Health measures a key issue as Legislature ramps up

March 4, 2019 GMT

Health care promises to be a key issue in the state Legislature this year, with bills already in play to regulate pharmacy benefit managers, define direct primary care, give tax credits to family caregivers, bring dental therapists to the state and let patients bypass some drug coverage requirements by insurers.

The measures are separate from topics included in Gov. Tony Evers’ proposed budget, such as Medicaid expansion and medical marijuana. A bill to protect insurance coverage for people with pre-existing conditions, passed by the Assembly in January, awaits action in the Senate.


In what is being promoted as a way to control prescription drug costs, a bill unveiled last week with bipartisan support would require registration of pharmacy benefit managers, which act as brokers between drug makers, insurers, pharmacies and patients.

The bill, similar to one introduced last session and to laws passed in other states, would make pharmacy benefit managers report rebates from drug makers and ban them from telling pharmacists they can’t inform patients of lower cost options.

Navitus Health Solutions, a pharmacy benefit manager expanding on Madison’s West Side, would be affected, though the bill is primarily aimed at three large companies — CVS Caremark, Express Scripts and OptumRx — that dominate the market.

The reforms would “have an immediate impact on the cost of prescription drugs here in Wisconsin,” said Senate President Roger Roth, R-Appleton, who introduced the measure with Democrats.

Primary care

Direct primary care, one way some consumers try to save money, would be defined in state law by a bill co-sponsored by Rep. Joe Sanfelippo, R-New Berlin, chair of the Assembly health committee.

In direct primary care, a national trend with mixed success, patients pay doctors monthly fees for routine visits and lab tests, outside of health insurance. Many of the patients carry high-deductible or catastrophic health insurance to cover major medical expenses.


The bill would make it clear the arrangements aren’t subject to state insurance regulations and don’t qualify as insurance under the federal Affordable Care Act, according to Sanfelippo.

A few doctors in Wisconsin provide direct primary care, and the bill could expand the practice, he said.

Adult caregivers

Caregivers of adult family members with Alzheimer’s or other conditions requiring assistance with daily living could claim 50 percent of qualified expenses for a credit of up to $1,000, under a bill introduced last month after failing to pass last session.

The caregiver’s annual income couldn’t exceed $75,000 for an individual or $150,000 for a couple.

The Medicaid programs Family Care and IRIS pay for caregiving expenses for low-income people, and some families have long-term care insurance, which covers many caregiving costs. But many people pay out of pocket or provide care free themselves.

“There’s this vast uncovered expense for people at the end of life, and family members are stepping forward and contributing in a pretty meaningful way,” Helen Marks Dicks, associate state director of AARP Wisconsin, told the Wisconsin State Journal last year. “This is an attempt to ease the burden and the stress on the caregivers.”

The bill would cost $179 million a year, assuming 363,000 people claimed an average credit of $494, according to the Department of Revenue.

Dental therapists

Dental therapists, mid-level providers who can fill cavities and pull teeth, would be allowed in Wisconsin under another bill introduced last month. It also didn’t pass last session.

Letting dental practices hire dental therapists “will allow for increased access, lower practice costs, and savings for the state, all without compromising quality of care,” according to a memo by the bill’s bipartisan sponsors, led by Republicans.

The Wisconsin Dental Association opposes the bill, saying it would be costly to add a new provider to the Medicaid program without increasing investment.

The association “remains skeptical of the long-term viability of dental therapists as a solution to the lack of access to oral health care,” a statement said.

‘Step therapy’

A bill introduced in January by the co-chairs of the Legislature’s budget committee would let patients bypass insurance requirements that they try cheaper drugs before taking more expensive ones, a process called “step therapy.”

“It’s not cost efficient to require patients to try and fail a drug in order to receive the medicine their doctor actually prescribed,” said Sen. Alberta Darling, R-River Hills, who introduced the measure with Rep. John Nygren, R-Marinette.

The bill would create five exemptions from step therapy, including already trying the cheaper drug or deeming it “not in the best interest of the patient, based on medical necessity.”

The pre-existing conditions bill awaiting action in the Senate would offer some protections for insurance coverage for people with medical problems in the event the federal Affordable Care Act is overturned.

Opponents say the bill doesn’t go far enough and have called for Wisconsin to withdraw from a federal lawsuit seeking to strike down the federal law.