Indiana expanded Medicaid under the Affordable Care Act in 2015, adding聽conditions designed to appeal to the state鈥檚 conservative leadership. The federal government the experiment, called the Healthy Indiana Plan, or , which聽is now up for a three-year renewal.
But a close reading of the shows that misleading and inaccurate information is being used to justify extending HIP 2.0.
This is important because the initial application and expansion happened on the watch of then-governor and now Vice President聽. And , who is President Donald Trump鈥檚 pick to lead the Centers for Medicare &聽Medicaid Services, helped design it. (Among other functions, CMS oversees all Medicaid programs.) So, states are watching to see if the approval of Indiana鈥檚 application is a bellwether for Medicaid鈥檚 future.
To get the program extended again, the Indiana Family and Social Services Administration has to prove to CMS that the experiment is and that low-income people in the state are indeed getting access to care and using health care efficiently.
The key part of Indiana鈥檚 experiment requires low-income participants to make monthly payments. Advocates say this promotes recipients鈥� taking personal responsibility for their health care. But some health policy experts say the information provided by the state shows that the provision isn鈥檛 working as well as it should. Some examples:
The Claim: Most members are making regular payments to maintain coverage.
The Fact: A lot of people are missing the first payment.
The state鈥檚 application says that 鈥渙ver 92 percent of members continue to contribute [to their POWER accounts] throughout their enrollment.鈥�
This claim is missing context. Here鈥檚 a primer on how HIP 2.0 works: Members can get HIP 2.0鈥檚 more complete coverage, the plan, by making monthly payments into a 鈥淧ersonal Wellness and Responsibility Account,鈥� or POWER account.
If they don鈥檛 make the payments, there are penalties. If a recipient makes less than the federal poverty level 鈥� about $12,000 a year 鈥� they鈥檙e bumped to HIP Basic, a lower-value plan that requires copays and doesn鈥檛 include vision or dental insurance.
If a recipient is above the poverty line and misses a payment, they聽become locked out of coverage completely for six months.
The state鈥檚 claim that 92 percent of members make consistent payments is based on data in a , a health policy research firm in Virginia that evaluated HIP 2.0鈥檚 first year.
But the Lewin report also says that when people sign聽up for HIP 2.0 they can be declared 鈥渃onditionally enrolled,鈥� which means they鈥檙e eligible but have not yet made their first payment.
According to the Lewin report, in HIP 2.0鈥檚 first year, about a third of people who were conditionally enrolled never fully joined.
鈥淚 don鈥檛 see those numbers being captured,鈥� said聽, senior policy analyst with the National Health Law Program, which advocates for low-income individuals. Machledt said the state should recalculate the figure to include those people, because it鈥檚 potentially an indicator that people are confused about how the program works or that they can鈥檛 afford the payments.
He added that the figure cited is based on the first year of HIP 2.0, and that the rate of losing coverage for missing payments has increased substantially since then.
The Claim: HIP 2.0 users check their POWER account.
The Fact: More than half of people don鈥檛 even know they have one.
The state says the POWER account is promoting personal responsibility in health care; meaning, if someone is aware of how much they are spending, they鈥檒l choose their medical care wisely. As evidence, the state writes in its application that 40 percent of HIP Plus members 鈥渃heck their [POWER Account] balance at least once a month.鈥�
Again, the state leaves out important context. According to the Lewin report, most people in HIP Plus didn鈥檛 know they had a POWER account. Of those who did, 40 percent checked their account once a month, but that鈥檚 much smaller than 40 percent of all HIP Plus members. In fact, an analysis of the numbers shows only about 19 percent of HIP Plus members reported checking the balance of their POWER account monthly.
Rather than evidence of personal responsibility, , vice president for Health Policy at Center on Budget and Policy Priorities, sees evidence of confusion.
鈥淚 think that鈥檚 another really significant finding [in the Lewin report] that so far I have never seen the state come to terms with,鈥� said Solomon.
A spokesperson for the state wrote in an e-mail that the phrase 鈥渙f the members surveyed鈥� was unintentionally omitted from the application.
The message did not address the overall concern that the statement was misleading.
The Claim: People on HIP Plus are more responsible.
The Fact: Experts say HIP Plus is just better insurance.
The application also says 鈥淗IP members who contribute [to their POWER accounts] are twice as likely to obtain primary care (31 percent to 16 percent), have better prescription drug adherence (84 percent to 67 percent), and rely less on the emergency room for routine treatment.鈥�
Machledt said simply showing that HIP Plus members use the emergency room less frequently than HIP Basic members doesn鈥檛 tell the whole story.
鈥淭hey don鈥檛 talk about the risk profile of those different groups,鈥� Machledt said. He said people who are above the poverty line are generally to frequent the ER in the first place. 鈥淭here鈥檚 no evidence to me that they鈥檝e risk-adjusted 鈥� to show that they鈥檙e comparing apples to apples,鈥� he said.
Indiana argues that the higher levels of primary care use and drug adherence for those making POWER account payments 鈥渃onfirms the principle of personal responsibility.鈥�
But Solomon said the differences in behaviors simply confirm something else: Those who pay their POWER account have better insurance. HIP Plus makes it easier for people to access primary care and to adhere to their prescription drug regimens, Solomon said.
鈥淭he policy for people in HIP Plus is that they get a three-month supply of drugs, and can even use mail order, without any copays,鈥� she said. Meanwhile, people in HIP Basic have to pay copays and are limited to a one-month supply of drugs.
Solomon said getting less primary care and relying on the ER for health crises is worse for patients and could also mean higher costs. 鈥淵ou have large numbers of people that are not getting care in the right place at the right time, and not maintaining adherence to prescription drug regimens.鈥�
The Claim: HIP 2.0 is meeting its enrollment projections.
The Fact: No,聽it isn鈥檛.
Enrollment projections for HIP 2.0 submitted to CMS in 2014. (Healthy Indiana Plan Expansion Proposal/FSSA)
The state鈥檚 application reads 鈥淗IP has continued to meet its enrollment goals with over 394,000 individuals fully enrolled in HIP as of December 1, 2016.鈥�
But the state isn鈥檛 meeting its enrollment goals. According to a chart published in 2014 in Indiana鈥檚 original proposal for HIP 2.0, its enrollment goal for December of 2016 was higher: 424,339. (The chart is off by a month, because the state started HIP 2.0 a month later than planned, so the actual projection for December 2016 appears on the line for November 2016.)
The most recent shows 403,142 HIP members in January 2017, short of the state鈥檚 projection of 427,702.
The Claim: The survey shows people like HIP 2.0
The Fact: The survey鈥檚 data聽and methodology are unreliable.
There鈥檚 reason to doubt the survey results that underlie much of the Lewin report, according to , director of the Center for Health Policy Research at the Milken Institute School of Public Health at George Washington University.
鈥淭hey were not using what would generally be considered best practices in their survey methodology,鈥� Ku said.
Ku said聽the methodology available to the public is vague. From the information provided, he said, there are multiple ways that bias could have been introduced into the survey results used in the Lewin report. For one thing, the sample sizes of the survey were too small to draw accurate conclusions, Ku said, and the data was analyzed using 鈥渘ot an optimal method.鈥�
Ku said that the results are not displayed in a scientific manner and that it appears the survey and analysis were done in a hurry. 鈥淵ou would not, as a survey researcher, have great confidence in the results that they show,鈥� he said.
Conclusion
As Indiana looks to extend HIP 2.0, health policy experts say it鈥檚 important to get an accurate picture of how well the program is working. Requiring POWER account payments was key to making the program a reality in Indiana, but they say a more traditional Medicaid expansion 鈥� one that does not require monthly payments and six-month lockouts 鈥� is a better option.
heads the Indiana Family and Social Services Administration, the government agency that runs HIP 2.0. She said that in order to comment on discrepancies between the state鈥檚 extension application and the Lewin report, 鈥淚 would have to go back and look at the way that these data were reported.鈥� She continued, 鈥淚鈥檓 happy to look into that and get that for you.鈥�
In a separate prepared statement, the agency noted that the state 鈥渉as made significant achievements鈥� on HIP 2.0鈥檚 stated goals and that it looks forward 鈥渢o continuing to build on these successes with future versions of HIP. 鈥� The analysis of this program is constant and ongoing and includes continuous conversation with our federal partners to discuss all aspects of the proposed waiver as well as program outcomes.鈥�
If the application does not go forward, the state could choose to expand Medicaid under the Affordable Care Act without any special provisions, or not accept the expansion at all. The federal government on Indiana鈥檚 application until March 17.
This story is part of a partnership that includes WFYI, , and Kaiser Health News.