Tom Oliver & Donna Friedsam: Reform in the Badger State

Tom Oliver, Ph.D., M.H.A., is Associate Professor of Population Health Sciences at the University of Wisconsin School of Medicine and Public Health and Associate Director for Health Policy at the University of Wisconsin Population Health Institute. His research examines the processes of policy development and implementation, and how issues of technical, economic, and political feasibility shape the substantive design of health policies. His current work includes studies of state health insurance reforms; the use of country health rankings to stimulate and guide population health improvement; the prospects for national health reform; strategies used by foundations to influence health policy; and patterns of new governance in the renewed war on cancer in the U.S. and European Union.

Donna Friedsam, M.P.H. is Director of Health Policy Programs at the University of Wisconsin Population Health Institute. Her work focuses on health care financing, coverage and access. Additional research interests include health care quality, disparities in health status and health care utilization, Medicaid and other safety net programs, care delivery setting and its relationship to continuity, quality, and outcomes.

Tom and Donna’s SHARE project seeks to evaluate program simplification initiatives that are part of Wisconsin’s BadgerCare Plus program. In this interview, we talked about the unsexy side of reform efforts, causal arrows, and edgy Wisconsin public radio.

One of the goals of the BadgerCare Plus reform is to provide access to health insurance to 98% of Wisconsin citizens – near universal coverage. Why hasn’t the media publicized it more?

FRIEDSAM: With BadgerCare Plus, Wisconsin is not restructuring the employer or private commercial insurance market. The reform aims to leverage a federal program to its maximum potential and make incremental changes to enhance access. Compared to a major restructuring, this effort does not seem as dramatic or sexy. Also, while the state’s goal is 98% access to affordable insurance, this is not the same as the kind of universal coverage initiatives that involve employer and individual mandates, which tend to attract more interest and debate.

OLIVER: Speaking as a political scientist, states such as Massachusetts and California have had highly visible elected officials that were active on this issue in a very public way. Although Wisconsin Governor Jim Doyle was a critical leader in creating BadgerCare Plus, the program became less visible as the legislature debated – and ultimately defeated- a much higher-profile universal single-payer proposal, which Governor Doyle did not support.

Why didn’t Wisconsin undertake the “sexy” option?

OLIVER: Wisconsin still has a relatively strong employer-based insurance system in comparison to other states. That lends itself to a strategy of protecting this system while acknowledging that there are individuals and families unable to get employer-based coverage. A real concern here was dealing with crowd-out - helping those unable to get coverage while preserving and promoting employer-sponsored coverage.

Is the issue of crowd-out the reason for the aggressive premium assistance portion of the plan?

FRIEDSAM: Premium assistance is part of an aggressive package of elements to support employer-sponsored insurance and prevent crowd-out. Given the number of protections in place, the possibility of individuals opting out of employer-sponsored insurance is fairly small. Nonetheless, we will be studying employers’ responses to this program in terms of changes in their offering of insurance.

How has the introduction of BadgerCare Plus affected access to health care in Wisconsin?

FRIEDSAM: BadgerCare Plus has significantly improved access, with over 90,000 new members—over 60,000 of them children—in its first 9 months. But we have to address a variety of disparities in costs and health outcomes. Although Wisconsin gets high marks for quality, it has very poor outcomes for minority populations and is among the highest in health disparities among states. For private insurers and employers, Wisconsin is also a high cost state. Medical care in six of our metropolitan areas is ranked among the highest priced regions in the country.

Does BadgerCare Plus address these disparities?

OLIVER: The fundamental question is whether a state first must walk the path to universal coverage before it can turn its attention to quality and efficiency. Which way does the causal arrow point? History and international experience suggests that coverage should come first in order to adequately tackle questions of efficiency. From a pragmatic standpoint, however, there is a need to deal with the efficiency of the delivery system in order to keep the system affordable.

When BadgerCare Plus is implemented and evaluated, what will other states be able to learn from Wisconsin’s experience?

OLIVER: Wisconsin is trying to reduce the number of residents who are eligible but not enrolled in its public health insurance programs by consolidating the categorical pathways to eligibility, expanding eligibility opportunities, and increasing awareness about the programs through well-planned outreach efforts. Our aim is to identify the promise and limitations of this broad and aggressive enrollment simplification and outreach, and how well this performs relative to more dramatic insurance market restructuring. This should be of great interest to other states.

FRIEDSAM: Another major point of interest to other states is how BadgerCare Plus addresses affordability of cost-sharing in the program, and churning or continuity of coverage. We are interested in understanding whether people who are eligible do not enroll due to cost sharing, and what happens to people when they leave this program, which is a reality faced by all states.

Dr. Oliver, you are a recent transplant from Baltimore, how do you like the Midwest?

OLIVER: I was thrilled with the opportunity to come to the University of Wisconsin, especially the chance to participate in the effort here to truly integrate medicine and public health. The university and my colleagues here are great. The University has a good relationship with the state government and we try to work hand in hand. I think it’s a wonderful paradigm – the Wisconsin idea that we’re going to work with people and try to inform important actions affecting every part of the state. My father was the dean of the University of Minnesota School of Dentistry years ago, so although I have not really lived here before the Midwest is still familiar territory for me.

What would you recommend for a first time visitor to Madison?

OLIVER: The first thing you should do is get a sandwich and a beer and sit at the lakefront on the Wisconsin
Union Terrace. There are beautiful views and great music.

FRIEDSAM: Madison is very bike-friendly and has some gorgeous bike trails. I would also recommend a visit to the
State Capitol, which is considered one of the most beautiful in the country. It also bears the distinction of being the only Capitol ever built on an isthmus.

OLIVER: If you can’t visit the city, you should listen to Michael Feldman’s public radio show. Garrison Keillor captures the friendly and folksy Midwest, whereas Michael Feldman is a funny, edgy cynic. He conducts interviews with all kinds of people and turns it into comedy. My sister got interviewed last weekend. You have to be a glutton for punishment.