Here are two big questions hovering over the Affordable Care Act in the coming weeks: Will the 22 states that have not expanded Medicaid see fit to give some four million poor people a chance to get health insurance? And if they do, what kind of coverage will it be?
A key part of the reform law was the expectation that Medicaid, the joint state-federal program, would be expanded to cover many more low-income people—largely at federal expense. But the Supreme Court ruled that each state would get to decide, and Republican governors and state legislatures have been largely recalcitrant, either refusing to expand or insisting on changes to the program. At the end of January, Gov. Mike Pence of Indiana finally got the federal government to sign off on his blueprint for offering Medicaid to some 350,000 Hoosiers. A key part of the plan: People who enroll will have to share some of the cost of their care.
Other states are now eyeing Indiana as the model to copy for expansion—and even for changing Medicaid altogether. “What the governor submitted is what the governor got,” said his health care policy adviser, Seema Verna. “This story is not just about HIP 2.0 [the state’s name for the expansion] and the approval of the waiver, but it is really about changing the traditional Medicaid program.”
Indiana’s success in persuading the feds to agree to its program its way was clearly big news, and local coverage was about what you’d expect. Brian Francisco, Washington editor for The Journal Gazette in Ft. Wayne, covered the governor’s visit to the city to promote the plan and led with the political question—whether the plan was really “Medicaid reform,” as the governor likes to call it or Obamacare expansion. Maureen Groppe from the Indianapolis Star’s Washington bureau served up a Q-and-A that covered the basics: How many Hoosiers could benefit? When will it start? Who will pay? Who was pushing expansion? Useful, but a Q-and-A that explained to thousands of low-income Hoosiers what they need to know about their coverage options would have been better. Indiana Public Media offered a little bit of that sort of coverage, with a skeleton outline of the program’s different coverage tiers.
But what I didn’t see, in the early coverage—and what’s needed in any state that expands, but especially in states that follow Medicaid reform paths—is a serious examination of how the program will work for people who enroll in it. How much does it improve their access to care, and how do the costs fit into their budget? At least some observers have questions, despite the federal signoff. “Indiana has a path to coverage, but it may be littered with debris,” says Joan Alker, executive director of the Center for Children and Families at Georgetown University.
The state, with the feds’ blessing, essentially set up two tiers of coverage. One tier, HIP Plus, gives adults 19 to 64 with incomes up to a little more than $16,000 a year a chance for good benefits, including dental and vision, with no cost sharing except for emergency room visits that turn out to be non-emergencies. They must make monthly payments of two percent of their income, or between $1 and $27, to a $2,500 savings account funded mostly by the state. People use that money first to pay for their care, and when it’s gone, the state pays for the rest of someone’s care. If a person doesn’t spend all the money in the account during the year, remaining contributions can be rolled over to reduce next year’s premium. The state also holds out the possibility of doubling the premium reduction if the person takes steps toward healthy behaviors.
Here’s the catch: The plan calls for beneficiaries to show “personal responsibility.” If residents whose incomes are above the poverty level—$11,770 for a single person—don’t pay the required monthly premium, after 60 days they are locked out of coverage for six months. Meanwhile, state residents whose incomes are below the poverty level get basic coverage with no vision or dental benefits, and must make copayments for most services.
The payments look small enough, but they “could add up to be extremely expensive for someone who gets sick,” says Caitlin Priest, director of public policy for the advocacy group Covering Kids & Families of Indiana. “The challenge is not getting people in the program but keeping them in.” Will people with so little income be able to make those payments? “It’s a matter of cutting costs as much as possible and having no surprises during the month,” said Adam Mueller, director of litigation at Indiana Legal Services—though he added cost-cutting might be tough considering that the monthly income of someone at the poverty level is only $980, and depending on circumstances $800 may go for housing and car expenses. The point of the program is to expand access to care. Will it really do that? The best way to find out is to get up close with the people it’s supposed to serve—to understand what the monthly household budget looks like, what it’s like to deal with Medicaid bureaucracy, and more.
These complications play out far from the offices of statehouse policy wonks, and that’s where the real stories lurk—like the rough transition to the new program that Melissa Hinkle has had. The 31-year-old was already on Medicaid: she was born with scoliosis, or curvature of the spine, which leaves her in pain most of the time and unable to work. Her mother covers most of her expenses. Last week, Hinkle received a six-page letter from the state informing her that she had been enrolled in the new HIP plan on Feb. 1 and “will not be charged anything for visiting the doctor or filling prescriptions.” Her only financial obligation is a $1 monthly payment, and emergency room copays if her condition is not emergent. Still, when she went to the doctor last week for an ear exam she was charged a $4 copay, and her mother paid $12 for medicines, her mother told me. Her physical therapist said she can’t have any more sessions, Hinkle’s mother added. And she was told Medicaid would not now pay for special shoes she needs because her hips are misaligned. She has never paid copays before, her mother said. According to the state’s letter, she shouldn’t pay them now.
Maybe the snafus will be worked out soon, and maybe the program will work for Hinkle and her family. But there will no doubt be other stories like this, and probably worse, and we need to hear them—just like we should hear stories about poor people getting access to care for the first time, when that’s the case. That sort of coverage will help us know if these programs are working—and if they’re not, they may create pressure to make them work better. As I wrote last year, when middle-class people and affluent people had complaints about dropped plans or higher rates caused by Obamacare, their stories made the media rounds because groups with political agendas placed them in the public eye. The same thing is not likely to happen with the thousands who will get coverage from these new-fangled Medicaid arrangements. Reporters will have to do that.