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

Indianapolis Star
February 21, 2016
Pence seeking help from Congress in Medicaid dispute
By Maureen Groppe

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.

http://www.indystar.com/story/news/2016/02/20/pence-seeking-help-congress-medicaid-dispute/80663058/

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

http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2015/rwjf420603

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Comment by Don McCanne

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.