Although many see the creation of “HIP 2.0” as a strange move for a Republican-controlled state, Indiana has suffered from several public health issues for years—not to mention a well-publicized drug epidemic that ballooned into an HIV outbreak under Pence’s watch—and has consistently ranked near the bottom in most state health indices. It quickly became clear that the HIP 2.0 program under Verma did not intend to be a very generous program. The plan sought to eliminate standard Medicaid protections and provisions for vulnerable people, exchanging them for a premium-based program that mimicked private plans. In her defense of those reforms, Verma wrote:

Medicaid was designed as a critical part of the safety net for our nation’s most vulnerable populations—individuals who are aged, blind, or disabled, and families with incomes well below the poverty line—many of whom possess limited ability to provide for their own well-being. Rules governing the program recognize the necessity of long-term enrollment for those facing serious medical challenges, making it easier for them to get in and stay in the program. Yet many of Medicaid’s enrollment and eligibility policies, which might make perfect sense for certain vulnerable populations, are not always appropriate for able-bodied adults possessing different capabilities and earning potential. Able-bodied adults need coverage, but not the same set of policy protections.

It’s unclear if any of Verma’s reforms in Indiana have had the desired effect. The state still sits near the bottom of all states in several outcomes, and drug deaths and infant mortality have still risen over the past year. The program has improved reimbursement for physicians and thus increased access to providers for Medicaid enrollees, but its scheme requiring enrollees to contribute to a health savings account and sometimes pay premiums has cost thousands of people their coverage. It also might not even be cheaper for the state than traditional Medicaid, despite implementing restrictions on enrollees designed to reduce costs.

Verma’s consultancy was also involved in a failed attempt in Ohio to bar Medicaid recipients from coverage until they’d paid premium arrears, and in the use of an 1115 Medicaid waiver in Kentucky to create a “work activity” requirement for the program. That waiver is still under consideration by CMS, and will be under her own review should she become administrator.

Although Verma’s biggest policy accomplishments came under the Obamacare Medicaid expansion, a provision that still seems to be on its way out, they could still signal what CMS’s priorities might be as the administration seeks to dismantle Obamacare and roll back public insurance. For one, until Congress does act to repeal Obamacare, CMS is authorized by an executive order from President Trump to “minimize the unwarranted economic and regulatory burdens” of Obamacare, and order that in practice might involve rolling back and privatizing as many elements of the ACA as possible under law. To that end, CMS has already proposed new rules slashing open enrollment times for the exchanges by over a month and relaxing the minimum standards for what qualifying exchange plans have to cover.