An estimated 275,000 Ohioans, including more than 100,000 in southwest Ohio, are expected to gain health coverage after Gov. John Kasich led an effort to expand Medicaid over the next couple of months.
For the first time, new enrollees will include single, childless adults who were previously excluded from the state-federal program for the poor, even though they didn’t earn enough to buy private coverage on their own or through the new health care marketplaces.
Medicaid will be available to anyone with annual income under 138 percent of the federal poverty level, or about $16,000 for an individual. The marketplaces — created by the Patient Protection and Affordable Care Act to offer subsidized health coverage to moderate-income consumers — cut off eligibility at 100 percent of the federal poverty level, or about $11,000 a year an individual.
Anyone falling in the income gap. and who was not a parent or disabled, was left with few options for health coverage, forcing them to rely on hospital emergency rooms and urgent care clinics, driving up the cost of care for everyone, said Bryan Bucklew, president and CEO of the Greater Dayton Area Hospital Association.
Statewide, the net loss for providing care to the uninsured — or the difference between the total cost and reimbursements — has risen by about 32 percent from 2008 to $1.2 billion last year, according to figures reported to the Ohio Department of Job and Family Services.
“Medicaid expansion…is an important and integral part of reforming health care to make it more efficient and effective,” Bucklew said. “This will not only help provide access to health care for thousands of individuals in the Dayton region, but it is also a sound financial decision for the region and the State of Ohio.”
Expansion will offer the greatest benefit to the working poor, who have jobs but nowhere to turn for preventive health care that might keep them out of hospital emergency rooms, said Peggy Vazquez, director of clinical operations at Primary Health Solutions, which operates three community health clinics in Butler County.
Many of the fathers of the children, who comprise more than half of the Medicaid patients seen at the clinics, work part-time or in low-wage industries but have no access to health insurance and simply ignore their health care needs until a crisis hits, Vazquez said.
“These are not people who are sitting at home doing nothing,” she said. “They are working and trying to make ends meet, but they can’t get the health care they need.”
The legal challenge
But before Medicaid expansion becomes a reality for the undeserved, it will first have to overcome legal and legislative challenges.
On Oct. 21, the State Controlling Board approved expansion after Kasich’s original proposal to expand Medicaid was stripped from his two-year budget by legislative opponents, who now say the Controlling Board’s action violated the “legislative intent” of the General Assembly.
The Kasich administration said it believes the board had the legal authority to accept $2.5 billion in extra Medicaid funds from the federal government for expansion.
But a group of six Republican legislators and two anti-abortion groups have filed a lawsuit contesting the Controlling Board’s actions, with the support of numerous opponents.
“It is disappointing to see Gov. Kasich maneuver around the General Assembly – which represents the interests of all Ohioans – in an effort to expand a broken Medicaid system,” said Eli Miller, Ohio state director for the conservative group, Americans for Prosperity.
Greg Lawson, statehouse liaison and policy analyst at the Buckeye Institute for Public Policy Solutions, noted that both houses of the state legislature not only voted to strip appropriations for Medicaid expansion from the governor’s budget, they also voted to expressly prohibit future expansion.
“We think it’s a very, very solid case that the will of the General Assembly was not to do this,” Lawson said. “If you look at the history, it’s practically impossible to argue that that was not the intent of the General Assembly, therefore we think it (Medicaid expansion) is not a legal act.”
Officials at the Ohio Department of Medicaid declined to comment on the lawsuit, but said they were proceeding with upgrades to the state’s Medicaid enrollment website — www.benefits.ohio.gov — to accommodate the newly eligible population.
State ready to enroll
The website was updated for the first time in more than three decades over the summer with federal matching grant money made available under the health care law. The website has had the capacity to enroll new people under expansion since Oct. 1, according to Sam Rossi, a spokesman for the Ohio Department of Medicaid, but the function had been “turned off” while expansion was being debated in the legislature.
“We are beginning the process of turning on that system,” Rossi said. “It’ll be a matter of weeks.”
The system will be up and running in time for the newly eligible to enroll before coverage begins Jan. 1, 2014, he said.
Medicaid expansion was originally intended to be a key component of the national health care law. But the Supreme Court ruled last year that states could determine their own fates when it came to Medicaid, while upholding the overall constitutionality of the law.
So far, 26 states, including Ohio, have committed to moving forward with a Medicaid expansion, according to the Henry J. Kaiser Family Foundation.
In Ohio, expansion will ensure that most of the nearly 1.5 million uninsured residents under age 65 will have access to some form of government subsidized health coverage.
More than 900,000 Ohioans would qualify for a subsidy through Ohio’s health marketplace, according to the nonprofit Families USA.
In addition, about 26,000 military veterans, along with 12,500 of their family members, would gain Medicaid coverage, according to the Ohio Department of Veterans Service. Meanwhile, the number of new Medicaid recipients is expected to grow to more than 450,000 by 2022, according to studies by Ohio State University and the Urban Institute.
“Without the Medicaid expansion, we know there would have been a lot of people left behind,” said Trey Daly, Ohio state director of Enroll America, a nonprofit working to help people navigate the health marketplaces and enroll in Medicaid. “This is going to fill a really big gap for a lot of folks who desperately need quality affordable health coverage.”
Even if it holds up in court, Medicaid expansion won’t cover everybody. Undocumented immigrants, Native Americans and people who choose to ignore the law and pay a tax penalty for not having health coverage won’t be covered, as well as those who are simply unaware of their eligibility for Medicaid, Daly said.
“There’s a small percentage of the uninsured who were eligible for (Medicaid) coverage before expansion who weren’t enrolled,” Daly said. “There will always be some people who fall through the cracks.”
Before expansion, those falling through the cracks included an estimated 20-30 percent of the 17,000 Ohioans diagnosed with HIV/AIDS who are not in treatment, said Bill Hardy, president and CEO of AIDS Resource Center Ohio.
Hardy said Medicaid expansion will not only open the doors to treatment for under-served HIV/AIDS patients, it will also free up federal dollars appropriated under the Ryan White HIV/AIDS Treatment Extension Act of 2009 for support services and other functions.
“If folks are hungry and not in housing, they’re not going to get medical care, and they’re not going to get their medication,” Hardy said. “Medicaid expansion would free up some of the current Ryan White money being used for medical care and medications for food, housing and transportation to get people to and from treatment.”
Expansion will bring new money, jobs
Medicaid expansion will be fully subsidized by the federal government for the first three years before those contribution are pared to 90 percent of the cost in 2020 and beyond.
Ohio’s budget can expect to see a net gain of $13 billion from increased federal spending, cost savings and the creation of 28,000 new jobs over the next seven years as a result of Medicaid expansion, according to the Kasich administration.
Not everyone’s buying that argument.
The temporary government shutdown resulting from a congressional standoff over the health care law shows just how fast things can change at the federal level, including funding priorities, said the Buckeye Institute’s Lawson.
“If everything goes according to plan, and the feds keep their matching rate, Ohio would be OK - at least temporarily,” he said. “But if there would be any changes to what the federal matching rate is, that could leave the state on the hook for a heck of a lot more.”
Simply backing out of expansion is unlikely to be an option.
“You’re talking about a quarter million to a half million more (Medicaid enrollees) in Ohio,” Lawson said. “And to think you’re going to throw them off once you’ve gotten them enrolled is simply not realistic.
“We look at it like ‘Hotel California’ — once we’re checked in, we can’t check back out,” he said, referring to the popular 1970s song.