HIP 2.0 filling gaps in Hoosier health care

April 03--BLOOMINGTON -- When Sarah Gilland got sick, seeing a doctor wasn't an option.

When Meghan Taylor needed an appendectomy and going to a doctor was her only option, she accumulated so much medical debt that she considered declaring bankruptcy.

"I think that's something a lot of people grapple with," Taylor said. "I just think of all the ways my life would've been different if I had had affordable care."

Before 2015, neither woman had health insurance. They fell into the coverage gap -- their income disqualified them from Medicaid, but the women didn't make enough money to purchase affordable health care through the federal marketplace.

"As a grad student, I can't work a lot, so I don't have a very significant income," said Gilland, who is attending Indiana University to earn a master's degree in public health.

In Indiana, the coverage gap was particularly wide: The Healthy Indiana Plan Medicaid demonstration project implemented in 2008 had an enrollment cap of 34,000 non-disabled adults without dependent children. By 2015, the state estimated that 350,000 Hoosiers with incomes up to 138 percent of the federal poverty level were uninsured who would otherwise qualify for Medicaid.

Gilland, who was covered by Medicaid until her 18th birthday, spent several years without insurance, "which is scary," she said. Taylor went to court twice over unpaid medical bills.

Still, among the HIP-insured population, the state saw a drop in unnecessary emergency room visits, and the program cost less than traditional Medicaid, said Joe Moser, director of Indiana Medicaid. Moser presented an overview of the program's first year at City Hall Thursday in honor of HIP 2.0's first anniversary.

In 2012, the Supreme Court ruled that Congress cannot force states to provide expanded Medicaid benefits at the risk of losing federal funds. Instead, states can apply for waivers to create their own state-provided health insurance system.

In late January 2015, the federal Centers for Medicare and Medicaid Services approved Indiana's Medicaid waiver, allowing the Indiana government to set up and run its own form of state-provided health insurance, now being called HIP 2.0.

"We are leading the country in Medicaid reform," said Joe Moser, director of Indiana Medicaid. Moser presented an overview of the program's first year at City Hall Thursday in honor of HIP 2.0's first anniversary.

In the year since the program began, more than 374,000 low-income Hoosiers are now on HIP health insurance plans. As of January 31, 2016, there were 6,993 adults in Monroe County enrolled in HIP, according to the city of Bloomington's Community and Family Resources Department statistics.

"When I get sick, I'm not avoiding the doctor like I used to because I didn't want to pay large amounts out of pocket," said Gilland, who was able to sign up for HIP after the state's waiver was approved, as was Taylor.

Through the help of state-licensed navigators who work with area nonprofits, Monroe County has a better-than-average enrollment rate, Moser said.

"In some surrounding counties, we could be doing a lot better," he said. "We know there are a lot of unmet needs out there."

Even HIP's staunchest critics can acknowledge the program's success based on how many people are now insured within the state's most vulnerable population, said Rob Stone, director of Hoosiers for a Commonsense Health Plan. However, Stone said, it remains to be seen if the state can prove the validity of the Medicaid expansion's most controversial aspect, which requires that members monetarily contribute to their health insurance plans.

Medicaid expansions like HIP 2.0 are required to meet same essential health benefits guaranteed under the Affordable Care Act. But states have the ability to test out new approaches to health care, such as HIP 2.0's "consumer-driven" Personal Wellness and Responsibility, or POWER, accounts.

HIP 2.0 members are required to contribute small amounts of money based on income to their POWER accounts monthly in order to receive the state's top benefits package, HIP Plus. Members who do not contribute to their POWER accounts are downgraded to the HIP Basic plan and lose vision and dental visits and have copays for health services.

Both plans mandate members to pay an increasing copay for every unnecessary emergency room visit, and Moser said that traditional Medicaid patients who transferred to HIP 2.0 had a 40 percent reduction in emergency room use.

No other form of Medicaid requires its members to pay for any services. But other states have approached Indiana government representatives with questions about POWER accounts "because it's working," Moser said.

Having "skin in the game," Moser said, makes members more engaged in their health care experience, and improves access and quality of care.

"My concern is that having 'skin in the game' is ultimately only going to put up another barrier to keep people from getting needed care," Stone said.

In the first year of HIP 2.0, 70 percent of HIP enrollees made contributions to their POWER accounts, Moser said, and the average monthly contribution was $9.99. Now, members have the option to pay their POWER account balance online, by check or credit card, through a bank transfer or payroll deduction, and in cash at all Wal-Mart locations. As of fall 2016, one-third of surveyed HIP members said that they check their POWER account balance monthly.

Gilland and Taylor's experiences on HIP align with the rest of the state's response to the program in its first year. Moser said 86 percent of Hip Plus said they were satisfied, 94 percent said they would re-enroll and 83 percent said they would be willing to pay more to be in the HIP program.

Local social service providers told Moser their clients still face barriers to using HIP 2.0 to its full extent to get the care they need. For individuals who haven't had insurance for long periods of time, HIP 2.0 doesn't always cover all of the medical and dental procedures they need to regain their health.

In order to assist their clients with signing up for HIP 2.0, case workers, volunteers and other navigators have to spend the time and money to be certified in compliance with state law.

"We had to make some tough decisions, and we had to make some tradeoffs," Moser said.

The state is looking into addressing the need for additional primary care physicians by allowing nurse practitioners to see patients, as well as bolstering the amount of Spanish-speaking navigators in communities, Moser said.

Taylor, who was eligible for marketplace plans during the last open-enrollment period, is now working to be certified as a navigator to help others not face the same insurance frustrations she did before HIP 2.0 expanded.

"You can prevent snowballing long-term costs down the road," Taylor said. "I'm a walking example."

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