Ohio’s legal aid organizations and the Ohio Poverty Law Center are monitoring proposed eligibility and funding changes to Medicaid, which currently provides health insurance to more than 3 million Ohioans with low income. In addition to improving health outcomes and life expectancy, access to healthcare underscores the ability to limit debt and maintain steady employment and school attendance. 

If you’re not a Medicaid expert, here’s some background to help you understand the current situation: 

• Pre-ACA: Prior to the Affordable Care Act (ACA), Medicaid insurance was mainly available to children and their caregivers, people with disabilities, and pregnant women, with states having some flexibility to set their own income-eligibility requirements.

• The FMAP: The portion of a state’s Medicaid expenditures that the federal government pays is called the Federal Medical Assistance Percentage (FMAP). The FMAP percentage rate is different for different eligibility categories. Ohio’s FMAP rates for those Pre-ACA Medicaid enrollee groups generally range between 60% and 80%. 

• Medicaid Expansion and Group VIII: In 2014 the ACA authorized states to expand Medicaid to include individuals between the ages of 18 and 65 with incomes less than 138% of the poverty level. (That’s about $21,000/year for a single individual in 2025.) The Medicaid term for this new set of enrollees is Group VIII.

• 90% FMAP for Group VIII: The federal government incentivizes states to participate in Medicaid expansion by setting the FMAP rate at 90% for this enrollee group, meaning that Ohio only pays 10% of what it costs to provide Medicaid to Group VIII.  

• 700,000 Group VIII Ohioans: More than 700,000 of the 3 million Ohioans enrolled in Medicaid fall within the Group VIII category. 

So what’s going on right now? 

The Ohio Biennial State Budget 

Last week the Ohio House of Representatives introduced its proposed state operating budget (House Bill 96). So far, the Ohio Poverty Law Center Policy Analyst Danielle De Leon Spires has identified two provisions in the 4,000+ page bill that have the potential to impact access to Medicaid. They are: 

• Group VIII trigger law: Section 126.70 states that should the Group VIII FMAP drop below 90%, the Ohio Department of Medicaid will immediately discontinue all medical assistance for the 700,000+ Ohioans who now qualify in Group VIII. 

• Federal cuts may lead to state cuts: Section 126.10 is less specific and could result in broader cuts to Medicaid. It states that if the federal government reduces, discontinues, pauses, or otherwise suspends any federal programs that provide federal funds for any corresponding state program, that program may be reduced, discontinued, paused, or suspended. 

Ohio Department of Medicaid Group VIII Waiver Application 

The Ohio Department of Medicaid (ODM) is preparing to submit a demonstration waiver application, requesting that the Secretary of Health and Human Services permit Ohio to mandate that Group VIII Medicaid enrollees satisfy work requirements. ODM’s stated goals of the waiver are to “promote economic stability and financial independence” and “improve health outcomes by encouraging individuals to be engaged with their health and healthcare.” 

The Ohio Poverty Law Center and members of the Alliance of Ohio Legal Aids Health and Public Benefits Taskforce submitted comments in opposition to the work requirement, citing research that indicates the requested waiver actually undermines its own stated purpose. Medicaid, without cumbersome work requirements, has already been shown to reduce barriers to employment while the chief outcome of imposing work requirements on Group VIII members has been a significant reduction Medicaid enrollment. 

Some highlights from the Alliance’s opposition comments: 

Health status is the strongest predictor of work*: While Ohio’s waiver application presumes that employment improves health outcomes, research, including ODM’s own studies, shows it is the other way around. The availability of medical coverage and access to healthcare reduces barriers to employment.

• ODM’s 2016 assessment of Group VIII enrollees showed that enrollment in Medicaid made it easier to continue working or seek work.**

• In 2018, ODM found the same. Nine out of 10 Group VIII enrollees reported that having Medicaid made it easier to continue working.***

• A study of Arkansas’s Medicaid work requirements showed that they resulted in no significant changes in employment or hours worked. In fact, prior to the implementation of the work requirements, 95% of the target population already met the requirement or qualified for an exemption.****

Work requirements reduce access to care with no apparent gain:  The Center for Community Solutions calculates that up to 450,000 Ohioans are at risk of losing Medicaid coverage under the terms of the proposed waiver.5 Any waiver that has the net effect of reducing coverage by tens of thousands of individuals (at a minimum) fails to further the Medicaid program’s most basic goal: to provide medical assistance to people whose income and resources are not sufficient to pay for the costs of necessary medical care. 

• Barriers to employment should not be barriers to health insurance: 64% of Ohio adults aged 18 – 64 are already working. For those who are not, research shows several barriers that limit capacity for employment, including access to childcare, transportation, and caregiving roles. While the waiver allows for exemptions, many of these documented barriers would not qualify for an exemption. 

• Increased costs with no programmatic gain:  Reduced Medicaid enrollment will result in increased individual premiums. That coupled with the cost of administering the work requirement program will result in a net increase in the total cost of Medicaid services in Ohio. 

• County JFS offices negligent in screening for work requirement exceptions: The Federal Department of Food and Nutrition Services (FNS) has reported for several years that Ohio’s County Departments of Job and Family Services are not adequately conducting work requirement screenings for SNAP applicants, leaving many who should be eligible for exemptions without SNAP benefits. The same County Departments would be responsible for screening Group VIII Medicaid enrollees.  

Read the full comments on the Medicaid Group VIII waiver application:   

• Health and Public Benefits Taskforce, Alliance of Ohio Legal Aids, Comments in Opposition to the Group VIII Demonstration Application 
• Ohio Poverty Law Center, Comments in Opposition to the Group VIII Demonstration Application 

We will continue to post funding and programmatic Medicaid updates as they emerge. 

*Madeline Guth et al., Understanding the Intersection of Medicaid and Work: A Look at What the Data Say, Kaiser Fam. Found. (Apr. 25, 2023), https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-work-a-look-at-what-the-data-say/.

**Ohio Medicaid Group VIII Assessment: A Report to the Ohio General Assembly, The Ohio Department of Medicaid (2016) at 4, https://medicaid.ohio.gov/wps/wcm/connect/gov/b0779c0a-5061-45f9-b441-9bf06e2f0070/Group-VIII

***2018 Ohio Medicaid Group VII Assessment: A Follow-Up to the 2016 Ohio Medicaid Group VIII Assessment, The Ohio Department of Medicaid (Aug. 2018) at 21, https://medicaid.ohio.gov/wps/wcm/connect/gov/2468a404- 5b09-4b85-85cd-4473a1ec8758/Group-VIII-FinalReport.pdf?MOD=AJPERES&CONVERT_TO=url&CACHEID=ROOTWORKSPACE.Z18_K9I401S01H7F40QBNJU3SO1F56 -2468a404-5b09-4b85-85cd-4473a1ec8758-nAUQnlt. 

****Benjamin Sommers, Medicaid Work Requirements – Results from the First Year in Arkansas, The New England J. of Medicine (June 19, 2019), https://www.nejm.org/doi/10.1056/NEJMsr1901772.