Q&A: Chief Justice Loretta Rush on mental health, bail and diversionary courts
About 11 years ago when a vacancy opened on the state Supreme Court, Indiana was one of just a few without a woman serving as a justice.
Loretta Rush, who had been serving as a juvenile court judge in Tippecanoe County, wanted to change that.
"That probably motivated me as much as anything," Rush told State Affairs.
Not only would she soon be appointed to the Indiana Supreme Court in 2012 by former Gov. Mitch Daniels, Rush would also within two years become the chief justice.
Rush is still one of just two female justices out of 111 to have served on the bench. (The other is Myra Selby, who served in the 1990s.)
She is also president of the Conference of Chief Justices and recently represented the United States when she traveled to Finland to meet with justices from other countries to learn about judicial trends across the globe.
As chief justice, Rush holds significant oversight and administration responsibilities for courts across the state.
In a wide-ranging interview with State Affairs, Rush spoke about state lawmakers’ discussion on the constitutional right to bail, why she wants to see more diversionary courts, and her support for expanded assistance for Hoosiers in a mental health crisis.
“What can we do to help stabilize,” said Rush, who has been an attorney or judge for more than 40 years, “and not just keep our jails full of people struggling?”
The conversation is edited for clarity, brevity and length.
You've been on the Indiana Supreme Court for more than a decade. What's different today compared to when you started?
There's been a sea change in the last decade. We've gone paperless. We have promoted technology. We have a unified case management system.
So if you want to look up something you can do it on your phone as opposed to getting in your car and going to the courthouse. People can access their court case without having to pay money. It's right at their phone.
We are working a lot with regard to unrepresented litigants. So many of our people are unrepresented. If you go to indianalegalhelp.org, you can access how to navigate guardianships, divorce, expungement, name changes, paternity, just a number of different cases.
Courts can often be mysterious places for people. It seems like a lot of those technology upgrades are meant to remove some of the mystery.
Very much so, I think that transparency is important. Our capital is public trust. Are you going to get a fair shake? Are you going to procedurally have a fair hearing? How much is it going to cost? We think about all those things.
Do you find that most people understand the role that the Indiana Supreme Court plays in the administration of courts across the state?
No, I don’t think they do. It’s not just deciding cases; you have that administrative engine.
We’re always looking at systems. Do we have enough interpreters? Does everybody understand what’s going on in court?
A lot of people go to court sometimes at their lowest moment. And you want to make sure that the procedural safeguards are there and we’re doing what the constitution requires us to do.
Lawmakers right now are considering an amendment to the Indiana Constitution that would restrict the right to bail. What role do you and the courts play in that public discussion?
Under separation of powers, we don’t have a role in that.
But we do have a role procedurally looking at pretrial and pretrial reform. Twenty-five years ago, only 25% of people were in jail on a pretrial basis. Now it's 75%. So we’re really looking at low risk, nonviolent offenders who are poor who need to be able to bond out. We require under Criminal Rule 26 a risk assessment to determine their level of risk.
Bail and bond have always been for two things: One, to make sure that they're not arrested again; and two, to make sure they show up [for court]. So we're trying to meld the constitutional purposes of bail and bond with the practicalities of what's going on in the jail.
In your State of the Judiciary speech, you talked about diversionary or problem-solving courts. You said there’s more work to do. What are the successes and what’s left to do?
We’ve tripled them in the last decade. I think we’re growing as fast, per capita, as any other state.
I just want to make sure we don’t have justice by geography. If you live in a county and there’s a problem-solving court, you have that option available to you in lieu of incarceration.
I went to a veterans court graduation down in Floyd County in southern Indiana. Now 10 years later, somebody who would be sitting in the Department of Correction has a company, bought a house, is supporting his family and contributing to his community and he's been clean and sober all this time.
So that extra work at the front end with regard to having a problem-solving court — with accountability, regular court hearings, a team of people working with them — it’s really important. They work.
Our Indiana constitution talks about reformative justice, which means not just punitive, but also reformative. And I think it's a huge part of fulfilling the constitutional charge of redemption, reformation. The idea of people going in and out of jail, in out and of jail, and in and out of jail — something has got to break that cycle. Problem-solving courts have been effective and our judges are really on board.
This year, we've got a legislative ask for them to be funded. And I think we will be able to expand more.
Is the holdup about funding or are there just some counties who are uninterested in participating?
I mean, we had a mental health summit last year and, two years before that, we had a substance abuse summit where we invited judges to bring teams from their county. Every county showed up with a team of people to deal with justice-involved individuals who are struggling with addictions and justice-involved individuals who are struggling with serious mental illness. They all came because they really want to see a better result.
When you sit on that bench day in, day out and you're watching some of the pathos that comes before you, there's got to be a better way than just this revolving door. Plus it's a tremendous cost to taxpayers as well. So who can be safely out in the community and who cannot be? It's a tough call and our judges are making those calls every day.
What I’ve learned in Indiana is that any criminal justice reform effort tends to come from an individual county or agency because so much of our system is decentralized. So are there counties or prosecutors offices, for example, fighting against those problem-solving courts?
I'm seeing fewer and fewer of those. Some of the biggest proponents have been prosecutors.
At the substance abuse summit, we had a prosecutor from St. Joseph County come down and say, “Listen, I was skeptical, but now I see it’s working.” And the same thing on pretrial reform with regard to doing risk assessments and determining who can safely be out in their communities.
These are evidence-based, and that's the key. We're not just throwing things at the wall. A lot of these programs and disposition alternatives have been studied to find that they work.
We had to train our judges on the science of addiction. We had to train them on buprenorphine, naloxone, methadone. We brought doctors in, we brought studies in. What is working, what’s not working, for substance use disorder? So that we’re just smarter dealing with criminal actions because when you’re a community it’s not just the one criminal case.
There’s always kids involved. And there’s an employer. And then there’s family members involved. When somebody’s life is spiraling down when they come to court, if you can do something redemptive and put them in a diversion program where they can safely go through treatment, you're not just working on their life.
In your State of the Judiciary speech, you also mentioned Indiana’s 988 crisis hotline. Why is the chief justice putting a spotlight on mental health?
It touches almost every docket. And the idea that to have someone to call, someone to answer and somewhere to go in a mental health crisis, and it's not just digging yourself deeper into the criminal justice system. And there are solutions.
I was just on a phone call this morning with the lieutenant governor and with people from the mental health community. I think it's critical. I think the dollars that we spend on incarcerating somebody with mental health, if we could put it more at the front end, I think it would be money better spent with a better outcome for those individuals.
The other big bill along those lines is House Bill 1006, which seems to clarify a lot of the judicial procedures around mental health treatment.
It's been a Herculean effort to try to set up a system where they can get assessed and out of the jails and stabilized in lieu of going down the criminal justice route.
I've got to give a lot of credit to the work that Rep. Gregory Steuerwald did on that bill. I mean, he's a lawyer. He's been in courtrooms. He's been in jails.
I’m going to ask the most controversial question of the interview now, and that’s about cameras in the courtrooms. Do you think judges are actually going to allow them?
Well, we piloted it with six seasoned judges and they all had them and it worked. It may not be as much as you may want right in the beginning.
We have live streaming of our oral arguments. We live streamed a lot of trials throughout the state during COVID. The sky didn't fall.
We had two separate pilot programs. It was interesting: The judges were disappointed that more media didn't want to come. There's only two states left in the country that don’t allow cameras in the courtroom.
And so I think there's a level of transparency and public trust that can come by seeing this.
The public perception is that the U.S. Supreme Court is growing more partisan. Does the perception of the U.S. Supreme Court ever concern how your court is perceived?
When the National Center for State Courts does a pretty broad survey on trust in government, it's very disappointing to see the trust in government go down. The trust in state courts is higher than the federal courts right now, but the trust in courts is down, but state courts are the most trusted branch of government.
I think you do everything you can to be those neutral arbitrators of the facts that come before you. Protecting the institution of the court is always at the forefront of what I'm thinking so that people think that it isn't going to be based on anything other than the facts and the law.
Contact Ryan Martin on Twitter, Facebook, Instagram, LinkedIn, or at [email protected].
Header image: Indiana Supreme Court Chief Justice Loretta Rush chats with President Pro Tempore Rodric Bray, R-Martinsville, and House Speaker Todd Huston, R-Fishers, before the 2023 State of the State Address on Jan. 10, 2023, at the Indiana Statehouse. (Credit: Ronni Moore)
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Treasurer Elliott explains his plans to keep the new ESG policy from becoming a ‘witch hunt’
He calls himself the “nerdy cowboy” — wearing boots with his suit and winning his election, in part, by driving his truck to far, less-populated corners of the state. State treasurer Daniel Elliott, a farm owner from Morgan County, took over the Indiana Treasurer of State office at the start of the year, but he’s …
Plans to turn junkyards and landfills into massive park take shape in southern Indiana
CLARKSVILLE — What once was undisturbed wildlife along the shore of Silver Creek now contains a trail of weedy gravel leading to a discarded mobile home. It’s the only thing left from a junkyard stationed among this patch of forested landscape.
“We call it the graveyard,” Vern Eswine, communications director of River Heritage Conservancy, said on a recent May afternoon. “The first thing you saw as you pulled into New Albany was all these trucks and buses and junk sitting here.”
Much has already been cleared, the latest steps in a process that began in 2016 to transform an unsightly mix of junkyards, landfills and other industrial properties into a massive park along the Ohio River in southern Indiana. Think hiking trails, kayaking and treehouses, but also the restoration of land and preservation of wetlands and waterways.
It’s called Origin Park, and Eswine is among an army of people who have been working — often behind the scenes, but increasingly out in the open — to ensure that the transformation takes shape. Hopefully sooner than later.
River Heritage Conservancy, the nonprofit group driving the change, is close to either acquiring or reaching agreements for about 430 acres. And it just received maybe its most important endorsement to date: The two-year budget passed by the Indiana General Assembly last month contained $37.5 million to accelerate Origin Park’s timeline.
The funding is key to a business plan at the center of Origin Park’s ambitions. It will pay for about half of the costs associated with building a 35-acre Outdoor Adventure Center that will house ziplines, climbing walls and manmade water recreation. The goal is to charge fees for access to that part of the park in order to pay for the conservation of the rest — not only protecting the wildlife but also ensuring free access to hundreds of acres of Indiana nature. And it’s just across the bridge from a city full of potential visitors in Louisville.
Plans for the Outdoor Adventure Center
Planners originally slated the Outdoor Adventure Center as maybe the third phase of the project. Work can soon begin, though, because of the cash infusion from the state.
“We basically push a lot of our deadlines way forward because of that,” Eswine said. “And now that’s totally jump-started our ability to actually start planning and permitting, just to actually start building this thing while we’re finishing phase one.”
The state’s spending on Origin Park is just one part of a larger investment into conservation and nature projects that have been celebrated by Gov. Eric Holcomb and legislative leaders in recent weeks: $30 million for new trails; $10 million to the President Benjamin Harrison Conservation Trust Fund; $5 million for ongoing storm damage cleanup at McCormick’s Creek State Park; and $1.9 million toward acquiring the land for the closed Minnehaha Fish and Wildlife Area. The list goes on.
Perhaps the most ambitious plan of them all, though, is Origin Park.
“We’re not going to own it, but in terms of setting aside property for the public, we’ll be making significant gains,” Holcomb told reporters following the passage of the state budget in late April. “I’m very pleased with the trails and park potential to keep our momentum going.”
Where Eswine stood next to the mobile home, at the northern end of the park, will one day become the Outdoor Adventure Center.
The plan for the Outdoor Adventure Center is modeled after Whitewater in Charlotte, North Carolina. A group from Origin Park visited there for inspiration, learning that it pulls in $2.5 million to $3 million in revenue each year, Eswine said.
The company that built Whitewater is going to build Origin Park’s version, Eswine said. Projections show it will draw up to $3 million in revenue each year.
In materials shared with Indiana lawmakers, planners said the park will also drive at least $8 million in new spending to nearby towns.
The goal is to open the Outdoor Adventure Center by 2028.
But that’s just a small slice of the overall plan. Other parts of the park are already open, with a lot more on the way.
Contrasts of abandonment and restoration
Just downstream from the mobile home is a new entry point into the water called Croghan Launch, which opened to the public in March.
A paved ramp gives way to a place to drag canoes and kayaks into Silver Creek. The creek is deep and wide enough for anglers, too. On a recent May afternoon, a man who had launched his motorized boat at a different point still waited near Croghan, fishing rod in hand. The creek serves as a tributary into the Ohio River.
On the other side of the boat launch, however, a landfill looms. Someone might think it’s just a hill, but it’s still there, towering beyond stretches of trees and grasses.
What will happen with some of the spaces remains to be seen. At one landfill, for example, park planners watched for years as a once-level horizon grew in height, driven by trucks that were dumping in heaps every day. That finally stopped about four months ago when the conservancy group acquired the land.
“You can’t really do anything with this. You can be on it, but you can’t dig into it,” Eswine said about the landfill. “There’s plans for it, but we’re not really dealing with that part right now.”
At one of the now-closed junkyards, the debris is mostly cleared but what remains is a barbed-wire fence running along a concrete pad where a semi-truck trailer has been sitting for what seems like decades by the look of it. But almost as if to prove Origin Park’s mission about the importance of reclaiming this space for wildlife, a wild turkey trotted just beyond the trailer on its way to a patch of trees.
Moments like that are common right now. The park is a study in contrasts between abandonment and restoration. It’s not just wild turkey surviving among the vestiges of a junkyard; within some draining wetlands live beaver that recently dammed Mill Creek, and soaring above a landfill is a red-shouldered hawk.
The lands are home to flying squirrels too, Eswine said, and more than 150 types of birds. A late May hike revealed the unmistakable calls of eastern wood-pewee and Carolina wren, in addition to much of the backyard fare typically found in Midwestern cities, such as American robins, blue jays and northern cardinals.
A 2019 ecological report also identified 20 species of mammals, including four types of bats, and several amphibians, reptiles and insects that have found homes amid the emerging wilderness.
Elevated walkways and protecting wetlands
What’s unique about much of this land is that it’s within the flood plain. Rather than fight the occasional floods, Origin Park’s planners are incorporating it into the design. Elevated walkways will allow visitors to have access year-round.
“It will literally be in the trees,” Eswine said. “When we started developing this park, we embraced the fact that it’s going to flood more often than not.”
Another goal is to add protections for the wetlands contained within Buttonbush Woods.
And on the southern end of the property, which stretches along the banks of the Ohio River, much of the land is eroding into the waters below. It’s so bad that a riverside road has been closed to motorists because large pieces of concrete have snapped like a Hershey bar. Planners are hoping to bring in a partner organization to slow the erosion.
Meanwhile, Origin Park is being supported by the Environmental Protection Agency. An $800,000 grant, announced last week, will help pay for cleanup of polluted and industrial sites inside the park.
Eswine, who runs New Albany-based The Marketing Company and has lived in southern Indiana for almost all of his adult years, said he is witnessing a revival among Indiana’s river communities, where downtowns are booming and festivals are filling with visitors.
And he sees Origin Park, which is aptly named to acknowledge that it’s linked to a new beginning, as inherently connected to the region’s revival.
“There is a lot of history along these banks, other than just the formation of Clarksville, New Albany and Jeffersonville,” Eswine said. “Wildlife and civilizations have called this home and we’re trying to honestly get back and protect as much as we can.”
Contact Ryan Martin on Twitter, Facebook, Instagram, LinkedIn, or at [email protected].
The debt ceiling, a lack of integrity and the possible fallout
In the coming days, the United States again confronts our statutory debt ceiling. This is a 1917 law (increased every year or so) establishing a cap on federal government debt. The law itself runs up against the 14th Amendment to the Constitution, which was intended to reassure bondholders that we pay our Civil War debts. That means the debt ceiling may be unconstitutional, giving the Biden administration the option of simply printing money to cover the debt.
The debt ceiling law is politically convenient because it offers an opportunity for members of both parties to engage in a bit of political theater. It is important to remain focused on the real issue of debt rather than the political shenanigans. I expect some sort of compromise, but that is more hope than actual analysis.
Neither the Republicans nor Democrats have performed satisfactorily on this ballooning public debt. The GOP showed zero concern about debt when a Republican president was in office. Not a single Hoosier Senator or member of Congress voted against the Trump administration’s Tax Cut and Jobs Act (TCJA) or the CARES Act. These bills fall in first and third place in terms of recent contributions to the debt.
The Democrats, who voted almost unanimously against the TCJA, voted unanimously for the American Rescue Plan, which came in second place for debt loading. There’s not a clean hand in Congress on the current debt. Insofar as I can tell, the sole Republican speaking honestly about the GOP’s profligate history is Mike Pence.
As I wrote at the time, each of these large spending bills had some merits, and there remain reasonable arguments for each. The problem is that so many now in office want to remake themselves as thoughtful budget hawks, but when it mattered, they were nothing of the sort. It is the lack of integrity that highlights the real problem. No one can be honest about the root of the problem.
In 1946, right after winning World War II, our debt-to-GDP ratio stood at 119%. Today it sits at 121%, down from 127% two years ago. But, there is no peace dividend. Our spending problems are not about our military spending, which is today at near historical lows as a share of GDP.
The big-budget items driving our deficit are spending for Medicaid, Medicare, Social Security, and federal government and military retirements. And yes, I know Social Security and Medicare are supposed to be separate budget items. They are not.
If we cut all foreign aid (including Ukraine defense), housing subsidies, environmental remediation, research, discretionary education spending, immigrants, parks, and clean air or water, we wouldn’t make a dent in our debt. Altogether, these spending items wouldn’t even cover the interest payments on our debt.
In order to reduce our debt in the coming decades, we are going to have to do two very unpopular things: raise taxes and cut spending. We are going to have to do more of both than almost anyone really imagines.
On the revenue side, we are going to have to sunset the TCJA and raise marginal income tax rates on middle- and high-income households. By middle, I mean everyone who pays an income tax. Also, we probably must extend the Social Security taxes (FICA) across all earned income types.
On the spending side, we are going to have to extend retirement age, probably to 70 years or so for younger workers. We won’t have to means-test benefits, because we will have higher taxes on more affluent households. But, we will reduce retirement benefits for younger workers, and end the practice of increasing Social Security for older adults who work. We are also going to have to reduce the rate of inflation adjustments for Social Security recipients.
If all of that sounds distasteful to you, too bad. What I have just outlined is probably the easiest resolution to our current debt problem. But, what if we choose a different path?
We could cut defense spending. I’d vote to eliminate the entire Marine Corps. If we did that, it would only take another 117 years to eliminate today’s debt, though that wouldn’t come close to balancing the current budget. So, we’ll have to cut something else. If we cut our foreign aid, we could pay off the current debt, not counting interest, in 600 years. Alternatively, we could reduce overall Social Security costs by 10%, through later eligibility, and extend FICA taxes to a further 10% of earnings, and retire the debt in 60 years.
It is probably wise to ignore the political talking points about our debt and focus on the arithmetic. Still, many might wonder what if we ignore all this and blow off our debts, and default. After all, many Americans declare bankruptcy. Well, that step would be somewhere between a crisis and a full-blown economic catastrophe.
The United States borrows money like every other government does. We have treasury bills notes, bonds, inflation-indexed securities, floating rate notes, domestic series bonds and the like. Altogether this is about $31.5 trillion in borrowing. About 13 cents on every federal tax dollar collected goes to paying interest on these debts (or about twice the annual cost of the entire Marine Corps).
The reason the U.S. can borrow all this money is simply that everyone believes we will pay it back. Our creditworthiness ensures a reasonably low rate of borrowing and keeps our currency as the world’s reserve currency. So what happens if we default?
Well, there will be a flight away from U.S. securities. This will lead to financial markets devaluing our bonds, leading to higher borrowing rates on futures. Since our bonds turn over all the time, that would mean an almost immediate increase in the share of taxes we have to spend to service the debt.
If the U.S. defaults on our debts, the stock market will decline precipitously. It would strengthen China and Russia, while weakening the U.S., perhaps sliding our economy into recession along with most of our allies. The worst forecast I have seen suggests that an extended default would result in a Great Recession-level shock to the global economy.
I think this is an unlikely scenario, only because the domestic political backlash would be so severe we will come to some compromise. But, I’m a notoriously bad political forecaster. Rather than risking default, we’d be wise to heed the rare wisdom of then-President Donald Trump’s advice on the debt ceiling: “That’s a sacred element of our country. They can’t use the debt ceiling to negotiate.”
Michael J. Hicks, Ph.D., is the director of the Center for Business and Economic Research and the George and Frances Ball distinguished professor of economics in the Miller College of Business at Ball State University. He can be reached on Twitter @hicksCBER.
Header Image: Debt ceiling (Credit: Douglas Rissing / Getty Images/iStockphoto)
Thousands of Hoosiers will soon lose Medicaid access, but the cost of the program is still increasing
Hundreds of thousands of Hoosiers are poised to lose Medicaid insurance access over the next year due to the end of a COVID-19 pandemic-era federal policy that prevented states from kicking people off Medicaid.
Despite that, state costs for the health program serving more than 2.2 million low-income Hoosiers, including more than 60% of Indiana’s children, are only expected to continue to grow over the next two years. That puts pressure on the system and the state’s budget.
Indiana spends billions of dollars on Medicaid each year, making it the second largest expense to the state’s general fund following K-12 education.
In the last decade, Medicaid assistance has doubled, growing at a faster pace than the state’s general fund budget as a whole. It now makes up nearly 18% of the general fund budget, which means less money for other priorities such as education, paying down state debt or infrastructure.
“If you ask me what I lay awake at night thinking about,” Senate President Pro Tempore Rodric Bray, R-Martinsville, said at the end of the legislative session, “it’s Medicaid spending.”
The increased pot of money needed for Medicaid makes it challenging for advocates of either expanded access or increased Medicaid reimbursement rates to make their case. It also means some Hoosiers, such as those who rely on Medicaid for autism services, fear cuts may be coming.
Why so many Hoosiers will likely lose access to Medicaid
Over the next year, the state estimates that a net 400,000 Hoosiers, or nearly one-fifth of the number currently on Medicaid, will lose their Medicaid insurance access.
During the pandemic, the federal government prevented states from disenrolling people from Medicaid even if they were no longer eligible, in exchange for more federal dollars. That caused the number of people on Medicaid in Indiana to increase by more than 800,000 enrollees over the three-year period.
The Biden administration prohibition ended at the end of March, which means that for the next year, the state of Indiana will start double-checking whether those receiving Medicaid still qualify, in a process known as unwinding.
Advocates are worried some people will be kicked off by accident, or won’t realize they lost insurance until it’s too late and they’re hit with a doctor’s bill. The Family and Social Services Administration (FSSA) is sending people at risk of losing access a notice, but Adam Mueller, executive director of the Indiana Justice Project, and other advocates say it’s possible people either won’t get the notice or won’t understand its importance.
“Our biggest concern is that folks who should still be eligible for Medicaid or HIP [Healthy Indiana Plan] or any of the programs could lose coverage for procedural or administrative reasons,” Mueller said. “Even where there’s not a giant unwinding going on, people slip through the cracks.”
To that point, a recent report from the state found that of the roughly 52,000 people who lost coverage in the first month, more than 88% of them lost their Medicaid simply due to procedural reasons such as failing to respond to FSSA, not because the state found them ineligible. That could signal a problem in how Indiana is unwinding, said Joan Alker, executive director and co-founder of the Center for Children and Families at Georgetown University.
“When you see a lot of procedural losses, there’s probably a lot of people, particularly children, who remain eligible, but they’re getting terminated anyways,” Alker said. “Is the state making clear that the children and the parents may have different outcomes, that like the parent is losing [Medicaid access, but] the child is still eligible?”
Advocates also fear that those who do lose access because they are no longer eligible won’t know where to find low-cost insurance options and will go uninsured instead.
So why are the costs still ballooning?
With a net decrease in Medicaid enrollees on its way, it seems counterintuitive that the costs for the program to the state would increase, so why is Indiana’s Medicaid general fund spending poised to increase by almost 40% from the previous budget?
It’s partially because the process of double-checking Medicaid eligibility will take 12 months, which means Indiana will continue to feel the effects of the pandemic requirement until May of next year. Meanwhile, the extra funding from the federal government, which typically covered the extra costs of continuous enrollment to the states, will be phased out by the end of 2023.
“There’s been some inaccurate rhetoric and claims flying around that states have been forced to carry this population, that it’s been very burdensome on them,” Alker said. “That wasn’t true because the federal government was giving them extra money.”
But even if the pandemic requirement had not been a factor, Indiana’s Medicaid costs would likely have increased due to the growth in those enrolling, and are poised to continue increasing in the future. Michele Holtkamp, a spokeswoman for FSSA, said that’s being driven largely by an increase in the number of seniors in Indiana, who often require more costly care.
Hoosiers aged 65 years and older are making up a growing share of the population, and that trend isn’t expected to slow down in the coming years. By 2030, 1 in 5 Hoosiers will be senior citizens, according to a 2018 report from the Indiana Business Research Center.
“That’s just something we and every other state in the country will have to deal with,” Allison Taylor, interim Medicaid director for FSSA, said during an April Medicaid forecast presentation.
Likewise, the state is spending more on behavioral health costs for children. There’s currently no uniform reimbursement rate for Applied Behavior Analysis therapy, commonly used to help children with autism, which means reimbursement amounts are often significantly higher than in other states, Holtkamp said. In 2022, the state spent $420 million on such services, which she called “not sustainable.”
Indiana has also expanded Medicaid in other ways. For example, a new federal rule will require states to provide 12 months of continuous coverage for children enrolled in Medicaid. That protects children from going off and on Medicaid due to minor changes in their parents’ income or other “red tape losses,” but once again, there is a cost. Indiana also extended postpartum eligibility.
The most recent data available from Kaiser Family Foundation puts Indiana near the middle of the pack when it comes to per-enrollee spending for Medicaid and 39th when comparing how much of the general fund is made up of Medicaid spending. But without more recent data, it’s challenging to know how Indiana compares today to other states.
What’s the solution?
Finding a way to stop costs from increasing is complicated because, typically, activists and lawmakers are pushing for an increase in Medicaid access or reimbursement rates — both of which might help Hoosiers but could drive up costs more. Already, Indiana requires those making over a certain income level to make a monthly contribution to their health care.
Some lawmakers pointed to one solution: fix Hoosiers’ dismal health outcomes in hopes that it will reduce the need for care among those using Medicaid. Valparaiso Republican Sen. Ed Charbonneau, who championed a revamp of the public health system in Senate Bill 4, hopes his bill will help.
“This may be a way to bend the curve just a little bit, because unless we prevent people from getting sick … it’s going to get worse,” Charbonneau said. “We can’t keep it up.”
Beyond that, Indiana could strengthen eligibility requirements or lower Medicaid reimbursement rates, both of which would likely be unpopular.
Starting this year, FSSA is undergoing regular Medicaid reimbursement rate reviews. That means costs to the state could go up or down depending on what rates the agency lands on.
Could those reviews cause problems?
They could. This year, for example, lawmakers are coming up with a uniform reimbursement rate for Applied Behavior Analysis therapy. That means some providers could experience cuts.
Indiana ACT for Families, which aims to protect access to care for children with Autism Spectrum Disorder, actively pleaded with lawmakers and the Holcomb administration during the legislative session not to cut funding.
“The outcome of this review has existential repercussions for the children we serve,” the organization wrote in an April letter to lawmakers. “A sudden and steep funding cut would make it extremely difficult for some providers to continue operations and would reduce availability of quality ABA therapy that is critical to the children and families that we serve.
Meanwhile, other Medicaid recipients spent the legislative session pleading with lawmakers to increase reimbursement rates. The Indiana Hospital Association, for example, said Indiana’s current rate only covers about 53% of costs.
Indiana is poised to share the first batch of proposed Medicaid reimbursement rates within the next few weeks, Holtkamp said. The state will look at others, such as hospital reimbursement rates, during the next budget cycle.
Aside from that, Mishawaka Republican Sen. Ryan Mishler, the chief budget architect on the Senate side, has made it clear that he wants to be very picky when it comes to legislation that would increase Medicaid costs.
“We still have a lot of bills out there where members want to keep expanding it and adding more people to the program, and that’s something we have to take a look at is how much do we really want to keep expanding? Because once we do it’s ongoing,” Mishler said during the legislative session. “We just have to figure out the growth of the Medicaid.”
Contact Kaitlin Lange on Twitter @kaitlin_lange or at [email protected].