Here we go again. This week, another effort to repeal the Affordable Care Act (ACA) is emerging in the U.S. Senate, representing a last-ditch effort to dismantle the law before the September 30th fiscal year deadline under the obscure Federal budget reconciliation process. Like other repeal efforts before it, the Graham-Cassidy Plan would undo the ACA’s Medicaid expansion, which extended health coverage to individuals earning below 138 percent of the Federal poverty level, and ban Medicaid reimbursement for family planning services provided by Planned Parenthood. The plan also allows states the ability to get waivers that let insurers charge sick patients higher premiums for pre-existing conditions and to stop covering certain essential benefits such as maternity care, well-care visits, and preventative screenings. In addition to the Medicaid expansion cuts, the Graham-Cassidy Plan would also drastically cut funding to the rest of the Medicaid program through the use of per-capita caps, which significantly shortchange current state Medicaid spending on non-expansion populations and increase the likelihood that states will need to raise taxes, cut other budget priorities, or make increasingly severe cuts to Medicaid eligibility groups, “optional” benefits like home- and community-based services, and provider payments. For states like Ohio, where coverage was expanded to 723,000 individuals, the Graham-Cassidy Plan would be devastating, rolling back the state’s coverage gains and causing hundreds of thousands of low-income individuals to lose access to health care.
But the biggest losers under the Graham-Cassidy plan may be Ohio’s rural women and families, and ongoing efforts to reduce Medicaid funding and halt expansion are an assault on their health, well-being, and economic stability. One in five Ohioans lives in a small town or rural community, and Medicaid plays a huge role in how these individuals obtain health care. Medicaid covers approximately 25 percent of working-age adults and 40 percent of children in rural communities.  Because individuals in rural communities are often older, sicker, and poorer than their urban counterparts, Ohio’s rural counties also have higher overall Medicaid spending per capita than the state average, and all but two of the 22 counties with the highest percentage of their population enrolled in Medicaid are rural. Moreover, women comprise the majority of Ohio’s Medicaid rolls, and the ACA’s Medicaid expansion has been the pathway to health insurance coverage for many of the state’s poorest women. For example, expanded Medicaid coverage allows women to remain continuously covered more than 60 days after the birth of a child and helps women who do not have children gain health coverage, providing access to effective contraceptive methods, preventative care, and mental health services.
But the impact of Medicaid cuts on Ohio’s rural health goes beyond women and families covered by Medicaid. Hospitals and health clinics in Ohio’s rural communities often have large numbers of Medicaid-eligible patients and are highly reliant on adequate Medicaid funding to avoid closure and continue providing essential services to geographically-isolated communities. Medicaid expansion in Ohio significantly reduced the numbers of uninsured patients in rural areas and reduced uncompensated care provided by hospitals and clinics. This led to improved financial stability for facilities and providers, impacting what services a hospital and community health clinics in rural communities were able to provide to all patients, including urgent/emergency care, labor and delivery units, primary care clinics, ambulance services, home-health services, and addiction counseling. Drastic cuts and changes to Medicaid funding and eligibility translates to fewer primary care doctors and specialists, closed emergency rooms, limited OB/GYN services, and, in some cases, shuttered hospitals and clinics in a rural area. Not only is access to essential health services impacted, but as the number of uninsured patients and uncompensated care increases, all rural taxpayers and consumers pay through rising health care costs and higher health insurance premiums. Additionally, any federal cutbacks to Medicaid funding must be offset by the state, where the options to address budget shortfalls include raising taxes for all citizens, cutting other programs such as public education and infrastructure, and scaling back already lean optional Medicaid services for the disabled and elderly.
Reduced Medicaid funding and eligibility also disproportionately impact the economic stability of rural communities. In some Ohio counties, particularly rural ones, almost a quarter of all jobs are in the health care sector, and rural hospitals are often the largest employers of their counties.3 Medicaid expansion has increased use of health services, reduced the levels of uncompensated care, and resulted in higher hospital revenues, which translates to more jobs and stronger local economies. 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. Additionally, the aging population in rural counties, coupled with Medicaid expansion, also mean health sector jobs such as home health care workers, certified nurses, and hospice workers – many jobs filled by women – are in high demand and have a reliable funding stream through Medicaid reimbursement.
Sadly, the assault on Ohio’s rural health doesn’t stop in Congress. Right now, in the Ohio General Assembly, House Republican leaders are actively pushing their members to support a veto override that would freeze Medicaid expansion enrollment, effectively eliminating the Medicaid coverage for more than 500,000 Ohioans, regardless of what ACA repeal bills do or do not survive in Washington. The Medicaid expansion freeze provision was added to the 2018-2019 state budget bill by Republicans in the Ohio Senate, but this freeze is one of 47 budget line items vetoed by Governor Kasich when the budget was signed in July. Since August, six of the Governor’s 47 vetoes have already been overridden by both the Ohio House of Representatives and Ohio Senate, and a possible veto override of the current Medicaid expansion freeze provision is the latest dispute between the Governor and his own political party over Ohio’s Medicaid expansion and program oversight.
These threats come at a time when Ohio faces a declining middle class; a workforce ravaged by chronic diseases, disability, and opioid addiction; and some of the highest rates of infant mortality, preventable hospitalizations, and drug deaths in the country. The state’s small, rural hospitals and rural health care professionals are at the front-lines of addressing these issues and have survived closure because of Medicaid’s current funding structure and expanded enrollment under the ACA. This is a critical time for Ohio’s leadership to be innovative and strategic in how it addresses our citizens’ vast health needs. Taking away health insurance from more Ohioans is the exact opposite of what our policymakers should be doing to make Ohio healthier and work-ready, particularly in rural areas that have been hardest hit by a stagnant economy. Support and funding of expanded health coverage for the State’s most vulnerable populations through programs such as Medicaid should be viewed as an investment in Ohio’s economy, workforce, and families.
ABOUT THE AUTHOR: Allison Russo, DrPH, MPH, is a public health policy expert and currently the Research Director for Kennell and Associates, a health policy and finance consulting firm. She has authored numerous reports on a wide-range of health care issues including access to appropriate care by vulnerable populations; determinants of health outcomes, the utilization of services, and healthcare costs; and payment policy options that incentivize the delivery of high-quality care. She is an outspoken advocate for universal access to affordable and quality health care and lives in Columbus, Ohio.
 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
 Policy Matters Ohio. “AHCA will strip away at Medicaid.” Kate Sopko, June, 2017. https://www.policymattersohio.org/research-policy/pathways-out-of-poverty/basic-needs-unemployment-compensation/ahca-will-strip-away-at-medicaid#_ftnref53
 Policy Matters Ohio. “AHCA Threatens Ohio’s Growing Health Care Sector.” Kate Sopko, May, 2017. https://www.policymattersohio.org/research-policy/pathways-out-of-poverty/basic-needs-unemployment-compensation/ahca-will-strip-away-at-medicaid#_ftn53