The fate of federal health care reform now hangs on the U.S. Supreme Court, which will rule next year on whether the measure can take effect.
But even if the 2010 law aimed at making health insurance available to all is upheld, how it will get implemented in Wisconsin is, at best, uncertain.
Walker administration officials in charge of putting the sweeping law into effect are openly hostile to the Patient Protection and Affordable Care Act, the formal name for the bill that Pres. Barack Obama signed into law after a grinding, yearlong battle in Congress. GOP legislators and the party's base are just as opposed.
Gov. Scott Walker did not wait long to take on the law. On the day of his Jan. 3 inauguration, he authorized Attorney General J.B. Van Hollen to join a multi-state lawsuit seeking to block the law. Later that week, the new Republican co-chairs of a special legislative committee in charge of implementing health care reform canceled the panel's next meeting. It hasn't met since.
And before the month was out, Walker had issued an executive order creating the Office of Free Market Health Care. The agency, a joint project of the Department of Health Services (DHS) and the Office of the Commissioner of Insurance, is charged with implementing the federal law's centerpiece requirement: a state health insurance "exchange" where consumers can shop for and purchase health insurance.
Walker's executive order mandated that the office take a "free-market, consumer-driven approach" in its mission. But he also directed it to explore ways to avoid having to establish a health insurance exchange at all.
These moves are the polar opposite of the approach taken by former Gov. Jim Doyle, who made the expansion of health care coverage a priority during his two terms in office.
"The vision of the Doyle administration was to build an exchange that would be as widely available as possible to residents in Wisconsin," says Tom Oliver, a professor and researcher at the University of Wisconsin Population Health Institute. That included the possibility of small businesses participating in the exchange in order to get better deals than they currently have access to in the market, adds Oliver.
The Doyle approach had the potential to "really rearrange the health care marketplace" by building a large pool of insured individuals and groups for whom health plans must compete on a level playing field, says Oliver. Ensuring that plans have real competition and that health coverage reaches both the very sick and very healthy is crucial to holding down costs for society as a whole, he adds.
Under Walker, the scope of the exchange has been narrowed to serve "only those who absolutely have no other options for health insurance coverage."
Beth Kaplan, a DHS spokeswoman who responded to an ,i>Isthmus request for an interview with someone from the Office of Free Market Health Care, said no one would be available. "There really is no news," she said, before emailing links to two press releases from the agency that were critical of the federal law.
Under the Patient Protection and Affordable Care Act, a federal grant program was established to inform consumers about their rights and responsibilities under the law, help consumers file complaints and appeals against insurers, and assist them in enrolling in health insurance plans.
States participating in the $30 million grant program also are required to keep data on consumer inquiries and complaints. This is intended to shed light on problems in the health insurance marketplace and to strengthen enforcement of the act.
In February, the state Office of the Commissioner of Insurance pulled out of the program.
In a statement posted on its website, the agency claimed it and "other public and private entities in Wisconsin [are] efficiently providing these services and that spending taxpayer money on the same services was duplicative and unnecessary."
The agency - which is supposed to police the insurance industry - advised consumers with questions about private health insurance to contact their employer or a health insurance salesperson.
The administration's continued efforts to undermine health care reform in Wisconsin were nowhere more clear than when the Office of Free Market Health Care released a report in August on the projected impact of the federal law.
The report, which had been commissioned by the Doyle administration, says that health care reform would extend coverage to 350,000 more people in Wisconsin, in part by expanding the market for affordable individual insurance for people who don't get coverage through work.
It also noted, among other things, that the law would lower insurance rates for older, sicker patients who might otherwise be priced out of any insurance at all.
Yet none of these points were reflected in the state's commentary on the measure. Instead, a news release issued by the Department of Health Services spun the results in an extremely negative light.
DHS claimed that the state's "traditional non-group insurance market" - in other words, people who have to buy their own insurance - would dwindle from 180,000 people to 30,000 and that another estimated 100,000 "will be involuntarily dropped from employer-sponsored health insurance."
The DHS release also said that 40% of individual insurance customers "will be forced to purchase richer health insurance benefit packages than they need."
This, presumably, because the federal law sets minimum standards for what insurance covers.
The release does not acknowledge that tax subsidies would be available to help make that insurance more affordable or that competition within the exchange is expected to drive down the cost of coverage. And it also ignores the likelihood that at least some of those policyholders need more than they get now, but just can't afford it under the current system.
A co-author of the report pointed out other distortions in the agency's news release and an associated op-ed article by DHS Secretary Dennis Smith.
MIT economist Jon Gruber, in an op-ed for WisOpinion.com, said the state's claim that the individual insurance market would shrink to 30,000 ignored the state health insurance exchange, which would grow that market to cover 320,000 people.
He also responded to DHS's criticism that some people's premiums would rise. Gruber acknowledged that was true, but explained it was because the federal law requires setting insurance rates based on the health of the whole community. Insurers now charge young, healthy people less and older, sicker people more.
Health care reform "will dramatically reduce the number of uninsured in the state, while creating both winners and losers among the existing non-group insurance holders," Gruber concluded. "The losers are those young and healthy individuals who benefited from discriminatory pricing in a lightly regulated insurance market."
Like the Walker administration, GOP legislators are doing everything they can to block implementation of health care reform or limit its reach. A bill now before the Assembly, for instance, would bar insurance plans sold through the state exchange from covering abortions.
And in November, Republican Sen. Frank Lasee of De Pere announced he planned to kill a state bill to implement the federal law. That bill had earlier passed the Republican-controlled Assembly 57 to 39; all but two Democrats voted against it, considering it too weak in consumer protection.
Even so, Republican activists condemned the Assembly vote and praised Lasee. They also criticized Walker's insurance commissioner for issuing an emergency rule that put into effect certain provisions in the killed law, mainly to ensure that state regulation of insurers would be consistent with federal law.
Health care advocates complain that GOP efforts to stall implementation of the state's health care exchange come at the same time the Walker administration is proposing wide-scale cuts to health insurance for low-income residents. The Wisconsin Legislative Fiscal Bureau projects the cuts could result in as many as 64,000 people being dropped from Medicaid and BadgerCare.
The fate of these programs and the people they serve are intertwined with the federal law, say advocates.
"We should be moving into a seamless system where either you're going to qualify for a Medicaid program, you're going to be offered employer-sponsored insurance, or you should be able to access affordable, quality health care through a state exchange," says Sara Finger, executive director of the Wisconsin Alliance for Women's Health.
"[Instead], they're saying that we're just going to shift people toward the exchanges that aren't even set up. It's kind of like leading people to a bridge that this administration is hoping blows up."