Association for Public Policy Analysis & Management

In February 2015, Indiana became the 29^th state to expand Medicaid; since then Alaska, Montana and Louisiana have followed suit. Indiana joined a handful of states that expanded coverage under a waiver that allowed the state to customize several features of the program. As more states consider Medicaid expansions through 1115 waivers, there is greater interest in understanding consequences of Indiana’s experience with the Healthy Indiana Plan (HIP 2.0). In addition, the Centers for Medicare and Medicaid Services (CMS) recently waived some of the requirements of Indiana’s state evaluation, increasing the need for independent evaluation of this unique program. This paper focuses on one aspect of such an evaluation, namely the impact of Indiana’s Medicaid expansion on access to care.

Indiana’s Medicaid expansion is unique in that it requires monthly contributions of enrollees in order to obtain full benefits. This program was designed while current Vice President Michael Pence was governor of Indiana, and current CMS Administrator Seema Verma assisted the state in the waiver proposal as a consultant. The program requires a monthly payment of 2% of income into an account similar to a health savings account. These payments must be made in order to have access to the full set of benefits; those in the 100-138% FPL range can be locked out of the program for six months for failure to make their monthly payments, while those below the poverty level are defaulted into a less generous plan with point-of-service cost sharing when they fail to contribute. In this paper we ask whether the financial barriers to achieving full coverage, health savings account incentives, potential point of service cost sharing, and the lockout provision have led Indiana’s Medicaid expansion to have a smaller impact on access to care than other traditional state expansions.

We use data from the Behavioral Risk Factor Surveillance System (BRFSS) and synthetic control methods to estimate the causal effect of Indiana’s expansion on insurance coverage and measures of access to care, including having a personal doctor, cost as a barrier to care, routine checkups, and flu shots. We then use the same methods to estimate the effects of expansion among other traditional Medicaid expansion states on these outcomes. We therefore quantify the absolute effect of Indiana’s expansion and compare it to the distribution of effects found in states without these unique program features to understand whether or not Indiana’s program design hindered access to care among new Medicaid beneficiaries.