Dana Simons’ clients already have enough on their plate. As the executive director of Next Step Foundation in Terre Haute, she and her staff of peer recovery coaches offer housing and other services to Hoosiers battling substance abuse.
“We have areas around us, small farming communities, that are just decimated by drugs. We talk about opioids but … 95% of our people are methamphetamine (users),” said Simons.
But a bill that would limit a Medicaid insurance program for able-bodied, moderate-income Hoosiers could disrupt Simons’ program, which she worried could reverse Indiana’s strides to combat substance abuse in her community and others.
“We’ve learned that what we’re doing is working. Indiana’s the only state that saw an 18% decrease in overdoses in 2023. We did so good and now you’re going to reverse all that,” Simons said. “We’ve done a really good job and the (Division of Mental Health and Addiction) has done an amazing job of funding all kinds of initiatives.
“But (the Healthy Indiana Plan) has been the driver and it is the source.”
Senate Bill 2 would introduce several restrictions on HIP, which pays for the health care needs of more than 750,000 Hoosiers. Beneficiaries would be required to work or volunteer for at least 20 hours a week — with a handful of exceptions — and overall enrollment would be capped at 500,000 people.
The overseeing state agency, the Family and Social Services Administration, would be required to review eligibility four times a year, quadrupling its duties and adding to its financial needs. FSSA, its contractors, health providers, law firms and “any other person or entity” would be prohibited from marketing Medicaid and its services after a Thursday amendment.
But Republican senators painted the effort as a way of controlling costs in the rapidly growing program while protecting coverage for the poorest Hoosiers.
“I don’t know that this bill is cutting services. I think of this bill as preserving services for those most vulnerable and making sure that we’re able to fund those services,” said. Sen. Liz Brown, R-Fort Wayne.
Over the objections of Democrats, Republicans on the Senate Appropriations Committee voted to move the bill forward for further consideration.
Medicaid concerns
Author Sen. Ryan Mishler (R-Mishawaka), who chairs the committee, has long voiced his concerns about Medicaid expenses, which are the second-largest and fastest-growing line item in the state’s $46 billion budget.
Medicaid makes up roughly one-third of the state’s budget. The federal government pays for roughly two-thirds of expenses for the program and 90% of HIP. The remaining 10% of HIP is covered by a provider tax on hospitals and taxes on cigarettes.
Mishler said he specifically wants FSSA to study whether it should review applicant finances back 10 years, rather than the federally mandated five years, to identify “health wealth” individuals who shelter or spend down their assets to become eligible for Medicaid. Medicaid is the only government insurance program that covers long-term care services like nursing homes for extended periods of time.
But, like many of the restrictions posed under his bill, that would need approval from the federal government.
“We’re stating our legislative intent of wanting a cap of 500,000 but also recognize that the federal government may say differently,” summarized Sen. Chris Garten, R-Charlestown.
The Biden administration opposed work requirements for Medicaid recipients, but President Donald Trump feels differently. However, Trump has floated Medicaid reform before — leaving a lot of uncertainty.
“I don’t know if we’ll know those answers (about Medicaid) before we get out of session, to be quite honest,” said Sen. David Niezgodski, D-South Bend.
For example, subsidies for those with incomes high enough for the federal marketplace could be phased out — though those were touted as an alternative for HIP beneficiaries by committee Republicans.
Niezgodski and other Democrats opposed the bill in committee, citing the need for greater clarity. It’s still unknown what would happen to the 250,000-plus Hoosiers enrolled on HIP who exceed the 500,000-person cap.
“There’s a lot more that I want to hear,” Niezgodski told the Indiana Capital Chronicle. “… I would love to have all of these answers answered … so Indiana can have a viable program.”
In committee, Mishler pushed back against Democrat concerns, saying the best way to reduce various Medicaid waitlists would be to limit the program to “the people who need it most.”
“I think there’s enough exemptions,” Mishler said about work requirements. “To me, if you can’t find a job, I understand … (but) all you have to do is volunteer. It’s not tough.”
Pushback to bill
Simons and other advocates gathered outside of the Senate Appropriations Committee room on Thursday noted that the amended version struck a previous provision that would have limited lifetime enrollment on HIP to three years.
The amendment also allows formerly incarcerated Hoosiers a “grace period” for 90 days upon release to retain health coverage.
Next Step Foundation currently serves roughly 100 Hoosiers, all of whom are enrolled on HIP, with 42 employees, Simons said. Losing the coverage provided by the Medicaid program “would be detrimental” to her clients and her staff.
For her 14 peer recovery coaches, who are recovering addicts themselves, there aren’t many other work opportunities available. Simon worried about where they would go if her clinic lost funding.
“We’ve done all of this work to build this recovery infrastructure and now we’re just going to dismantle it by losing access to Medicaid,” Simons said. “… we see miracles every day. We see … the joy that they have in life. And that’s all at risk of going away.”
The bill does provide an exception to the work requirement for someone who “participates in a substance use treatment and rehabilitation program” but Simons noted it doesn’t specify if there’s a time limit.
Other work requirement exceptions are carved out for those with physical or mental impairments, parents of children under six years old and parents of children with serious medical conditions.
The state’s rolls swelled during the pandemic and haven’t returned to pre-pandemic levels. According to Senate Bill 2’s author, HIP has nearly doubled in size over the last five years.
But Simons said her program has work and volunteering requirements already. Many of those enrolled on HIP are working Hoosiers in rural areas with jobs that didn’t provide adequate, or any, coverage.
Additionally, Simons pointed to issues with the rollout of member contributions, where many Hoosiers reported paying their monthly premium and still getting ejected from the program. Such contributions were struck down by a federal judge last year but could also be reintroduced under a new administration.
But Simons compared problems with such payments to the task of tracking the work and volunteering requirements, saying she saw this “as one more layer where things can go wrong.”
“I get it. They need to do a better job of tightening up who gets (on), who’s eligible (and) who’s not eligible,” Simons said “They don’t want to be on HIP forever, but it’s not their fault, right? So we’re penalizing them for something that the state didn’t do a good job (on).”