I woke up a little bleary eyed on Wednesday, November 7th. I stayed up way too late on election night (and maybe had one Christmas Ale too many) trying to take in the results as they rolled in, forgetting I had an 8:30 a.m. meeting scheduled on Wednesday morning. Probably like many of you I was pleased with some results, but less so with others. But I was happy to know that the relentless television commercials and emails were likely to come to an end or at least diminish. Here then are 5 things I believe Ohio health and human service advocates and providers, who are interested in Medicaid policy, should be thinking about post-election. Post-election, which five #Medicaid policies should Ohio consider? Find out in this @CommunitySols blog post Click To Tweet

Pay attention to the Ohio General Assembly during lame duck

A lame-duck legislative session refers to the time after an election when the legislators who were either defeated or chose not to run again can vote on legislation without possibly worrying about the opinions of voters. Governor John Kasich vetoed several provisions related to Medicaid in the most recently adopted state budget. The legislature overrode some of these vetoes but not all of them. One of the vetoes that has not been overridden is a Medicaid “freeze,” which would require the Ohio Department of Medicaid to cease enrolling newly eligible people while the state is seeking a waiver to Ohio to implement only a partial Medicaid expansion only open to adults with “mental illness” or “drug addiction.” If the waiver is approved, and that is not certain, approximately 400,000 people would lose coverage and the state would lose the enhanced 90% federal matching dollars that it gets today. This would cost the state more than a quarter of a billion dollars. Legislators have up to the last day of the current legislative session to override this veto, so the situation bears watching.

Future of Medicaid expansion in Ohio will play out in next state budget

If the legislature doesn’t dismantle expansion during the lame duck it will likely tackle the issue of expansion during the next state budget process. After winning the Republican primary, Governor-elect Mike DeWine said he supported continuing the Medicaid expansion but with new limitations or changes. During the campaign DeWine indicated he supported a “reasonable work requirement” and “implementing a wellness program” within Ohio’s Medicaid expansion program. The U.S. Centers for Medicare and Medicaid Services (CMS) recently approved a Medicaid waiver in Wisconsin, a non-expansion state, that included both and work and wellness elements. It should be noted, there is a long history of Medicaid wellness programs with very mixed results, and they’ve demonstrated only minimal success at either improving health outcomes or lowering costs. In fact, implementing a wellness program will initially lead to additional costs, not savings.

During the campaign DeWine indicated he supported a “reasonable work requirement” and “implementing a wellness program” within the Ohio’s Medicaid expansion program.

Medicaid Behavioral Health Redesign likely to be scrutinized, again

Legislators are hearing that behavioral health care providers are shutting their doors because they can’t cope with the complexity and burden of Medicaid Behavioral Health Redesign. Providers and their associations have complained about serious issues with claims processing, delays in payment, underpayment, stretched infrastructure and overall financial strain. Many more might have closed if an agreement hadn’t been reached to extend the cash advances that were originally provided by the Medicaid managed care plans as part of the transition from fee-for-service to managed care. Speaker of the Ohio House, Ryan Smith, has taken a special interest in this issue and has participated in conversations with the Ohio Department of Medicaid, Medicaid managed care plans, behavioral health providers and their trade associations. It may not be possible to resolve the issues during lame duck, but Smith’s interest means the issues will be considered by legislative budget writers next year.

Children’s health issues likely to get increased attention under DeWine

Most of the Medicaid policy bandwidth over the past eight years has been focused on issues largely related to adults: Medicaid expansion; moving dual eligibles into Medicaid managed care (and failing to move long term care into managed care); and behavioral health redesign (which also included children). DeWine, in ways reminiscent of former Ohio Governor George Voinovich, made several detailed commitments to children’s health related issues. These included increased home visiting services for at-risk, first time mothers, increased investment in Ohio’s child welfare system and ensuring that every Ohio school has access to a mental health professional. He has already named LeeAnne Cornyn as his Director of Children’s Initiatives. Cornyn will report directly to the governor and coordinate children’s programs across all state agencies.

DeWine has already named LeeAnne Cornyn as his Director of Children’s Initiatives. Cornyn will report directly to the governor and coordinate children’s programs across all state agencies.

Prescription and pharmacy spending once again under scrutiny

Early in the current administration, The Ohio Department of Medicaid tasked Medicaid managed care plans with the management of pharmacy benefits, which total more than $2.5 billion dollars. But earlier this year the department came under intense pressure after an ongoing series of articles by The Columbus Dispatch revealed that pharmacy benefit managers were charging Ohio $248 million more than they were paying pharmacies in the state. DeWine told the Dispatch he was “working with eight separate state agencies to investigate pharmacy benefit managers,” and that he was “examining whether or not they are complying with their contracts or if they are cheating the Ohio taxpayers.” Both current agency leadership and DeWine agree that at a minimum greater “transparency” is needed.

The Ohio Department of Medicaid tasked Medicaid managed care plans with the management of pharmacy benefits, which total well over $2.5 billion dollars.

Other questions to consider include the future of the Ohio Office of Health Transformation which Governing magazine recently described as the “tiny government office [that] has transformed the way health care has been delivered in the state.” Despite its successes, Ohio government is replete with examples of other successful offices and initiatives launched by previous governors either disappearing (e.g. Executive Medicaid Management Administration) or slowly fading away.

Some pundits said the big winner on election night was the Medicaid program itself. Voters in Idaho, Nebraska and Utah went around their legislatures and approved Medicaid expansions. In Kansas, Maine and Wisconsin, governors who had opposed Medicaid expansion were replaced by supporters. Election results delivering control of the U.S. House of Representatives to the Democrats means that Medicaid is likely protected from block grant proposals or efforts to repeal the expansion nationally. CMS administrator Seema Verma and her colleagues will likely spend a lot of time on Capitol Hill answering questions and producing documents related to the many waivers and other controversial policies that they have approved. This “oversight” can bog an agency down and make it difficult to move policies forward.

The good news for the new governor and general assembly is that state revenues are more than $100 million ahead of estimates four months into the state fiscal year. At the same time, Medicaid caseloads are dropping, and according to the Ohio Office of Budget and Management’s October 2018 monthly financial report, Medicaid year to date general revenue fund spending is $313 million under estimates. The combination of greater tax revenues and lower Medicaid caseloads could make the budget writing process for a new governor easier.

Medicaid caseloads are dropping, and according to the Ohio Office of Budget and Management’s October, 2018 monthly financial report, Medicaid year to date general revenue fund spending is $313 million under estimate

If the economy continues to hum along at its current healthy pace and Medicaid caseloads keep declining, it could also result in revenue projections being revised upwards during budget deliberations instead of down as they have in the more recent past. But for now, mark your calendars for Friday, March 15, 2019 because Governor Elect DeWine is obligated to release his first budget proposal by that date.