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The state of Indiana has been grabbing headlines lately with its Hoosier Healthwise program and tobacco tax initiative, two innovative policies that are also spurring conflict with Washington. Indiana State Senator Patricia Miller, who co-authored the state’s unique health program, spoke with PT to explain the initiation and maintenance of these state and federally-funded measures

PT: Could you tell us a little about Hoosier Healthwise, and why it is such a unique program?

Senator Miller: First of all, it’s based on principles. One is that this would essentially be like private insurance—it’s sort of a combination of health insurance with a medical savings account. The state underwrites the insurance premium, but the whole program is implemented through private insurance companies. We wanted to help individuals without health insurance obtain it, and we wanted to make sure they have an appropriate plan.

PT: Could you explain to me how the measure progressed to its current state, and at what stage is the bill currently in?

Senator Miller: It should take effect January 1, 2008, but we’re still jumping through all the hoops to get our 1,115 waivers, because this is a federal program. It has to be approved by the federal government; and one of the requirements is that it remains revenue neutral for the federal government. So we’re going through all of these efforts to show the federal government that what we’re doing is cost effective, not only for the federal government, but for the folks that we’re going to help to get health insurance. The goal is for the insurance plan to begin providing coverage in January.

PT: What types of obstacles did you encounter while pushing this legislation in Indiana?

Senator Miller: We’ve had a great deal of support in the House and the Senate, among both Republicans and Democrats. The most controversial issue was the funding mechanism. Most people were supportive of the program—we worked long and hard on the policy statement; but we only worked on the funding mechanism in the last 24-36 hrs of the session.

Initially the governor proposed a 25-cent cigarette tax. In the final analysis, we passed a 44-cent increase in the cigarette tax, but not all of it goes to this program. Three cents go towards increasing reimbursement to health care providers, and 11 million dollars goes to immunization.

PT: Is this a sustainable funding mechanism?

Senator Miller: We believe it will be adequate to fund the program. In 5-10 years we’ll see how this will work. But at the time that we were considering it [Health care for Hoosiers], we were not aware that Congress was looking at its own cigarette tax increase, which could have a negative impact on Indiana. If the program that Congress is looking at should pass, Indiana will be a donor state, so essentially 300 million would go out of Indiana, and only about 60 million would come back. So money from Indiana would go to fund plans for California, Texas, New York and other states, which we think is a very negative thing for us. It may also reduce the amount of revenue we’re able to raise for this health insurance program.

PT: When working to pass health care legislation, how do you steer away from the politicized buzzwords associated with the topic?

Senator Miller: We’ve had to have individual involvement, individual responsibility and accountability, and, as I said, this is the state subsidizing a program for low-income people to get health insurance.

The first thing about this plan is that it is not an entitlement. The amount of people covered is based on the amount of revenue we have. It doesn’t ensure that everybody gets health insurance. It provides a health insurance program for those who choose to purchase their own health insurance. They’ve purchased it based on a sliding scale indexed to their income, but no one pays more than two percent of their annual income towards the premiums, or they could pay up to 4.5 percent of their income. No one pays more than $1,100 a year for their health insurance. The fact of the matter is that this is not an entitlement. It is an optional program.

PT: How do you address the argument that the fight for better health care is a matter of ensuring equality for many Americans who live in poverty and do not have access to medical care?

Senator Miller: Indiana is not a state of many wealthy people. We have lots of folks without health care. This is a private program, with the state underwriting the premium for individuals. I don’t see the question relating to the Indiana program at least.

First of all, poor individuals get Medicaid. The people we’re trying to cover are classified as “working poor”. This is a method for them to purchase health insurance. The individual who will get this health insurance will get the same quality of care as Medicaid. When someone walks into a hospital, doctors and nurses don’t make decisions based on who the payer is. When they get in, they get the same quality of care as anyone else with an insurance plan. In fact, this is a much better quality for these individuals because if they’re not insured they tend to get the least-effective and the most costly insurance and that’s emergency care. This includes wellness and preventative care. We have incentives for businesses to help their employees get health insurance included as well. I would argue that this plan makes sure that these people get the same quality as everyone else. That includes the promotion of wellness, prevention, immunization—it’s all in there.

PT: Could you tell me more about the demographics of the uninsured, and why they don’t have health care?

Senator Miller: A lot of them are working poor, like I said. They’re working two different jobs, they have a lower income, or work for employers who don’t give health insurance. It’s not a matter of not wanting it—they just can’t afford it. This gives them affordable health insurance, because the state underwrites their premium. Many of them are in-between jobs, where they had it last week, but they may not have it this week. I guess I refer to them primarily as the working poor.

PT: Could you tell me a little bit more in your role in getting this legislation passed, and how did this program came to be?

Senator Miller: I authored it as a senate bill, until the last 24-36 hours into the bill, when we had to have the funding mechanism. At that point it was passed from the Senate to the House.

PT: How did you break health care legislation down into manageable pieces so it doesn’t become overwhelming, and how can you strike a balance between the needs of your constituents and the needs of the federal government?

Senator Miller: It took over a year, we asked our administration to look at ways to help the uninsured get health care; it took lots of effort, with many trips to Washington to talk to CMS and other groups in order to find out how we could get a waiver.

There were some specific things that the Bush administration wanted—that it be private, for one, and that there was some accountability and personal responsibility, and we think that was a very important part of it. This was [bill] was a way for individuals to take responsibility for how they live, and to take on wellness programs in the appropriate manner. For example, we require them to get a laundry list of things they have to get per year: annual physicals, mammograms, they have to engage in what we would call wellness and preventive care. Those kinds of accountability are there for people to use it in the most appropriate way.

For the big picture, the more people get health insurance, the more affordable health insurance is going to be for everyone. Right now, we’re paying for people who are uninsured and with that comes higher health care costs, higher premiums, higher taxes—from federal taxes to property taxes to pay for people who are getting care through charity care or emergency care and other kinds of things.

Ultimately it can be a benefit for everyone, certainly in the business community as well as for individuals.

This will probably be one of those things that, for right now, we think we have an excellent plan, and can’t wait to see people start to enroll here in a couple of months.

PT: Senator Miller, thank you for your time.

Patricia Miller serves Indiana’s 32nd Senate District. She chairs the Health & Provider Services Committee in the Indiana Senate.