When then-Gov. Mike Pence faced the worst public health crisis to hit Indiana in decades, he turned to Obamacare — a program he vilified and voted against.

In 2015, as a rash of HIV infections spread through rural southern Indiana, state health officials parachuted into Scott County and enrolled scores of people into Obamacare's expanded Medicaid program so they could get medical care and substance abuse treatment. Many were addicted to opioids and had contracted HIV by sharing dirty needles.


Two years later, Pence is helping to lead the Republican effort to dismantle the program that helped him halt the deadly outbreak in an impoverished swathe of Indiana.

"These are good salt-of-the-earth folks who got caught up in a disaster. Not funding this would be like removing sandbags during a flood,” said Blake Johnson, who helps people in Scott County enroll in health coverage on behalf of Covering Kids & Families of Indiana, a nonprofit patient group.

On the campaign trail, Donald Trump had been among several GOP presidential candidates who talked about the plight of Americans addicted to opioids. “I would dramatically expand access to treatment slots and end Medicaid policies that obstruct inpatient treatment,” Trump said last fall, three weeks before his election. He also talked about dismantling Obamacare and turning Medicaid into a block grant program — an approach that caps federal support and could force states to cut benefits or eligibility.

Pence was one of the GOP governors who had agreed to expand Medicaid under Obamacare, albeit with certain conservative tweaks. He signed his state’s Medicaid expansion known as the Healthy Indiana Plan 2.0 in 2015 — the same year as the HIV outbreak.

Some Pence critics have said his strong anti-abortion stance, which led Indiana to close several Planned Parenthood clinics including one in Scott County, may have worsened the outbreak by making HIV testing less accessible.

His health department relied heavily on the program to respond to the HIV crisis in southern Indiana. Officials set up a “one-stop-shop,” next to a free needle exchange, in the tiny, impoverished town of Austin, and offered hot meals, HIV screenings, vaccinations and assistance to help people enroll in insurance — many for the first time — through HIP 2.0.

Within a month, about 168 people were approved for the program, according to figures provided by the Indiana Family and Social Services Administration. About 2,280 people in the Scott County are currently enrolled, many of whom are now getting substance abuse treatment.

“A lack of health insurance was one of the first barriers to testing and treatment identified in Scott County,” said Jeni O’Malley, a spokesperson for the Indiana State Department of Health. “HIP 2.0 helped address that gap and opened doors to medical care and treatment that have been life-changing for people living with HIV and hepatitis C.”

Clients could get new needles as part of the needle-exchange program in Indiana in 2015. | AP Photo

Health insurance is pivotal for HIV patients, since their condition is chronic and requires consistent treatment and medication. And since the outbreak in Scott County was fueled by people contracting the infection by sharing needles, many were in need of robust substance abuse treatment services that are also covered through HIP 2.0.

The Affordable Care Act provided money to fully fund expanded Medicaid through 2016, but the share of the government’s tab dips gradually to 90 percent by 2020. Under the law, eligibility was expanded to people earning up to 138 percent of the federal poverty level, or about $16,400 for an individual, and was no longer limited to pregnant women, children, or the disabled.

Pence put a conservative spin on the program by requiring enrollees to make monthly contributions — $1 a month for many. But people with HIV and chronic substance abuse disorders are exempt from such contributions and also qualify for enhanced benefits such as vision, dental and nonemergency transportation. The plan covers outpatient services and case management programs that are essential for people with chronic conditions like HIV.

Now, health care providers and patient advocates are nervously watching the Obamacare repeal debate play out in Washington, worried about what might happen if HIP funding goes away and the law’s coverage of mental health services is weakened.

“We are currently in a panic about what’s going to happen,” said Jaymes Young, a medical case manager for The Damien Center, the largest AIDS service organization in the state.

A recent analysis by the nonpartisan Kaiser Family Foundation found that coverage for people with HIV increased significantly as a result of the law's Medicaid expansion.

Another study published in Health Affairs found that fewer uninsured HIV patients were hospitalized in states that had expanded Medicaid. In fact, between 2012 and the middle of 2014, the percentage of hospitalizations among uninsured HIV patients dropped from 13.7 percent to 5.5 percent since more people had coverage. Meanwhile, in states that didn't expand Medicaid, the percentage of hospitalizations for uninsured HIV patients rose from 14.5 percent to 15.7 percent.

Researchers also found that HIV patients without health insurance were nearly 40 percent more likely to die during their hospital stay, compared to those with health insurance.

To be sure, HIV-positive patients in Indiana may get coverage through other sources, including traditional Medicaid, insurance funded through the Ryan White HIV/AIDS program and commercial coverage on the exchanges. But HIP 2.0 was particularly important for this population because it provides substance abuse and mental health treatment that includes case management and even non-emergency transportation to get people to doctors’ appointments and therapy sessions.

Pence, a longtime Obamacare foe who voted against its 2010 passage as a lawmaker, has assured people in his state that HIP 2.0 will remain even if the law is repealed, portraying it as an innovative state program that he suggests is unconnected to Obamacare.

In an op-ed published in the Indianapolis Star last year before he was tapped to be vice president, Pence said, “HIP will exist after the ACA.” though he conceded the program would be altered.

“Of course, when Obamacare is repealed, there will need to be a transition period...allowing a new administration in Washington the ability to reform Medicaid and provide states even more flexibility to innovate and strengthen programs like HIP 2.0,” Pence wrote.

The Trump administration and Republicans on Capitol Hill support making Medicaid a block grant program that would provide a set amount of funding to every state based on its number of enrollees. While federal spending would be capped, states would have more flexibility about how to spend the money.

Providers and caregivers in Indiana worry the switch will harm patients.

“Hopefully the ACA stays,” said Young of The Damien Center. “It was complicated and imperfect but now we’re used to it. More changes will do damage to our clients.

Even Republican state lawmakers are concerned about change.

“We've made great strides serving a very vulnerable, high-risk population with HIP 2.0,” said state Rep. Ed Clere, who chaired the House health committee around the time of the HIV outbreak.

Clere added that he is open to block granting, but "it shouldn't limit access, It has to be for the right reasons. It can’t just be about saving the federal government money."

The threat of Obamacare repeal comes even as Indiana officials are asking the Trump administration to tweak its own Medicaid expansion program. The updated waiver proposal vastly expands substance abuse treatment coverage to anyone in Medicaid and includes inpatient, as well as outpatient, treatment for substance abuse.

“The expanded access we seek through this waiver extension will prove critical” Pence’s successor, Republican Gov. Eric Holcomb, wrote in a letter to the Trump administration.

The waiver application, which was largely crafted by Seema Verma, Trump’s pick to lead CMS, is expected to be approved. However, if the ACA is repealed, the program’s future is unclear.

“It’s been a miracle for Indiana,” said Susan Jo Thomas, the executive director at Covering Kids and Families of Indiana. “I don’t want to talk or think about the consequences of losing it. It’s terrifying.”