Valid concerns have emerged about whether Indiana's HIP 2.0 program may be shutting out some of the low-income people it is supposed to help. But after a tumultuous year in health care policy, it's important to remember things could be worse for Indiana's low-income patients – a lot worse.
More than 440,000 people are enrolled in HIP 2.0, so it was very good news last week that Indiana has been granted another three-year waiver for the program. And the new version of HIP 2.0 will provide crucial support in the struggle against opioid abuse as well as new incentives that could help reduce the state's even more deadly and costly tobacco-use problem.
There was some cognitive dissonance last year as Gov. Eric Holcomb extolled the success of the program for low-income Hoosiers even as he and Republican members of the state's congressional delegation were supporting efforts to reduce Medicaid funding. HIP 2.0 is a state program, but it largely relies on federal funds made available through the Medicaid expansion provisions of Obamacare. Holcomb said he was confident the state could continue to provide for those who needed care if Medicaid were cut, but it wasn't at all clear where the money would come from.
The survival of the Affordable Care Act ensures Indiana will have the funding to sustain HIP 2.0 – for now, at least. And now the U.S. Department of Health and Human Services has granted permission for the state to continue its conservative-friendly variation on basic Medicaid expansion.
In truth, it would have been a huge shock if the federal government had rejected Indiana's request. Though neither of them participated in reviewing Indiana's application, Vice President Mike Pence and U.S. Centers for Medicaid and Medicare Services Administrator Seema Verma were the architects of HIP 2.0. Turning Indiana down for permission to continue the program would have endangered what many consider Pence's most impressive achievement as Indiana governor.
To receive full coverage, HIP 2.0 has required participants to put some “skin in the game” by paying at least a couple of dollars and as much as $100 a month into a health care account.
Pence maintained those provisions would encourage participants to make wiser choices about how they consume medical care – making fewer unnecessary visits to emergency rooms, for instance – and how well they guard their own health. A state-funded study last year seemed to validate that theory.
In its application for renewal of the federal waiver, the state notes that “only 5% of members who left the program did so for affordability reasons.”
But from HIP 2.0's launch in 2015 through last October, about 25,000 adults lost coverage because they didn't pay the small premiums the program requires, Kaiser Health News reported last week, and only half of them found another source of coverage. So that 5 percent represents a lot of people. If the point is encouraging personal responsibility rather than raising revenue, perhaps the state should take another look at how much “skin” some of HIP 2.0's enrollees really can afford to put into the game.
Now the work requirement, which will apply to about a quarter of those enrolled in HIP 2.0, is expected to cause another group of enrollees to allow their coverage to elapse. The aged, the infirmed and many caregivers will be exempt from the provision. But the state needs to keep a careful eye on how this provision is rolled out next year, to ensure people aren't being thrown out of the program because the rules are too arbitrary or complicated. Compassion is part of the equation, but so is smart public policy – people who can't get health care coverage may end up costing us all more in the long run.