Put affordable health coverage out of reach for many

Executive summary

The American Healthcare Act (AHCA), passed by the House in May and now heading fast toward a Senate vote, has been gathering a formidable coalition of opponents, including the American Medical Association, the AARP, the American Hospital Association, the American Diabetes Association and the American Heart Association. And for good reason: the AHCA will cost 23 million Americans their health coverage, and will compromise the coverage of many more. It threatens protections put in place by the Affordable Healthcare Act (ACA) for people with pre-existing conditions like cancer, diabetes and asthma from prohibitive premiums or denial of coverage, effecting 50 percent of Ohioans who have these illnesses.

The AHCA will allow states to apply for waivers from mandating insurers to cover basic services like maternity and newborn care, substance abuse treatment and prescription drugs, compromising quality of coverage in any state that chooses not to protect its residents.

It will reverse public health gains made by enrolling many previously uninsured Americans in affordable insurance under the ACA.

Older Americans will pay far higher out-of-pocket costs for Marketplace plans under the AHCA’s tax credit structure compared to the ACA’s.

While these serious outcomes are deservedly receiving a great deal of critical attention, the AHCA plan to gut Medicaid (a program that covers one in four Ohioans) from several angles and de-fund Medicaid expansion is getting far less attention than it warrants.

The AHCA restructures Medicaid as a per capita cap structure, which caps federal funding per Medicaid enrollee. Per capita caps save the federal government money by setting the cap at a growth rate lower than Medicaid costs are expected to grow. States are responsible for covering all Medicaid costs above these caps, costs that will grow steadily over time.

Under per capita caps, when health care costs suddenly explode due to a public health emergency like Ohio’s opioid epidemic, additional federal resources would no longer be triggered. Additional costs of care would fall to the states.

Ohio will have to come up with $6.4 to 8.5 billion by 2025 to make up for this tremendous loss in federal funding to Medicaid, or cut some combination of Medicaid payments to providers, service options and eligibility for Ohioans.

Across the board, the people who will lose most under per capita caps are those who are expensive to treat: senior citizens, special needs children and anyone with a pre-existing condition. As states face growing funding cuts, these groups will likely lose benefits— and the AHCA will give states the latitude to change eligibility requirements in order to make service cuts.

The AHCA also de-funds Medicaid expansion, which allowed any Ohioan making below 138 percent of the federal poverty line to enroll in Medicaid. Over 723,000 Ohioans have enrolled in Medicaid through expansion, which, under the ACA has been almost entirely covered by federal funding. The AHCA sharply rolls back the federal match rate, and, by 2021, Ohio will be responsible for an additional $735.5 million to maintain coverage for its expansion enrollees. Under serious budget shortfalls, it is unlikely Ohio will be able to maintain costs of Medicaid expansion over time.

The Urban Institute projects that between a likely loss of Medicaid expansion in Ohio and additional cuts to enrollment due to per capita caps, 814,700 Ohioans will lose Medicaid coverage by 2022.

The AHCA strips away Medicaid and Medicaid expansion funds in the name of cost savings, but starting in 2018, it cuts taxes to high-earning households— amounting to $663 billion in lost revenue over 10 years. This trade-off between affordable health coverage for millions and tax cuts for millionaires is unacceptable.

The AHCA puts the health of many Ohioans, especially the state’s most vulnerable residents, on the line, and it does the most damage through Medicaid.

Introduction

The American Healthcare Act (AHCA), passed by the House in May and now being used as the basis for the Senate bill, has been widely critiqued for its reversal of protections for people with pre-existing conditions and the fact that it will result in 23 million Americans losing health coverage.

The Congressional Budget Office (CBO) estimates that under the AHCA,14 million Americans will lose their health coverage next year alone.[1]

The AHCA would be particularly damaging to the state of Ohio and its residents. Under it:

• 814,700 Ohioans will lose their Medicaid coverage by 2022 as a result of changes to Medicaid under the AHCA.[2]
• Increases in total out-of-pocket costs for Marketplace coverage will force many of the 238,843 Ohioans enrolled in these plans to lose coverage as it become unaffordable.[3] Older Ohioans with low-incomes would be especially at risk: in some cases, older Ohioans people would have to pay close to half their yearly income toward premiums.[4]
• 4.8 million non-elderly Ohioans with pre-existing conditions like asthma, diabetes, hypertension and cancer would lose protection against higher premiums or outright denial of coverage due to their illnesses.[5]
• The AHCA allows states to apply for waivers from mandating insurance providers to cover basic services like emergency room visits, maternity and newborn care, mental health and substance abuse treatment, prescription drugs and pediatric services. These have been considered Essential Benefits that are required to be covered under the Affordable Healthcare Act (ACA).
• Ohio will face substantial cuts in federal funding to Medicaid— between $16.3 and 22.3 billion— by 2025.[6]
• By far, the ACHA poses its biggest threat to Medicaid and the one out of every four Ohioans who depend on the program for health coverage. This paper explains how, and what’s at stake for Medicaid if the AHCA passes.

What per capita Caps will cost Ohio

Currently, the federal government pays a fixed percentage of a state’s Medicaid costs for all who are eligible. In Ohio, the federal government pays 63 percent of the program’s costs. If costs of care change due to increased Medicaid enrollment, a public health emergency, changes in who is enrolled, or changes in costs of medical technologies, the federal government still pays the same share of the cost of care.

The AHCA would change Medicaid’s financing to a structure (known as a “per-capita cap”) that would cap federal funding per Medicaid enrollee starting in 2020. State by state, these cap amounts will be set based on each state’s 2016 Medicaid spending and multiplied by enrollment for each group.

The AHCA saves the federal government money by setting the cap rate of growth lower than Medicaid costs are expected to grow.[7] States will be responsible for covering all Medicaid costs above these caps.

Under per capita caps, when health care costs suddenly explode due to a public health emergency like Ohio’s opioid epidemic, additional federal resources would no longer be triggered. Additional costs of care would fall to the states.

The bottom line of per capita caps is that states will have to cover a steadily growing portion of Medicaid costs. According to projections from the Center for Community Solutions, Ohio would have to come up with $6.4-8.5 billion by 2025 under a per capita cap structure, or cut services, to maintain projected Medicaid funding levels.[8] County by county, projected cuts to Medicaid by 2025 are deep.[9]

Ohio will have to make up for this tremendous loss in federal funding by either cutting other state budget items, or cutting some combination of Medicaid payments to providers, service options and eligibility.[10]

Across the board, the people who will lose most under per capita caps are those who are expensive to treat: senior citizens, special needs children and anyone with a pre-existing condition. As states face growing funding cuts, it is likely to be these groups who will see changes in benefits— and the AHCA will give states the latitude to change eligibility requirements in order to make such service cuts.

The Center for Community Solutions projects that under per capita caps, spending on Medicaid groups will have to be cut as follows by 2025:

• Children: Monthly, per member spending will have to decrease by $106, or 21 percent.
• Adults: Monthly, per member spending will have to decrease by $339, or 32 percent.
• The disabled: Monthly, per member spending will have to decrease by $213, or 7 percent.
• The aged: Monthly, per member spending will see a gain of $570, or a 30 percent increase.[11]

Per capita caps penalize states that are operating cost-efficient Medicaid programs. Caps in these states will be pegged to lower rates of spending, hemming in what can be spent in the future.[12] Because nationally, the growth of Medicaid’s costs-per-beneficiary nationally was slower than expected as of 2010, the CBO dropped its projection of federal Medicaid spending by 9.3 percent for the next decade.[13] There is concern that if per capita caps are set off of these current low spending rates, they may not keep up with cost growth in the future.

Per capita caps also open up the door for policymakers to tinker with the Medicaid growth rate any time they want to cut Medicaid funds to pay for other priorities, like future tax cuts. There is already evidence of this danger: just weeks after the House-passed AHCA, President Trump cut an additional $616 million from Medicaid and the Children's Health Insurance Program (CHIP) over ten years as part of his 2018 budget.[14] This was on top of the massive $834 billion in cuts to Medicaid within the language of the AHCA itself. Now, imagine this happening over and over again. That is what re-structuring Medicaid allows.

As much as rhetoric around the AHCA emphasizes greater state flexibility, what we are actually seeing is the states being asked to do more with far fewer resources.

Medicaid expansion in Ohio

The ACA helped reduce the percentage of uninsured Ohioans from 11 to 6.5 percent in just two years’ time.[15] While many associate the ACA with Health Insurance Marketplace plans, it is actually Medicaid expansion that accounted for the vast majority of newly-insured Ohioans. The ACA allowed states to expand Medicaid eligibility beyond those Medicaid has traditionally served (the disabled, the blind, pregnant mothers, children and senior citizens), to all residents making up to 138 percent of the federal poverty line.[16]

Fully 723,000 Ohioans are enrolled in Medicaid expansion coverage today,[17] compared to the 238,843 Ohioans who enrolled in private insurance through the Healthcare Marketplace in 2017.[18] The majority of expansion beneficiaries in Ohio were Caucasian, single and male, and 75 percent were previously uninsured.[19]

Medicaid expansion in Ohio had immediate— and overwhelmingly positive— health outcomes:[20]

• 59 percent of Ohio expansion enrollees reported better management of chronic conditions.
• A majority reported increased use of preventive and primary care services, allowing over one in every four enrollees to get diagnosed and treated for chronic medical conditions that had not been previously flagged. This type of ongoing care can help stave off critical and expensive medical complications.
• 34 percent reported reduced emergency room visits, and more appropriate usage of the ER, an important cost-saving measure to hospitals.
• 45 percent reported decreased medical debt, which was often cited as a major obstacle to care in the past.

Reducing the number of uninsured under the ACA saved American hospitals $7.4 billion in uncompensated care costs (the costs for caring for uninsured patients) between 2014 and 2015. Five billion of these savings were in Medicaid expansion states like Ohio.[21] As more and more people lose coverage in the first year after AHCA passage, Ohio hospitals can expect to spend $263.7 million more on uncompensated care.[22]

Medicaid currently pays one in four dollars spent in health care transactions in Ohio, and Medicaid expansion alone brought $3.6 billion in federal dollars into the state, which has been used to staff hospitals and health centers and pay for health services for so many newly-insured Ohioans.[23]

These dollars mean a lot in Ohio, where health care jobs continue to grow as part of the state economy. Between 2000 and 2015, jobs in Ohio’s private health care sector grew by more than 10 percent, while private sector jobs statewide grew by just 0.2 percent.[24] Four of the state’s ten largest employers are now hospitals or hospital systems, whose employees are in part supported by Medicaid and Medicaid expansion funds now under threat by the AHCA.[25] The Economic Policy Institute projects Ohio can expect a .7% decrease in job growth under the AHCA, amounting to 81,385 jobs statewide.[26]

The end of Medicaid expansion

Despite marked benefits for health outcomes in all Medicaid expansion states (and for Ohio’s growing health care sector), the AHCA would sharply cut federal funding to Medicaid expansion, which would soon make it financially impossible for the state to maintain it.

Under the ACA, Medicaid expansion was 100 percent paid for by federal funding in its first three years, and would be 90 percent covered by federal funds moving forward. Under the AHCA, however, the federal share of funding for each new expansion enrollee would drop starkly in 2020, down to the regular Medicaid rate (63 percent in Ohio).

By 2021, Ohio will be responsible for an additional $735.5 million to maintain coverage for expansion enrollees.[27] As the state now faces a budget shortfall of over $800 million, it is hard to imagine how even a state like Ohio, where Governor John Kasich has been a proponent of expansion, will be able to afford maintaining services and coverage under these cuts.

A federal match rate of 90 percent will be maintained for expansion beneficiaries who were enrolled prior to the changes taking effect in 2020,[28] but this rate only applies to people who maintain continuous coverage. This requirement is at odds with the needs of many expansion enrollees. The top jobs held by expansion enrollees— including restaurant and food service work, construction, home health care, and temp employment— are all occupations where employment can begin and end suddenly and cyclically, or where income often spikes and drops.[29] This means that many people have to disenroll and re-enroll in Medicaid regularly, which would slowly make many Ohioans ineligible for the higher expansion match rate. The AHCA also mandates that Medicaid enrollees have their coverage renewed every 6 months, rather than annually, which will also speed up the process of kicking people off the rolls.

This is why the CBO projects that under the AHCA, fewer than 5 percent of Medicaid expansion enrollees can expect to remain in the program by 2024.[30] The Urban Institute projects that between a likely loss of Medicaid expansion in Ohio (where state legislators are already pushing to freeze expansion enrollment in 2018)[31] and additional cuts to enrollment due to per capita caps, 814,700 Ohioans can expect to lose Medicaid coverage by 2022.[32]

AHCA proponents suggest that Americans who lose expansion can instead purchase private coverage on their own using the House bill’s tax credits. But even after accounting for tax credits, premiums would eat up 10 percent of the annual income of a 45-year-old, and 48 percent of the income of a 60-year-old whose earnings are at the federal poverty line.[33] This not a real option for a person living in poverty.

In what has been a notably closed-door process, the Senate is pursuing revisions to the House-passed AHCA that do little to address how much damage the bill will do to Medicaid and Medicaid expansion, while making it appear that helpful compromises are being made.

Ohio Senator Rob Portman is advocating a phasing in of the AHCA’s massive cost shifts to states. Yet, a June Center on Budget and Policy Priorities report shows this would have little discernable effect on coverage losses.[34] A Charleston Gazette-Mail editorial put it aptly after West Virginia Senator Shelly Moore similarly signed onto a phase out of expansion after promising not to throw 170,000 W.V. expansion enrollees off a cliff: “Instead, she would drop them off a cliff on the installment plan.”[35]

What do cuts to Medicaid mean to Ohio?

Medicaid Cuts Would Make It Harder for Ohio to Fight the Opioid Crisis

Ohio’s fast-growing opioid epidemic continues to claim lives across the state, with fatal overdoses increasing by more than 25 percent in 2016.[36] While Senator Portman emphasizes the need to bring more resources to effective addiction treatment, the truth of the matter is that AHCA cuts to Medicaid and Medicaid expansion funding would paralyze two programs that have been addressing this issue head-on.

In fiscal year 2016, the state of Ohio spent just under $1 billion through 11 state agencies on efforts to reduce drug use and percent overdose fatalities. By far the largest portion of this spending— $650.2 million’s worth— happened through Medicaid addiction and behavioral health services.[37] Ohio Medicaid paid for over 30,500 doses of Vivitrol (a monthly injection the blocks brain receptors that trigger feelings of euphoria when on opioids) in 2016.[38]

This fact is not lost on health care providers as they watch Congressional efforts to dismantle Medicaid. At a May 25 hearing sponsored by Senator Portman on shipment of synthetic opioids to the U.S.,[39] Dr. Terry Horton, a Delaware addiction treatment physician, said that the critically-important addictions treatment he provides “is entirely dependent on Medicaid… Without Medicaid, that care would collapse.”

Because substance abuse disorders are not considered a disabling condition, many of those in need of treatment prior to the ACA often were not eligible for Medicaid. After expansion based Medicaid eligibility on income rather than disability, addiction treatment became much more available to Ohioans. Because of this, many Ohio providers point to expansion as one of the state’s most powerful tools for getting people struggling with addiction into treatment.[40] Andy Albrecht, CEO of Counseling Center (a substance abuse treatment program serving counties throughout southern Ohio) calls Medicaid expansion the single biggest thing to ever happen to his agency. Through it, Counseling Center has been able to offer addiction treatment to 1,100 men across southern Ohio who would not have been eligible for Medicaid prior to expansion.[41]

Though expansion has helped 500,000 Ohioans gain access to substance abuse treatment and mental health services, Senator Portman supports eliminating expansion, and has pushed for a separate pot of money to treat opioid addiction.[42] The $45 billion opioid treatment fund reportedly set aside by the Senate as a part of AHCA negotiations barely touches costs of treatment. If treatment needs continue to grow as they have been, the Center for American Progress projects that Ohio will need $2.2 billion for opioid treatment in 2026 alone. This fund would provide Ohio just $272 million that year.[43]

It is not only through cuts to Medicaid that ACA repeal will harm efforts to curb overdose fatalities. Substance abuse treatment is another of the ten essential benefits the ACA mandated insurers cover that will now be left up to the states. In so many ways, the AHCA is making it impossible for states to address real health concerns in ways that have proven to be effective.

AHCA puts Ohioans with complex medical conditions at risk

Prior to the ACA, Americans with pre-existing condition like asthma, diabetes, cancer, or hypertension (among a list of many) were either unable to purchase private insurance plans, or subject to prohibitive premiums. The ACA required that health plans cover people with these conditions without additional premiums.

The AHCA allows states to apply for waivers that would let them charge higher premiums to high-risk people. If states do not adopt their own protections for people with pre-existing conditions, many of those in most dire need of coverage will no longer have care options they can afford. This measure threatens coverage for over 50 percent of non-elderly Ohioans.[44]

After a massive outcry from Americans who would lose coverage, the House added a last-minute— and woefully inadequate— $8 billion over five years in the AHCA for high-risk pools. This comes nowhere near the estimated $327 billion over 10 years it would cost make high-risk pools a viable alternative for people with pre-existing conditions.[45]

The ACA’s limits on annual out-of-pocket spending and prohibition of lifetime limits under private insurance plans have also helped people with chronic illnesses afford care. Over 3.8 million Ohioans under private and employer-provided insurance plans face lifetime coverage limits if the AHCA removes these protections.[46]

Older Ohioans will pay more under the AHCA

In what has been dubbed an “age tax,” the AHCA changed how tax credits for helping Americans pay insurance premiums are calculated to be based more on age then on income[47] (as it was under the ACA.)

The result is huge spikes in premium costs for older Ohioans. Annual premiums for a 60-year-old making $30,000/year living in rural Hocking county would rise astronomically, by $12,100 a year, from what she or he would have paid under the ACA. A 60-year-old Hocking resident making $20,000/year would pay 73 percent of his or her yearly income on premiums, or $13,620.[48]

Though senior citizens can be capped separately to account for higher costs of care under per capita caps, caps do not account for the much higher costs of care for older senior citizens. As people in their 80’s and 90’s have more serious health problems and a higher likelihood of being in nursing facilities, costs of care for them are 2.5 times more than for those between 65-75 years of age.[49] Ohio’s population of senior citizens aged 85 and older is projected to increase by 18 percent from 2025-2035, which means the state will be faced with finding funds to cover these increasing costs over time.[50]

Rural Ohioans will be hit hard by the AHCA

One out of every five Ohioans lives in a small town or rural area, where Medicaid plays a huge role.[51] While many people associate Medicaid beneficiaries with urban centers, the percentage of rural and small-town children and adults enrolled in Ohio Medicaid is just slightly higher than children and adults in urban Ohio.[52]

More rural than non-rural Ohioans enrolled in Medicaid through expansion, and all but two of the 22 Ohio counties with the highest percentages of their population enrolled in Medicaid are rural counties.[53]

Rural residents continue to have less immediate access to health care. Fifteen of the 18 Ohio counties that will have no longer have a Marketplace insurer after Anthem exits the Market next year are counties where every census tract qualifies as rural.[54] As Medicaid funding dries up, many Ohio rural hospitals and health centers face fears about how they will remain solvent.[55]

This is important because health care employment is playing a growing role in many rural Ohio counties. Between 2008-2015, private health care jobs increased an average of 13.9 percent in rural Ohio counties, compared to an average 8.1 percent in urban counties, while both saw a slight decrease in overall private sector jobs.[56]

As a major employer and provider of benefits, any cuts to Medicaid will have an outsized effect in rural Ohio.

The AHCA would harm Ohio’s most vulnerable children

Half of all births and two out of every five kids in Ohio are covered by Medicaid.[57] As the largest enrollment group, services to children will be disproportionately impacted by cuts to Medicaid. Under per capita caps, Ohio can expect to lose 1.6 billion dollars in federal Medicaid funding to non-disabled children between 2020-2026.[58]

In a good example of how re-structuring Medicaid opens to door for serious benefits cuts, the AHCA would eliminate current requirements for states to provide EPSDT screenings—essential preventative screenings and ongoing health services for youth up to 21 years old—under a block grant option for Medicaid.[59] Once the door is open for services to be cut, states will be more and more likely to cut back costly services as funding decreases over time.

This erosion of services is a particular concern for the 20 percent of kids nationally with special needs, especially those with the most critical conditions like autism or Down syndrome, whose costs of care run far higher than other kids.[60] Many of them receive Medicaid-funded care in school. Salaries for nurses, counselors and speech pathologists paid for by the $81.5 million in Medicaid funds Ohio schools get annually to bring health services to students with disabilities will also be under threat.[61]

Several of the essential benefits that will no longer be guaranteed in private insurance plans under the AHCA hit pregnant mothers and children hard, among them maternity care, newborn care and pediatric dental benefits. In states that waive these benefits, costs to consumers will go up by thousands of dollars a year.[62]

The upshot

Medicaid is clearly filling a great need, and it does so more cost efficiently than private insurance. Through a combination of lower out-of-cost payments to beneficiaries and lower payments to providers, payments on adults enrolled in Medicaid are 22 percent lower than if they were covered under private insurance.[63] Over the past thirty years, Medicaid costs-per-beneficiary have been growing more slowly than those in the private insurance market.[64]

So, what is behind the mathematical acrobatics going on in Congress, when demand for Medicaid is clearly not going away and the program is doing its job efficiently? At the same time the AHCA guts Medicaid through a myriad of funding cuts, it is also cutting taxes to high-earning households starting in 2018 that will amount to $663 billion in lost revenue over ten years.[65]

If concern for health care access was present in this debate, a trade-off of steep cuts to Medicaid for $50,000 tax breaks for millionaires would never be acceptable.

Yet, it is all there in the same bill, now being hashed out without public hearings and rushed toward a Senate vote before their next recess at the beginning of July.

Acknowledgements

Thank you to the following organizations for making this report possible:

The Center on Budget and Policy Priorities

Progress Ohio

The Ford Foundation

The George Gund Foundation

Saint Luke's Foundation

UHCAN Ohio

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[1] Congressional Budget Office. “H.R. 1628, American Health Care Act of 2017.” May 24, 2017. https://www.cbo.gov/publication/52752

[2] Urban Institute. "The Impact of the AHCA on Federal and State Medicaid Spending and Medicaid Coverage: An Update." June, 2017. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2017/rwjf438186

[3] Centers for Medicare and Medicaid Services. “Biweekly Enrollment Snapshot: 2017-02-03.” https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-02-03.html.

[4] Kaiser Family Foundation. “Premiums and Tax Credits Under the Affordable Care Act vs. the American Health Care Act: Interactive Maps.” April 17, 2017. http://www.kff.org/interactive/tax-credits-under-the-affordable-care-act-vs-replacement-proposal-interactive-map/

[5] Center for American Progress. “Number of Americans with Pre-Existing Conditions by Congressional District.” April 5, 2017. https://www.americanprogress.org/issues/healthcare/news/2017/04/05/430059/number-americans-pre-existing-conditions-congressional-district/

[6] Center for Community Solutions. “Update 2.0 Per Capita Cuts: Proposed American Health Care Act Costs Ohio $16-22 Billion.” Loren Anthes, May 15, 2017. http://www.communitysolutions.com/assets/docs/Health_Policy/2017_2019/issue%20brief%20per%20capita%20cuts%20update%202.0_lanthes_05152017.pdf

[7] To try to account for different costs of care for different recipient groups, caps for most beneficiary groups would be figured by tying historical costs to the medical Consumer Price Index (CPI), adjusted for inflation. In the House-passed AHCA, 1 percent was added in the aged and disabled categories, which is why aged Ohioans are the only group that can anticipate a budget surplus under AHCA per capita cap changes.

[8] Center for Community Solutions. “Update 2.0 Per Capita Cuts: Proposed American Health Care Act Costs Ohio $16-22 Billion.” Loren Anthes, May 15, 2017. http://www.communitysolutions.com/assets/docs/Health_Policy/2017_2019/issue%20brief%20per%20capita%20cuts%20update%202.0_lanthes_05152017.pdf

[9] County-level projections for loss of Medicaid funding from the Center for Community Solutions. The Population Trend projects cuts using Medicaid enrollment estimates based on projected population estimates by county. The Historic Enrollment column projects cuts using historic Medicaid enrollment trends by county.

[10] Congressional Budget Office. “Cost Estimate: American Health Care Act.” March 13, 2017. https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/americanhealthcareact.pdf

[11] See footnote 7 for an explanation of the surplus for the Aged as compared to other groups. Center for Community Solutions. “Update 2.0 Per Capita Cuts: Proposed American Health Care Act Costs Ohio $16-22 Billion.” Loren Anthes, May 15, 2017.

[12] Brookings. “Effects of the Medicaid Per Capita Cap Included in the House-Passed American Health Care Act.” Loren Adler, et al, May 10, 2017. https://www.brookings.edu/research/effects-of-the-medicaid-per-capita-cap-included-in-the-house-passed-american-health-care-act/

[13] Center on Budget and Policy Priorities. “Medicaid Per Capita Cap Would Shift Costs and Risks to States and Harm Millions of Beneficiaries.” Edwin Park. 2/27/17.

[14] NPR. “Medical Research, Health Care Face Deep Cuts in Trump Budget.” Alison Kodjak and Rob Stein, May 23, 2017. http://www.npr.org/sections/health-shots/2017/05/23/529654114/medical-research-health-care-face-deep-cuts-in-trump-budget

[15] Policy Matters Ohio. “Repeal of Health Law Threatens Ohioans.” January 11, 2017. https://www.policymattersohio.org/research-policy/quality-ohio/revenue-budget/repeal-of-health-law-threatens-ohioans

[16] An income of $16,400/year for an individual.

[17] Health Policy Institute of Ohio. “Medicaid Basics 2017.” Pulled from Ohio Department of Medicaid Caseload Reports, February, 2017. http://www.healthpolicyohio.org/wp-content/uploads/2017/04/MedicaidBasics_2017_ExecutiveSummary_Web.pdf

[18] Centers for Medicare and Medicaid Services. “Biweekly Enrollment Snapshot: 2017-02-03.” https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-02-03.html. Note: 174,000 Ohioans received federal assistance to help pay for these Marketplace plans as of March 2016, according to the Centers for Medicare and Medicaid Services Effectuated Enrollment Snapshot.

[19] Of Ohio expansion enrollees, 72 percent were Caucasian, 56 percent were male and 84 percent were single. Ohio Department of Medicaid. “Ohio Medicaid Group VIII Assessment: A Report to the Ohio General Assembly.” January, 2017. http://medicaid.ohio.gov/portals/0/resources/reports/annual/group-viii-assessment.pdf

[20] Ibid.

[21] U.S. Department of Health & Human Services. “Insurance Expansion, Hospital Uncompensated Care, and the Affordable Care Act.” March 23, 2015.

[22] Joint Economic Committee Republican Health Care Plan Charts Packet. 3/20/2017. https://www.jec.senate.gov/public/_cache/files/5dfdd14f-e11a-4f31-b50a-0b16fe0f892e/ahca-chart-packet.pdf

[23] Robert Wood Johnson Foundation’s State Health Reform Assistance Network. “Medicaid Capped Funding: Findings and Implications for Ohio.” April 5, 2017. http://www.statenetwork.org/wp-content/uploads/2017/04/OH-Fact-Sheet_rev-4.4.17.pdf

[24] Policy Matters Ohio. “AHCA Threatens Ohio’s Growing Health Care Sector.” Kate Sopko, May 23, 2017. https://www.policymattersohio.org/research-policy/pathways-out-of-poverty/basic-needs-unemployment-compensation/ahca-threatens-ohios-growing-health-care-sector

[25] Ibid.

[26] Economic Policy Institute. “The AHCA’s Drag on Potential Job Growth.” Josh Bivens, March 24, 2017. http://www.epi.org/publication/how-many-jobs-could-the-ahca-cost-your-state?

[27] Center on Budget and Policy Priorities. “House Republican Health Bill Would Effectively End ACA Medicaid Expansion.” Matt Broaddus & Edwin Park, June 6, 2017. http://www.cbpp.org/research/health/house-republican-health-bill-would-effectively-end-aca-medicaid-expansion

[28] Center for Community Solutions. “Update 2.0 Per Capita Cuts: Proposed American Health Care Act Costs Ohio $16-22 Billion.” Loren Anthes. May 15, 2017. https://ccs.memberclicks.net/assets/docs/Health_Policy/2017_2019/issue%20brief%20per%20capita%20cuts%20update%202.0_lanthes_05152017.pdf

[29] Policy Matters Ohio. “Repeal of Health Law Threatens Ohioans.” January 11, 2017. https://www.policymattersohio.org/research-policy/quality-ohio/revenue-budget/repeal-of-health-law-threatens-ohioans

[30] Center on Budget and Policy Priorities. “House Republican Health Bill Would Effectively End ACA Medicaid Expansion.” Matt Broaddus & Edwin Park, June 6, 2017.

[31] Dayton Daily News. “Ohio Senate Wants to Freeze New Enrollment in Expanded Medicaid Program.” Lynn Hulsey, June 20, 2017.

http://www.daytondailynews.com/news/state--regional-govt--politics/ohio-senate-wants-freeze-new-enrollment-expanded-medicaid-program/J8Amr2oFvTTsrTNEjkz3KK/

[32]Urban Institute. "The Impact of the AHCA on Federal and State Medicaid Spending and Medicaid Coverage: An Update." June, 2017.

[33]Premiums calculated off an estimated 2019 federal poverty line of $12,600/year for an individual. Center on Budget and Policy Priorities. “People Losing Medicaid Under House Republican Bill Would Face High Barriers to Coverage.” Tara Straw, June 6, 2017. http://www.cbpp.org/research/health/people-losing-medicaid-under-house-republican-bill-would-face-high-barriers-to

[34] Implementing a lower matching rate in 2020 would leave just 1 percent of Medicaid expansion enrollees at the enhanced matching rate by the end of 2027. Delaying implementation until 2022 would only increase the number of grandfathered enrollees keeping the higher expansion rate to 3 percent of current expansion enrollees by the end of 2027. Center on Budget and Policy Priorities. “House Republican Health Bill Would Effectively End ACA Medicaid Expansion.” Matt Broaddus & Edwin Park, June 6, 2017.

[35] Charlestown Gazette-Mail. “Editorial: How Long Will Sen. Capito Give WV on Health Care?” June 13, 2017. http://www.wvgazettemail.com/gazette-editorials/20170613/gazette-editorial-how-long-will-sen-capito-give-wv-on-health-care

[36] New York Times. “Drug Deaths in America Are Rising Faster Than Ever.” Josh Katz. June 5, 2017. https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html?_r=0

[37] Ohio Governor’s Office of Health Transformation. OBM analysis of FY 2016 expenditures. http://www.healthtransformation.ohio.gov/LinkClick.aspx?fileticket=JlxqRvpq8Yo%3d&tabid=254

[38] The Plain Dealer. “Ohio's Spending on Opioid Addiction Treatment Drugs Vivitrol and Suboxone Spikes, Spurs Debate on What Treatments Work.” Rachel Dissell, May 1, 2017. http://www.cleveland.com/metro/index.ssf/2017/04/ohios_spending_on_opioid_addiction_treatment_drugs_like_vivitrol_and_suboxone_spikes_spurs_debate_what_treatments_work.html

[39] Testimony of Dr. Terry Horton. May 25, 2017. https://www.c-span.org/video/?429049-1/senate-panel-looks-stopping-flow-synthetic-drugs-us&start=9031

[40] Ibid, and Cincinnati Enquirer. “Rob Portman's Dilemma: How to Repeal Obamacare Without Undermining Opioid Fight.” Deirdre Shesgreen. June 9, 2017. http://www.cincinnati.com/story/news/politics/2017/06/09/portman-dilemma-obamacare-opioid-figh/374039001/

[41] Comments at a May 23, 2016 Tele-conference for the release of the Policy Matters Ohio report “AHCA Threatens Ohio’s Growing Health Care Sector.”

[42] Columbus Dispatch. “GOP Plan to Kill Ohio Medicaid Expansion May Fuel Drug Crisis.” Catherine Candisky & Jim Siegel. April 28, 2017. http://www.dispatch.com/news/20170428/gop-plan-to-kill-ohio-medicaid-expansion-may-fuel-drug-crisis

[43]Center for American Progress. “Senate’s Opioid Fund Cannot Substitute for Health Coverage.” Emily Gee & Richard Frank, June 20, 2017. https://www.americanprogress.org/issues/healthcare/news/2017/06/20/434708/senates-opioid-fund-cannot-substitute-health-coverage/

[44] Center for American Progress. “Number of Americans with Pre-Existing Conditions by Congressional District.” April 5, 2017.

[45] Business Insider. “The Republican Healthcare Bill Still Has a Massive Problem.” Bob Bryan, May 3, 2017. http://www.businessinsider.com/ahca-high-risk-pools-healthcare-vote-obamacare-2017-5

[46] Brookings Institute. “Health Insurance as Assurance: The Importance of Keeping the ACA’s Limits on Enrollee Health Costs.” January 17, 2017. https://www.brookings.edu/blog/up-front/2017/01/17/health-insurance-as-assurance-the-importance-of-keeping-the-acas-limits-on-enrollee-health-costs/

[47] The AHCA changes tax credits to a flat rate which varies only by the age of the person purchasing the plan: $2,000/year for people under 30, $2,500 for people ages 30-39, $3,000 for people ages 40-49, $3,500 for people ages 50-59, and $4,000 for people ages 60 plus. Credits vary little by income (though they phase out for high-earning households) or local premium costs. Younger people will see decreases in premium payments, while older Americans will take a large hit. The AHCA also eliminates the ACA’s cost-sharing subsidies for people making below 250 of the federal poverty line, which helps lower deductibles and other co-payments.

[48] Kaiser Family Foundation. “Premiums and Tax Credits Under the Affordable Care Act vs. the American Health Care Act: Interactive Maps.” April 27, 2017. http://www.kff.org/interactive/tax-credits-under-the-affordable-care-act-vs-replacement-proposal-interactive-map/

[49] Center on Budget and Policy Priorities. “Medicaid Per Capita Cap Would Shift Costs and Risks to States and Harm Millions of Beneficiaries.” Edwin Park. 2/27/17. http://www.cbpp.org/research/health/medicaid-per-capita-cap-would-shift-costs-and-risks-to-states-and-harm-millions-of

[50] Center on Budget and Policy Priorities analysis of state demographic projections applied to July 2015 Census Bureau population estimates. http://www.cbpp.org/growing-share-of-seniors-will-be-85-or-older

[51] Georgetown University Center for Children and Families & Health Policy Institute. “Medicaid in Small Towns and Rural America.” Karina Wagnerman, et al, June, 2017. https://ccf.georgetown.edu/wp-content/uploads/2017/06/Rural-health-final.pdf

[52] Ibid. 40 percent of rural children and 19 percent of rural adults, compared to 36 percent of urban children and 17 percent of urban adults were enrolled in Medicaid in Ohio in 2014-15.

[53] Ibid.

[54] Significantly, Anthem's withdrawal was partially in response to Republican legislators refusing to allocate funds to Cost-Sharing Reductions payments to insurers. These CSR payments are federal reimbursements to insurers for providing lower premiums to low-income Americans under the ACA. Threats to withhold them have destabilized the Marketplace. http://www.cbpp.org/blog/anthems-ohio-withdrawal-makes-consequences-of-marketplace-sabotage-even-starker

[55] Columbus Dispatch. “Obamacare Repeal Uncertainties Worry Central Ohio Hospitals.” Joanne Viviano and Mary Beth Lane, January 30, 2017. http://www.dispatch.com/news/20170130/obamacare-repeal-uncertainties-worry-central-ohio-hospitals http://ohiovalleyresource.org/2017/02/24/obamacare-rural-health-providers-nervous-affordable-care-act-repeal/ and Ohio Valley Resource. “After Obamacare: Rural Health Providers Nervous About Affordable Care Act Repeal.” Mary Meehan, February 24, 2017. http://ohiovalleyresource.org/2017/02/24/obamacare-rural-health-providers-nervous-affordable-care-act-repeal/

[56] Policy Matters Ohio. “AHCA Threatens Ohio’s Growing Health Care Sector.” Kate Sopko, May 23, 2017.

[57] Comments from John Corlett of Center for Community Solutions at American Medical Association Panel on AHCA, June 14, 2015 and Kaiser Family Foundation Ohio Medicaid Fact Sheet. June 2017. http://files.kff.org/attachment/fact-sheet-medicaid-state-OH

[58] Avalere, for the Childrens’ Hospital Association. “The Impact of Medicaid Capped Funding on Children.” May 18, 2017. http://go.avalere.com/acton/attachment/12909/f-0483/1/-/-/-/-/Avalere%20-%20Childrens%20Hospital%20Association%20Report%20on%20Medicaid%20Capped%20Funding%20embargo.pdf

[59] Ibid.

[60] In fiscal year 2011, Medicaid spending per child with a disability was on average $16,802, compared to $2,463 for other children.

[61] Center on Budget and Policy Priorities. “Medicaid Helps Schools Help Children.” Jessica Schubel, April 18, 2017. http://www.cbpp.org/research/health/medicaid-helps-schools-help-children?utm_source=CBPP+Email+Updates&utm_campaign=f4e6391c43-EMAIL_CAMPAIGN_2017_04_18&utm_medium=email&utm_term=0_ee3f6da374-f4e6391c43-111059065

[62] Congressional Budget Office. “Cost Estimate: H.R. 1628, American Health Care Act of 2017.” May 24, 2017. https://www.cbo.gov/publication/52752

[63] Kaiser Family Foundation. “What Difference Does Medicaid Make? Assessing Cost Effectiveness, Access, and Financial Protection Under Medicaid for Low-Income Adults.” May, 2013. https://kaiserfamilyfoundation.files.wordpress.com/2013/05/8440-what-difference-does-medicaid-make2.pdf

[64] Center on Budget and Policy Priorities. “Frequently Asked Questions About Medicaid.” Edwin Park, et al. March 29, 2017. http://www.cbpp.org/research/health/frequently-asked-questions-about-medicaid#_ftn3

[65] Center on Budget and Policy Priorities. “House Health Bill: Tax Cuts for Wealthy, Insurers, and Drug Companies Paid for by Low- and Middle-Income Families.” Chye-Ching Huang and

Brandon Debot, May 22, 2017. http://www.cbpp.org/research/federal-tax/house-health-bill-tax-cuts-for-wealthy-insurers-and-drug-companies-paid-for-by