美国国家公共电台 NPR The Future Of Medicaid May Be Found In Indiana, Where The Poor Pay（在线收听）

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OK, let's hear now how a Trump presidency could remake one federal program. Medicaid provides health insurance for the poor and disabled. To run the agency that oversees Medicaid and also Medicare, Donald Trump has nominated the architect of Medicaid in Indiana. As NPR's Alison Kodjak reports, the poor in Indiana have to pay for their Medicaid benefits or they face consequences.

ALISON KODJAK, BYLINE: Seema Verma is a private consultant. She was hired by Indiana Governor and Vice President-elect Mike Pence to design a Republican-friendly expansion of Medicaid. Now she'll be in a position to determine whether other states can remake their health programs for the poor in the same mold. In congressional testimony in 2013, she said Medicaid is a mess.

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SEEMA VERMA: Its rigid, complex rules designed to protect enrollees have also created an intractable program that does not foster efficiency, quality or personal responsibility.

KODJAK: Personal responsibility is a theme in a lot of Verma's work. She's advised several states - Ohio, Kentucky, Iowa and many others - on ways to revamp their health care systems for the poor. Many include cost-sharing features like premiums or health savings accounts or incentives for healthy behavior.

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VERMA: The cost-sharing policies is not to burden the individual. I think it's to incentivize them and to empower them to be a part of the equation.

KODJAK: First off, it's important to note that Indiana's expansion under Obamacare did bring Medicaid coverage to about 246,000 people who weren't eligible before. It has a complex system of carrots and sticks. People make monthly payments into individual health savings accounts, and the state also contributes money. That money can be used for doctor visits and prescriptions, and beneficiaries get premium discounts if they get vaccines or other preventive care. But they can also be penalized. If their incomes are just above the poverty line, they can be cut off for months if they miss a payment. Those below poverty are knocked down to a plan with fewer benefits. Cindy Mann is an attorney with the law firm Manatt.

CINDY MANN: There are many ways to try and effectuate personal responsibility. The Indiana philosophy was to set up a health savings account and to require everybody to contribute to the account.

KODJAK: Mann was an official in the Obama administration who negotiated the deal with Indiana to expand Medicaid.

MANN: And so the responsibility was really translated into payment requirements and - with pretty strong consequences if somebody wasn't able to pay.

KODJAK: Mann says Indiana wanted the consequences to be even harsher - a full year with no coverage for people who missed payments. But the Obama administration said no. So how does Indiana's program work in practice? For Amber Thayer - a mom of three who lives in a homeless shelter in Indianapolis - it's been a bit of a nightmare.

AMBER THAYER: Well, unfortunately, I am a recovering addict.

KODJAK: She's been clean for six months with the help of the medication Suboxone, and she's training to be a nursing assistant.

THAYER: It's been quite the struggle, but we've gotten there, and we're doing great, and we're getting ready to get into our own home.

KODJAK: Thayer pays a dollar a month for her Medicaid insurance. But in October, someone lost track of her dollar - her insurance company or the state - and her coverage was cut off. She had a bank statement and a receipt that showed she paid, but she still spent six weeks trying to get her coverage back. All the while, she scraped together enough money to buy Suboxone one dose at a time so she could get through her nursing assistant exams.

THAYER: I'm fearing, you know, the withdrawals, but I'm fearing, you know, I'm getting ready to go into clinicals, you know? If I miss a day of clinicals, I'm not going to get my stipend. If I don't get my stipend, we're not going to have our money to, you know, help us get into our home.

KODJAK: It's these types of complications that have some advocates worried. Joe Thompson is CEO of the Arkansas Center for Health Improvement where he helped develop a Medicaid program with many of the same personal responsibility features as Indiana, including premium payments and health savings accounts. In the end, he says, it just wasn't worth it.

JOE THOMPSON: We had about a year and a half of experience there, and, candidly, the administrative cost and the operating aspects exceeded what the legislature subsequently perceived the benefit of that program was, and so they stopped the health independence accounts, the health savings accounts.

KODJAK: He says the ideas about personal responsibility are politically popular, but...

THOMPSON: When it comes to operationally having low-income Americans have to participate through that in addition to the complexities in our health care system, we lose too many folks along the way, and we may be causing more challenges than we're solving.

KODJAK: But if Seema Verma is confirmed as administrator of the Center for Medicare and Medicaid Services, there could be many more states moving to Medicaid systems that put a stronger emphasis on personal responsibility. Alison Kodjak, NPR News.

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