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.”