Ohio Medicaid Expansion: Story behind the surprise

Though I'm editor of an industry magazine and, therefore thought by some people to be in touch with "what's going on," I must confess complete surprise at the news two weeks ago that Ohio Governor John Kasich's administration had figured out a way to bring the Medicaid expansion to the Buckeye State. 

It seems that in a space of about six weeks, between early September and October 23, the Kasich Administration hatched a plan that would overcome what they hadn't been able to overcome for a year: the adamant opposition of a majority of legislators in the General Assembly and Senate. 

The plan was pretty simple: Ask the Ohio Controlling Board, a body of six legislators and a single appointee that adjusts spending appropriations for the state's biennial budget, to accept some available federal funding that the General Assembly hadn't counted on in the budget they approved in July. Some adjustment: $2.5 billion in federal-only support for the Medicaid expansion in 2014 and 2015, the period covered by the new budget, and coincidentally, two of the years when the federal government pays the entire cost of the expansion. So, no appropriation of state matching dollars was required.

The Controlling Board approved the expenditure by a 5-2 vote late on Monday afternoon. The approval will increase Ohio's Medicaid population from 1.9 to about 2.2 million people, with the influx beginning in January. According to John McCarthy, the Ohio Medicaid program director who addressed a group of county directors this week, the expansion strategy was thoroughly analyzed by the Governor's team, which is said to be very confident that it will withstand any legal challenge.

That is important, since a legal challenge was announced only two days later by a Ohio's 1851 Center for Constitutional Law on behalf of a group of six conservative members of the Ohio General Assembly and two right-to-life groups in Cleveland and Cincinnati. The lawsuit seeks a writ of mandamus - a judicial order that would "remind" the Controlling Board of its duty to follow the will of the General Assembly in administering spending decisions. However, that will is said to be unclear, since Gov. Kasich used a line-item veto to eliminate a budgetary provision explicitly barring adoption of the Medicaid expansion without an affirmative vote of the Assembly.

Advocates celebrate a victory

The Controlling Board's vote marked a victory for a broad coalition of health, business, education, economic, law enforcement, and behavioral health advocates who banded together for more than a year to see the Medicaid expansion through. According to Cherie Walter, CEO of the Ohio Association of Behavioral Health Authorities (OACBHA) in Columbus, the victory was shaped by a multitude of associations: the NAMI, psychology, psychiatry, behavioral health, consumer groups, Legal Aid, law enforcement, justice and reentry advocates, hospitals, and many more. 

Though the coalition was disappointed by the General Assembly's vote in July, they took heart in Governor Kasich's support for the expansion, which has not wavered since he announced his position in early 2013. Contending that the expansion was "the right thing to do" and that expansion opponents failed to understand "what it's like to walk a mile in another person's shoes," Kasich promised at a summer rally that expansion "was only a matter of time." On the grassroots level, expansion advocates were also mounting a petition drive to put the expansion on the state's ballot in 2014, an effort that was picking up steam statewide.

For behavioral health advocates like Karen Scherra, executive director of the Clermont County Mental Health and Recovery Board (Batavia, Ohio) the expanded Medicaid eligibility means that it might be possible for her organization to offer services that were always seen as necessary, but never adequately funded. For years, state budget decisions meant that Ohio's county boards were asked to pay the state's Medicaid match - about 35 percent of program funding - out of their own local treatment and service budgets. 

In Clermont County, just east of Cincinnati, that meant a $6 million annual budget could only deliver about $4 million in services, Scherra explains. Because more of those who need publicly funded mental health and addiction treatment services will become eligible for Medicaid, "we will be able to free up budget dollars for services, finally putting more money where we have never had enough."

That means going beyond essential addiction treatment services and public mental health services limited to the most seriously mentally ill people in the county. With more of these essentials now covered as Medicaid funded medical services, Scherra estimates that she will be able to redeploy available funds to support services that sustain longer term recovery. These include housing, job and vocational training, peer support programs, prevention, and mental health services to the general population - not just the seriously mentally ill - who need them. 

In anticipation of the Governor's action, Scherra's county board authorized hiring of a benefits specialist to assist in preparing the Medicaid applications needed to "turn on" care on January 1. Her county, and many surrounding counties, are seeking to sign up many working people who can't afford insurance, as well as a significant group of people who are addicted to heroin or opiates, a huge problem in the region.