Gov. Pence insists on consumer-driven principles for low-income patients

Pence seeking help from Congress in Medicaid dispute

By Maureen Groppe
Indianapolis Star, February 21, 2016

Gov. Mike Pence wants Congress to get involved in his dispute with the Obama administration over the evaluation of Indiana’s alternative Medicaid program.

Pence has accused the administration of hiring an evaluator that is biased against Indiana’s approach.

Indiana is one of a handful of states that received permission to not follow some federal rules when expanding Medicaid coverage under the Affordable Care Act.

One of the conditions of such waivers is that the demonstration program be evaluated to see whether it’s meeting the expected result. Indiana must submit an interim evaluation of the program by mid-2016.

For example, Indiana is testing whether requiring participants to make monthly contributions to a health account that can be rolled over if not used for health care reduces the use of unnecessary care.

That feature is based on high-deductible insurance plans with health savings accounts that are becoming increasingly common in private insurance coverage.

Pence argues that the Urban Institute, one of the evaluators chosen by the federal government to assess Indiana’s plan, has previously been skeptical of using the health savings account model for Medicaid recipients.

Pence wrote Health and Human Services Secretary Sylvia Burwell in December, asking that the federal review be dropped as the Healthy Indiana Plan has already been evaluated by a state-hired contractor.

In a Feb. 10 response, Burwell said the federal evaluation will not duplicate the state’s analysis, and a rigorous evaluation will help the federal government determine whether other states should be allowed to use Indiana’s model.

Pence said he is “wholly unsatisfied” with that response, and will ask the GOP-controlled Congress to review the agency’s vendor selection process.

While Pence said Burwell always worked in good faith with him while they negotiated the terms of Indiana’s alternative program, there are people “deep in the bureaucracy” who are “very antagonist towards consumer driven health care.”

“The administration wanted Indiana — and still wants every state — to just expand traditional Medicaid,” he said. “We have the most significant Medicaid reform in the 50-year history of the program, and it’s working.”

A coalition of health care and other advocacy groups wrote a letter last month in support of the federal government’s evaluation of HIP 2.0. The coalition — which includes Families USA, the March of Dimes and the American Cancer Society Cancer Action Network — said there can be a conflict of interest with state-contracted evaluations.

“When a state pays an organization to assess the merits of its own program there is the potential that the evaluator’s objectivity will be compromised,” the coalition wrote to the director of the Center for Medicaid and CHIP Services.

The groups said aspects of Indiana’s program are potentially harmful to beneficiaries and need to be evaluated before the federal government decides whether other states can adopt them. Those features include the option of charging monthly payments to recipients below the poverty line, blocking coverage for those above poverty who miss their monthly payments, and the overall complexity of HIP 2.0.

The RWJF/Urban Institute report that Pence argues shows a bias against using healthy savings accounts in Medicaid:



By Don McCanne, M.D.

Gov. Mike Pence of Indiana wants to select his own facts for a report to CMS confirming that their consumer-directed health program for Medicaid, authorized by a Sec. 1115 waiver, is meeting Medicaid requirements for the patients.

They have already independently contracted with the Lewin Group to provide a report to CMS, but numerous organizations have expressed the concern that this report could be biased because of the conflict of interest. CMS has contracted with the Urban Institute, but Gov. Pence objects because Urban has produced a previous report expressing some concerns about the option to charge premiums for individuals living in poverty and about the administrative costs and inefficiencies of health savings accounts that are used in Indiana’s program. Also there is concern about Medicaid patients being locked out of care if they are in arrears with their premium payments.

Indiana’s program is driven by ideology rather than by objective application of health policy principles. Pence touts their success at “applying consumer-health care principles to the Medicaid population.” It is more important for him to require patients to demonstrate individual responsibility through sharing in the costs of care than it is to ensure that they do receive the care that they need. It has been demonstrated that requiring payments creates barriers to care, particularly for low-income individuals.

Imagine instead having one national standard program that automatically includes everyone, gives them free choice of their health care professionals, and removes financial barriers to care. We could have that with a single payer national health program, as long as we keep ideologues like Pence out of the way.