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    Indiana's Medicaid Expansion Makes Poorest Pay

    By Phil Galewitz

    Thu, Mar 24 2016

    GARY, Ind. — Reginald Rogers owes his dentist a debt of gratitude for his new dentures, but no money.

    Indiana’s Medicaid program has them covered, a godsend for the almost toothless former steelworker who hasn’t held a steady job for years and lives in his daughter’s basement. “I just need to get my smile back,” Rogers, 59, told his dentist at a clinic here recently. “I can’t get a job unless I can smile.”

    Rogers is among the more than 240,000 low-income people who gained health coverage in the past year when Indiana expanded Medicaid as part of the Affordable Care Act. Rogers pays $1 a month — a fee that is a hallmark of the state’s controversial plan.

    Healthy Indiana pushes Medicaid’s traditional boundaries, which is why it has the attention of other conservative states. The plan demands something from all enrollees, even those below the poverty line. The poorest Hoosiers can get coverage with vision and even dental benefits, but only if they make small monthly contributions — ranging from $1 to $28 — to individual accounts similar to health savings accounts. Individuals who fail to keep up lose the enhanced coverage and face copayments. Others who are above poverty can temporarily lose all coverage if they fall behind on contributions.

    If that sounds more like commercial insurance, it’s by design. So is the plan’s tough-minded approach to paying for low-income Americans’ health care.

    Proponents say the strategy makes Medicaid recipients share financial responsibility for their care, which they say will save Indiana money by reducing unnecessary services and inappropriate emergency room use.

    Several states, including neighboring Kentucky and Ohio, are looking at Indiana Medicaid as a possible model.

    Detractors worry that its complexity could make health care harder for the poor to access — the opposite of a core goal of expansion. There is no proof that the state is yet saving money or that its approach is making beneficiaries healthier.

    “Other states have looked at it, but the Obama administration has made it pretty clear that Indiana is going to be a test case and much evaluation will need to be done before they approve any more like it,” said Matt Salo, executive director of the National Association of Medicaid Directors. No other program has been allowed to require health spending accounts, much less threaten a loss of coverage for not paying in, he noted.

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