Frederica Freyberg:

I'm Frederica Freyberg. Tonight on “Here and Now,” a “First Look” at the Republican American Health Care Act, what it means in Wisconsin. After that, a “Closer Look” at what potential federal cuts to great lakes restoration efforts may cause. Then, in our “WisContext” segment, the water battle ongoing in Waukesha. It’s “Here and Now” for March 10.

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Funding for “Here and Now” is provided, in part, by Friends of Wisconsin Public Television.

Paul Ryan:

It repeals Obamacare's taxes. It repeals Obamacare’s spending. It repeals Obamacare's mandates. It creates a vibrant market where insurance companies compete for your business, where you have lower costs, more choices and greater control over your health care.

Frederica Freyberg:

House Speaker Paul Ryan. A “First Look” tonight at the GOP repeal and replace plan for Obamacare. Here’s a statement on the bill from the other side of the aisle from Wisconsin U.S. Senator Democrat Tammy Baldwin. She says quote President Trump promised insurance for everybody, but Trumpcare breaks that promise by putting millions of people she says at risk of losing health care coverage and forcing millions to pay more for less care. Here are the major provisions of the American Health Care Act: it gets rid of mandates to have insurance, replacing those with a 30% surcharge on policies if plans have lapsed. It replaces income-based subsidies with tax credits mostly based on age. For example, those aged 20 to 29 would get a $2,000 credit. Those 60 and older would receive $4,000 to help cover insurance costs. It maintains allowing dependents to stay on parents’ insurance plans until age 26, bans coverage denial based on preexisting conditions and bans caps on coverage. On Medicaid, it gives states a per capita amount based on how much they spent in 2016. Now, the GOP plan also repeals a tax on high-income earners that helped pay for Obamacare. So who are the winners and losers and how does the new plan treat Wisconsin? We turn to expert Donna Friedsam, policy director at the Population Health Institute at UW-Madison. Thanks very much for being here.

Donna Friedsam:

Good to be with you.

Frederica Freyberg:

So as to that first question, who are the winners and losers in this?

Donna Friedsam:

Well, I should start out by saying that we don’t have the definitive evidence right now because we’re awaiting the congressional budget office to score the bill. That’s a standard procedure with legislation. Generally, when we have legislation in Congress, the Congressional Budget Office, which is a nonpartisan agency, will go through a bill and do its scoring procedure and we’ll learn from them what the bill will cost and how it will have various impacts. This is a little unusual in the fast track that we’re on right now, that the house is going ahead and voting on the bill without having the CBO score. So we can only go, given that we don’t have a CBO score, we’re expecting it to come out around March 13, right now we can only go on the various estimates out there from a range of different analysts that are affiliated with different groups or think tanks and the like. So I’m just going to preface my comments with that. From reading across the various spectrum, partisan spectrum and from different academic analysts and the like, it looks like the way the tax credits are structured and the various other provisions of the bill will have different impacts on different people. So that certainly young people will benefit from this relative to older people. People in urban areas where the premiums might be lower than rural areas might benefit. And people with higher income will benefit relative to lower income. If you want to talk about winners and losers, that’s a way of framing it. Younger people, people with higher incomes and people in areas where premiums are lower, usually urban areas, are going to so-call win and people who are older or sicker and people who are in rural areas and with lower incomes will so-call lose.

Frederica Freyberg:

So with that said, how do you think it treats Wisconsin?

Donna Friedsam:

So Wisconsin is going to be no different than other states in that regard. Wisconsin happens to have quite a large number of people relative to many other states enrolled in the Affordable Care Act or Obamacare. So we have about 230,000 people enrolled right now in Affordable Care Act plans. And that’s throughout the state. So in — our rural counties actually have larger percentages of their population enrolled in Obamacare policies than do our urban counties. So we have a fairly significant investment in our state in the Affordable Care Act as it stands today. About — of the 230,000 people that are enrolled in Obamacare, about 84% of them are currently able to enroll in Obamacare plans because of the availability of the premium subsidies, which are tax credits. So those people, the 190,000 people who currently get those tax credits in our state, are going to be at some risk with the change in tax credit structure.

Frederica Freyberg:

Because, as we described in the introduction, the tax credit structure, and, again, looking at older people and younger people, let’s say for somebody over 60, income $75,000 or less, it’s a $4,000 tax credit. How does that compare to what someone in Wisconsin in that demographic would be getting if they were enrolled in an Obamacare plan?

Donna Friedsam:

So keep in mind that the bill in the House currently, the subsidies are not linked to income. They’re linked to age.

Frederica Freyberg:

Right.

Donna Friedsam:

But it’s capped at $75,000 for an individual and $150,000 for a family. So the $4,000 credit would be available to a person over age 60 and $2,000 credit for a younger person around age 20. So $2,000, $3,000, $4,000. That’s much less in subsidy than what’s currently available under the Affordable Care Act. So while a $2,000 credit might be fairly significant for a young, healthy person to be able to buy a fairly thin health insurance coverage because that’s all they need, so maybe it will cover most of their cost, but $4,000 for a 60-year-old low-income person is not going to come near what they would need to purchase their policy. It may not even cover a third or a quarter of what they would need to purchase a health insurance policy.

Frederica Freyberg:

And then meanwhile kind of tacked onto that this GOP plan would allow insurers to charge older people five times more than they charge younger customers and that’s more also than the Affordable Care Act.

Donna Friedsam:

Right. The Affordable Care Act has what we call rate bans that allow insurers to vary the rate three to one. So a person that’s the same in every other way except age, they can charge three times more. And this bill changes it to five times more. Now, that’s not necessarily a bad idea if you provide proper subsidies for lower-income people to afford that. But the challenge here is that these subsidies are linked to age but not to income. So you could have a 60-year-old who’s making $75,000 a year getting the same $4,000 that a 60-year-old that makes $10,000 a year. And so it’s very unlikely that that low-income older person is going to be able to afford that coverage.

Frederica Freyberg:

As long as we’re talking about young and old and kind of the insurance pool, I know that the GOP talks all the time about how Obamacare is in a definite death spiral. Is that true?

Donna Friedsam:

Most — I would say that most objective observers would say that it’s not the case that Obamacare is in a death spiral. Certainly there were and are challenges with regard to trying to get more younger and healthier people into the insurance pool and there are fixes that can and should be made to either the existing law or a change in the law to get more younger, healthy people in. But a death spiral would be if we were observing a decline in enrollment, which we are not. We saw more people in Wisconsin enroll this year than we did last year. And it would say that there’s an increase in premiums that we were unable to identify reasons why and unable to fix those reasons. And that is not the case.

Frederica Freyberg:

All right. I want to ask about another prong of this and there are many more I want to ask about, but it is this issue of high-risk pools envisioned in this plan.

Donna Friedsam:

Right.

Frederica Freyberg:

Would you expect those to work?

Donna Friedsam:

So we did have a high-risk pool in Wisconsin before Obamacare. I do want to say I use Obamacare and the ACA interchangeably. And it was called HIRSP and it was a very successful plan by most accounts for what it did do. It served people who could not get insurance elsewhere and who had various conditions. The issue with HIRSP was that at the height of its enrollment, it enrolled about 21,000 people and it was still fairly expensive for people to enroll and there was a six-month waiting period for people with preexisting conditions.

People still found it fairly expensive even with some available subsidies by the state to purchase that insurance. So think about at the time that HIRSP existed and reached its peak enrollment at 21,000, we still had over half a million people in our state who were uninsured. And those people just couldn’t find available or affordable options for themselves for various reasons. So it was not a solution at the time. People do talk about various ways to make high-risk pools more tenable, but it would by most analyses require a lot more money to make it work for the population than what is contemplated in the current bill.

Frederica Freyberg:

Let's talk about, speaking of a lot of money, talk about Medicaid. The new plan would give states a per capita amount based on 2016 spending. Does that hurt Wisconsin, which didn’t take the expansion?

Donna Friedsam:

So it’s a rather complicated answer. There are provisions in the bill to allow an extra amount of money to states that did not participate in the Affordable Care Act’s expansion and to allow them to do various things to bring them toward some kind of equity with states that did take the Affordable Care Act expansion. So it’s not a direct hurt, as some people might characterize it. The bigger concern, I think, is that the per capita caps would pin the amount that the federal government is going to pay the state to 2016 outlays and whatever we’re paying now per individual, according to five different groups: children, parents, elderly, et cetera. And it would say whatever we’re paying now plus the rate — the CPI and 1%, that’s what the federal government is going to contribute going into the future regardless of what the expenses turn out to be for these different populations. And I think most, many analysts would suggest that the rate of cost for these populations is very likely going to exceed that rate of inflation, number one. And for Wisconsin right now, we actually are at the low end of what we pay per capita for several of these populations relative to other states. So we’re going to start out at a baseline getting a lower per capita payment than many of these other states and in that regard we may end up being relatively disadvantaged.

Frederica Freyberg:

Let's take a listen to another soundbite from Speaker Paul Ryan who was talking specifically about how states can manage their Medicaid.

Paul Ryan:

Our problems in Wisconsin are a whole lot different than the problems they have in New York or in Nevada or in Utah or California. So we propose more efficient spending, bring the spending on Medicaid to something that is sustainable so it doesn’t go bankrupt and have a safety net for the most vulnerable. Give local control to our states and our governors so they can craft and customize Medicaid to work for their populations.

Frederica Freyberg:

When he says bring the Medicaid to something that is sustainable, does that sound like a cut?

Donna Friedsam:

Well, I mean, people use the word differently, but certainly it may be sustainable for the federal government. It will certainly provide some control and large cuts in the amount of federal spending toward the Medicaid program. The states are going to be left having to manage with a lot less federal money in their pockets. For the current Medicaid program and going forward, they will have a declining amount of federal share and will have to figure out how to work with much less federal contribution. The only way to handle that, there’s three ways. They can reduce the eligibility, so the way that people can get enrolled in the program. They can reduce the benefits in the program. Or they can reduce payments to providers. But they’re going to have to figure out as the rate of costs in the Medicaid program increase more than the federal contribution, states are going to be left having to handle that within their own budgets, unless they’re willing of course to allocate more money to the Medicaid program.

Frederica Freyberg:

Now overall does this new plan in your estimation result in fewer people being insured, as Tammy Baldwin would say?

Donna Friedsam:

From what we know today — and again we’re waiting for the Congressional Budget Office to weigh in so I don’t have definitive estimates, but the various estimates that are out there suggest that anywhere from 10 to 20 million people will lose insurance under the current plan. And if you listen to the House leadership talking about the plan, they’re not trying to suggest that that isn’t the case. They’re saying we’re not trying to measure the plan by the amount of people covered under insurance. We’re measuring the plan by a number of different factors. And so I think that we need to decide are we interested in maintaining the level of insurance coverage per se or are we interested in some other policy goals?

Frederica Freyberg:

All right. We need to leave it there. Thank you very much for your expertise on this.

Donna Friedsam:

Thank you.

Frederica Freyberg:

A “Closer Look” now at a federal proposal to drastically cut annual funding to the Great Lakes Restoration Initiative, from $300 million to $10 million. The initiative began in 2010 to speed up efforts to protect and restore the Great Lakes, described as the largest system of fresh surface water in the world. The initiative works to clean up particular areas of concern, prevents and controls invasive species, reduce algae blooms and restores habitat. Last year alone, Wisconsin saw nearly $300 million in funding from the Initiative. In tonight’s “Closer Look,” potential impact of cuts to Great Lakes restoration. Joel Brammeier is the president of Alliance for the Great Lakes. He joins us from Chicago and thanks very much for doing so.

Joel Brammeier:

Thanks for having me.

Frederica Freyberg:

Well, first, what is your reaction to the proposed funding cuts?

Joel Brammeier:

Well, the cuts would be devastating to the Great Lakes. The Great Lakes Restoration Initiative has really brought the region back from the brink, in terms of supporting clean-ups of some of these contaminated sites, protecting the Great Lakes from things like Asian carp which made headlines several years ago. And so the program has been wildly successful. It’s funded more than 2,000 projects across the Great Lakes region and we’re really looking forward to continue and we think it can because it has a lot of bipartisan support in Congress.

Frederica Freyberg:

The Great Lakes Restoration Initiative is funding to kind of accelerate clean-up. Could it be regarded as a booster fund in addition to other efforts that are already ongoing?

Joel Brammeier:

Well, states and cities are also spending millions of dollars every year to restore the Great Lakes. And what the Great Lakes Restoration Initiative has done has really brought all of that effort together as a partnership from the federal level all the way down to the local level. And so you’re actually now seeing billions of dollars of restoration money being invested across levels of government and the private sector. The GLRI, as it’s known, has had this sort of collaboration-inducing effect in addition to the raw dollars. We stand to lose a lot of that collaboration if this program goes away.

Frederica Freyberg:

I know in Wisconsin the Initiative has worked to address the Sheboygan River and lower Fox River, designated as areas of concern because of industrial contamination and pollution. How does the funding address that kind of clean-up?

Joel Brammeier:

Part of the Great Lakes Restoration Initiative is designated to support cities around the region like Sheboygan and like the lower Fox River area that experienced that legacy of contamination. In a very real way, the Midwest built the world. We provided the steel, the cars, the paper. There’s a legacy of contamination that goes with that. So dozens of cities around the Great Lakes have a very heavy contamination burden. The GLRI is sparking clean-ups across the region. Four of the most contaminated areas in the United States have been cleaned up as a result of the GLRI and other partnerships. And there’s a couple dozen more on the list still waiting.

Frederica Freyberg:

So what are some kind of specific examples of work that has happened because of the funding of which you speak?

Joel Brammeier:

Well, you brought one up already right there in Wisconsin. The Sheboygan clean-up has received substantial funding from the GLRI, from a number of federal agencies, and combined with local investment is making a huge difference in the comeback of Sheboygan's Lake Michigan resources. A little south of there you’ve got Milwaukee, what’s called an area of concern that’s in the process of being cleaned up. In Illinois, just a little bit south Waukegan. There’s example after example of a city on the coast of the Great Lakes that doesn’t actually get all the benefits of being on the Great Lakes because they’ve got this legacy of contamination. We also have, of course, the effort to protect the Great Lakes from species like Asian carp, which is being directly funded in Illinois to the tunes of tens of millions of dollars each year. Part of that is coming out of the GLRI.

Frederica Freyberg:

So if this funding gets reduced to the extent that is proposed, is it your expectation that these projects would just stop in their tracks?

Joel Brammeier:

That federal spark is almost critical to the future of these clean-ups. You’ve got to have that federal engagement to drive those clean-ups forward or the projects face a very real risk of grinding to a halt. To give you an example, in the 20 years prior to the creation of the GLRI, there were designations on the books, there were plans that had been written, there were community forums, but there was no dollars actually going to make these clean-ups happen. And the GLRI fast forwarded all that. Now we’re on the pace to actually get those projects done.

Frederica Freyberg:

How would you describe kind of the current health of the Great Lakes?

Joel Brammeier:

I think we’re at some very real risk. Places like Toledo, Ohio that can’t access clean drinking water sometimes because the water is so contaminated from toxic algae. You’ve got locations like the bay of Green Bay, where clean water concerns are doing damage to the region’s image, not to mention the fact that people are having a hard time accessing safe drinking water northeast of Green Bay. And there’s examples like that all over the Great Lakes. We’re facing some very real risks right now. It’s not as though the clean-up is done and we can just walk away.

Frederica Freyberg:

How likely do you think it is that these funding cuts will actually become reality?

Joel Brammeier:

Well, if there is a silver lining here, it’s that there has been a massive effort over the last ten years to build up the bipartisan support for restoring the Great Lakes. And so you’ve seen, for example, this spring there was a letter sent in Congress that nearly 50 members of Congress, Republicans and Democrats from the Great Lakes region, signed on to supporting full funding for this initiative. It was authorized officially by Congress at the end of last year. I think there’s a great prospect to actually get this program back where it needs to be, regardless of what the White House puts forward.

Frederica Freyberg:

We'll be watching. Joel Brammeier out of Chicago, thanks a lot for joining us.

Joel Brammeier:

Thank you.

Frederica Freyberg:

It’s been less than a year since Waukesha gained approval to divert Lake Michigan water for its own use. A diversion granted as an exception to the Great Lakes Compact as the city argued it needed the water because its wells are contaminated by radium. But next week there’s a hearing on a challenge to the decision approving the water diversion. We sat down with Scott Gordon, journalist for WisContext, for more on the status of the Waukesha water deal and started by asking why a group representing cities surrounding the Great Lakes in the U.S. and Canada is bringing a challenge to it.

Scott Gordon:

So their big overarching concern is to make sure that the Great Lakes Compact is being enforced the way they think it should be. So that whole issue of precedent is a big one. But they’ve also are kind of looking at this from an environmental standpoint, you know, what kind of affects Waukesha will have in drawing the water and discharging wastewater back into the Great Lakes through the Root River. And they also are still contending that Waukesha still has alternative water sources.

Frederica Freyberg:

You’re reporting on what happens to the water that Waukesha pulls out of Lake Michigan, treats and returns to the lake via the Root River under the agreement and specifically the river itself. What have you found about the Root River?

Scott Gordon:

The Root River has some environmental problems, especially with the level of phosphorus in the water. The Department of Natural Resources considers it impaired for its level of phosphorus. Other issues include the fact that sometimes the flow of the river is very low and it’s struggled to maintain some of its fish population and stuff, which has effects on other things like recreation and tourism, which are important to Racine.

Frederica Freyberg:

Meanwhile, Waukesha says that the water it treats will go back into the Root River cleaner than the Root River was originally.

Scott Gordon:

Right. It’s an interesting argument they are making because Waukesha is basically saying that its sewage plant that it’s going to be discharging this water from, they actually call their sewage plant the clean water plant. That’s the actual name of it so clearly they take pride in how they’re treating it. But they’re saying that they’re going to be able to discharge water that meets pretty high standards, that it will have lower concentrations of phosphorus than what’s already in the river. Kind of an interesting argument they’re making – well we’re actually improving the quality of the river by diluting it even if we’re adding more phosphorus into the overall picture.

Frederica Freyberg:

So what have you learned about what happens once that water that’s running through the Root River that has been, you know, discharged from the clean water plant in Waukesha, what happens when it reaches the lake?

Scott Gordon:

One city like Waukesha by itself is probably not going to have a huge environmental impact on the Great Lakes, just because it’s such a large body of water when you put it altogether. The Great Lakes overall are in fairly decent shape in a lot of senses when it comes to phosphorus. It’s gotten a lot better since the ’60s and ’70s, probably better than a lot of people would expect just given the amount of large cities around the Great Lakes and the amount of shipping and other activities that go on. Lake Erie obviously is an exception. It has had huge problems with phosphorus. But I think the concern is less about what Waukesha by itself could do to the system and more about what would be the cumulative effect of more communities coming and doing this.

Frederica Freyberg:

None of this is happening anytime soon, though, right? What’s the status of this project itself?

Scott Gordon:

So Waukesha still has to build some infrastructure to be able to actually do this. The water itself is coming in from Oak Creek, so they’ll be taking the water from Lake Michigan and then Waukesha has to build a pipeline that takes the water from Oak Creek to Waukesha. Then they have to build another pipeline that takes wastewater from their treatment plant to an outflow site on the Root River, which is going to be in Franklin, Wisconsin. And of course they still have to finalize plans and get permits to construct all of that. And they’re saying at this point that won’t start happening until 2019 and, you know, the whole drawing and wastewater issue won’t actually start happening until probably 2023. So it’s a while out, but right now Waukesha is really confident that the agreement will be upheld and they’re basically kind of already behaving as if it’s full speed ahead with this thing.

Frederica Freyberg:

All right. Scott Gordon, thanks very much.

Scott Gordon:

Thanks very much, Fred.

Frederica Freyberg:

That was journalist Scott Gordon. Look for his reporting at WisContext.org, a collaboration of Wisconsin Public Radio and TV and UW-Extension. Now a “Closer Look” at other Wisconsin news at the state capitol. The Assembly passed two bills on Tuesday that could help the severely ill. One legalizes CBD oil, a cannabis exact, which has proven useful in treating seizure-causing conditions like epilepsy. The other commonly known as the
“right to try” bill allows people suffering from terminal illnesses to try drugs not yet approved by the FDA. Organizations like the Wisconsin Medical Society have been critical of the bill, saying it could slow down the formal FDA approval process. And that is our program for tonight. I’m Frederica Freyberg. Have a great weekend.

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Funding for “Here and Now” is provided, in part, by Friends of Wisconsin Public Television.