In his first TV ad after winning the state’s Democratic nomination for governor, Tony Evers blamed incumbent Scott Walker for high health care costs in Wisconsin.

The 30-second ad focused on the Republican governor’s decision to turn down federal funds that would have expanded Medicaid in 2014.

"When Walker was running for president, he played politics and rejected millions in federal health care money that would have lowered costs for our families," the ad says. "Minnesota’s governor took the funds. They made changes. Wisconsin families now pay nearly 50% more than Minnesotans for the same health care."

There’s a core statistical claim about health care costs, but also implications about the reasons behind it. Let’s dig in.

States far apart in 2018 premiums

The 50 percent claim is simple enough.

The Kaiser Family Foundation, a nonprofit think tank focusing on national health issues, uses benchmark plans for comparisons between states — specifically the second-lowest cost silver premium for a 40-year-old in each county. Their approach, which is widely accepted, shows a $569 average premium for Wisconsin in 2018 and a $385 average premium for Minnesota.

Thus, Wisconsin premiums are about 48 percent higher for people purchasing individual insurance through the state and federal marketplaces created after the Affordable Care Act, according to the latest data.

So the ad is largely correct about the number. But it is incorrect to attribute that number to "families," since the analysis it is drawn from is based on the cost an individual would pay.

The ad also focuses on why those premiums are higher, pointing to Walker’s Medicaid decision.

Declining Medicaid was part of Walker’s Obamacare alternative, and was his first major policy initiative as a presidential candidate. (Democrats have come after Walker for this decision before, including a claim by then-gubernatorial candidate Dana Wachs that the move cost Wisconsin $1 billion, which we rated Mostly True in June 2018.)

Medicaid expansion would have covered everyone making less than 138 percent of the federal poverty level. Walker instead did what’s called a "partial expansion" of Medicaid, covering everyone making less than 100 percent of the federal poverty level.

The full expansion would have moved more low-income people out of the marketplace, which affects premiums for those who remained in it. But how much?

Medicaid just one of many factors

Experts say Medicaid may be a factor in the premium difference, but it is just one of many that could explain differences in premiums between two states.

A handful of studies have shown Medicaid expansion has some impact on premiums, but not much, said Adam Searing, a research professor at Georgetown University. Several studies showed Medicaid expansion reduced premiums by 2 percent to 7 percent, while a study in New Hampshire actually showed an increase in premiums after Medicaid expansion.

JP Wieske, deputy commissioner of the Wisconsin Office of the Commissioner of Insurance, called it "total poppycock" to claim that Medicaid decisions drove the difference between Wisconsin and Minnesota premiums. He said Medicaid would be "very far down" the list of factors affecting Wisconsin health care premiums.

"I’m not sure it would be top three or five," Wieske said.

Other factors in premium determination include reinsurance, risk pool differences and competition between insurers and providers, said Linda Blumberg, a fellow at the nonpartisan Urban Institute in Washington, D.C. She said the amount attributable to Medicaid is "likely to be small relative to the other factors."

Sabrina Corlette, another research professor at Georgetown University, said the ad over-reaches and oversimplifies by comparing two states based primarily on the Medicaid distinction.

"It is just challenging to draw hard and fast conclusions when you’re just comparing one state to another, because states can have very different policy and market dynamics," she said.

Minnesota’s health care system has a unique history that includes a state-run high risk pool (for the most costly patients) that dates to the 1970s and MinnesotaCare, which at the time of the Medicaid expansion already covered many people who became eligible, said Jim Schowalter, chief executive of the Minnesota Council of Health Plans. So Medicaid expansion had a different impact in Minnesota than Wisconsin.

"It’s an apples and oranges comparison because of the different programs and eligibility," Schowalter said.

Corlette said it’s fair to note, though, that Minnesota has been more proactive than most states about addressing health care costs.

"Minnesota has really leaned in, and where there are policy levers available to try and keep people covered, get rates lower, make the marketplace run smoothly, they have taken advantage of those," she said. "I think that’s fair to say about Minnesota and its political leadership."

Sam Lau, a spokesman for Evers’ campaign, said the ad was drawing a distinction between the states’ leadership.

"In contrast to Scott Walker's inaction, there are numerous decisions and changes Minnesota made to lower its health care costs, and now in 2018, average health costs in Wisconsin are nearly 50% higher than in Minnesota," he said. "Health care policy is complex, but despite its complexities, health care costs can be lowered."

Reinsurance helped Minnesota, soon Wisconsin, too

Walker campaign spokesman Austin Altenburg said the ad actually makes the case for Walker’s record on health care.

Walker pushed for a reinsurance program for Wisconsin, which will be in effect for next year. The plan, called the Health Care Stability Plan, is projected to lower premiums by 10 percent compared to what they would have been and takes effect in January, according to the insurance commissioner office. It is funded by $166 million in federal money and $34 million in state dollars.

The 50 percent gap in premium costs only developed this year after Minnesota implemented reinsurance.

In 2017, Wisconsin actually had lower premiums than Minnesota — $368 compared to $412. But Wisconsin’s premiums jumped to $569 in 2018 as insurers raised rates after losing $500 million in the Wisconsin marketplace from 2014 to 2017, said Elizabeth Hizmi, spokeswoman for the Office of the Commissioner of Insurance. Some insurers reduced coverage areas and others left the Wisconsin market altogether.

Meanwhile, Minnesota’s rates stayed consistent as the state instituted reinsurance. Under that program, the state paid a portion of medical expenses for insurers beyond $50,000 and until $250,000, meaning insurers took on less risk from the sickest people and could offer lower overall rates.

"Our premiums today have everything to do with reinsurance," Schowalter said.

Our rating

Evers’ ad is built around the claim that Wisconsin premiums are 50 percent higher than Minnesota’s, but it goes astray on several fronts.

The ad attributes the figure to "Wisconsin families," when it comes from an analysis that looks at the premium cost for a 40-year-old individual in each county.

And while the ad notes Minnesota "made changes," the framing of the issue — starting with Walker’s rejection of the funds and ending with the difference in health care costs — leaves viewers with the impression that Walker’s decision is the sole, or at least a primary reason, the states have such different premiums.

Experts say that’s not correct. Several other policies and market dynamics play a more significant role than Medicaid in determining premiums.

Furthermore, differences in the health insurance markets between Wisconsin and Minnesota make simplistic comparisons between the states unreasonable.

The ad contains an element of truth but ignores critical facts that would give a different impression. That’s our definition of Mostly False.