The success of the conservative approach to Medicaid devised by Indiana Gov. Mike Pence—Donald Trump's pick for vice president—is a mixed bag so far, according to a report that offers fodder for both sides of the political spectrum.
A new analysis funded by the state shows both positive and concerning elements to Indiana's alternative Medicaid expansion. It again exposes the dichotomy of Pence embracing President Barack Obama's healthcare reform law even though his presidential running mate, Donald Trump, has called for full repeal of the Affordable Care Act.
The report also comes as Indiana state officials continue to raise objections to the CMS performing its own analysis to see if Pence's Medicaid expansion has been harmful to beneficiaries. Pence has argued there is no need for the agency to perform its own evaluation because the state already commissioned a report by the Lewin Group, an independent consultancy.
Pence's version of Medicaid expansion took effect last year. His Healthy Indiana Plan 2.0—which includes premium contributions, health savings accounts, incentives for healthy behaviors and a benefit lockout for people who don't pay premiums—has become a model for conservative Republican governors in other states such as Kentucky and Ohio.
More than 90% of HIP 2.0 beneficiaries have been able to continue to make contributions into an HSA as a condition of coverage, according to the report. Payments range from $3 to $25 a month depending on income level.
But almost half of Medicaid enrollees sometimes, usually or always worried about being able to make those HSA contributions.
People living below the federal poverty level who don't pay into the HSA will still have basic Medicaid coverage, but will lose dental and vision benefits, according to Indiana's waiver. People living above the poverty level who miss HSA payments are locked out of coverage for six months.
As of January 2016, there were 345,656 HIP 2.0 enrollees. Over the first year of the demonstration, 2,677 individuals above the poverty line were disenrolled from HIP and not allowed to return for six months for failing to pay their contribution, according to the report.
The state revealed 21,445 Medicaid members transitioned to the basic offering due to nonpayment of the contribution.
Affordability was not the leading reason for not making the contributions. Instead, most cited confusion over the fact that they needed to make a payment, or when the payment needed to be made. Indiana's HSAs are called Power accounts.
“It appears that Power account contributions do not constitute a barrier to enrollment in the HIP program,” the Lewin report says. But almost 1 out of 5 Medicaid enrollees were “always” worried about making their contributions, indicating there's still a level of financial hardship for the state's poorest residents.
Seventy-four percent of HIP 2.0 beneficiaries said they were able to get routine care as soon as they needed it and nearly 80% had no trouble getting access to specialists. Overall, 58% of members reported that they were very satisfied with the new Medicaid program, while an additional 22% said they were somewhat satisfied.
Consumer advocates and policy experts were skeptical of some of the findings. “If the results are as good as Pence and others are saying it is, they should welcome having another reviewer taking a look,” Dee Mahan, Medicaid program director at Families USA, said of CMS's attempts to evaluate HIP 2.0.
Observers note an independent federal evaluation is important if other conservative states decide to copy Indiana's expansion as a model.
“The stakes are pretty high since other Republican states are interested in similar designs, and CMS wants to understand how these reforms are affecting beneficiaries before greenlighting it for other states,” said Katherine Hempstead, a senior adviser at the Robert Wood Johnson Foundation.
Republican insiders were mixed on what the report may mean for Pence and Trump's bid for the White House. On one hand, it shows the ticket achieved some sort of right-leaning legislative success.
“The program demonstrates the governor's character—compassion, desire to solve problems and guidance by conservative principles,” Joey Fox, an Indiana-based GOP strategist and former legislative director for the Indiana Department of Health under Pence, said in an email. “Americans will be impressed with those qualities.”
But Pence's embrace of the Affordable Care Act, a law that is anathema to Trump and congressional Republicans, draws unfavorable attention to the Republican bid for the White House.
“Increased attention to Pence's expansion of Medicaid may harm his conservative credentials,” said Yevgeniy Feyman, a fellow at the Manhattan Institute, a conservative think tank.
“I don't think it matters," countered Douglas Holtz-Eakin, an adviser to Sen. John McCain's presidential campaign in 2008 and former director of the Congressional Budget Office. “He is the vice president pick, not the nominee, and it's the nominee's policies that matter.”
He said that because Trump opposes the Affordable Care Act and is in favor of Medicaid block grants, the success of HIP 2.0 would be moot should Trump become president.
“I don't think there will be pressure to produce the Indiana model anywhere else,” Holtz-Eakin said.