Nearly 1 million people stand to lose coverage by 2019

Ohio has made remarkable strides on health care in the past six years. But efforts by the incoming Trump Administration and Republican Congress to quickly repeal the Affordable Care Act (ACA) without a clear replacement plan would halt this progress. Repealing the ACA would jeopardize the health coverage of almost 1 million Ohioans and place their families at greater financial risk.

The ACA has helped many Ohioans get basic, essential health care. More than 900,000 additional Ohioans have health coverage today due to provisions of the Affordable Care Act.[1] That’s a huge swath of our neighbors, family members and colleagues: almost 10 percent of the population.

Republicans in Congress have voted 60 times to repeal the Affordable Care Act since 2010.[2] They are already moving to do so again. They are likely to attack core provisions of the law, including the Medicaid expansion, federal financial assistance for marketplace coverage (premium tax credits and cost-sharing reductions), and the individual and employer mandates. Even as ACA opponents rush to repeal the law, Americans are continuing to demonstrate its importance, as enrollment on the ACA-created health care marketplaces has surged during the current open enrollment period.[3]

Repeal of health reform would place us all at risk. Nationwide, it threatens the coverage of some 30 million people by 2019.[4] In Ohio, repeal would mean the federal funds flowing to Ohio’s state budget, to its health care providers and to the many families who are benefitting from expanded coverage would be slashed.

The Affordable Care Act in Ohio

The Affordable Care Act builds on America’s existing system of public and private insurance. It provides subsidies to help middle-income families buy private insurance. It also expanded Medicaid, a public program, to more low-income workers and their families. It ushered in social, economic and health achievements of historic proportions.

• The Urban Institute estimated the impact of an approach similar to the reconciliation bill that President Obama vetoed in January 2016, which would have repealed - after two years - the ACA’s Medicaid expansion and subsidies for insurance marketplaces. Those changes, alone, would raise the number of uninsured by 22.5 million when they took effect in 2019. Another 7.3 million people would become uninsured in 2019 because, together, the bill’s immediate repeal of the individual mandate, eventual elimination of marketplace subsidies, and retention of ACA protections for people with pre-existing conditions would cause the individual insurance market to “virtually collapse.” [5]

• Nearly 690,000 Ohioans enrolled in coverage as a result of the Medicaid expansion by December 2016.[6] An estimated 212,000 people enrolled in marketplace coverage, most with subsidies that offset much of the cost.[7]
• The share of Ohioans without health insurance dropped sharply, from 11 percent of the population in 2013, to just 6.5 percent in 2015. This is better than the national rate of 9.4 percent.[8]

• Before the ACA, more than 4 million Ohioans with employer-sponsored or individual-market coverage had a lifetime limit on their insurance policy, meaning that the insurer capped the amount of benefits it would pay out over the course of the person’s life.[9] The ACA prohibits insurers from imposing either lifetime or annual limits on the coverage they provide.

• In 2009, more than 5 million Ohioans had pre-existing condition that, prior to the ACA, would have meant insurers in the individual market could deny them a plan or quote them exorbitant premium rates.[10] The ACA prohibited these practices, which along with the marketplace subsidies, made the individual insurance market a viable place for many more people to purchase coverage.
• Under the ACA, health plans must cover preventive services — including flu shots, cancer screenings and contraception — at no extra cost to consumers, benefitting an estimated 5,240,575 Ohioans.[11]

Who loses the most from ACA repeal?

Working people and families: Nationally, the vast majority (82 percent) of people who would lose insurance in 2019 are in working families and do not have college degrees (80 percent). More than half are white. With repeal, about 1.6 million Ohioans would be uninsured in 2019, up from just 621,000 today.[12]

The poorest workers: The ACA’s Medicaid expansion covered people earning up to 138 percent of the federal poverty level, or a yearly income of about $16,400 for an individual and $27,800 for a single parent with two children. An individual would earn about this much by working a full-time job that pays the minimum wage, and the parent with children would be at this income level with a $13.40 hourly wage. People earning this little struggle to pay for basic expenses such as food, rent and childcare, and they frequently don’t have access to health benefits through their jobs.[13]

Ohio’s largest occupational groups: Nationally and in Ohio, about half of Medicaid expansion participants are employed or living in families in which one or more members are working.[14] Workers eligible for Medicaid coverage are employed in some of Ohio’s largest job sectors, such as restaurants and food service, which are often low-paying. Figure 1 shows the 10 job sectors with the greatest coverage from the Medicaid expansion.

In March 2014,[15] the Ohio Department of Job and Family Services provided a list of Ohio’s 50 largest employers with workers and their family members enrolled in Medicaid. Retail, fast food and restaurants, health care and temporary agencies dominate the list, in Table 1 below.

The Ohio residents who would be hurt by ACA repeal are our friends, family members and people we interact with every day. They are the servers at our favorite restaurant, the friendly temp worker answering our phone call and the salesperson helping us improve our homes and stock our kitchen.

People who depend on the individual insurance market: Repeal is likely to immediately destabilize the individual insurance market. If lawmakers eliminate the requirement for most people to have coverage or pay a penalty, some people — mainly those who are healthier— would drop their individual-market plans. This would result financial losses for insurers, likely causing some to leave the market and others to raise premiums dramatically for the customers that remain. The elimination of the marketplace subsidies would further unravel the individual market bringing it “near collapse,” according to Urban Institute analysis of a prior repeal bill.[16]

Ohio’s success story

The goal of the ACA was to improve health by expanding health care access to all Americans. In Ohio, it did. By May 2016, 702,000 people had signed up for coverage through Medicaid expansion. This dramatically increased coverage. For struggling adults (those under 138 percent of poverty) Ohio went from nearly one in three (32.4 percent) being uninsured, to 14.1 percent, cutting the uninsured rate of that group in half and bringing overall uninsurance to its lowest level in two decades.

Medicaid expansion was especially important for white men in Ohio. The majority of enrollees (referred to by the Ohio Department of Medicaid as ‘Group VIII’) were white (71.5 percent), male (55.8 percent), with a high school degree or less (58.1 percent), without custody of a child (82.1 percent). Forty-three percent were employed. This group had higher blood pressure and cholesterol and higher levels of chronic disease than patients that had previously been on Medicaid, a sign that they were acutely in need of access to health care.

Recent attention to the fact that life span is actually diminishing among middle-aged white males nationally heightens the importance of this coverage expansion.[17] Just more than one-quarter (27 percent) of Group VIII enrollees had been diagnosed with a chronic health condition and almost a third (31.9 percent) with depression or anxiety. As a result of enrollment, 43.3 percent reported a decline in unmet health needs and almost half (47.7 percent) reported an improvement in overall health.

Prior to Ohio’s adoption of Medicaid expansion, some critics had raised concerns about its effectiveness.[18] The General Assembly required the Department of Medicaid to evaluate the progress of expansion. That report documents remarkable success.[19] For example, unemployed participants reported overwhelmingly that having access to health care made it easier for them to seek employment. Among workers, most reported that Medicaid participation made it easier to continue to maintain their jobs. Many Ohioans said having access to health care had made them more financially stable. The report found that even in the short time that has passed since Medicaid expansion, people who gained coverage through it reported gains in physical and mental health status gains, as well as an increase in household, employment, and health security.”

A stronger economy

The Affordable Care Act subsidies, which help people with moderate and low incomes afford to purchase health coverage and afford health care services, brought new resources to Ohio families. Medicaid expansion, which covered 100 percent of the cost of coverage for low-income adults, brought billions of dollars into the state. The benefits have strengthened the budgets of families, communities and the state in many ways.

In 2016, Ohioans in marketplace coverage received an average tax credit of $240 a month, which covers 59 percent of the premium for comprehensive coverage.[20] This has been critical to families’ budgets and their peace of mind. Preventive care that is available at no cost under marketplace plans helps people stay healthier and more productive, the plans’ comprehensive benefits and protection from catastrophically high costs help families access medical care they need and the severe financial strain that would otherwise accompany a health crisis.

In Ohio, repeal of the ACA would mean the loss of $535 million in federal marketplace spending in 2019 and $5.8 billion between 2019 and 2028. Ohio would lose $3.5 billion in federal Medicaid funding in 2019 and $42.2 billion between 2019 and 2028.[21]

Medicaid covers almost 3 million people in Ohio, a quarter of the population. The federal government pays almost two-thirds of the bill for most Medicaid enrollees. It has paid 100 percent of the cost of Medicaid expansion to date and in future years will continue to pay the vast majority (95 percent in 2017, phasing down to no less than 90 percent by 2020). The expansion of Medicaid has brought billions of dollars for health care to Ohio counties (see appendix for county-by-county data). Medicaid expansion has also brought significant new revenues to local public services.[22]

Where repeal would hurt the most

Repeal of the ACA would hit the residents of some of Ohio’s poorest counties especially hard. Many residents of these areas would lose coverage and access to health care. Figure 2 shows the share adults aged 19 to 64 by county relying on Medicaid expansion in November 2016. Rural counties of southeast Ohio and counties with large cities are the darkest blue, showing the highest need for the Medicaid expansion. In rural Meigs County, almost 12.2 percent of people of working age (19 to 64 years of age) rely on Medicaid expansion for health insurance. In urban Mahoning County, it is 14.4 percent.

Suburban counties also have residents benefitting from Medicaid expansion: the share of Medina County’s population of 19 to 64 year-olds was 6.3 percent and Delaware County, 4.3 percent. Medicaid expansion has been critical to densely populated urban counties like Cuyahoga County. In December of 2016, Cuyahoga County had 97,525 enrolled in the Medicaid expansion (Group VIII) and Franklin County, 70,347 enrollees.[23]

Medicaid expansion brought federal funds to pay for care into state and local economies, strengthening the health care system and providing the care so many need. In Cuyahoga County, Medicaid expansion brought more than $55.5 million into the health system in December of 2016. The health care systems of Hamilton County, with 56,546 Medicaid expansion enrollees, received $35.3 million. Meigs County, as noted one of the poorest counties in the state, received $1.2 million. Erie County hospitals and health systems received $2.5 million.[24]

This funding contributes to the local economy, boosting money circulating in the community. Repeal of the ACA and Medicaid expansion without an adequate plan for replacement threatens hospitals, physical therapy offices, laboratory services, doctor’s offices and even the pizza parlor where health care workers stop to get lunch.

Not only does repeal threaten the local economy, it threatens individuals and families by threatening financial strain on the health care providers they rely on. It could hurt preventive and emergency care for thousands in every county and affect every hospital and health care system in Ohio. Hospitals that care for the poor would face severe financial difficulty with loss of the ACA. After the impressive drop in Ohio’s uninsured rate — to 6.5 percent compared to a national average of 9.4 percent, as noted — a rebound in the number of the uninsured would mean a surge in the cost of uncompensated care. Medicaid expansion now covers the costs of health care for the poorest, and along with the subsidized marketplace plans, reduces hospitals’ burden of caring for people who otherwise couldn’t pay. As the share of people with insurance has gone up, federal payments to help with the cost of indigent care has been reduced.

Federal payments to hospitals that deliver a disproportionate share of uncompensated care are called Disproportionate Share Hospital (DSH) payments. DSH payments were budgeted at $451.5 and $237 million in the Ohio budget in FY 2016 and 2017, respectively.[25]

The impact of a repeal is uncertain, but if policies are not put in place to restore federal DSH payments to pre-ACA levels, than many Ohio hospitals face financial difficulties as people lose insurance. The Urban Institute estimates that, with ACA repeal, growth in the number of uninsured residents would increase demand for uncompensated care by $1.1 trillion nationwide between 2019 and 2028. Without resumption of the federal payments provided before the ACA, state and local governments and health care providers would have to bear this cost.[26] A study commissioned by the American Hospital Association estimates that if the ACA is repealed, but changes to DSH payments and other funding tied to more universal care are not restored to pre-ACA levels, Ohio’s hospitals could lose close to $15 billion dollars between 2018 and 2026.[27]

Repeal would harm Ohio’s state budget

Ohio faces significant health care challenges. According to the Health Policy Institute of Ohio, the state ranks 47th in “health value,” an index that captures 106 metrics in health outcomes and costs. In testimony to the Joint Medicaid Oversight Committee in August of 2015, Amy Rohling McGee, the president of the Health Policy Institute of Ohio, stated: “This tells us that we are not getting good value for our healthcare dollar. We rank 40th in terms of population health outcomes, where we looked at metrics such as overall health status, adult smoking and adult diabetes.” [28] The ACA, which has improved health by expanding access to health care, [29] addresses Ohio’s pressing needs. But repeal would snatch away this progress from the state.

Ohio’s median wage is lower than the national average and lower today, adjusted for inflation, than it was 40 years ago.[30] Medicaid is a critical support to Ohioans and to the economy. Over the current two-year budget window, Medicaid in Ohio is funded with $66.3 billion, with the federal government paying $54.4 billion and the state paying $11.9 billion (of a total state budget of $128.3 billion).[31]

When Medicaid expansion was authorized, $2.5 billion federal dollars were drawn into the system for FYs 2014 and 2015. Enrollment was greater than predicted, so the federal dollars have grown. The rise in caseload did not drive up state spending because the federal government paid 100 percent of costs between 2014 and 2016. In 2017, the federal share drops to 95 percent. The state has budgeted about $135 million to cover its share in the first half of 2017.[32] The Urban Institute estimates that, if the ACA is repealed, the state budget would lose $3.5 billion in Medicaid funds to pay for the Medicaid expansion population in 2019.[33]

The Ohio Department of Health has estimated the ACA has reduced state costs by $25 million for programs including immunization, HIV/AIDS treatment, breast and cervical cancer treatment, the Mothers and Children Safety Net and the Children with Medical Handicaps Program.[34] If the federal ACA funds that underwrote these reductions are eliminated, will the state step in to backfill?

The ACA’s “State Innovation Model” grant program provided more than $75 million to Ohio, sparking new policies that let Ohio better gauge health outcomes and tailor payments for cost effectiveness. The “Balancing Incentives Payment Program” of the ACA brought $160 million into Ohio to balance the long-term care system between institutional care and home and care for elderly and disabled Ohioans. Programs like these, which help states design better and more cost-effective service delivery, may be in limbo with a repeal.

Summary and conclusion

Repeal of the ACA would harm Ohio and its residents in many ways. The Urban Institute estimates 964,000 Ohioans could lose health coverage in 2019, with the loss of the ACA’s coverage expansions (both in Medicaid and the marketplaces) and because the individual market, so recently improved, would start to unravel. Loss of Medicaid expansion will be hardest on working poor Ohioans. These are the people employed in Ohio’s largest job sectors: retail, fast food, home health care, transportation, and clerical work. They would return to a situation where they don’t go to the doctor for a bad cough. When the cough becomes pneumonia, they’re forced into emergency room treatment. But they cannot pay. That is harmful to the hospital — especially if pre-ACA payments for indigent care is not restored. But the real harm is to the individual and her or his family, who need care for sooner to assure recovery of the patient.

The state’s hospitals and other health care providers would be hit with a resurgence of uncompensated care costs, as a result of so many people becoming uninsured, especially in places of low-income. Hospital finances could become destabilized, particularly in poor rural areas where many people are covered by Medicaid expansion. Gains in health care employment could falter. Local economies would be weakened as workers lose jobs and families face new financial strains.

The Urban Institute estimates that Ohio’s budget would lose $3.5 billion in federal dollars in 2019. Hard choices loom, with life threatening consequences. With loss of federal funds, Ohio legislators face decisions like whether to designate state funding to maintain public health programs, like the HIV programming covered by the Medicaid expansion, or to cease such public health activity.

Americans and Ohioans have gained significantly from the ACA, even if they may not realize it. People with pre-existing conditions can get a health plan in the individual market. Young adults can stay on their parents’ plans. Moderate income families qualify for subsidies so they can afford private coverage and pay their out-of-pocket costs. Poor, working families can depend on Medicaid so they can stay employed. More people are getting care, and, importantly, preventive care.

Getting rid of these advances, as repeal of the ACA would do, will hurt Ohio’s people, its budget and its economy. If Senators and Congress members are going to break this system, they must make clear how they will fix it.

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Appendix Table 1: Medicaid expansion enrollment and funding by county in Ohio

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Sources

[1] This is based on the most current figures for the Medicaid expansion (December 2016) and enrollment in the healthcare exchange for Ohio (March, 2016). See Ohio Department of Medicaid “Medicaid (Title XIX) Eligibles and Expenditures Reports,” December 2016 at http://medicaid.ohio.gov/RESOURCES/ReportsandResearch.aspx and Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, January—June 2016,” National Center for Health Statistics: https://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201611_01.pdf

[2] John C. Goodman, “Do the Republicans Really Want to Repeal Obamacare?” Forbes Magazine, August 4, 2016 at http://www.forbes.com/sites/johngoodman/2016/08/04/do-republicans-really-want-to-repeal-obamacare-maybe-not/#34cb502c6101

[3] Robert Pear, “Health Exchange Enrollment Jumps, Even as G.O.P. Pledges Repeal,” New York Times, December 21, 2016 at http://www.nytimes.com/2016/12/21/us/health-exchange-enrollment-jumps-even-as-gop-pledges-repeal.html

[4] Linda J. Blumberg, Matthew Buettgens, and John Holahan, “Implications of Partial Repeal of the ACA through Reconciliation,” Urban Institute, December 2016 at http://www.urban.org/research/publication/implications-partial-repeal-aca-through-reconciliation

[5] Judy Solomon, “Republican Health Reform Repeal Plan Would Leave 30 Million More Uninsured,” Center for Budget and Policy Priorities, December 7, 2016 at http://www.cbpp.org/blog/republican-health-reform-repeal-plan-would-leave-30-million-more-uninsured; based on Linda J. Blumberg, Matthew Buettgens, and John Holahan, “Implications of Partial Repeal of the ACA through Reconciliation,” Urban Institute, December 2016 at http://www.urban.org/research/publication/implications-partial-repeal-aca-through-reconciliation

[6] Ohio Department of Medicaid “Medicaid (Title XIX) Eligibles and Expenditures Reports,” December 2016 at http://medicaid.ohio.gov/RESOURCES/ReportsandResearch.aspx

[7] “Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, January—June 2016,” National Center for Health Statistics: https://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201611_01.pdf

[8] American Community Survey

[9] US Department of Health and Human Services, “The impact of the Affordable Care Act on Ohio,” December 16 state by state data sheet at https://www.hhs.gov/healthcare/facts-and-features/state-by-state/how-aca-is-working-for-ohio/index.html

[10] Id.

[11] Id.

[12] State factsheets based on Linda J. Blumberg, Matthew Buettgens, and John Holahan, “Implications of Partial Repeal of the ACA through Reconciliation,” Urban Institute, December 2016 at http://www.urban.org/research/publication/implications-partial-repeal-aca-through-reconciliation linked in blog post by Judy Solomon, Op. Cit.

[13] Gary Claxton and Larry Levitt, “Diminishing Offer and Coverage Rates Among Private Sector Employees,” Kaiser Family Foundation, September 14, 2016 at http://kff.org/private-insurance/issue-brief/diminishing-offer-and-coverage-rates-among-private-sector-employees/

[14] Thalia Farietta, MS, and Rachel Tumin, PhD. “Profile of Ohio’s Medicaid-Enrolled Adults and Those who are Potentially Eligible, Ohio Colleges of Medicine Government Resource Center, Ohio Medicaid Survey 2015 (May 2016) at http://grc.osu.edu/sites/default/files/inline-files/MedicaidAdultsChartbookFINAL_1.pdf.

[15] This is the most recent information the Ohio Department of Medicaid has provided on employers with workers and family members enrolled in Medicaid.

[16] Linda J. Blumberg, Matthew Buettgens, and John Holahan, “Implications of Partial Repeal of the ACA through Reconciliation,” Urban Institute, December 2016 at http://www.urban.org/research/publication/implications-partial-repeal-aca-through-reconciliation

[17] Olga Khazan, “Why are so many middle aged white Americans dying?” The Atlantic Monthly, January 29, 2016 at http://www.theatlantic.com/health/archive/2016/01/middle-aged-white-americans-left-behind-and-dying-early/433863/

[18] The Heritage Foundation has critiqued Medicaid care quality; Policy Matters reviewed such claims and found that this was not an issue in Ohio. See Policy Matters Ohio, “Medicaid Works: Good Outcomes, Good for Ohio,” May 2013 at http://www.policymattersohio.org/medicaid-works-may2013

[19] Unless otherwise footnoted, the data in this section comes from the Ohio Department of Medicaid’s Group VIII Assessment, December 2016 at http://medicaid.ohio.gov/Portals/0/Resources/Reports/Annual/Group-VIII-Assessment.pdf.

[20] ASPE Issue Brief, “Health Insurance Marketplaces 2016- Open enrollment period: Final enrollment report, Appendix Table B-1 (11-1-15 to 2-1-16) https://aspe.hhs.gov/sites/default/files/pdf/187866/Finalenrollment2016.pdf

[21] Blumberg, Op.Cit.

[22] The MCO tax faces changes in the 2018-19 budget; see Wendy Patton, “Medicaid provider tax fix must not hurt counties, transit agencies,” Policy Matters Ohio, July 2016 at http://www.policymattersohio.org/wp-content/uploads/2016/07/MCO-tax-final1.pdf

[23] For a full breakdown, which includes the number of adults at risk with repeal of the ACA and the potential loss of federal funds by county, see the Appendix.

[24] See appendix for details and local data.

[25] Ohio Legislative Service Commission, Op.Cit.

[26] Blumberg et al, Op.Cit.

[27] Allen Dobson, Ph.D., Joan DaVanzo, Ph.D., Randy Haught and Phap?Hoa Luu, M.B.A., “State Level Estimates of the Impact of Repealing the Affordable Care Act on Hospitals,” prepared for the Federation of American Hospitals and the American Hospital Association, December 15, 2016.

[28] Testimony to the Joint Medicaid Oversight Committee, July 2015 at http://www.jmoc.state.oh.us/assets/meetings/HPIO_JMOC_Testimony_July_2015.pdf

[29] Ohio Medicaid Group VIII Assessment: Report to the General Assembly, December 2017 at http://medicaid.ohio.gov/Portals/0/Resources/Reports/Annual/Group-VIII-Assessment.pdf

[30] Amy Hanauer, “The State of Working Ohio 2016,” Policy Matters Ohio at www.policymattersohio.org

[31] Ohio Legislative Service Commission, Greenbook for the Ohio Department of Medicaid, 131 General Assembly, August, 2015 at http://www.lsc.ohio.gov/budget/mainbudget.htm

[32] Id.

[33] Blumberg, Op.Cit.

[34] Joint Medicaid Oversight Committee staff report, December 2015, “Review of Ohio Department of Health Treatment Programs, Appendix A at http://www.jmoc.state.oh.us/Assets/documents/reports/Appendix_A-Mathmatica_Report.pdf Appendix Table 1: Medicaid expansion enrollment and funding by county in Ohio

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