Governor Kasich defends Medicaid expansion
Ohio accepted federal funding to expand Medicaid, and about 700,000 residents have gained coverage under the new eligibility rules. Ohio Governor John Kasich is not a fan of the Affordable Care Act (ACA), but he was one of the few Republican Governors who supported Medicaid expansion early in the process. Kasich has remained steadfastly supportive of Medicaid expansion, including during his presidential campaign in 2015/2016.
On January 3, Republican lawmakers began taking steps to repeal the ACA. The next day, Governor Kasich warned his fellow Republicans that repealing the ACA — without an equally robust replacement — could be disastrous. He pointed to the 700,000 Ohio residents who have gained coverage as a result of Medicaid expansion (a number that had grown to 725,000 by July 2017), and asked Republican lawmakers to explain exactly how those folks would continue to access coverage and healthcare without Medicaid expansion.
Kasich also noted that Medicaid expansion in Ohio has played a key role the state’s fight against opioid abuse, as people — who would otherwise have been uninsured — have been able to receive rehabilitation services covered by Medicaid.
Lawmakers vote to freeze Medicaid expansion; Kasich vetoes
Lawmakers in Ohio came to a compromise on their budget bill on June 27 and sent it to Governor Kasich, who had just two days to review it before the June 30 deadline for the state to enact the budget for the 2018 fiscal year, which began July 1. The Senate’s version of the bill had included a freeze on new Medicaid expansion enrollments after July 1, 2018, and that provision remained in the bill after it went through the conference committee process to reconcile the differences between the House and Senate versions of the budget.
Kasich had noted that the Medicaid expansion freeze would result in 500,000 people losing coverage in the first 18 months, since people would lose coverage if their income increased and would then be unable to get back on Medicaid if their income subsequently decreased (income volatility is particularly common among low-income populations).
Kasich used his line-item veto power to eliminate the Medicaid expansion freeze, and he also vetoed provisions in the budget that would have imposed a work requirement for Medicaid expansion enrollees and required some of them to pay monthly premiums for their coverage (under current Medicaid expansion rules, work requirements and monthly premiums require approval from CMS; the Obama Administration never approved any work requirement proposals, and only approved limited premium requirements, although the Trump Administration has signaled that they’ll make it easier for states to impose these types of requirements on Medicaid expansion enrollees).
On July 6, lawmakers in the House overrode Kasich’s veto regarding premiums for Medicaid expansion enrollees, but they did not vote to override his veto of the Medicaid expansion freeze (the Senate will have to agree on the veto override for it to be successful). The premiums would be part of a “Healthy Ohio” program that was initially proposed in 2016 but did not receive approval from the Obama Administration (in 2016, Ohio was requesting permission to charge premiums even for enrollees with income below the poverty level, which is not part of their 2018 budget proposal). The Trump Administration is more likely to grant Medicaid waiver flexibility to states, even when the outcome is likely to be fewer people covered.
The “Health Ohio” program would, if approved by the federal government, require non-pregnant, childless adults with income above the poverty level (ie, between 100-138 percent of the poverty level) to pay premiums, averaging about $20 per month (but not more than 2 percent of household income), for their coverage. This type of premium arrangement has been allowed in some other states under the Obama Administration.
Since lawmakers didn’t vote to override Kasich’s veto of the Medicaid expansion freeze, the state’s Medicaid expansion program is no longer facing a sunset date for the time being. But the House could still vote to override Kasich’s veto later in the year. And federal lawmakers are working to roll back Medicaid expansion nationwide. The House passed the American Health Care Act (AHCA) in May, which would end the enhanced federal match for new Medicaid expansion enrollees after 2019. The Senate’s version of the bill, the Better Care Reconciliation Act (BCRA) would gradually taper off the enhanced federal match from 2020 to 2023. The BCRA would also specifically grant states the flexibility to impose work requirements for Medicaid, despite the negative ramifications for population health.
Medicaid expansion in Ohio
Kasich announced in early 2013 that the state would expand Medicaid using federal money to pay for the vast majority of the cost (the federal government paid the full cost through 2016, and under the current rules the federal government will always pay at least 90 percent of the cost of covering the newly eligible population).
Ohio lawmakers who were opposed to Medicaid expansion brought a lawsuit against the Kasich administration in an effort to block expansion, because the full legislature was not involved in the decision to expand Medicaid – it was done through the Controlling Board (six legislators who handle budget adjustments in the state – most states do not have something like this) after the Ohio House and Senate both voted to block Medicaid expansion and Kaisch vetoed their measure.
Ultimately, in late 2013, the Ohio Supreme Court ruled in favor of Governor Kasich, and Medicaid expansion took effect as scheduled in 2014. During the 2015 legislative session, lawmakers agreed to allow Medicaid expansion to continue, although the issue was just part of the budget agreement – there was no separate legislation on Medicaid expansion.
Obama Administration CMS denied request to make expansion more conservative
In September 2016, CMS denied a new waiver proposal from Ohio that would have required all enrollees (including those with income below the poverty line) to pay 2 percent of their income (but no more than $99 per year) into a health savings account. The problem for CMS was that the new guidelines would have resulted in people losing their Medicaid coverage if they got more than 60 days behind on their health savings account payments, and they would have had to get caught up on the payments in order to be able to re-enroll in the coverage.
The state noted that their estimate was that 125,000 people would lose coverage under the new guidelines, which was a non-starter for CMS — particularly because the state wanted to bar people from re-enrolling until they paid their overdue contributions. The feds have approved some states’ Medicaid waivers that require premiums or health savings account payments for people with income above the poverty level, but has not yet approved any states’ requests to condition continued eligibility for people under the poverty level upon payments to a health savings account.
The budget that lawmakers in Ohio passed in June 2017 calls for the state to submit a waiver to CMS asking for permission to charge premiums for Medicaid, but only for enrollees with income above the poverty level. Governor Kasich vetoed this provision, but lawmakers in the House overrode his veto. If the Senate also overrides the veto, the state will move forward with submitted a waiver proposal to CMS.
Who is eligible for Ohio Medicaid?
Because Ohio has expanded Medicaid under the ACA, low-income adults without dependent children became eligible for the first time in 2014. The following residents can enroll in Medicaid in Ohio (immigration rules apply):
- Adults with household income up to 138 percent of poverty.
- Children with household income up to 206 percent of poverty.
- Pregnant women with household income up to 200 percent of poverty.
How do I enroll?
Enrollment in Medicaid is year-round; you do not need to wait for an open enrollment period if you’re eligible for Medicaid
- Ohio uses the federally-run insurance marketplace, so you can enroll through HealthCare.gov or use their call center at 1-800-318-2596.
- You can use the Ohio Medicaid (Ohio Benefits) website to enroll. You click on “check your eligibility” first, and if you’re eligible it will take you to the enrollment page.
- You can call or visit your county Department of Job and Family Services office (click on your county to see contact information).
Once you enroll in Ohio Medicaid, you’ll get a basic Medicaid (fee-for-service) ID card in the mail. Shortly after that, most new enrollees will receive a letter from Ohio Medicaid, asking them to select a Medicaid Managed Care program. There are five available: Buckeye Health Plan, CareSource, Molina Health Plan, Paramount Advantage, and UnitedHealthcare. Ohio Medicaid puts out a report card each year, giving the managed care plans star ratings for various aspects of the coverage. The 2015 report is available here.
During the first open enrollment period (October 2013 through April 2014) 156,899 Ohio residents were enrolled in Medicaid or CHIP (those who were newly-eligible under the expanded Medicaid guidelines were able to begin enrolling on December 9, 2013).
But people can enroll directly through Ohio Medicaid as well, and enrollment in Medicaid and CHIP continue year-round; it’s not a limited enrollment window like rivate plans. From the fall of 2013 to April 2017, total Medicaid and CHIP enrollment in Ohio grew by 30 percent. Net enrollment grew by more than 640,000 people during that time frame. A total of 725,000 people have gained coverage under the expanded eligibility rules, but people move in and out of the Medicaid system continuously.
Ohio Medicaid history
Ohio enacted Medicaid in July 1966, just six months after the earliest states to do so. The state implemented CHIP (Children’s Health Insurance Program) in 1998, initially covering children up to age 19 with household income up to 150 percent of poverty (that upper threshold was later increased to 200 percent of poverty).
The federal government pays 67 percent of the cost of Ohio’s traditional Medicaid program, and the state pays the remainder. But the state gets a far better deal when it comes to Medicaid expansion: For 2014 – 2016, the federal government has paid 100 percent of the cost of covering the population that’s newly-eligible population under the ACA’s Medicaid expansion guidelines. That percentage will decline to 95 percent in 2017, and by 2020 the state will be paying 10 percent of the cost of covering the newly-eligible population.
In 2011, Governor Kasich created the Ohio Governor’s Office of Health Transformation to “modernize Medicaid, streamline health and human services programs, and pay for value.”
And although the ACA’s Medicaid expansion took effect in January 2014 in Ohio (as it did in all states that were early adopters of Medicaid expansion), the state also used a Section 1115 waiver to expand Medicaid in 2013 to cover 30,000 non-elderly adults in Cuyahoga County. The eligibility threshold extended to 138 percent of the poverty level (the same as the ACA guidelines), so unless they had a change in income during the year, those early enrollees were able to transition to regular Medicaid expansion starting in 2014.