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Medicaid could be in line for a makeover. The government program provides health insurance for more than 70 million Americans, most of them poor. As NPR's Scott Horsley reports, President-elect Trump's choice to lead the program wants to weave more personal responsibility into the social safety net.
SCOTT HORSLEY, BYLINE: Seema Verma, who Donald Trump has tapped to oversee Medicaid and Medicare, is the architect behind an ambitious experiment to reshape health care for the poor in Indiana. That state agreed to offer Medicaid to more people but only if recipients were required to pay at least a little bit for their own coverage.
Verma crafted the so-called Healthy Indiana Plan as a consultant to Governor and Vice President-elect Mike Pence. She's also been an adviser to other red states looking to adopt the Indiana model.
JOAN ALKER: She's certainly been a thought leader in the last few years for Republican states on the direction they'd like to see the Medicaid program go in.
HORSLEY: Joan Alker studies Medicaid as head of the Georgetown University Center for Children and Families. She says the philosophy behind the Indiana Plan is that Medicaid recipients will make better decisions about health care if some of their own money is at stake. Alker herself is skeptical of how that might work on a national level.
ALKER: We can expect to see some far-reaching changes contemplated for Medicaid that will erect many more barriers to coverage and, in some cases, very punitive barriers.
HORSLEY: Indiana health care advocate Susan Jo Thomas had some of those same concerns, but she agreed to go along with Verma's plan knowing it was the only way policymakers in conservative Indiana would agree to expand Medicaid to cover more people.
SUSAN JO THOMAS: What I have come to understand is that three quarters of a loaf of bread is still pretty good (laughter) if you're hungry.
HORSLEY: And Thomas, who heads a group called Covering Kids and Families of Indiana, has been pleasantly surprised by the results. Hundreds of thousands of Hoosiers signed up for expanded Medicaid coverage. The modest premiums recipients are required to pay go into a savings account which is supplemented by the government to be used for medical expenses.
There are penalties for recipients who overuse costly care in the emergency room and incentives to promote preventive care and other healthy choices. Thomas says any improvement would be welcome.
THOMAS: We rank in the bottom third of everything - everything that's good (laughter) - and in the top third of everything that's bad. If you're fat and you smoke, you probably live in Indiana.
HORSLEY: It's too soon to say whether the Indiana model improves health outcomes or saves money for the government. But as Medicaid overseer in the Trump administration, Verma will be in a position to promote similar experiments around the country. Thomas, who's known Verma for more than 20 years, thinks she'll approach that job without any rigid ideology.
THOMAS: Whatever she proposes will be a practical program. That I can say with a hundred percent. It's sort of an Indiana thing. She's not a native Hoosier, but she's been here long enough that's she's starting to think like us.
HORSLEY: Joseph Antos of the conservative American Enterprise Institute says Verma's efforts to reshape Medicaid are just part of what's likely to be a larger Republican push to shrink the federal government's role in health care while also trying to introduce more market mechanisms.
JOSEPH ANTOS: For the last six or seven years, Republicans have been talking a pretty good game about conservative-oriented health reform. Now Republicans are in charge. Now they actually have to follow through. It'll be interesting to see how that works out.
HORSLEY: There are likely to be some big fights with Democrats and even among Republicans. Georgia Congressman Tom Price, who Trump has picked as his new health secretary, wants to eliminate the Affordable Care Act's Medicaid expansion. That would strip away the money that paid for Indiana's Medicaid experiment. Scott Horsley, NPR News.
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