In February 2008, Wisconsin launched a health reform effort with three goals: provide universal coverage for children, simplify existing public programs, and remove barriers to stable coverage for families. The coverage reforms were implemented in two phases. Phase I consisted of a new coverage expansion under Wisconsin's CHIP, Medicaid, and Healthy Start programs called BadgerCare Plus, which extended eligibility for uninsured children at all family incomes and many caretaker adults. A recently launched Phase II will use the BadgerCare Plus "Core Plan" to increase coverage among uninsured, low-income, childless adults.
Despite extremely challenging economic times, Wisconsin's Governor Jim Doyle strongly supported enactment and continued funding for these health coverage reforms. The state is also supporting a rigorous evaluation of the program to ensure that it is achieving its goals among its target populations.
Expanding Coverage
Starting in February 2008, all children without access to affordable health insurance (defined as an employer contributing at least 80 percent of the cost of a family premium) became eligible for BadgerCare Plus regardless of income, with sliding-scale premiums and cost-sharing for families with income above 150 percent of the FPL. Pregnant women with income up to 300 percent of FPL became eligible, while eligibility for parents and caretakers was extended to 200 percent of FPL (Figure 1). BadgerCare Plus administrators check applicants' access to affordable employer coverage using an Employer Health Insurance Verification database that is maintained by a contractor to the Department of Health Services' Division of Health Care Access and Accountability. The database tracks elements of employer coverage, including companies' contribution to premiums and variations in health plans offered to different units within the same employer. BadgerCare Plus also simplified the income calculation used to determine eligibility, basing it only on gross income minus child support payments and student income, and eliminating a number of other income "disregards."
Figure 1. (click to view)
The evaluators of these health care reforms report that total enrollment in BadgerCare Plus rose 14 percent between December 2007 and September 2008, from 516,000 to 590,000 people. More than 42,000 children and over 31,000 adults gained coverage, and there was a reduction in people exiting the program.
"We believe that enrollment is particularly robust for multiple reasons: the program's message is simply that all kids are eligible, and eligibility is not limited to children. Previous data have shown that children are more likely to be enrolled when their parents and whole families have the opportunity to be enrolled," said Donna Friedsam, a member of the University of Wisconsin research team evaluating the program.
Almost two-thirds of the increase in children enrolled was among those in families with incomes at or below 200 percent of FPL (Table 2). "One of the things we're most proud of is the success of the outreach effort for BadgerCare Plus," said Karen Timberlake, secretary of the Wisconsin Department of Health Services and a partner in the evaluation effort. "Most of the children being enrolled have incomes low enough that they were already eligible before the expansion, but they had not been reached before."
Table 2. Child Enrollment in BadgerCare Plus, by Family Income Level
|
Dec. 07 |
Sept. 08 |
Change |
% of Change |
Total |
337,817 |
379,825 |
42,008 |
100% |
=150 FPL |
317,502 |
327,375 |
9,873 |
24% |
151–200 |
19,157 |
37,447 |
18,290 |
44% |
201–300 |
829 |
12,480 |
11,651 |
28% |
>300 |
196 |
2,520 |
2,324 |
6% |
Source: DeLeire, T. University of Wisconsin Population Health Institute, 2009.
Enrollment Strategies
In addition to expanding eligibility, Wisconsin implemented a variety of strategies that appear to have succeeded in enrolling eligible individuals. "This program required a very strong, broad-based communication effort to convey the message that all kids were potentially eligible, regardless of income," said Timberlake.
One strategy involved limiting "crowd-out" restrictions, allowing people with incomes below 150 percent of FPL to enroll in BadgerCare Plus even if they had an offer of employer-sponsored insurance. Data had suggested that, even when offered employer-sponsored insurance, those with very low incomes are often not able to afford the cost-participation requirements, and thus remain uninsured. With implementation of BadgerCare Plus, responsibility for verifying whether an individual has employer coverage or access to employer insurance also shifted from applicants to the state. Further, the program no longer holds applicants responsible if their employer fails to respond to requests for such information. Also, BadgerCare Plus automatically enrolled family members of already-enrolled children if they were found to be eligible under the expansion guidelines.
A broad outreach and enrollment effort involved more than 200 organizations in identifying and enrolling eligible families, including community health centers, hospitals, food pantries, schools, faith-based organizations, and community advocacy groups. In addition, BadgerCare Plus gave grants of up to $25,000 to 31 organizations for community outreach and enrollment, paying $50 for each approved application.
About 39 percent of applications are submitted using the state's online application system, ACCESS, which screens applicants for eligibility for health care programs in addition to food stamps, tax credits, and other benefits. Organizations were trained to use the online application system as part of the outreach.
Wisconsin is financing the coverage expansion with a variety of strategies, including the premiums and cost-sharing for enrollees with incomes above 150 percent FPL, a hospital assessment that increases the federal funding available for Medicaid, greater efficiencies in prescription drug purchasing, and a $1 increase in the cigarette tax. The state may also seek cost savings through other reforms.
The ongoing evaluation of BadgerCare Plus is examining take-up rates by various income and age groups, rates of "churning" on and off public programs among enrollees, the impact of the coverage expansion on employers' offering of insurance, movement from private to public coverage among people who were newly eligible, and enrollment among people who were uninsured despite being eligible for private or public coverage. The second phase of reform, aimed at covering childless adults with incomes up to 200 percent of FPL, began statewide enrollment in June 2009.
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