The federal Office of Management and Budget has approved an emergency request by the CMS to let it examine whether Indiana's conservative-friendly, alternative Medicaid expansion model has hurt beneficiaries' access to care.
The OMB's quick approval of the three beneficiary surveys proposed by the CMS is critical, because other Republican-led states including Arizona, Kentucky and Ohio are looking to implement versions of Indiana's plan, said Judith Solomon, vice president for health policy at the left-leaning Center on Budget and Policy Priorities. Acquiring data on the impact of Indiana's expansion strategy will quickly offer insights about whether there are any drawbacks for patients, she said.
When the CMS approved Republican-controlled Indiana's waiver request to expand Medicaid to low-income adults under the Affordable Care Act last year, it gave the state permission to not cover non-emergency transportation services until December 2016. Patient advocates warned that exemption could prevent beneficiaries from getting to dialysis, chronic-care visits or mental-health appointments.
The CMS must decide whether to let the state continue to forego the transportation benefit. It sought emergency approval to bypass the usual OMB clearance process in order to more quickly conduct a patient survey on whether access to care has been reduced.
The OMB approval comes at a time of tension between the Obama administration and Indiana's Republican Gov. Mike Pence, who spearheaded the Healthy Indiana Plan 2.0. Pence has argued there is no need for the CMS to perform its own evaluation of his plan because the state already has contracted with the Lewin Group, an independent consultancy, to do so.
A February 2016 report from the Lewin Group said the impact of the transportation benefit waiver in Indiana has been minimal. Of the 286 beneficiaries interviewed, 11% cited lack of transportation as their reason for missing appointments.
But some Democratic state lawmakers and Medicaid policy experts have raised concerns about whether features of Indiana's alternative model will reduce enrollment by the population eligible for the expanded Medicaid program and hurt access to care.
Under the waiver agreement, Indiana launched an initiative known as Healthy Indiana Plan 2.0. It has three different levels of coverage for residents with incomes up to 138% of the federal poverty line. Those below the federal poverty level can get free basic healthcare coverage, with the option of paying $3 to $15 a month for enhanced coverage, depending on their income. If they don't pay that premium, they will not receive dental or vision benefits, and will face copayments for basic care.
Those above the poverty level are required to make monthly contributions of 2% of their income, up to $25 a month, into a health savings account (HSA). They are locked out of coverage for six months if they skip their contributions for two consecutive months, unless they qualify for narrow hardship exemptions.
Pence said in a letter to HHS Secretary Sylvia Mathews Burwell late last year that a second evaluation “has the potential to create contentious outcomes which can impede fair, impartial and empirical analysis of demonstration projections.”
Pence also expressed concern that HHS chose the Urban Institute as one of the evaluators of the Healthy Indiana plan, because the institute's employees have written critically about using health savings accounts with Medicaid recipients. HSAs are a key part of Indiana's plan.
A Pence spokesman did not comment on the OMB's decision.
Usually when the CMS develops consumer surveys, it posts them for public comment before sending them to the OMB for approval. The OMB must then approve the surveys before they are administered to the public. The CMS received permission to bypass that first step, sending three consumer surveys directly to the OMB without first getting public comment.
“Following the regular clearance process would jeopardize the timely completion of CMS' evaluation of the state's upcoming non-emergency medical transportation (NEMT) waiver,” the CMS said in a Federal Register notice. “Most importantly, it would potentially cause significant harm by depriving Medicaid beneficiaries—especially those affected by the (transportation benefit) waiver—of appropriate medical services and needed care.”
When the OMB approved the CMS' request, it signed off on one survey to determine the impact of the transportation-benefit waiver. A second survey asks about the ease of the sign-up process for coverage, and the third asks about the impact of a Healthy Indiana plan feature that locks beneficiaries with incomes from 100% to 138% of the federal poverty level out of the program if they don't pay their monthly contributions to an HSA.
Some provider organizations in Indiana say they've seen no negative affects on care as a result of the Healthy Indiana Plan. “I recognize the program has its critics, but we are serving tens of thousands who did not previously have access to care,” said Phil Morphew, CEO of the Indiana Primary Health Care Association.