FSSA secretary: Braun administration ‘inherited a mess’

When it comes to the Family and Social Services Administration — which oversees Medicaid alongside other state programs like child care subsidies — Gov. Mike Braun "inherited a mess," FSSA Secretary Mitch Roob said Friday.

Roob is taking his second turn leading the agency, which has the single largest budget due to its federal funding. Previously, he led FSSA under former Gov. Mitch Daniels.

Donning his now-standard "Make Medicaid Boring Again" hat, Roob said the state had "no other choice" than to make the program more sustainable and fiscally sound. He spoke at the Indiana Fiscal Policy Institute's 2025 Policy Summit in Indianapolis.

"Very few people wear — other than (President) Donald Trump — wear their job description on their hat, but I do," said Roob. "That is our task for the next four years."

Under Daniels, Roob launched the earliest version of the Healthy Indiana Plan, which covers moderate-to-low-income Hoosiers but has grown since its first iteration. HIP 3.0, on the other hand, would return to its roots and "inject personal responsibility for able-bodied adults again," Roob said, putting it into alignment with federal discussions on work requirements for the Medicaid program.

Also in his first term, Roob said the agency conducted monthly finance reporting and other fiscal checks to tamp down on spending. He said departing from that norm in subsequent administrations is when the program went awry, pointing specifically to cost growth for applied behavior analysis therapy and attendant care.

The former is a treatment sought by some parents with autistic children while the latter is a program that previously allowed parents to be paid as caregivers for their children with complex medical needs.

"… that lack of accountability, that lack of paying attention to the dollars is why we had ABA therapy growing at a pace that we did. It's why we had attendant care growing at the pace that it did," said Roob. "It's very difficult to put that genie back in the bottle here because, in both of those cases, we had created, inadvertently, a dependency."

He never specifically named former Gov. Eric Holcomb in his criticism.

Details on health programs

In 2019, Indiana's Medicaid program spent $120 million on ABA therapy, but the program ballooned to $639 million by 2023. In response, Braun established a panel to consider cost controls earlier this month.

"If you think this is sustainable, you're budgeting at the federal level," quipped Roob. "Because this will bankrupt Indiana."

Similarly, attendant care costs for parents of disabled children grew rapidly during that time span. Roob said the agency spent $11 million monthly in July 2020 but the number soared to $84 million each month by May 2024, when the agency diverted parents to a structured family caregiving program that paid at a lower rate.

Combined, Roob said those numbers contributed to a December 2023 state forecast determining Indiana was $1 billion short in its Medicaid budget.

"Many folks look at the Medicaid program and they go, 'How did you get in debt a billion dollars?' Well, it's because you have so many more people receiving care and help. Because we are paying so much more for very discrete parts of the agency," Roob said.

Another program that transitioned care for elderly Hoosiers from state oversight to a contract with insurers — known as managed care entities — would "never" be something he would pursue, said Roob.

"I have been quite clear this program … I never would implement (it)," said Roob. "Because it's very difficult for managed care companies to manage the care of individuals who are in nursing homes. What is the value?"

Early pitches said the PathWays to Aging program would deliver savings because the state would pay a flat fee for Hoosiers and private companies would manage their care, rather than Indiana paying piecemeal for every cost. However, the transition to get there "is very difficult," Roob said.

"We have not, today, seen the results that we are hoping for," said Roob, adding that the state will pay $300 million extra to the companies in cost overruns this year. "… it's been painful for everybody involved so far and that pain shows signs of easing — but only signs."

Other comments

Roob didn't limit his criticisms of previous administrations solely to health care programs, also saying there was "a lack of planning" when it came to the state's child care options. Roughly 75,000 children currently receive some form of child care through the agency, an increase initially funded by federal pandemic dollars, Roob said.

"Their plan was in April of this year simply to take children off of the child care program with no particular warning," asserted Roob. "Gov. Braun and the legislature felt that was probably not the best answer, so they have allowed us to create a slope to slowly drop people from the child care program.

"That doesn't minimize the fact that we're losing over 20,000 daycare slots for the children of men and women who make below 127% of the poverty level," continued Roob.

Additionally, the "lack of planning and forethought by our predecessors" meant that there would be even fewer options for parents seeking child care for infants or one year olds.

Part of the problem with Indiana's Medicaid spending can be attributed to the state's high health care costs, an explicit priority for Braun. Since his tenure under Daniels, Roob said the disparity between what Hoosiers pay and what they receive has worsened.

"When Gov. Daniels was in office, I used to tell people that Indiana residents were buying a Cadillac and getting a Chevrolet," Roob said. "Unfortunately, today, we're no longer driving Chevrolet. We are driving a used Kia."