Nichole Robarge, right, describes the challenges faced by people with disabilities she assists when enrolling in Medicaid. With her is Kathleen Cummings, who provides similar assistance to people 60 and older. Both said impending changes to the program are likely to increase those challenges. (Photo by Erik Gunn/Wisconsin Examiner)

With the Congressional mega-bill that cuts $1 trillion from Medicaid now law, people who have relied for their health care on the state-federal insurance plan and their advocates are scrambling to figure out  how and when it will hit home.

The timing of many of the law’s changes is still uncertain.

“This bill was written very hastily,” said Tami Jackson, policy analyst for the Wisconsin Board for People with Development Disabilities (BPDD), at a discussion of the law Thursday morning in the Wisconsin Capitol.

“There are implementation dates for various pieces of Medicaid that are not all in alignment,” Jackson said. “So, you’re going to get this in waves.”

Janet Zander of the Greater Wisconsin Agency on Aging Resources paraphrased promises from members of Congress who publicly defended the bill.

“It’s really easy to listen to what we’re hearing about — ‘This isn’t going to harm us here in Wisconsin. We’re not doing anything that’s going to hurt older adults, people with disabilities, low-income families,’” Zander said. “Those of us who are working in these programs know that’s not the case at all.”

The new law imposes requirements for Medicaid participants to work or be preparing for work — although a majority already are working — or else be approved as exempt from having to meet the requirement.

That provision’s implementation date of Jan. 1, 2027 is less than 18 months away, Jackson said. And it could be up to a year before the federal Department of Health and Human Services (HHS) produces an administrative rule to direct states on how they manage the requirement.

That doesn’t allow for much time to work out “20 or 30 unanswered questions” about how to require people to demonstrate they’re working, qualify for an exemption or prove that they’re exempt, Jackson said.

The added requirements will also impose new demands on agencies in charge of implementing the Medicaid changes in each state, as well as county agencies that help people navigate the program.

“If you are ramping up the workload and how much people have to do, and ramping up the staffing it takes to do that, that’s a lot more that counties are going to be doing locally, or will have to do,” Jackson said. “That’s going to exacerbate how many people lose coverage.”

Other items have no implementation date — which is usually interpreted as taking effect with the bill’s signing, said William Parke-Sutherland, government affairs director at Kids Forward.

“This bill, which is being kind of talked about as a tax and spending bill, is really a health care redesign bill, and it makes the most substantive changes to the health care system that we’ve seen since the Affordable Care Act,” Parke-Sutherland said.

That national health care law had four years to be implemented. With the new Medicaid changes, “we have no time in comparison.”

But the probable long-term impact remains dire, advocates said — making it harder for people to get coverage and keep coverage.

Taking together the projected loss of Medicaid coverage as well as the projected loss of Affordable Care Act coverage for low-income people who lose subsidies for their premiums that expire at the end of this year, as many as 17 million people in the U.S. could lose health care and long-term care coverage, Zander said.

The state Department of Health Services estimated in April that at least 52,000 Wisconsin residents could lose Medicaid coverage. Changes the Senate made in the bill will likely increase those estimates, however, according to advocates.

Safety-net barriers, old and new

As ultimately passed by the U.S. Senate and the House of Representatives and signed into law by President Donald Trump, the legislation has thrown new barriers in front of the nation’s safety-net programs, including Medicaid as well as the federal food aid program, SNAP.

Existing barriers were already very high, advocates said.

Kathleen Cummings works for the Columbia County Aging and Disability Resource Center assisting people who are 60 or older applying for Medicaid and other benefit programs. Based on their annual income and total assets, some people on Medicare also qualify for Medicaid to cover their out-of-pocket Medicare costs.

Cummings recounted the experience of a woman who had qualified for Medicaid but recently contacted her because she was getting bills for her health care. The woman accidentally failed to renew her Medicaid coverage when the renewal form she received got buried in a flurry of other Medicaid-related mail, Cummings said.

Under current law the client can get coverage retroactively for bills incurred in the last three months. But with the new law, “that will be changing to 30 days, so we will not, in the future, be able to request that backdated coverage for bills under the situation that she is in,” Cummings said.

Another client has had extensive treatment for lung cancer, she said. The man “is just barely, barely over the federal poverty level” — about $1,300 a month.

“A lot of my clients are very proud and do what they can with what they have,” Cummings said. “But when something like lung cancer comes along, he’s suddenly faced with all these bills that he only had limited coverage [for].”

She’s helping the man apply for Medicaid coverage backdated three months to cover those bills, she said. “Once he shows proof that he qualified, which he will, [he can] get some of these bills paid.”

Nichole Robarge also works for the Columbia County ARDC, helping people from ages 16 to 59 who qualify for federal Supplemental Security Income (SSI) disability benefits and other programs.

Robarge said that currently the disability application takes 12 to 18 months for a decision. As many as 85% of applications are denied at first, she said, and about 20% get overturned on appeal, which takes another 18 to 24 months. A second appeal, with a hearing before an administrative law judge, can take another two years.

In Wisconsin, approval for SSI automatically qualifies a person for Medicaid coverage. Until the SSI decision is resolved, however, the applicant has to apply for Medicaid separately, Robarge said — something that a disability can make much more difficult.

She pulled out the Medicaid application, which currently must be completed annually — a 41-page document that is a half-inch thick.

“Can you imagine getting one of these in the mail and having a cognitive disability or a physical disability, or maybe you had a stroke?…Or maybe you can’t read at all,” Robarge said.

“I bought a house and had less paperwork. I’ve bought a car and I’ve had less paperwork than what it takes to fill one of these out,” she added. “It’s tedious and it’s treacherous … This first barrier is huge, and this is even without getting the documents that you need to provide the proof that they’re asking for.”

Unintended consequences

The new law is poised to make those delays worse, advocates argue — blocking people from Medicaid coverage even though they meet the program’s qualifications.

“Medicaid is a wildly complicated program,” said Lisa Hassenstab, public policy manager for Disability Rights Wisconsin. “What we’ve seen in this bill is that all of these little changes [and] the unintended consequences, because people don’t understand what the program is. They don’t understand what it is, and so they don’t understand what the impact of these changes is really going to be.”

One thing the law won’t do, advocates said, is protect taxpayers.

“It won’t protect me,” said Tyler Engel, whose Medicaid coverage enables him to live more independently in the community with coverage for his caregivers.

“This bill saves money by making it so that, for somebody who is now currently eligible for health care, the provider who provides that care is not going to get paid,” Parke-Sutherland said. “This saves money by people who are currently eligible for health insurance” with federal help “not getting health insurance or having to pay more for it. That’s the only way that this bill saves money.”

Two-thirds of Medicaid participants are working, and therefore they are taxpayers, too, Jackson said.

“It’s a cost shift to the taxpayers,” said Jackson, because when people aren’t covered by Medicaid, “somebody else picks that up — whether it’s uncompensated care, whether it’s a medical bankruptcy, whether it’s your private insurance or your group premium going up.”

“If you stop paying for care, people’s care needs don’t go away,” Parke-Sutherland said. “You still pay. So this isn’t a boon to the taxpayers.”

American Family Children's Hospital, part of the UW Health system, is seen in Madison, Wis., on April 1, 2020. (Photo by Dee J. Hall/Wisconsin Watch)

Republished from Wisconsin Watch. 

Multiple Wisconsin health care systems have removed diversity, equity and inclusion language or resources from their websites in the wake of President Donald Trump’s federal ban on funding for DEI programming.

The systems include SSM Health, Aurora Health, UW Health and, most recently, Ascension. Froedtert ThedaCare Health has maintained its DEI webpage, though it removed a link to its equal employment opportunity policy in recent months.

Aurora Health, Ascension, Froedtert and SSM Health made the changes quietly, without directly alerting the public. UW Health, however, released an op-ed in Madison 365 April 8 explaining the changes.

“As we enter the next phase of this important work, we are further aligning with our organizational mission under the name of Social Impact and Belonging,” the op-ed said. “This reflects both the evolved nature of the work and our desire that these mission-focused priorities endure despite the current tumultuous political environment.”

The changes occurred in the weeks after President Donald Trump’s executive order abolishing DEI programs from all federally funded institutions and programs.

The executive order, issued Jan. 20, states the “Biden Administration forced illegal and immoral discrimination programs, going by the name ‘diversity, equity, and inclusion’ (DEI), into virtually all aspects of the Federal Government, in areas ranging from airline safety to the military.”

In response to attacks on DEI programs by the federal government, some organizations have pushed back, arguing Trump’s actions are a threat to a multiracial democracy. Some institutions are also suing the federal government for its actions, such as threatening to withhold federal grants and funding.

Harvard University has filed a lawsuit, citing First Amendment principles to protect “academic freedom” and “private actors’ speech.”

But while some federally funded institutions are pushing back, others are not.

Different approaches to DEI purge

In the past couple of months, SSM Health removed the word “diversity” from its website, including changing a page titled “Our Commitment to Diversity” to “Our Commitment to Culture & Inclusion.”

SSM has hospitals located throughout Wisconsin including Ripon, Fond du Lac, Waupun, Baraboo, Janesville, Madison and Monroe.

In changing the webpage, SSM Health also removed an entire section regarding its commitment to fostering a diverse workplace and health care center, including a section that read, “​​SSM Health makes it a point to work with diverse organizations broadening our reach into the communities we serve to support and promote a more inclusive society.”

SSM Health also notably replaced the section discussing diversity with comment on SSM Health’s mission as a Catholic ministry. On the updated page, the system discusses its commitment to follow in the footsteps of its founders to ensure “all people have access to the high-quality, compassionate care they need.”

In removing the word “diversity,” SSM replaced the statement “At SSM Health, diversity is an integral part of who we are and a reflection of our mission and values” with “At SSM Health, inclusion is an integral part of who we are and a reflection of our Mission, Vision and Values.”

”Today, our belief that every person was created in the image of God with inherent dignity and value calls us to foster a healthy culture, inviting each person to be the best version of themselves,” SSM Health communications consultant Shari Wrezinski said when asked for comment.

Wrezinski said the organization’s mission has remained the same, and its communications, policies, programs and practices reflect the organization’s mission.

“This has not and will not change,” Wrezinski said. “As such, our website and other communications materials are continually updated as we strive to clearly convey our commitment to a welcoming environment where everyone feels valued and respected.”

Despite removing the section on diversity, SSM Health has maintained its equal opportunity section.

Froedtert did the opposite, by maintaining its webpages on diversity, equity and inclusion, but removing its equal opportunity policy document from the pages.

The equal opportunity document, which can still be found online but was removed from the DEI website, specifically outlines Froedtert’s commitment and policy to maintain equitable and nondiscriminatory recruitment, hiring and human resources practices.

The document outlines two policies specifically: “FH is committed to its affirmative action policies and practices in employment programs to achieve a balanced workforce” and “FH will provide equal opportunity to all individuals, regardless of their race, creed, color, religion, sex, age, national origin, disability, military and veteran status, sexual orientation, gender identity, marital status or any other characteristics protected by state or federal law.”

Froedtert did not respond to requests for comment.

The Froedtert system serves patients primarily in the Milwaukee area. Froedtert recently merged with ThedaCare, serving Wisconsin residents in the Fox Valley and Green Bay. In 2020, the system reported receiving tens of millions in federal funding through the CARES Act in response to the COVID-19 pandemic.

While removing a link to an equal opportunity document may be a simple change, the Rev. Marilyn Miller, a partner in Leading for Racial Equity LLC, said every small change pushes society further back in achieving full access and equity.

“So it might be a small tweak now, but what does that open the door to later? So, yeah, it’s impactful because any change that’s stepping back from full equity is a problem,” Miller said. “There’s populations that don’t feel any security anymore.”

Aurora Health Care also has removed DEI language in the past couple of months since the executive order.

In 2018, Aurora merged with Advocate Health, a system with more than 26 hospitals throughout the Midwest. Advocate Aurora Health later merged with Atrium Health in 2022, creating the third largest nonprofit in the nation.

Earlier this year, Aurora removed an entire page on diversity, equity and inclusion. The page now redirects to Advocate’s page titled “Access & Opportunity.”

That change cut statements such as: “Our diversity, equity and inclusion strategy is anchored by our purpose to help people live well and to deliver safe, consistent, and equitable health outcomes and experiences for the patients and communities we serve.”

A spokesperson for Aurora Health Care said the organization will continue to “deliver compassionate, high-quality, consistent care for all those we serve.”

“As our newly combined purpose and commitments state, we lift everyone up by ensuring access and opportunity for all,” the spokesperson said. “To provide our patients and communities clear and consistent information that explains our programs, policies and services, we are making various changes to our websites.”

Ascension, one of the largest nonprofit hospital systems in the nation, took down the entire page on diversity, equity and inclusion. The health care system currently operates at over 165 locations in Milwaukee, Racine, Appleton and Fox Valley.  The system still has modules on “Identifying & Addressing Barriers to Health” and “Ensuring Health Equity.” Ascension did not respond to a request for a comment.

Making a statement

UW Health removed its page on diversity, equity and inclusion, replacing it with a page titled “social impact in belonging.” In doing so, UW Health removed “anti-racism” from its entire website. It used to be one of the main themes.

UW Health removed the anti-racism modules titled “Being a leader in anti-racism” and “anti-racism funding,” and now in their place are modules called “Being a social impact leader” and “Community giving.”

Chief Social Impact Officer Shiva Bidar-Sielaff and CEO Alan Kaplan addressed the changes in a video, stating social impact and belonging align with their mission, values and strategies as a health care organization.

“At UW Health, social impact refers to the effects health care policies, practices and interventions have on the well-being of individuals and communities, improving health outcomes, access to care and quality of life,” Bidar-Sielaff said. “Belonging is the understanding that you are valued and respected for who you are as an individual.”

UW Health reported receiving $315 million in federal funding, totaling over half of the $622 million in grant funds — federal and non-federal — awarded to the School of Medicine and Public Health. That total is 37% of all grant funding awarded to UW-Madison.

Despite claims by health care centers that missions remain the same, advocacy groups in Wisconsin are raising concerns regarding the impact these changes could have on communities in Wisconsin.

Chris Allen, president and CEO of Diverse & Resilient — an advocacy group focused on health inequities for LGBTQ+ people in Wisconsin — said these quiet language shifts are significant.

“They send a message that commitments to addressing disparities may be weakening, even if that’s not the stated intention,” Allen said.

William Parke Sutherland, government affairs director at Kids Forward, a statewide policy center that advocates for low-income and minority families, said many health care partners feel pressured to preserve funding sources.

In Wisconsin, maternal mortality rates are 2.5 times higher for Black women than white women. Maternal morbidities — or serious birth complications — were the highest among Black women and people enrolled in BadgerCare, the state’s largest Medicaid program. From 2020 to 2022 there were 7.8 stillbirth deaths per 1,000 births among Black babies, compared with 4.5 among white babies.

Disparities in maternal and infant mortality rates could be attributed to stress caused by poverty, lack of access to quality care, or systemic racism, according to health care researchers. If a mother is stressed over a long period of time, that can cause elevated levels of stress hormones, which could increase premature births or low birth weights for infants.

For Black women, midwives have been found to reduce the disparities they otherwise may experience during pregnancy, reducing the risk of maternal mortality or morbidity. Access to midwives is currently covered by Medicaid, so losing federal funding could harm these services.

Regardless of language, “Wisconsin’s racial disparities in health access and outcomes aren’t going away on their own,” Sutherland said in an email.

Removing language that acknowledges DEI efforts will not reduce the health care disparities felt by Wisconsin residents, Sutherland said. Federal funding cuts could also hurt rural families in Wisconsin, specifically those who rely on Medicaid for their health care needs.

“We cannot begin to address these challenges if we’re not willing to acknowledge them,” Sutherland said. “A colorblind approach has not helped in the past.”

This article first appeared on Wisconsin Watch and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.