Indiana officials say the CMS is planning to use a biased survey to evaluate the state's conservative approach to Medicaid expansion.
In April, the federal Office of Management and Budget approved an emergency request by the CMS to let it examine whether Indiana's conservative-friendly, alternative Medicaid expansion model known as Healthy Indiana Plan 2.0, or HIP 2.0, 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.
Indiana Gov. Mike Pence, a Republican, has argued there is no need for the CMS to perform its own evaluation of his plan because the state already hired the Lewin Group, an independent consultancy, to do so.
Surveys developed by the CMS and posted for public comment until June 3 would track the experience of current and new beneficiaries, as well as those who have left the program or been locked out of coverage for failing to pay monthly contributions were.
The Pence administration has raised several concerns about the surveys (PDF), including the use of questions it says are biased and that include response options that are leading.
For instance, enrollees are asked to consider their overall experience and then asked about the specific reasons for being dissatisfied. However, there is no question asking about being satisfied.
“The lack of balance points to dissatisfaction and is leading,” according to Tyler Ann McGuffee, insurance and health policy director for Pence, said in a comment letter to the CMS. “The dissatisfaction question is found in all of three of the surveys, and there are no questions regarding reasons for satisfaction in any of the surveys.”
A CMS spokesman said the agency's aim “is to learn from demonstrations, like HIP 2.0, which includes provisions that we have not previously approved.”
“It's important that the federal government evaluate the impact of those provisions to inform any consideration of approving them in other states,” the CMS spokesman said.
Indiana launched HIP 2.0 in January 2015 under a waiver agreement with the CMS. It has two different levels of coverage for residents with incomes up to 138% of the federal poverty line—one called HIP 2.0 Plus that includes dental and vision benefits and one called HIP Basic that does not.
Individuals are required to pay anywhere from $3 to $25 a month, depending on their income level, into a health savings account as a condition of coverage. They can be locked out of coverage for six months if they skip their contributions for two consecutive months and are above the federal poverty level. If a person is below the poverty level and doesn't pay, they will be placed in the basic coverage plan.
Indiana also got permission to eliminate coverage for non-emergency transportation services until December 2016. The permission can be renewed by the CMS pending an impact analysis by the state and agency.
Another concern of the Pence administration was the use of questions that imply that consumers have an active choice between the enhanced and basic coverage options in HIP 2.0. Everyone is placed in the “plus” offering when they enroll. Residents only end up in the basic plan if they fail to pay their monthly contributions and have incomes below the poverty level.
McGuffee said survey questions that mischaracterize that structure could produce misleading results.
The National Health Law Program, or NHeLP, voiced similar concerns, saying questions that suggest beneficiaries have a choice are “fatally flawed.” “Someone who cannot afford monthly contributions may have no true choice between HIP's two benefits packages,” the advocacy group said in a comment letter.
But NHeLP also says it's good that the CMS is conducting its own survey because the Indiana's contractor isn't going far enough.
For instance, 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.
NHeLP noted these results only focused on scheduled visits and did not track instances where a person decided to not seek care because they didn't have a ride.
“An individual who knows she has no way of getting to a doctor is unlikely to even schedule an appointment,” the group says. “The state's evaluation does not capture or even consider such individuals and so is not an adequate measure of the impact of waiving" non-emergency transportation.
Planned Parenthood also said it supports the CMS' separate evaluation and pushed the agency to go further than the proposed survey by including questions related to women's healthcare. Women make up approximately 64% of the state's non-elderly adult Medicaid population.
“Without including questions that are specific to women's healthcare services, the survey will not accurately represent how the majority of Medicaid enrollees experience HIP 2.0,” Planned Parenthood said in its comment letter.