Health care. It is one of the most basic needs for all citizens, yet there are citizens who do not have access to quality care for various reasons.

In response to this need, the federal government enacted the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act last month to help those vulnerable citizens get coverage.

There have been many who criticize the merits — and the legality — of this set of bills. In particular, Wisconsin Attorney General J. B. Van Hollen requested permission from state leaders to join with other state attorney generals to file suit contesting the constitutionality of the bills.

However, most agree these bills will make sweeping changes across the nation with effects varying depending on each state.

For example, while Wisconsin has always been a leader in health care, Department of Health Services spokesperson Seth Boffeli said the state will still need to make adjustments to meet the new national health care standards.

The bills

The House of Representatives first passed the Affordable Health Care for America Act in November 2009 as a means of reforming the U.S. health care system, but this bill did not make it past the Senate. Instead, the Senate crafted the PPACA, which the House then passed, along with the HCERA to amend parts of the PPACA.

The PPACA prohibits insurance companies from rating customers based on preexisting health conditions or current health status, and it set up a national “health insurance exchange” where qualifying insurance companies can be listed on a marketplace for consumers to browse the best coverage option.

This bill also forms a public health insurance option to ensure competition, allow for unmarried older children to stay on their parents’ insurance up to age 26 and offer small businesses and low-income residents tax credits to help them afford coverage.

The HCERA also makes such amendments to the PPACA as increasing tax credits to buy insurance, closing the Medicare Part D coverage gap, giving seniors a $250 rebate and having the government pay the total costs of Medicaid expansion from 2014 until 2016, when the percentage will decrease incrementally to 90 percent after 2019.

“As I looked across the well of the House, I saw so many of my colleagues tearing up because I think like me they sense the … history of this vote, the history of this moment,” U.S. Rep. Tammy Baldwin, D-Wis. said in a video statement following the PPACA floor vote.

However, U.S. Rep. Paul Ryan, R-Wis. did not share Baldwin’s opinion of the bills and criticized the government’s “power grab” during the March 21 floor debate.

“Health care affects each and every one of us. It is the most personal thing there is. And yet, here we are debating whether the government should have a bigger role in making those decisions,” Ryan said.

Wisconsin’s changes

According to Boffeli, the key changes to Medicaid and the state’s own BadgerCare program deal with eligibility options.

Boffeli said the new income level to qualify for Medicaid will be 133 percent of the poverty level, as compared to the current 200 percent poverty level requirement for the BadgerCare Core Plus program for childless adults.

Core Plus ran into issues last October when the DHS had to cap enrollment and start a waiting list due to budget constraints. The state Legislature recently passed a bill to create BadgerCare Basic as an alternative where participants pay around $130 per month for low-level health coverage.

“In order to maximize the number of people that can get into Basic with the available money, we curtailed the coverage available below the benchmark level for Medicaid,” Boffeli said. “When the national health care reform starts in 2014, they will be eligible for Medicaid.”

BadgerCare Basic, Boffeli said, is only meant to be a temporary step for those waiting to get on the Core Plus plan, and Core Plus in turn is a bridge until the federal reform bills go into effect.

The new eligibility standards will deal with income levels, not individual groups.

The biggest benefit for seniors in the reforms, Boffeli said, is the $250 rebate to help offset the Medicare Part D coverage gap, which forces some seniors to pay out of pocket for their prescriptions. However, he added the state’s SeniorCare prescription drug assistance program will not be affected because it is separate from Medicare.

Boffeli said the online health care exchange set up under the reforms will help those looking for insurance save a lot of money while finding the right plan for their needs.

“You can go online, whether looking for BadgerCare or private insurance coverage, and just type in who you are and what you’re looking for, then it sends back plans you can choose from along with the prices,” Boffeli said. “For insurance companies, the benefit is that they can offer lower rates because of the volume.”

Dan Schwartzer, spokesperson for the Wisconsin Association of Health Underwriters, disagreed the exchange would benefit insurance companies or consumers.

Schwartzer said it will be hard for insurers in the exchange to keep premiums low due to all the taxes put on the companies under the new reforms, so many insurers will drop out of the market, resulting in “quasi single-payer government insurance.”

“We do need health care reform, but we need it on costs, and [these bills] didn’t accomplish that,” Schwartzer said.

He added by providing a subsidy to those who get coverage through the exchange, the costs will only artificially be lowered and will not benefit those insurance companies.

Linda Reivitz, a University of Wisconsin faculty associate in nursing, said she thinks the exchange will benefit consumers by providing more choices and more knowledge of costs and coverage included in policies.

“To me, the purpose of an exchange is to provide people with choices, and a lot now don’t have choices,” Reivitz said. “Right now, if you say to someone ‘Call and ask your insurance a question of care cost at…(various clinics),’ they will say, ‘We can’t tell you that now.’ The exchange can provide that transparency for consumers.”

Reivitz added if insurance companies feel they cannot get enough business through an exchange system, she could understand why they would not be enthusiastic about the reforms.

Looking forward

Boffeli said one of the first steps for states is to come up with a plan to implement an insurance exchange by the year 2014.

“There is money out there for all states to set up exchanges. They have to demonstrate they are ready and have plans in place,” Boffeli said. “If they don’t, the feds come in and create one for them.”

Another first step, Boffeli said, is for states to apply for money to set up an insurance pool for high-risk individuals. Wisconsin, he said, has already done this through its Health Insurance Risk-Sharing Plan, so depending on the funding awarded, the state will decide how to improve the program.

He added there will also be to be an option for people whose income falls between 200 percent of poverty level — the Core Plus requirement — and the new Medicaid standard of 130 percent of poverty level, but those decisions lie two to three years in the future.

Reivitz said she is happy the reform bill passed, but the future effects of these bills on health care costs are still unclear.

“[The bills] will provide insurance and access to providers for many who are now uninsured, but it remains to be seen whether the legislation will also help to control health care costs,” Reivitz said. “I think the only thing you can say is that Congress just started health reform. This is not the end, this is the beginning.”

She added the mandate in the bills stating individuals must have some health insurance coverage is likely to be an issue brought before the U.S. Supreme Court.

That mandate is what spurred Van Hollen to write a letter to Gov. Jim Doyle and legislative leaders asking for their permission to join the other state attorney generals in filing suit against the federal government.

However, legislation proposed by Rep. Roger Roth, R-Appleton, to allow Van Hollen to proceed did not make it to the agenda of the floor vote April 22, the last day of the legislative session.

Department of Justice spokesperson Bill Cosh said Van Hollen told Fox News host Greta Van Susteren during a recent interview the next option could be to resubmit a request, depending on if there is a Republican governor or a Republican-controlled Legislature in the future.

“Because the most egregious parts of the reform … won’t be implemented until 2014, that gives time for a change in governors or legislature in order to bring suit,” Cosh said.

UW political science professor Donald Downs agreed there will most likely be legal consequences for the mandate, but the law is not exactly clear either way on the issue.

Downs said the states could make an argument Congress is overreaching its bounds in requiring individuals to purchase a health care plan or face a penalty.

“[The reform] does raise a question of liberties. I don’t think the courts have dealt with a situation where the government requires someone to do something,” Downs said. “Usually there are conditions where you have to do something to get a government benefit.”

Downs also said in an e-mail to The Badger Herald that the federal government could defend its actions by saying the law falls under the “necessary and proper” clause of the Constitution.

He added the federal government will have to show this law would not “open Pandora’s box” to future laws giving too much government control over citizens’ choices — a “Nanny State.”

“The problem is that the government can’t pay for this enormously expensive bill unless it requires everyone to be covered and paid for by their employers or by themselves,” Downs said in the e-mail. “The key question (is) if this mandate is okay, what about other mandates to individuals?”

Boffeli said no matter what the feelings on the reform, the main priority for DHS is informing citizens on what these reforms mean. He added the website of the newly-created Office of Health Care Reform offers fact sheets and updates for residents.