The Facts
Medicaid Access in Northeast Ohio
Answers to Frequently Asked Questions
The Center
for Health Affairs
2015
FAQ
The Affordable Care Act included a provision that would
expand Medicaid coverage to all individuals under the
age of 65 with incomes up to 138 percent of the federal
poverty level beginning in 2014. However, with its July 2012
decision to make Medicaid expansion optional rather than
mandatory, the Supreme Court essentially left the decision
to expand Medicaid to each state. During Ohio’s last round
of budget negotiations, Governor Kasich’s proposal to
expand Medicaid was removed by lawmakers in the
General Assembly.
Since extending coverage on Jan. 1, 2014, more than
492,000 newly eligible Ohioans have enrolled in Medicaid.
In addition to greater access to care, health outcomes have
continued to improve in part because healthcare providers
can deliver care in a more coordinated fashion. Governor
Kasich and his administration have recognized this, which
is why the current Executive Budget proposal continues to
accept federal funds for the next two years. The decision
now rests in the hands of the Ohio General Assembly, who
has the authority to leave the Medicaid provision in the
budget as is, change it or remove it all together. As such,
this publication includes a number of questions that have
been regularly raised by legislators as they have evaluated
their support for this measure.
Please visit our website at chanet.org, or contact Deanna
Moore at 216.255.3614 or [email protected] for
additional information.
Introduction
When Medicaid expansion through the traditional
legislative process proved unsuccessful, Governor
Kasich asked the little-known Controlling Board to
vote on it. On Oct. 21, 2013, the Controlling Board
voted by a 5-to-2 majority to authorize the state
to accept $2.56 billion in federal funds to expand
Medicaid to all adults earning up to 138 percent of
the federal poverty level. Since the Controlling Board’s
decision permits the state to accept federal funds only
through June 30, 2015, lawmakers in Ohio are again faced
with the question of whether or not to continue extending
Medicaid coverage for the next two years.
The Facts
Who is eligible for Medicaid expansion based on income? 01
What populations would benefit from closing the gap in Medicaid coverage? 02
Are there other characteristics that distinguish the newly eligible population? 03
Do people without insurance use the emergency department (ED)
04
as a primary source of routine care?
What happens when people use the ED as a primary source of routine care? 05
What is the impact of Medicaid expansion on EDs? 06
Does broadening coverage create a culture of dependency? 07
Does expanded coverage provide a disincentive to strive for a
higher-paying job? 08
How many people in Northeast Ohio have benefited from
Medicaid expansion so far? 09
How many Ohioans have received health coverage since Medicaid expansion? 10
What is the percentage of people who are uninsured in Northeast Ohio? 1 1
How will we know if expansion actually improves health? 12
Have other states moved forward with Medicaid expansion? 13
Q.
A.
Who is eligible for Medicaid
based on income?
Beginning Jan. 1, 2014, a new group of Ohioans became
eligible for Medicaid coverage in Ohio. This group
includes adults between the ages of 19 to 64, who are
between 0 – 138% of the Federal Poverty Level (FPL) and
are not eligible under another category of Medicaid.1
Household Size






138% FPL
$16,243
$21,983
$27,724
$33,465
$39,206
$44,497
2
01
Q.
What populations would
benefit from closing the gaps
in Medicaid coverage?
200
90%
FPL %
250
138
100
Children
Pregnant
Women
Parents
Childless Adults
Disabled
Workers
Disabled
Children Pregnant Parents Childless Disabled Disabled
Women
Adults Workers
Current Subsidized Health Coverage Eligibility
400
FPL %
Those who benefit
the most are
those who in the
past would have
been ineligible for
Medicaid and could
not afford insurance
otherwise. Adults
without dependent
children, parents
between 90 and 138
percent of the FPL
and disabled adults
above 64 percent
of the FPL are
among the groups
who benefit from
closing the gaps in
Medicaid coverage.
64%
A.
Past Medicaid Eligibility
400
250
200
138
100
Children
Children
Pregnant
Pregnant
Women
Women
Parents
Parents
Medicaid
Childless
Childless
Adults
Adults
Disabled Disabled
Disabled
Disabled
Workers
Workers
Exchange (with subsidies)
3
02
Q.
A.
Are there other characteristics that distinguish
the newly eligible population?
There is no one “type” of person this policy change benefits.
Many people benefit including working families, veterans,
homeless people, empty nesters, ex-offenders and the
recently unemployed. Nationally, more than half of the newly
eligible – 52 percent – are employed.
Distribution of the Nonelderly Uninsuerd by Family Work Status
OH
US
At Least One Full-Time Worker
70%
71%
Part-Time Workers
13%
14%
Non Workers
17%
15%
Distribution of the Nonelderly with Medicaid by Family Work Status
OH
US
At Least One Full-Time Worker
12%
14%
Part-Time Workers
48%
35%
Non Workers
37%
46%
4, 5
03
Q.
Do people without insurance use the emergency
department (ED) as a primary source of routine care?
A.
Yes, in fact a recent survey by the National Center
for Health Statistics found that almost 62 percent
of patients without insurance receiving care in the
ED said they were there because they had no other
place to go, reflecting lack of access to a primary
source of routine care. This is higher than the percent
of individuals with private insurance or with public
insurance who said they were at the ED because they
had no other place to go.
Adults Ages 18-64 Selecting “No Other Place to Go”
as Reason for Visiting Emergency Department
61.6%
48.5%
38.9%
Uninsured
Private insurance
Public insurance
6
Note: Data was collected from January 2011 - June 2011 and represents information on the
respondent’s last hospital visit in the past 12 months that did not result in hospital admission.
04
Q.
A.
What happens when people use the ED
as a primary source of routine care?
Simply put, healthcare costs rise and patients arrive
sicker. A study by the Government Accountability
Office found the average cost for a non-emergency visit
to an ED was $792, more than seven-times higher than
the cost of a visit to a community health center.
$108
Non-emergency community health center
$792
Non-emergency ED Visit7
05
What is the impact of
Medicaid expansion on EDs?
Q.
A.
While the full impact of Medicaid expansion will take time to measure,
there are several pilot programs – known as 1115 demonstration
waivers – which provided access to Medicaid benefits to the expanded
population prior to the Jan. 1, 2014 start date. Those demonstration
projects have shown a decrease in ED usage and an increase in
primary-care enrollment.

20-60%
ED Use

50-55%
8,9
Primary Care
06
Q.
A.
Does broadening coverage create
a culture of dependency?
No. Medicaid enrollment is cyclical and based on how
well the economy is doing. Research shows that in times
of recession, Medicaid enrollment grows as people
lose jobs and income. This is especially true for families
and children. Conversely, during times of economic
prosperity, Medicaid enrollment slows, stays flat, or
decreases. If anything, Medicaid coverage increases the
likelihood that people will have access to a usual source
of care and the ability to address any previously unmet
health needs, causing them to miss fewer work days and
making them better positioned to work productively.
Lastly, the average time an individual is enrolled in
Medicaid is nine months, debunking the assertion that
individuals are dependent on the program.10
Medicaid Spending & Enrollment Growth Increase During
Economic Downturns11
12.7%
10.4%
9.3%
8.7%
9.7%
8.5%
7.5%
6.8%
7.7%
7.6%
6.4%
5.6%
5.8%
4.3%
4.7%
7.8% 7.2%
6.6%
3.8%
3.2%
4.4%
3.1%
3.2%
0.2%
3.8%
2.5%
1.3%
0.4%
3.2%
1.0%
-0.5%
-1.9%
Spending Growth
1998
1999
2000
2001
2002
2003
2004
Economic Downturn
Enrollment Growth
2005
2006
2007
2008
2009
2010
2011
2012
2013
07
Q.
A.
Does expanded coverage provide a
disincentive to strive for a higher-paying job?
The Affordable Care Act contains provisions that make
it easier for individuals with low and modest incomes
to afford insurance. For instance, let’s explore what
happens when an individual on Medicaid secures a
higher paying job which would then make them ineligible
for Medicaid coverage. If their employer does not offer
health insurance, or does not provide what is deemed
“affordable insurance,” tax credits and cost-sharing
subsidies can help make care purchased in a marketbased health insurance exchange more affordable.
Specifically, tax credits to reduce premium costs for
insurance purchased in a market-based health insurance
exchange are available to individuals earning
between 100 percent and 400 percent of the
federal poverty level. In addition, people with
incomes up to 250 percent of the
federal poverty level are also eligible
for reduced cost sharing for coverage
bought in an exchange.
08
How many people in Northeast Ohio have
benefited from Medicaid expansion so far?
A.
Q.
The nonpartisan Health Policy Institute of Ohio recently
analyzed the county-level impact of Medicaid expansion
in Ohio. The results show that each county has seen
more people covered through Medicaid and, as a result,
fewer uninsured individuals.
Medicaid Expansion in Northeast Ohio
County-level
enrollment
18- to 64- yearold population
by county
Percent of 18- to 64- yearold population enrolled in
Medicaid expansion
Ashtabula
3,559
60,286
5.9%
Cuyahoga
70,751
784,419
9.0%
Geauga
1,149
54,504
2.1%
Lake
6,087
140,672
4.3%
10,551
185,027
5.7%
3,257
106,873
3.0%
Northeast
Ohio ounty
Lorain
Medina
Total NEO Enrollment: 95,93412
09
Q.
A.
How many Ohioans have received health
coverage since Medicaid expansion?
As anticipated, Ohio has seen steady Medicaid enrollment
trends since it began enrolling this new population.
Monthly Medicaid Enrollment of Newly-Eligible Population, 201413
366,483
391,976
412,245
429,638
444,520 450,941
338,863
309,837
267,351
186,399
136,769
Jan
Feb
March
April
May
June
July
Aug
Sept
Oct
Nov
10
Q.
What is the percentage of people who
are uninsured in Northeast Ohio?
A.
Percentage of Uninsured in Northeast Ohio, 201314
ASHTABULA
13.5%
CUYAHOGA
10.7%
GEAUGA
15.1%
LAKE
9.0%
LORAIN
MEDINA
9.3%
7.6%
11
Q.
A.
How will we know if expansion
actually improves health?
Since the State of Ohio just recently extended
Medicaid benefits to those under 138 percent of the
FPL in January 2014, data on health outcomes of the
newly-eligible is still in the process of being collected.
However, under a waiver granted by the federal
government, MetroHealth implemented its own
pilot of Medicaid expansion – covering nearly 30,000
Northeast Ohio residents – in early 2013 and has been
monitoring and reporting on the patients enrolled in
that program. Based on preliminary results, several
health outcomes for the population of patients
enrolled through this waiver have improved.15

Better control of blood pressure/hypertension
Better management of diabetes
12
Have other states moved forward
with Medicaid expansion?
A.
Q.
Yes. In fact, a majority of the country has decided to
move forward with implementing Medicaid expansion,
includuing many states with Republican-controlled
legislative and executive branches.16
States that adopted
29
States still discussing
6
States not adopting
16
13
Acknowledgements
This publication was created by The Center for Health Affairs. Special
thanks are also extended to the members of the Northeast Ohio Health
Advancement Coalition, NEOHAC, who assisted with content, research
and strategy.
Endnotes
Ohio Department of Medicaid, Extension FAQ. http://medicaid.ohio.gov/FOROHIOANS/GetCoverage/
WhoQualifies/ExtensionFAQ.aspx
1
HealthCare.gov, Incomes that Qualify for Lower Costs. https://www.healthcare.gov/qualifying-forlower-costs-chart/
2
Health Policy Institute of Ohio, Medicaid Enrollment Trends and Impact Analysis, December 2014.
http://www.healthpolicyohio.org/wp-content/uploads/2015/01/PolicyBrief_MedicaidEnrollment
Trends_FINAL.pdf
3
Kaiser Family Foundation, State Health Facts. http://kff.org/uninsured/state-indicator/distribution-byemployment-status-2/
4
IBID.
5
Gindi, et al. “Emergency Room Use Among Adults Aged 18–64: Early Release of Estimates From the
National Health Interview Survey, January–June 2011,” Centers for Disease Control and Prevention,
May 2012. http://www.cdc.gov/nchs/data/nhis/earlyrelease/emergency_room_use_januaryjune_2011.pdf
6
U.S. Government Accountability Office, Hospital Emergency Departments: Health Center Strategies
That May Help Reduce Their Use, May 2011. http://www.gao.gov/assets/130/126188.pdf; The
Kaiser Commission on Medicaid and the Uninsured, Sicker and Poorer: The Consequences of Being
Uninsured, Updated February 2003. http://www.kff.org/uninsured/loader.cfm?url=/commonspot/
security/getfile.cfm&PageID=13971.
7
Oregon Health Authority, Office of Health Analytics, 2014 Mid-Year Performance Report, January
2015. http://www.oregon.gov/oha/Metrics/Documents/2014%20Mid-Year%20Performance%20
Report%20Executive%20Summary.pdf
8
Robert Wood Johnson Foundation, Aligning Forces for Quality, Safety Net in Greater Cleveland
Demonstrates What Is Possible with Medicaid Expansion, May 2014.
http://forces4quality.org/node/7377#.U4YovL5nuHs.twitter
9
U.S. Department of Health and Human Services, A Profile of Medicaid Chart Book, September
2000. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/
TheChartSeries/Downloads/2Tchartbk.pdf
10
Kaiser Family Foundation, State Fiscal Conditions and Medicaid: 2014 Update.
http://kff.org/report-section/state-fiscal-conditions-and-medicaid-2014-update-issue-brief-8572/
11
Health Policy Institute of Ohio, Medicaid Enrollment Trends and Impact Analysis, December 2014.
http://www.healthpolicyohio.org/wp-content/uploads/2015/01/PolicyBrief
MedicaidEnrollmentTrends_FINAL.pdf
12
Ohio Department of Medicaid, Monthly Caseload Report Summary, November 2014.
http://medicaid.ohio.gov/Portals/0/Resources/Reports/Caseload/2014/11-Caseload.pdf
13
U.S. Census Bureau, Cleveland.com Database. http://www.cleveland.com/datacentral/index.
ssf/2014/09/census_income_poverty_uninsure.html?appSession=191488972115664&cbSearchAgain
=true&AppKey=95d31000b3ec538157e049bab26b
14
Robert Wood Johnson Foundation, Aligning Forces for Quality, Safety Net in Greater Cleveland
Demonstrates What Is Possible with Medicaid Expansion, May 2014.
http://forces4quality.org/node/7377#.U4YovL5nuHs.twitter
15
Kaiser Family Foundation, Medicaid & CHIP. http://kff.org/state-category/medicaid-chip/
16
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