Today is the gubernatorial primary for the state of Ohio. The state has had one of the most successful Medicaid expansions in the country in terms of the number of people who became newly eligible. Regardless of who wins this primary, Medicaid in Ohio is bound to change and how it changes will be determined in large part by this election and the general election in November.
Governor Kasich took a risk when he defied his state legislature and passed Medicaid expansion in 2013 using a procedural rule in the state that allows the governor to bypass the legislature. Not only did he defend the policy at the state level despite many attempts to cut or eliminate the program by the legislature, he ran on the successes of the Medicaid program when running for president. His appeal to the moderate sides of the Republican party through his support of Medicaid expansion has given him the name of a compassionate conservative or a moderate in support of government programs.
However, his state has submitted a work requirement waiver proposal that goes beyond any proposal that has been approved to date. Kasich himself is term limited and will not be running for re-election in November. The two main candidates for governor in the state have taken a hard stance against the Medicaid expansion. Baring the election of a Democrat in office in November, it appears that the Medicaid expansion in Ohio is on the cusp to dramatically change.
The lead Republican candidate for governor, Mike DeWine, is the current Attorney General and has previously served in the House and Senate as well as lieutenant governor. DeWine has been relatively quiet on his Medicaid expansion stance. He has repeated that he would ask the Trump Administration for waivers. He has not specified exactly what these waivers would include and provide any additional details about his plan. During a debate in April he responded to pressure to answer whether he would keep the Medicaid expansion with, “Mary, it will not exist as we know it today. It can’t, and it was your administration that took it.” He then proceeded to artfully redirect the debate to his challenger’s performance as lieutenant governor. It is likely that his plan is to impose work requirements, lifetime limits, or other restrictive policies outlined by the Trump administration that would limit the number of people in the Medicaid program. During the primary he is pushed to have a position against the Medicaid expansion but he is caught with the fact that he will likely have to run on a more moderate position surrounding health care in the general election. This means he’s trying as much as possible to not provide too many details on his plan at this time. Advocates in favor and against Medicaid are pushing to get him on the record so they can run against him on either side either in the general election or the primary, respectively.
The challenger, Mary Taylor, is the current lieutenant governor and has run on a platform of repealing the Medicaid expansion. During the campaign she has insisted that the expansion has been bad for Ohio and that she would get rid of the expansion all together. She has not always had a negative view of the Medicaid expansion, however. In serving as the lieutenant governor she has been supportive of actions of the Kasich administration including the decision to expand. When Kasich was running for President, she supported his decision to expand Medicaid in an op-ed she penned. Taylor is running behind DeWine in the latest polling but has been surging in recent months. Her political strategy is likely to run to the right of DeWine and in the general trust that the Republican electorate will turn out.
The work requirement proposal submitted by Kasich in recent weeks goes beyond any proposal submitted thus far. It is hard to imagine how DeWine could envision a waiver program that is more conservative than the one Ohio has pending. The proposal would require Medicaid beneficiaries to meet an 80 hour monthly work requirement. If beneficiaries fail to do so they will be required to work without salary to pay for the cost of their Medicaid coverage. Not only does this requirement present serious concerns for labor laws, from a health policy perspective it will incentivize people to use less care. We already know that when low-income people are charged cost sharing for their health care services that they are less likely to use health care. We also know that this is detrimental to their health. Similarly, if a person knows that they will have to work for free if they use health care services they are likely to not use needed health services. This could cause the low-income population to have worse health outcomes than if they had no insurance or than if their Medicaid was not tied to work. One of the main arguments that the Trump administration has made surrounding work requirements in the Medicaid program is that work improves ones health. From the research that was proven in the seminal RAND health insurance experiment, we know with certainty that barriers to care are detrimental to the health of low-income people. Certainly, working for no pay would be an equivocal disincentive to getting care as a few dollars in copayments had been in the RAND experiment.
Meanwhile the Democratic candidates for governor in Ohio have not run to limit Medicaid either through a waiver or ending the Medicaid expansion. Richard Cordray, the former director of the Consumer Financial Protection Bureau and former Ohio Attorney General is leading a crowded field of candidates. His main competitor, former Congressman Dennis Kucinich, is about 15 points behind in the polls. Both candidates have campaigned on protecting the Medicaid expansion. They have also extended their campaigns to focus on ways to ensure more Ohioans have access to health insurance and strengthening the Medicaid program.
No matter what happens in the gubernatorial election the Medicaid program is likely to change before Kasich leaves office. Ohio is a dynamic health care market with unique and difficult challenges including the opioid crisis. Today’s election will present an opportunity for voters to make their perceptions of the Medicaid program known to the elites.