Act?

Last summer, the Affordable Care Act was for the most part entirely upheld by the Supreme Court. However, they ruled that states have the option of not expanding their Medicaid programs, as was in essence mandated by the original form of the law.  States which choose to expand to the full extent of the ACA will receive a 100% reimbursement from the federal government for the first three years for all newly eligible enrollees.  After that, the reimbursement will gradually fall to 90% by 2020.  Partial expansions (below 138% of the poverty level) will not solicit additional federal reimbursement for state Medicaid costs; rates of funding will continue as they were before partial expansion.  For Wisconsin, this means that federal funding would continue at only 59%.

It is estimated that expansion would end up saving states more money in the long-term than keeping Medicaid enrollment at its current rate – this is true in states such as Colorado, and likely Wisconsin as well.

What can we do?

As we arrive closer to the opening of the Marketplaces and state expansions of Medicaid across the nation, more people are expected to  enroll in Medicaid.  This will occur, even in states like Wisconsin without expansions, because of the individual mandate which will make enrollment easier.  If you enroll within the Wisconsin Marketplace, the system will evaluate your application and inform you if you are in fact eligible for Medicaid.  There will also be increased publicity about Medicaid eligibility.  Therefore, stay informed on Wisconsin’s progress towards implementing the ACA, and be a resource for others who may not know their new options for health insurance.

Lastly, because of all the reasons we’ve outlined as to the importance of Medicaid for Wisconsin women, we support the Strengthen BadgerCare Act, a bill which has been introduced in the Wisconsin State Legislature.  This bill outlines the steps necessary to expand our state BadgerCare programs.  Use your voice, and a few moments of your time, and write or call your legislator in order to encourage them to support this bill.  Even though Governor Walker has released his hybrid Medicaid expansion plan, the Wisconsin Legislature still must agree to his plan – therefore it’s not over yet!

Here at the Wisconsin Alliance for Women’s Health we support the expansion of BadgerCare because it fills much of the gap in insurance coverage for women in our state!