The following interview featuring Alex Ignatowski originally ran in Wisconsin Health News on April 7, 2023.
A Wisconsin conservative think tank recently released a bevy of health policy recommendations, including a call to shift childless adults from Medicaid to the Affordable Care Act marketplace.
Alex Ignatowski, director of state budget and government reform at the Institute for Reforming Government, billed their report as “a new look.”
The institute’s study comes as other conservative groups in Wisconsin dive into healthcare too.
“This has been an issue that’s been mostly owned by the left,” Ignatowski said. “This is a time for conservatives to propose some solutions that are going to take the healthcare policy debate in a different direction.”
The report includes two policy briefs, one focusing on Medicaid and the other on ways to boost healthcare competition. The latter was crafted in collaboration with Tomas Philipson, a University of Chicago public policy professor and former acting chair of the White House Council of Economic Advisers for President Donald Trump.
Ignatowski spoke to Wisconsin Health News about the report and some of its recommendations.
Edited excerpts are below.
WHN: What is driving this push by your group and others into healthcare policy?
AI: Healthcare policy, in general, has always been something … that’s been monopolized by more liberalleaning or left-leaning policymakers, lawmakers, interest groups. It’s been steered mostly by the left. And what we’ve seen is that the cost of healthcare has continued to rise …
This is maybe an overgeneralization, but I think it’s primarily true — the liberal response to anything in healthcare is to spend more or have more government intervention. What we’ve seen is that more spending in the public setting and more regulation ultimately leads to higher costs for everybody else. We need a new approach.
This is the time for conservatives to get more involved in healthcare, to understand what has been done in the last 40, 50, 60 years and find ways that will actually improve healthcare in this country, improve the cost and quality. Because the same old approaches are only going to lead to the same old results, right? If we continue going down the same road that we’ve been on, we’re going to get the same results that we’ve gotten in the last 60 years, which is higher cost, more regulation, more red tape.
This is a main thing that most families in Wisconsin have to find a way to pay for, right? They have to have some sort of health insurance coverage. And with everything else that’s going on in the economy, with inflation and everything else, we need to start taking a look at some of these big cost drivers for families so that they can keep some more money in their pockets, but allow them to still have the coverage that they need.
WHN: One of your recommendations is to shift childless adults from Medicaid to the Affordable Care exchange. Why are you proposing that?
AI: This is something that would take a change at the federal level because, right now, the current eligibility level is at 100 percent (of the federal poverty level) and above. But the thinking behind this is this would help states to get some of that cost off the books. But the other thing is that from a principle standpoint, this would put folks into private health insurance with the mindset that when there’s a public expenditure in healthcare, it’s not to just have somebody just maintain some sort of government-funded program, but to help them on their way to self-reliance. So by having somebody in a private health insurance plan, it sets the mold right away that this is something that will help you along your journey as you start to increase your income and become more selfsufficient without having to use public benefit for health insurance.
The other aspect of this is … there’s a lot of folks that churn, obviously, between Medicaid and the exchange. This gets rid of that churning as well.
WHN: What about concerns that people may not be able to afford cost-sharing associated with ACA plans? Would policymakers have to provide any additional investments to ensure affordability?
AI: If this would move to the federal government actually taking some sort of action that would set this in motion, that would have to be considered.
WHN: Your report suggests a Medicaid pilot project for direct primary care, which is an arrangement where clinicians receive periodic, flat payments to provide care. What would that look like?
AI: A relationship with a primary care doctor is going to lead to the best health outcomes, rather than having somebody with a chronic condition or some disease that’s unmonitored go on and escalate into something that, at the end of the day, is going to be a much more costly fix for them or will drive them to a higher-cost setting like an emergency room or something like that.
This would promote and push the use of a primary care physician to monitor the individual’s health so that we can avoid the high-cost expenditures that happen when things aren’t taken care of right away.
A pilot program could start out to be something smaller, whether it’s just in a certain region or whether it’s a certain population within Medicaid itself. We don’t necessarily lay out the specific details of what a pilot program should look like. That’s something that the Legislature, if they wanted to move forward with something like this, would have to decide on their own. A limited pilot, but something that’s broad enough that you can show results after a couple of years, would be good.
WHN: The report calls for reassessing state limits on nursing home beds. Nursing homes have largely cited staffing challenges as a limiting factor for providing care, particularly when it comes to accepting patients being discharged from the hospital. How would reassessing bed limits address that?
AI: The motivation behind this is two-fold. One, in talking to some of the other stakeholders, they talked about this issue where hospitals are not able to actually move folks on to some sort of acute care setting outside of the hospital setting because there aren’t beds available. So that’s part of it. The other thing is that if you look at the historical trend, the number of nursing home bed licenses has gone from somewhere around 50,000 to about half of that now.
This is taking somewhat more of a free market approach to say, ‘Maybe there needs to be more bed licenses, maybe we need to just eliminate the cap altogether.’ If we give the market a chance to claim some of these bed licenses, let them innovate and figure out the best way to deliver care.
Yes, there is a workforce shortage in just about every aspect of the economy right now. But we see this as just another limit on top of the workforce issue itself. So the best thing the state could do in this case is to remove one restriction and allow for innovation to happen.
WHN: Other recommendations touch on the Medicaid certification process for insurers and payment-for-performance incentives in the program. What would you like to see?
AI: If the Medicaid program itself could build a structure that makes it a little bit more competitive for some of these HMOs and MCOs to deliver better quality, better bang for buck on Medicaid itself, deliver better outcomes with a more cost-effective solution, I think that that would be good. It’s just something where we need to infuse a little bit more competition into something that is just kind of been status quo for a while and see if we can get some better results.
WHN: What kinds of solutions do you see needed to support the workforce?
AI: The simple thing that we suggest in the report is expanding the scope of practice for nurse practitioners. Our mindset is that they should be allowed to practice up to their full skillset in a way that would allow for more access to healthcare and then, frankly, for less expensive healthcare as well.
You don’t always have to go see a doctor. You can sometimes go see a nurse practitioner. If they’re allowed to practice more, to the full extent of their education, training and skills, that would be a net positive for healthcare quality, but then also cost as well.
And then certainly the number of physicians. In our report, Professor Philipson notes that by 2035, we’re going to face a shortage of roughly 2,200 physicians in Wisconsin. We need the medical schools to start accepting more and increasing the volume of medical doctors that are going in and coming out of school and practicing in Wisconsin in order to fill that shortage.
WHN: What changes would you like to see for private insurance?
AI: Flexibility for insurers will allow for folks that are in the market for health insurance to pick a plan that fits their needs and what they have.
By having more requirements or more regulation over the top of what insurance companies have to provide to reach some sort of network adequacy, you raise the price for services that some folks might not actually need.
If you look at providing a little bit more flexibility, you’d give people the same amount of choice that they need, but also you would lower the cost for folks.