Indiana's Medicaid alternative life-saving and frustrating
WASHINGTON – Indiana’s alternative Medicaid program enabled one Hoosier to get life-saving back surgery.
Others who have told the federal government about their experiences with the Healthy Indiana Program also credit HIP 2.0 with saving their lives through care they would not have previously been able to afford.
“If it wasn’t for HIP 2.0, I would be dead,” one patient wrote in comments the U.S. Department of Health and Human Services collected as part of the agency’s consideration of Indiana’s request to continue the program, which has been touted as a model for other states.
Criticism, however, was more prevalent than praise in the nearly 100 comments submitted.
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The program – which provides health care to more than 400,000 Hoosiers — still has the enthusiastic support of Indiana’s hospitals, the insurance companies which offer the Medicaid plans, and some groups in the state which had urged Indiana to expand Medicaid under the Affordable Care Act.
“Outreach workers have seen patients break into tears after learning they would finally be able to afford the treatments and prescriptions to keep their chronic conditions under control,” wrote Philip Morphew, CEO of the Indiana Primary Health Care Association.
But many – including some participants – complain the program is too complicated and confusing, isn’t as effective as traditional Medicaid and hasn’t proven that its “consumer-driven” components make patients better health care consumers.
“While I appreciate the help, this needs to be much simpler,” a college-educated mom on HIP 2.0 wrote.
Participants pay up to 2 percent of their income into a monthly Personal Wellness and Responsibility Account, which helps pay for their care. The POWER accounts are intended as an incentive for patients to be more efficient users of health care – getting preventive care, not seeking unnecessary care and comparing costs of services. Depending on their income, patients who don’t pay their monthly contributions are either temporarily locked out of the system or placed in a different level of service with co-pays and fewer benefits.
“Clients struggle to understand the basic program concepts and the tiered coverage structure,” wrote a person who received training to help Hoosiers enroll.
“To tell you quite honestly, I don’t even know what the power account does,” wrote one user who nonetheless emphasized gratitude for the program.
The architect of that program – Indiana health care consultant Seema Verma – now heads the division of the Department of Health and Human Services which will decide if HIP 2.0 continues.
Verma worked with former Gov. Mitch Daniels to create the initial version of HIP, then with former Gov. Mike Pence to modify it as the vehicle for Indiana’s expansion of Medicaid to people making up to 138 percent of the federal poverty line. She was chosen by President Trump to head the Centers for Medicare and Medicaid Services.
“The Healthy Indiana Plan is about empowering individuals to take ownership for their health,” Verma said at her confirmation hearing. “We don't assume just because somebody's poor that they don't want choices about their health care.”
Gov. Eric Holcomb has asked CMS to extend the program, which the Obama administration wanted to evaluate before deciding if it could continue past this year.
Pence, as governor, resisted the Obama administration’s efforts to do its own review of HIP 2.0. Some of the public comments filed on Holcomb’s extension request argue the state’s evaluation is incomplete.
The American Diabetes Association says there’s not enough information to determine whether the POWER accounts could actually be deterring patients from getting necessary care. The Indiana Coalition for Human Services likewise says some of the state’s claims aren’t backed up by data, including that having “skin-in-the-game” is working.
More than a dozen comments referred to a National Public Radio story pointing out problems in the state’s application, including its assertion that HIP 2.0 is meeting enrollment projections and an overstatement of what share of participants make their monthly payments and regularly check their POWER accounts. Although the state’s application says a survey showed 40 percent check their accounts monthly, that figure is only for the participants who told the pollster they were aware of the POWER accounts. More than half were not.
“I make my monthly payments but am totally confused by the power account thing,” one participant told the federal government. “Never check it.”
A woman who has both been on HIP 2.0 as well as helped others sign up for coverage told the federal government it’s a wonderful program “if you’re stable and literate enough to make a monthly payment.”
But, in addition to the confusion caused by the POWER accounts, she wrote, because eligibility is based on monthly income, staying in the system can be a time-consuming and error-prone process.
"Being on Medicaid in Indiana is a part-time job consisting of keeping good records and advocating strongly for yourself," she wrote. "Unfortunately, if you're living in poverty, you probably don't have the energy, resources or ability to do those things."
Indiana Legal Services has represented several clients who have had trouble with their POWER accounts, most often because the state’s computer system didn’t recognize they’d made a payment. Resolving the problem has been difficult and led to lapses in coverage, wrote attorney Jon Laramore.
A woman who is on HIP 2.0 with her husband and has been “mostly satisfied,” disagrees with the premise that paying into a POWER account equates to taking personal responsibility for health care.
“It is absurd to classify the character of an individual based on their inability to afford health care coverage,” she wrote.
Another participant still hasn’t figured “exactly what my POWER account does or how it benefits me,” but “I will gladly continue to make my payments in order to have the peace of mind HIP 2.0 provides me.”
And one participant echoed Verma’s description of the program, calling it empowering.
“Paying into the system the little I am able to do is better for my self-esteem than simply being a 'charity case,’” the recipient wrote.
The federal government has no deadline to respond to Indiana’s request to continue the program. But Verma and HHS Secretary Tom Price recently sent a letter to governors promising to grant them more program freedom as well as “fast-track” approval of such requests. The Indiana Family and Social Services Administration, said spokesman Jim Gavin, is "very pleased and encouraged by the pace and content of our ongoing discussions."
Contact Maureen Groppe at mgroppe@gannett.com. Follow her on Twitter: @mgroppe.
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