Niki Kelly: FSSA excels in one area, strikes out in another

On one hand, Indiana’s Family and Social Services Administration (FSSA) has performed well in the sensitive process of dis-enrolling people who are no longer eligible for Medicaid. But it has similarly faltered in proposing large cuts to a program helping parents care for disabled children.

I’ll start with the positive.

New data show Indiana is moving through Medicaid unwinding in a conscientious, efficient way.

During COVID-19, the federal government barred states from purging their Medicaid rolls and enhanced the federal match, paying for nearly three-quarters of the cost of coverage rather than the traditional two-thirds. Indiana’s rolls grew from just over 1.5 million enrollees in February of 2020 to over 2.3 million in March of 2023, the last month of protections.

KFF, formerly known as Kaiser Family Foundation, reported that 10 months into the unwinding of the Medicaid continuous enrollment provision, states have conducted renewals for roughly half of all enrollees in the program. Previously, the health care organization ranked Indiana highly for its policy choices to protect Hoosiers during the unwinding process.

Indiana is at 43.6%. The highest state is Oregon at 87% and lowest is Wyoming at 18%.

Overall, Medicaid enrollment has declined by nearly 10% across states since the start of unwinding — a decline of almost 10 million people. However, the national decline in Medicaid enrollment masks significant variation across states.

The enrollment decline in Indiana is around 10% — again, right in the middle. The highest is 31% in Idaho and the lowest is less than 1% in Hawaii.

FSSA has used an awareness campaign to educate Hoosiers on the process. And while initial rejections were high, they have leveled out.

And yet the same agency has floundered on handling proposed Medicaid cuts needed after revealing a $1 billion forecasting error in the program last year. FSSA has refused to answer basic questions — from reporters, from lawmakers, from parents and from stakeholders.

We know the agency has proposed a collective $300 million in cuts. But it’s declined to share how much of that will come at the expense of an attendant care program for parents of medically complex children.

“The estimated savings from the cost containment strategies that have been outlined are all interdependent and can not accurately be broken down any further,” agency spokeswoman Michele Holtkamp said.

Attendant care refers to skilled and unskilled care provided by another individual — whether a nurse, parent, spouse or another family member. Legally responsible individuals are a class of individuals, usually those parents and spouses, that the state paid to provide attendant care for medically complex Hoosiers.

To break that category down even further, I’m focusing on the roughly 1,600 children whose parents provided state-paid unskilled care like bathing, dressing or feeding.

Just two years ago, only 456 children used attendant care at a cost of $9.3 million, according to FSSA. But with over 1,600 children, the costs soared to $172 million — a number that includes a Medicaid increase implemented over the summer.

As costs surged, the agency decided to transition those families to structured family caregiving and make up some of $1 billion deficit. Families decried the move, which would transition them from an hourly rate to a lower per diem. They also note that none of the state’s current structured family caregiving providers offered pediatric care.

It’s clear the state let this program get out of hand and is abandoning it instead of adding guardrails.

According to the New York Times, some states moved to keep but control the program. For instance, Ohio made its caregiving program permanent, but eligible parents or spouses must prove they cannot hire an aide, and paid hours are capped at 40 a week.

State Sen. Ryan Mishler, a Republican who is the chairman of the Senate appropriations committee, told the New York Times that in a few cases providers had billed the state more than $200,000 for the care of a single individual, weakening an argument that home care was more cost effective than institutional care.

If true, that could easily be nipped with appropriate limitations. And capping what percentage of payment the third-party provider who trains the parents gets to keep also could reduce costs. Parents reported receiving $15 per hour, less than half of the $36 FSSA said it paid providers.

Holtkamp said “the agency explored many considerations, and determined that structured family caregiving was the best path to allow all (aged and disabled) waiver recipients who wished to have paid caregiving delivered by a legally responsible individual to do so in a fiscally sustainable manner.”

“If a parent wants their child to continue to receive attendant care services they can do so, but it must be provided by a caregiver who is not a legally responsible individual after July 1,” she added.

Families say somebody needs to provide care but, with a nationwide nursing shortage, there’s no one available. Some parents worry that leaves them doing so at a rate just above poverty. And they note it is too time-consuming to work a full-time job.

Lawmakers implemented a few weakened transparency provisions during the session but seemed to want to stay out of policymaking. Private discussions focus on whether it’s appropriate for the state to pay a parent to care for their child, which is already their duty as moms and dads, versus the overwhelming amount of care needed in some families.

Lawmakers were happy to wipe their hands clean and leave town, but that leaves FSSA holding the bag — and no one is particularly happy with the final outcome.

Niki Kelly is editor-in-chief of, where this commentary previously appeared. She has covered Indiana politics and the Indiana Statehouse since 1999 for publications including the Fort Wayne Journal Gazette. Send comments to [email protected].