About a year after Congress passed the 2010 Patient Protection and Affordable Care Act - a.k.a. Obamacare - Wisconsin was one of six states to get a unique opportunity. The federal government awarded the states "early innovator grants" to set up insurance exchanges to help people find and buy health insurance and help insurance companies comply with the law.
Wisconsin's share was $37.7 million, and the state was poised to show other state governments how an exchange could work. But after taking office, Gov. Scott Walker sent the money back. At the time, Walker explained: "Stopping the encroachment of Obamacare in our state, which has the potential to have a devastating impact on Wisconsin's economy, is a top priority."
Walker was betting that the U.S. Supreme Court would overturn the federal law or that Obama would be ousted as president. But the court upheld most of the law in June, and Obama was reelected last week.
"Now [Walker's] caught in a situation where health care reform is moving forward and he's back with his feet in hardening concrete," says Bobby Peterson, executive director of ABC for Health.
While Walker can't stop health care reform, he can still stymie its implementation here. State officials have been mum about their plans. J.P. Wieske, spokesman for the state Office of the Commissioner of Insurance, says only, "All options are on the table."
Every state will have to decide by this Friday, Nov. 16, whether to start its own insurance exchange or let the federal government set up one for them. Peterson says states would do better to set up their own exchange "so it reflects better what's going on in your state."
But, he adds, "I just don't know if the Walker administration can stomach it right now."
Robert Kraig, executive director of Citizen Action of Wisconsin, recently obtained documents through a public records request showing that the administration has done some planning for an exchange - but that it is likely to be "substandard."
"Any insurance plan currently sold in Wisconsin would be on the exchange," Kraig says. "There are a lot of products that don't meet the minimum standards, and they want them to be in the exchange."
Many plans now sold in the state funnel 40% to 50% of premiums into administrative costs and profits, Kraig says. "The Walker position would be that those should be sold on the exchange."
The Walker administration also must decide whether it will expand Medicaid to help cover more people, though there is no deadline. There are currently about half a million people in Wisconsin without health insurance.
Under Obamacare, if a state expands Medicaid coverage, the federal government will pay 100% of the cost for the first three years (currently, they pick up 60% of the cost for Medicaid). After 2016, the federal contribution drops to 90%. The benefits of expanding the program would be enormous, Peterson says, not just for poor people, but also for county governments, which are now paying for mental health treatment that Medicaid would cover.
Peterson realizes that the Walker administration hates the idea of Obamacare, but says there's an opportunity for it to develop something palatable to both sides. He's happy to help.
"I'd be willing to talk to them and share some ideas," he says. "We're partisan on behalf of low-income people who need health care, but we'd be willing to work with them.
"The Supreme Court has spoken and the people have spoken. Deal with it."
