On June 30, the Ohio Department of Medicaid (ODM) submitted its application for the legislatively required 1115 Demonstration Waiver known as “Healthy Ohio” to the U.S. Department of Health and Human Services (HHS). Throughout the state development process, we have written and posted about Healthy Ohio in order to address our concerns and questions regarding the potentially negative effects of the waiver on the Medicaid program. Now, as the state has its application reviewed by the federal government, we want to revisit the process associated with applying and discuss the potential next steps.

State Public Comment Process
In April, pursuant to federal requirements established by the Affordable Care Act, the state held two public hearings in Columbus and Cincinnati and collected testimony and written comment. The chart below shows how many comments included the following issues:

• 956 total comments
• 28 testimonies
• Majority of comments provided via email by individuals
• Most comments centered on negative impacts to recipients and the administrative complexity

 Federal Review
As of July 8, HHS reviewed the application and determined it to be “complete.” This included a review of the goals, objectives, data, and budgeting associated with submission. Regarding the state’s public comment process, written documentation associated with the compliance of the public notice requirements, as well as a report and a consideration of those comments, were required. Interestingly, in its submission, ODM did not change the majority of its content, including estimates regarding budget neutrality, stating the following: “Many respondents requested changes be made to various parts of the waiver. However, absent a state statutory change, the Department is unable to modify the waiver.” This is consistent with our reading of the statute, but means that all the comments submitted during Ohio’s public comment process should be the same upon federal review.

Now that HHS has accepted the application, the federal comment period of 30 days begins. To comment during this federal process, CMS maintains this Website.

What’s Next
One only need to look to Kentucky to see what HHS’ likely response may be. Recently, HHS gave its most forceful statement yet in response to Governor Bevin’s proposal to implement reforms similar to Healthy Ohio, with HHS Press Secretary Ben Wakana stating, “…states may not limit access to coverage or benefits based on work or other activities, nor may they impose premiums or cost sharing that prevent low-income individuals from accessing coverage and care.” Moreover, on July 7, during an event in Cleveland, Secretary Burwell stated, “If we’re taking steps that reduce affordability or reduce access, those aren’t things that we will approve.”

The map to the right shows the percentage share of individuals who would be affected by the Healthy Ohio proposal relative to that County’s population. This includes parents, Group VIII (Medicaid Expansion), foster children, low-income special needs children, and women with Breast and Cervical cancer.

To see how many people would be affected in any given county, we also developed a table below to show you impact by county and eligibility category, which you can find at the end of this post.

 

 

 

Conclusion
The efforts of reformatting the Medicaid program to include more personal responsibility are far from over. While the response during the state comment period for the Healthy Ohio waiver was very robust, and while it should be the same response during the federal process, this is not the end of the conversation regarding Medicaid costs, funding, and “skin in the game.” In all likelihood, the state still has options to develop cost-sharing policies without a waiver through the Deficit Reduction Act of 2005, but these are limited. With that said, Ohio has also greatly benefitted from the program’s current design, generally, helping the state’s budget during a period of revenue shortfall. Given the geographic diversity of those who may be affected by any policies which encourage disenrollment, as well as how program design has benefitted the state financially, any future changes to the program may drastically alter the state’s overall budget regardless of whether that is a waiver or if it’s something else entirely.