The architect of Indiana’s Medicaid expansion has been hired by the incoming Donald Trump administration. If what Seema Verma did to Mike Pence's state is any indication, Medicaid could soon become a more profitable enterprise on the backs of the poor and disabled.

Verma has been named to run the Centers for Medicare and Medicaid Services. According to an NPR report, she was previously hired by Indiana Gov. Pence to create a “Republican version” of Medicaid under the Affordable Care Act. For a $5 million fee, Verma devised a system that requires the poor and disabled to pay a monthly fee for Medicare. The program expanded Medicaid to an additional 246,000 people, who all pay from $1-$27 a month into individual health savings accounts.

If they don’t pay, they lose their health care. Those above the poverty level lose their health care for three months. Anyone below the poverty level who can’t pay has their plan taken down to a lower level of care. The plan hasn’t gone into effect yet, however. They asked for a waiver to work out the kinks.

“The Medicaid program has not kept pace with the modern health-care market,” Verma said during a 2013 congressional hearing. “Its rigid complex rules designed to protect enrollees have also created an intractable program that does not foster efficiency quality or personal responsibility.”

She wants to see the poor take responsibility. If people get vaccines or other preventative care, they earn discounts on their premiums the next year.

Amber Thayer, a mother of three who has been living in an Indiana shelter, calls the program a nightmare. She’s a recovering addict who has been clean for six months and is training to be a nursing assistant. Thayer has been giving $1 a month to her health care, but said that each month she gets a $1 invoice from a different company.

“It is only a dollar,” she says. “I could pay a dollar a month or I could pay $12 and that will cover me for the year. Unfortunately, at that time I only had I believe it was like $2.38 on my card.”

She paid her dollar, but somehow the state lost track, perhaps because it changed the companies. So her health insurance was cut off. Thayer had bank statements and receipts to prove she had paid, but it still took her six weeks on the phone to get her health care reinstated. That meant paying out of pocket for the medication helping with her sobriety.

She was also scared the insurance problem might prevent her from being able to take her nursing assistant exam. If she couldn’t take her exam she wouldn’t get the stipend she receives because she is in a job training program.

“If I don’t get my stipend, we’re not going to have our money to help us move into our home.”

Adam Mueller, a lawyer for Indiana Legal Services, explained that the idea of “personal responsibility” being attained by paying $1 a month for health care doesn’t exactly work out in the real world.

“They don’t feel like they have skin in the game,” Mueller says. “One guy told me that it feels like Indiana is trying to take his last $12.”

Arkansas had a similar program, but it was scrapped after a few years because it wasn’t worth it.

The state’s former surgeon general Joe Thompson explained that the GOP value of “personal responsibility” sounds great politically, but in practice, it doesn’t work.

“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,” Thompson says. So they canceled the program.

“We lose too many folks along the way, and we may be causing more challenges than we’re solving,” he says.

President-elect Trump campaigned on repealing and replacing Obamacare “on day one,” but with Americans setting new records signing up for the program, it’s unclear what it will be replaced with.