Once again, Medicaid seems forgotten as another wave of protests and media stories rocks the Capitol. Wednesday night's surprise vote by GOP lawmakers will have a dramatic impact on not just collective bargaining rights, but on the benefits of 1.2 million Wisconsin residents in public health programs.

But you'd never know it.

Virtually all of the news coverage and outrage remains focused on how the measure acted on so hastily Wednesday by Republican senators will strip decades of collective bargaining rights from tens of thousands of state workers. This is huge, of course, but advocates for the one out of every five state residents on Medicaid say the bill's impact on them is huge as well.

The bill hands unprecedented powers to the state health department to revamp and even gut Medicaid programs without following the usual legislative processes and with little public input. We have been posting regularly about the campaign advocates and recipients have been mounting against the bill, and about their frustration over how tough it has been to get heard. Over the past several weeks this campaign has included protests, press conferences, e-mail and phone lobbying, and even a wheelchair occupation of state GOP headquarters. Advocates had recently felt they were gaining ground.

So their ommission from the grand finale unfolding Wednesday night in the Senate and Thursday, as demonstraters continue to pour into the Capitol, rubs salt in the wounds of advocates for the elderly, the disabled, and the poor and middle class, already smarting from a vote they feel ignored their pleas.

Advocates were as caught by surprise as the rest of the state late yesterday afternoon as news spread that the Republicans would be hacking off parts of the original bill, which Walker had insisted were fiscal items necessary to balance the budget, into a separate measure.

The GOP tactic was a way to get around a rule that had been holding the bill up for weeks---the requirement that any fiscal legislation get a quorum of 20 senators, which in this case meant at least one Democrat had to be present along with the 19 Republicans.

So Republicans stripped the original legislation of its controversial collective bargaining pieces and turned them into a separate measure. They then peeled off all the Medicaid provisions and added them, too, to a measure that many critics say now is like the emperor with no clothes---naked policy.

That doesn't mean, though, that the revised legislation is at all clear. I spoke to several advocates and analysts about what got passed last night, and they said that the language of the measure---which many of them had only received after the vote--- was so complex that aspects of it baffled them. Still, they understood enough of the new proposal to say that the parts of the original legislation that most concerned them are indeed part of the package approved Wednesday night.

These include the provisions handing the state health department authority to revamp the Medicaid program, which could include a major rewrite of eligibility standards and co-payments. For years, such changes have needed to go through a legislative process involving hearings and public input.

Making advocates especially nervous is the fact that the state's new secretary of health is Dennis W. Smith, a Washington bureaucrat well-known for his staunchly conservative views, including opposition to federal health care reform. As I have reported before, Smith as a senior fellow at the conservative think tank The Heritage Foundation authored a series of memos advocating that states walk away entirely from Medicaid programs.

A couple of tweaks to the original proposal have been made.

It appears that the administration has reworked language around the emergency rule-making authority so that now the health department must hold public hearings and any proposed rules will be referred to standing committees in each house. (In the earlier version, all that would have been required was a passive review of requested changes by the Joint Finance Committee.) Advocates say that while this change won't necessarily give them the ability to prevent changes they oppose, at least they will be able to voice that opposition.

Still, several advocates said the change is not necessarily good news, since it may make it harder for them to fight the legislation on legal grounds, using the argument raised by the bill's own drafting attorney that it violates the separation of powers doctrine.

As Madison as it gets: Get Cap Times' highlights sent daily to your inbox

It also appears that the health department's extraordinary authority to rewrite Medicaid rules will expire in 2015, when the Walker administration's term is up.

But again, I should note that on Thursday even folks familiar with reading legislation remained confused by what the Medicaid provisions in the bill actually mean. I will update information and their thoughts as soon as I can.

What is obvious is that advocates are furious and devastated at not just the outcome of the vote, but at the sneaky manner in which it was conducted.

A flurry of press releases went out shortly afterward. "We have just witnessed a stunning lack of leadership; a callous disregard for the workers and medically needy of our state," said Public Interest Attorney Bobby Peterson of ABC for Health in one of those statements. "The Wisconsin Senate disparaged the law and ramrodded profound policy changes in a process that is both corrupting and corrosive to democracy. This action shall not stand and will not stand. The Walker Administration, Senator Scott Fitzgerald and the remaining Senate Republicans supporting this vote will get their comeuppance from the people of Wisconsin."

Members of the Medicaid community were swarming into the Capitol, determined to make their voices heard along with those of thousands of other protesters, many chanting, others in tears. "One fifth of Wisconsin residents are affected by Medicaid, the most vulnerable people in our state," said Dane County Board Supervisor Barbara Vedder from the Capitol Rotunda Wednesday night. Vedder was paralyzed in a car crash years ago and gets around in a wheelchair.. "How this was done is disgusting and reprehensible."

Jon Peacock, the research director for the Wisconsin Council on Children and Families, sifted through the measure until nearly midnight Wednesday trying to make sense out of it. The "small improvement" he found that now requires the health department to use the existing rule-making process, as opposed to the indefinite extension of emergency rules called for in the earlier version of the policy changes, "does not cure the fundamental problem of giving an unelected state official a blank check to supersede nearly all of the Medicaid statutes that have been carefully crafted over the last two decades," he said.

"Enactment of this legislation will strip everyone in this state of our fundamental right to engage with our elected legislators on Medicaid policymaking and to hold our legislators accountable for the decisions that are made," Peacock said.