Ohio moves on Medicaid Expansion

On at least two occasions earlier this year, Ohio Governor John Kasich heard loud and clear that majority Republicans in the General Assembly were against the Medicaid expansion. But at a rally with expansion advocates at the State House this summer, he promised that the expansion was “only a matter of time.”

On October 23, he made good on that promise, circumventing a sure “no” vote in the General Assembly by winning a 5-2 vote by the Ohio Controlling Board - a seven-member panel empowered to make spending adjustments to the state budget. And, just like that, Medicaid expansion in the Buckeye State is “on” for January 1.

The $2.5 billion budget “adjustment” approved by the Controlling Board will inject $482 million of federal Medicaid expansion funds into the current fiscal year’s budget from January through the end of June, and another $2 billion into the following fiscal year, at which time the current biennial state budget will expire. At that point, the expectation is that the General Assembly will be compelled to continue the expansion or risk bankrupting the state’s Medicaid system - an act barred by state law.

While a handful of far right legislators has already filed suit against the Governor’s move, a broad coalition of interests, including Ohio’s huge healthcare sector, are squarely behind it. In response to critics, Kasich has repeatedly said that they “need to walk a mile in the other person’s shoes.”

‘A huge difference’

“This will make a huge difference for those who until now have been without insurance, without access to care except through a visit to the emergency room,” says Tracy Plouck, director of Ohio’s now unified Department of Mental Health and Addiction Services (MHAS). “In the aggregate, we expect to enroll up to 366,000 Ohioans as a result of the increase in the income limit,” she adds, noting that state officials “are now working on enrollment strategies.”  

At present, Ohio provides Medicaid coverage to adults with dependent children with incomes up to 90 percent of the federal poverty limit (FPL), but it offered no help to childless adults. In January, the Medicaid eligibility level will rise to 138 of FPL and childless adults, many of whom are men, will be able to qualify.

Specific to behavioral health, Plouck predicts that community mental health and addiction services will see a shift as some $75 million in treatment dollars flow directly in from Medicaid, replacing the treatment dollars that, until the expansion, have been provided through one of Ohio’s 53 local behavioral health services authorities.

As federal Medicaid dollars displace local authority dollars, Plouck says that local boards will be able to redirect dollars previously spent on the essentials of treatment - often for individuals in crisis - to fund strategically important but currently underfunded priorities. These priorities include efforts to promote health and wellness, to offer prevention or early-intervention programs, to develop additional affordable housing resources, to advance job training and employment support efforts, and extend peer services that promote recovery focused relationships and communities.

Time to ‘gear up’

“For us, the impetus was on 60,000 folks with an addiction and another 55,000 with mental illnesses that we believe are going to benefit from expansion,” says Cheri Walter, CEO of the Ohio Association of County Behavioral Health Authorities (OACBHA). She points out that “Ohio is in the midst of a huge opiate epidemic” as well.

For much of the year, Walter and other behavioral health advocates worried as the Medicaid expansion fell to the wayside in the 2014 state budget, which was passed by the Republican-dominated General Assembly in July. It appeared that hopes for Medicaid expansion would be dashed in the Assembly’s September session as well, where talk was about reforming the current Medicaid system, not expanding it.

Walter credits the Governor’s Office of Health Transformation with a series of reforms that have already improved the Medicaid system within the past several years. And, she calls Kasich “a champion who really stepped in to push” the expansion forward.  In the end, the Governor was joined by a coalition including behavioral health, consumers, medical and hospital groups, members of the business community, law enforcement, education, and other leaders.

But the new opportunity brings challenges of its own, she says. Across the system, “we’ve got to get geared up, because we haven’t had the money to support greater access to services,” she continues. But actually strengthening or expanding service capabilities will take time for Ohio’s providers and depend on a sustained boost in available treatment dollars after years of cutbacks. She believes that with access to primary care through the expansion, “we’ll have healthier people overall, better able to overcome their problems. With fewer emergencies due to better care, we believe that we can help keep people stable and out of the hospital.”

While critics deride expanded government assistance and assert that it creates greater dependency, Walter asserts that “getting people healthy is the only way to get them back into the workforce.”

County directors speak

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, she says that “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. As more of these essential services are covered by Medicaid, Scherra says that existing local funds can be redeployed into support services that truly 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. Such supports provide a stronger foundation for people to maintain health, stability, sobriety, family and work relationships.

Since the Medicaid go-ahead, the Clermont county board has authorized hiring of a benefits specialist to assist in preparing the Medicaid applications needed to “turn on” care on January 1. Scherra says that the goal for her county, and for the rest of Ohio’s 88 counties, is to sign up thousands of working people who can’t afford insurance and to extend treatment to the growing number of opiate-addicted people.

Up north in Cleveland, Cuyahoga County Alcohol, Drug Abuse and Mental Health Services (ADAMHS) board director William Denihan, another vocal advocate, is delighted that Medicaid expansion will bring primary healthcare coverage “to tens of thousands of people that don’t have it.” While that is a big help, Denihan, together with city and county officials, knows that even the expansion dollars won’t fill the void for drug and alcohol-treatment services, services that have never been covered by Medicaid.

The scope of the county’s heroin epidemic is such that heroin overdose is now the leading cause of accidental death, surpassing even falls and motor vehicle accidents. While additional Medicaid dollars will relieve some stress on Cuyahoga County’s $33 million ADAMHS board budget, Denihan and other county leaders pushed hard and won a November levy to boost ADAMHS board funding to over $45 million per year. This amount, says Denihan, enables the county to undertake a vigorous prevention program and add critically needed detox, residential treatment, and sober living capacity.

“It’s like someone once told me:  ‘If you don’t have enough to fund prevention, you’ll never have enough to fund treatment.’” So, for this former Cleveland police chief, two fights are won, but more battles surely await.