For the second consecutive year, Wisconsin has seen a record number of residents enrolling for health coverage through the Affordable Care Act (ACA). State officials announced recently this year's enrollment figures reached 313,579 individuals, marking an 18% increase from the previous year’s already high numbers.
According to the federal Centers for Medicare & Medicaid Services (CMS), this impressive growth during the ACA's open enrollment period—from November 1, 2024, to January 15, 2025—reflects both the increasing need for health insurance and the effectiveness of the outreach efforts by state officials, primarily under the leadership of Governor Tony Evers.
"Health care should not be a privilege only afforded to the healthy and the wealthy, and the Affordable Care Act has been transformational for millions, including Wisconsinites who have pre-existing conditions," said Evers, highlighting the significance of the enrollment spikes during this pivotal moment for many.
The Insurance Marketplace, available through Healthcare.gov, allows individuals to acquire health plans if they do not obtain coverage through employers or qualify for Medicaid or Medicare. Marketplace plans are enforced to comply with ACA stipulations, ensuring comprehensive coverage and prohibiting discrimination against individuals with pre-existing conditions.
Federal subsidies tied to income have significantly alleviated premium costs for many participants. A large majority of those enrolling in these plans have benefitted from these subsidies, saving on average $573 monthly. These subsidies were bolstered during the pandemic under the 2021 American Rescue Plan Act and the 2022 Inflation Reduction Act, though there are concerns as these enhancements face expiration without congressional action.
While many Wisconsinites enjoy the benefits of the ACA, not all experiences are without pain points. Consider Callie Anderson, 25, from Scranton, Pennsylvania. Initially seeking relief from birth control pills, Anderson decided to opt for an intrauterine device (IUD). She initially encountered what many assume is complete coverage provided through insurance under the ACA, only to discover this was not entirely the case.
"I was probably in the room for less than 10 minutes, including taking clothes on and off," Anderson said of her doctor's visit last March, where she paid just her $25 copay for the office visit. Everything went smoothly until the shocking bill arrived, totaling $14,658.
The breakdown revealed $117 for pregnancy tests, $9,862 for the Skyla IUD, $4,057 for clinic services, and $622 for the doctor's services. Anderson discovered her insurance plan, obtained through her father’s coverage linked to his retired state police benefits, was "grandfathered." This means the plan, established before the ACA's implementation on March 23, 2010, was not required to cover certain contraceptive methods.
Anderson was left bewildered, having assumed her procedure would be fully covered. After multiple calls to Geisinger, her doctor’s office, and her insurer, she found out the extent of her plan's limitations.
Danika Severino Wynn, vice president for care and access at the Planned Parenthood Federation of America, expressed disbelief. "Fourteen thousand dollars is astronomical. I’ve never heard of anything as high for an IUD," she stated, shedding light on how costs can vary widely based on insurance coverage.
The Pennsylvania State Troopers Association, whose plan covered Anderson, confirmed it was, in fact, grandfathered and excluded many forms of birth control, including the IUD. Without insurance negotiations to lighten the load, Anderson faced the entire burden of her bill overwhelmingly, which constituted more than 20% of her annual income.
After engaging repeatedly with billing departments and the financial assistance office at Geisinger, she received some relief through discounts—yet still ended up paying over $5,000 out of pocket.
This incident encapsulates significant issues around insurance coverage for reproductive health services, particularly under grandfathered plans. Patients must proactively navigate complicated healthcare landscapes to prevent future financial burdens.
Experts advise individuals to carefully read through their benefit information and directly consult with insurance representatives before scheduling any non-emergency medical procedures to assess coverage and total out-of-pocket costs. Given the complexity of different insurance brackets, being vigilant becomes the patient’s responsibility.
Shifting back to Wisconsin's results this year, the historic enrollment numbers offer hope against opposition. Previously, Wisconsin was part of efforts to dismantle the ACA, but the present-day administration has embraced it, leading to improved outcomes for residents.
Evers’ continued advocacy for the ACA emphasizes the necessity for policies enabling accessibility and comprehensive care across the board. Ensuring affordable healthcare is no longer just about legislative shifts but also about empowering citizens to take charge of their healthcare options.