Wisconsin health leaders worry future work requirements for Medicaid recipients will create both an administrative and ethical burden for doctors and other providers
Starting next year, adults ages 19 to 64 will be required to work, go to school or volunteer for 80 hours per month to qualify for coverage under the safety-net program
The new rule, which was included in Republicans’ “One Big Beautiful Bill Act” last year, provides exemptions for several groups, including people who are pregnant, live with children under 19 and those with a recognized disability
There is also an exemption for people with serious or complex medical conditions, or those considered “medically frail.”
In guidance released in June, the Centers for Medicare and Medicaid Services, or CMS, said state Medicaid programs should consider not only a person’s diagnosis or condition but also “the extent to which the condition impairs an individual’s ability” to meet the new requirements
But Dr. Ken Schellhase, a primary care physician and member of the Wisconsin Medical Society, said making that determination is not simple, even for a doctor
“That will require training and skills that the typical primary care doc does not have,” he said. “Honestly, that’s a big reason why most docs in primary care practices don’t do the official disability evaluations for Social Security.”
Doctors working in occupational medicine or rehabilitation are specially trained to objectively determine someone’s functional capacity, Schellhase said, but few such providers practice in those fields
Speaking to reporters on July 30, Wisconsin Department of Health Services Secretary Kirsten Johnson said the state needs more guidance from CMS as it develops a system for verifying who qualifies for the exemption
She said DHS plans to use existing records like medical billing to verify that someone is unable to meet the work requirements. CMS will also allow recipients during the first year to self-attest that they are unable to work
Scott Stewart, CEO of the Wisconsin Primary Health Care Association, said the existing system for health insurance claims is not designed to indicate a person’s level of impairment or their ability to work
“It’s set up to say this is what a patient has, but it’s not set up to say anything more than that,” Stewart said. “You have to really also think about the privacy aspects of that. Now you’re saying that I have to potentially give a patient’s chart, which they have to sign off on in terms of HIPAA, to say that they are medically frail and meet all definitions?”
Schellhase worries that involving medical charting and billing could influence how doctors care for their patients, including how quickly they make a diagnosis. He described someone seeking for treatment of asthma symptoms
“Not everybody who wheezes has asthma, and so sometimes we struggle with as a diagnosis code,” he said. “Do we put in just wheezing? Or have we seen it enough times, but it’s just not absolutely confirmed that yeah, this person probably has asthma? There’s a lot of gray area in that.”
He said patients with conditions not considered severe enough for exemption could see their health decline if they lose health insurance. And he worries the new process will create a conflict of interest for doctors who have a professional obligation to help, not harm, their patients
“We’re supposed to be that patient’s advocate, to do whatever’s in our power to help them and get them the help that we think that they need,” he said
Stewart, whose organization represents the state’s federally supported community health centers, said increasing paperwork requirements have lead to more people losing access to care
He’s concerned that health systems will be incentivized to help patients qualify for an exemption to keep their coverage so providers can continue to bill the program for care
“We’ve seen issues with the Medicare Advantage program and things like that in the same way, around wanting patients to have access to these programs, but having the kind of perverse financial incentive to get them on (the program),” he said
WPR contacted several major Wisconsin health systems for comment on the potential impact of the work requirements but received no responses
The Wisconsin Hospital Association, or WHA, declined WPR’s interview request. In a statement, WHA’s senior vice president for finance and payment, Christian Moran, said the association appreciates DHS’s efforts to “minimize additional regulatory burdens on hospitals and providers while helping eligible individuals maintain Medicaid coverage and reducing the risk of higher uncompensated care in Wisconsin hospitals.”
Moran wrote that WHA will continue to watch the state agency’s plans as more details become available
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