The American Health Care Act and preserving Medicaid

Last week we wrote the following letter to Senator Rob Portman, which several of our members signed on to, regarding the American Health Care Act (AHCA).

Dear Senator Portman,

The Philanthropy Ohio Health Initiative began as a member-initiated coalition focused on improving the health of Ohioans. Our membership includes private and community foundations, corporate funders, public charity grantmakers and United Ways. The Health Initiative envisions a future where Ohio communities – including the philanthropic sector and the health care system – support health promotion, disease prevention and patient-centered, quality care accessible by all Ohioans. To do this we also work with other community organizations, government and partners who share our goals, many who have joined us in signing this letter. Like many others who invest in the health and welfare of our communities, we are deeply concerned about the impact on Ohioans of key changes being considered in the American Health Care Act (AHCA).

Senator Portman, we appreciate your leadership in directly confronting the impact of Medicaid changes proposed in the House-passed version of the AHCA. As you said in your letter to Senate Majority Leader McConnell (dated March 6, 2017), Medicaid “reform should not come at the cost of disruption in access to health care for our country’s most vulnerable and sickest individuals…and we will not support a plan that does not include stability for Medicaid expansion populations or flexibility for states.” We could not agree more.

We respect the concerns about the cost to the state and federal government of providing Medicaid coverage and want to collaborate with good-faith partners in addressing these concerns. However, we believe the longstanding state-federal financing partnership is not fundamentally broken.

As you indicated with Anthem’s announcement to withdraw from the Obamacare Exchange (the Marketplace), “the status quo is unsustainable.” We agree. The Anthem withdrawal leaves 19,000 Ohioans in 20 Ohio counties without any option to purchase an individual plan on the Marketplace; that is 11% of Ohio’s total Marketplace enrollment. However, despite the need to fix the Marketplace, there is no need to alter the current underlying federal-state financing structure for Medicaid—it works.

Today, Medicaid efficiently provides comprehensive health care for 3.1 million Ohioans, including 723,000 receiving coverage through the Medicaid Expansion. The AHCA’s proposal to shift Medicaid financing to ‘per- capita caps’ will jeopardize Ohio’s ability to provide health care to all Medicaid enrollees, including children, seniors, and people with disabilities, and would have a significant negative economic impact on our state. Consider the following:

Per-Capita Cap, Children & Other Extraordinary Medical Needs

• Ohio’s child protection system is seeing a dramatic increase in the rate of opioid-exposed babies. The life threatening medical issues these babies face result in immediate and long term needs for care and support. These babies are not covered by the Medicaid Expansion. Their needs require an ongoing, guaranteed federal- state partnership, which cannot be assured with “medical CPI plus 1%.”
• Ohio spends $2,488 per child on Medicaid, the 11th lowest in the country. With per-capita caps in place, this would become a permanent federal funding ceiling. Can we absorb the short and long-term cost of care for the opioid-exposed babies or other unexpected emerging public health threats? Further, as we work to improve health care quality and efficiency for children, if our spending falls below the federal cap, the recently discussed idea of periodic “rebasing” would further lower our federal funding ceiling, making the per-capita caps even more damaging.
• We ask: How do we absorb the short and long-term cost of care for the opioid-exposed babies? How would Medicaid financed by per- capita caps support our state’s needs in times of health and economic distress?

A Dedicated Pot to Replace Medicaid Funding for Opiate Treatment

• $650 million of the $1 billion dollars Ohio spent last year to reduce drug use and overdose fatalities was paid for by Medicaid. More than 50% of all prescriptions in Ohio for Buprenorphine (an opioid recovery medicine) in 2016 were paid for by Medicaid. Our healthcare system and these services are increasingly integrated to serve individuals holistically across the continuum of care, whether the need is identified in primary care, emergency rooms, or specialized services locations.
• We ask: Will the opiate funding pot that is being contemplated be large enough and grow commensurate with our $650 million need? How would this pot address each individual’s comprehensive needs and be integrated in a system of care? Why would we create a pot of funding for treating opiate addiction? We don’t pay for hip replacements or care for diabetes that way–these are part of holistic healthcare coverage.

Impact on Rural Communities, Veterans, Elderly, and Intellectually Disabled Individuals

• A Medicaid per-capita cap and phasing out the Medicaid Expansion will have a disproportionate impact on rural communities. Roughly 21% of Ohio’s Medicaid Expansion are individuals who live in rural communities. From 2009 to 2015, Ohio had the third largest decline in the number of uninsured adults nationally, as an additional 115,000 adults received Medicaid or Marketplace coverage.
• The uninsured rate among non-elderly Veterans has dropped 42% since 2014.
• Medicaid home and community-based services are an optional service. Today Ohio is serving almost 100,000 individuals in community services; that is 65% of our Medicaid long-term services spending. While seniors and people with intellectual and developmental disabilities would have a more generous growth rate in the per-capita cap, from 2000 to 2011 Ohio’s growth rate was higher than most states; 3.5% and 5.1% for aged and disabled, respectively.
• We ask: Faced with estimated reductions of $22 billion dollars over a ten-year period to Ohio, can we honestly assure families and individuals that these optional home and community based services will be supported at a level commensurate with their changing needs and will not be a prime target for reduced funding? Can Veterans and those in rural Ohio feel secure that there will not be disruption in their access to services, at the expense of others who also have significant needs?

A per-capita cap means that Ohio will have fewer resources over time to address these issues and will not be able to respond effectively to future public health crises. A federal funding cap cannot account for the specific spending pressures, needs and values of Ohio. The current federal matching formula already takes into account changes in each state’s demographic and economic conditions. Ohio’s health transformation is being driven by Governor Kasich and his Medicaid leadership team: the fundamental federal-state partnership doesn’t need to be abandoned, but deliberate progress continued. The President’s new team at HHS has many tools to continue and enhance this progress.

With this in mind, we strongly urge you to oppose any health reform bill that would cause Ohioans to lose health care coverage or benefits that they currently have. Specifically, we urge you to vote against any bill that would effectively end the Medicaid expansion, as we know it by completely phasing out the enhanced federal match or end the Medicaid program as we know it by shifting billions in Medicaid costs to states through a per-capita cap.

In closing, we, and the others who have signed on, pledge to work with you in any constructive manner to improve our state’s health care system. We appreciate your continued leadership on these important issues.

Sincerely,

Philanthropy Ohio

U.S. House vote ends Medicaid Expansion

I’m disappointed in last week’s U.S. House vote repealing the Affordable Care Act (ACA), ending the Medicaid Expansion that we have supported since Governor Kasich first introduced it. Over 700,000 Ohioans have health insurance because of the expansion, insurance that is critical to getting care – whether it’s care that addresses pre-existing and chronic conditions or wellness and prevention – that improves their health, keeps them in school or lets them get and keep jobs. Ohio philanthropies – private and community foundations, United Ways, health conversion foundations and more – are strong co-investors in improving the health of Ohioans, and, because of Medicaid Expansion’s coverage of so many who were previously uninsured, have been able to redirect their resources to intractable problems like infant mortality and opiate addiction crises in the state. Philanthropy can’t possibly fill the gap that will be left by the bill’s elimination of the expansion group and the restructuring and decreased funding for Medicaid.

I’m glad that Reps. Joyce and Turner stood firm in their objection to the American Health Care Act and disheartened that so many of their colleagues chose to support the bill: Reps. Chabot, Davidson, Gibbs, Johnson, Jordan, Latta, Renacci, Stivers, Tiberi and Wenstrup. About half – 323,000 – of the Medicaid Expansion population lives in the districts of those who supported the repeal.

The bill now moves on to the Senate and faces two distinct barriers. First, the Senate parliamentarian must determine that the various provisions are appropriately in a budget bill. Second, as I’ve been hearing for months, the Senate (including our own Senator Portman) has its own ideas about repealing and replacing the ACA and will likely introduce its own version. Once any bill moves through the Senate, congress will need to iron out the differences.

Our advocacy efforts will continue in coming months with members of Ohio’s delegation, educating them about the negative consequences of the AHCA bill as passed and urging them to keep Medicaid Expansion and the current structure and funding of the Medicaid program in place.

Claudia Y.W. Herrold

Pass SB 332 to reduce infant mortality

The number of Ohio babies who die before their first birthday is simply unacceptable and that is why Philanthropy Ohio supports SB 332. We urge the Ohio House of Representatives to follow the lead of the Ohio Senate and pass SB 332 when it returns to its scheduled sessions after the November election. The bill passed the Senate with broad, bipartisan support as seen by its 29-1 vote.

Consider just a few facts about infant mortality, deaths before age 1 per 1,000 live births:

• Ohio ranks 45^th in the nation in overall infant mortality rates;
• 7 of every 1,000 babies born in Ohio died before their first birthday in 2014;
• The rate of black babies who died in Ohio is twice that – 14.3 – and actually increased from previous years; and
• The national rate was 6.05.

Philanthropy has worked with government and community partners to develop and implement various initiatives to address this crisis in their local regions. For example, Interact for Health and United Way of Greater Cincinnati support Cradle Cincinnati, a collective impact initiative that focuses on three aspects of reducing infant mortality: preventing premature births, reducing tobacco and other substance use during pregnancy and promoting safe sleep. Hamilton County’s infant mortality rate in 2014 was 8.8, two points higher than the national rate. Fifth Third Bank also supports efforts through its funding of Cincinnati Children’s Center for Prevention of Preterm Birth, a partner in Cradle Cincinnati.

At the other end of the state, the Toledo Community Foundation has been deeply committed to the cause of saving infants. The foundation is an active partner with the Hospital Council of Northwest Ohio’s Northwest Ohio Pathways HUB program.

Pathways HUB is a system designed to find at-risk pregnant women and link them to services that contribute to positive birth outcomes. The program was created to address the high number of preterm infants born to African American women living in Lucas County. Since its founding in 2007, 1,400 at-risk African American pregnant women (2,772 all races) enrolled in the Pathways HUB and the program has shown positive results: from 2013-2015, African American women enrolled in Pathways at least 90 days had a much better birth weight rate (8.2%) than the overall rates for African Americans in Lucas County (14.7% in 2014).

These are just a few examples of philanthropy’s engagement across the state: there are also collaborations in Cleveland (First Year Cleveland) and Columbus (CelebrateOne) that our members support.

But these efforts, along with the state’s policy efforts to combat the high infant mortality rate, are not enough. SB 332 is a statewide, coordinated approach – critical if not sufficient – to reduce the number of infants who die each year.

The bill is innovative and deliberate in its focus on the social determinants of health, a focus that is critical to preventing the death of our youngest residents. By addressing housing issues and increasing the number of qualified community hubs providing services to at-risk populations the bill can go a long way toward saving babies and keeping them out of hospital NICUs. Its other provisions are also important, from tobacco cessation efforts to birth spacing and safe sleep education, to keep babies alive. These are interventions that work – we have proof of that – and strengthening these provisions will help our state move the needle on infant mortality.

Call your representative in the Ohio House to urge their support for the bill, moving it through committee and to the House floor before the end of this session.

Claudia Y.W. Herrold

Philanthropy Ohio Opposes Healthy Ohio Waiver

Philanthropy Ohio recently submitted comments to the director of the Ohio Department of Medicaid, stating its opposition to the waiver the state will be asking the federal government to approve. The waiver, which the Ohio General Assembly required in its last budget bill, and our reasons for opposing it, are more fully explained below.

Our comments:

Philanthropy Ohio is a statewide membership association serving private and community foundations, corporate giving programs, government agencies, United Ways and other public charity grantmakers as well as individual philanthropists. Our mission is to be the leading voice and premier resource for philanthropy across the state, particularly serving our over 210 members who collectively awarded more than $4 billion in grants last year. We have been engaged with the department as well as the Office of Health Transformation in recent years, through our member-driven Health Initiative that focuses on the state’s health policy reform efforts. We hope that our comments in opposition to the waiver, based upon the initiative’s principals and endorsed by our Board of Trustees, provide insight into philanthropy’s perspectives on the waiver being submitted.

Ohio, with the second largest number of health-focused foundations in the country, has philanthropic organizations with deep experience and commitment to improving the health of residents and working with government to do so. In an average year, Ohio’s philanthropic organizations invest almost $300 million in grants related to health. While these numbers pale in comparison to government resources, they are nevertheless important supports in countless communities across Ohio.

Philanthropy Ohio supported Medicaid expansion, testifying at hearings and signing on to the amicus brief submitted to the Supreme Court defending Governor Kasich’s expansion. We did so because of our deep belief – based upon research – that access to care through health insurance is key to improved health outcomes for what then were about 1.5 million Ohioans without health insurance. Our engagement in education and outreach activities during open enrollment periods has been extensive, supported by our members both financially and in leadership, and we have been very pleased that so many Ohioans now have insurance that can provide them with access to the kinds of services they need to get and stay healthy.

It is for this reason that we oppose the Healthy Ohio Waiver, believing that it will ultimately result in the loss of access to insurance and care for thousands of people who are dis-enrolled. Ohio has made such great strides under the expansion by covering more than 600,000 Ohioans: why would we choose to go backwards?

When thousands of Ohioans lose access to medical services – if the waiver is approved and implemented – to whom will they turn? Philanthropy, which cannot possibly fill the resulting gap. Its resources pale in comparison to what would be needed to assure continued access to cost-effective primary care. While many of our members support health clinics in their communities, we know from that history that these clinics often operate on thin financial margins and will not be able to cover growing amounts of uncompensated care if coverage is weakened. Inevitably, there will be high use of emergency departments, which analysis from the Ohio Office of Health Transformation and Ohio Department of Medicaid (ODM) highlights as the most expensive and least efficient avenue of care.

With ODM’s estimate of the waiver affecting 1.66 million Ohioans, a conservative 15 percent figure would result in nearly 180,000 people being dis-enrolled. Indeed, other states that implemented premiums saw much higher rates of drop-off, such as Oregon with 77 percent and Vermont with 30 percent. Losing coverage due to non-payment of premiums has significant, serious, potential results:

• creates churn within the Medicaid system, with accompanying administrative impacts;
• disrupts continuity of care for patients as well as providers;
• puts individuals at higher risk for negative health outcomes; and
• increases economic insecurity.

Additionally, the implementation of premiums has potential negative consequences for Ohio’s health care providers. The mandatory collection of co-pays, for instance, will be neither administratively easy nor cost-effective and interruption of care for those with chronic conditions makes the job of clinicians more difficult. The waiver, if implemented, would also likely reverse Ohio’s cost containment of Medicaid, an issue of critical concern to the legislature and administration. Continued enrollment has been shown to increase the health of the population and lower costs of care, so the churn likely created by disenrollment until premiums are paid, would be counterproductive. And, the development of a complex system of establishing and managing thousands of Buckeye Accounts – complete with financial transactions, monthly statements, contributions and the point system for health behaviors (yet to be defined) – will be a cumbersome and costly venture.

The waiver also creates hardships for those Ohioans living on very limited incomes, as nearly half of Ohioans who earn less than $15,000: either totally lack or have limited banking access necessary to pay premiums and monitor accounts; often lack financial literacy; may have credit problems compromising their eligibility for accounts; and would have problems paying fees to access or maintain accounts.

We are also particularly concerned about potential implications the waiver has for Ohio’s most vulnerable – its children. Much of our members’ work has concentrated on ensuring the next generation of Ohioans, our children, have the greatest opportunity to be successful educationally and economically, which means they need regular access to health care. Healthy Ohio creates potential disruptions in care for children, including foster children and low income children with special needs. The potential disenrollment of parents means low-income children will face another barrier in becoming more successful.

It is for these reasons that Philanthropy Ohio believes the waiver does not advance the best interest of Ohio and its most-at-risk population.

Claudia Y.W. Herrold

 

 

 

Healthy Food for Ohio launches

At two launch events last Monday, access to healthy, affordable food became one step closer to reality for many of Ohio’s food deserts. A public-private partnership has created a pool of nearly $10 million – with more dollars possible – that will provide loans and grants to develop retail groceries in low-income, underserved communities across the state.

The pooled dollars come from a variety of sources, including a $2 million state budget allocation as well as from the federal government and individual banks. Through a competitive application process overseen by the Finance Fund, grants and loans will be available “for costs associated with land acquisition, predevelopment, construction, equipment, infrastructure and related expenses as well as credit needs not typically filled by conventional financial institutions.” The Finance Fund anticipates funding 5 – 10 projects that will overcome the barriers of opening or developing retail stores. Ohio joins 10 other states with similar projects.

The fund grew out of the Ohio Healthy Food Financing Task Force that mapped nearly 1 million Ohio residents – including one-quarter of a million children – living in areas without sufficient access to healthy foods. See the report.

Close to 1 million Ohio residents live in areas with greatest need throughout the state. Those areas are highlighted in red and reflect low income, low sales and high deaths.

U.S. Representative Steve Stivers, who spoke at one of the launch events, applauded the partnership and its potential to impact areas like Vinton County, which has not had a grocery store since 2013; county residents must travel 30 miles to Athens to get fresh food. “I hope this program will help not only Vinton County but also other food deserts,” Rep. Stivers concluded.

Echoing his remarks, Ohio Representative Ryan Smith – who was instrumental in getting state funds allocated to the project – said “Access to healthy food is important to battle chronic disease, healthier Ohio citizens and a positive driver in workforce and economic development. I feel confident this program will be successful.”

Philanthropy played a strong role in getting the project to this exciting new stage, including funding reports and serving on the task force. David Ciccone of Central Ohio United Way co-chaired the task force, and these other Philanthropy Ohio members served and supported its work:

• The Cleveland Foundation
• The Columbus Foundation
• The George Gund Foundation
• Interact for Health
• Ohio Association of Foodbanks
• Ohio Children’s Foundation
• Saint Luke’s Foundation
• Sisters of Charity Foundation of Cleveland
• United Way of Greater Cincinnati
• United Way of Greater Cleveland

In addition to contributing to the funding pool, philanthropies could also think about how to partner with retailers to fill other needs, such as nutrition education, and for sustainability of local food stores. More information, along with pre-application materials, are available online.

 

Claudia Y.W. Herrold

On to the Senate with Medicaid expansion!

Philanthropy Ohio truly appreciates the unanimous, bipartisan support for last week’s state budget bill amendment that focuses both on extending healthcare coverage for many vulnerable Ohioans and continued reform of Medicaid. We remain so grateful for Governor Kasich’s leadership on these issues and for the tireless efforts of Representatives Sears, Antonio, Foley and Amstutz. At this time last week, we were facing a state budget bill with no provisions for extending healthcare coverage. After last Thursday, the House of Representatives defined a pathway for further consideration of these vital policy matters. We now look forward to making our case for extended coverage to the Ohio Senate.

Philanthropy Ohio’s Health Initiative is a group of nearly twenty foundations and other grantmakers who together support nonprofit health entities with over $200 million each year in grants. Their commitment to improving community health status, including access to care, could not be stronger. Health Initiative members feel the urgency of having the state reach consensus about adopting extended healthcare coverage because they understand how critical the need is for the more than 275,000 vulnerable Ohioans who need coverage now—including 26,000 uninsured veterans, 60,500 Ohioans with addiction and 55,000 Ohioans with unmet mental health needs.

On April 11, more than 2,000 Ohioans gathered at the Statehouse to encourage legislators to support extending health benefits to people without reliable medical care. Thanks to funding from a member of the Health Initiative, a video was taped and produced that tells the stories of those who need this coverage. The video is being distributed statewide to media and will be shared with Ohio Senators as debate continues there. Please watch, distribute and link to the video on your own websites, if you care about this issue.

http://www.youtube.com/watch?v=wvaE10z6aoo

Kudos to Governor Kasich

Philanthropy Ohio applauds Governor Kasich for his decision to propose the expansion of Medicaid in the budget he presented last week to the General Assembly. It’s a courageous move on his part and one that we agree with, because we know that it will bring positive impacts – both health and economic – to Ohio. As we said in a letter to him, there is no policy decision that has greater potential to improve health access and thereby the health status of Ohioans than that of Medicaid expansion.

Improving the health status of Ohioans is a subject that foundations, individuals and other philanthropic organizations have a long history of supporting. There are countless health improvement initiatives funded by more than $200 million a year by grantmakers and another $400 million in charitable contributions that individuals provide to health-focused nonprofits. These significant dollars support a wide array of services, from school- based health care to neighborhood clinics, free pharmacies and thousands of other projects that improve the health of vulnerable Ohioans. Philanthropy Ohio, through its Health Initiative project, is committed to supporting Governor Kasich’s proposal as it works its way through the legislature. We invite other philanthropies to join us.

OGF Members Form Coalition to Help State Implement ACA

This week’s guest post by Marcia Egbert, senior program officer at  The George Gund Foundation, describes a new funder coalition whose work OGF is managing. The full article appears in the June OGF Connection newsletter.

How and why did the coalition begin?
With the passage of the Patient Protection and Affordable Care Act (ACA) last year, an avalanche of state and local issues were unleashed on how best to effectively implement federal health care reform at the state and local level.

To aid foundations active or interested in health reform-related grantmaking,  understand the new law and explore collaboration on implementation, the Saint Luke’s Foundation and The George Gund Foundation joined forces to convene a set of meetings in 2010 with funders from around the state. These meetings were to help funders understand what is actually in the law, separate fact from fiction and learn when various aspects of the law go into effect. It quickly became apparent that there was great interest in the topic (34 representatives from 21 grantmaking institutions representing a very broad spectrum of community, private and corporate funders attended the meetings) and there was substantial interest in thinking through how we might best work together—both regionally and statewide—to influence and support effective implementation of the law’s myriad provisions.

Why is this work important?
We believe this new funders’ network is invaluable for several reasons. First, support for effective implementation of federal health care reform in Ohio is far beyond the reach of any one foundation to accomplish. The complexity of the issues involved call for a coordinated approach.

Second, this project represents an unusual collaboration among a broad cross section of foundations. The launch and development of the Health Policy Institute of Ohio (HPIO) has been, to date, the most significant statewide collaboration among a set of health-related grantmakers, with nine funders supporting HPIO’s operations. Health care reform implementation offers an opportunity to build upon and extend that collaboration to an even broader set of partnerships.

In addition, there will likely be competition and controversy at every step along the way toward implementation. Foundations are recognized as “neutral brokers” and conveners on matters of public concern. This effort can promote collaboration over competition among communities and the state with a goal of maximizing the potential benefits of the law.

Third, while the law is far from perfect, the provisions of ACA can have a profoundly positive impact for hundreds of thousands of Ohioans who are uninsured or underinsured and lack adequate access to preventive and primary care. ACA represents an historic opportunity to boost the health care access of thousands of this community’s citizens. But that potential will only be realized if we identify and engage creative, effective partnerships to make the most of this chance.

Anyone interested in more information about the coalition and its work can contact Claudia Herrold at 614.224.1344.

OGF members to help state with grant writing

Grantmakers in Health (GIH), with support from the Robert Wood Johnson Foundation, has awarded a $15,000 matching grant to a group of Ohio funders, all of whom are members of Ohio Grantmakers Forum.

The funders will use the grant dollars to offer grant writing support to the Ohio Department of Health as it implements the Affordable Care Act. The George Gund Foundation, The Health Foundation of Greater Cincinnati, Kaiser Permanente, Mt. Sinai Health Care Foundation and Saint Luke’s Foundation of Cleveland, Ohio submitted the proposal (with assistance from OGF) and are providing the match dollars required by the GIH grant.

Karen Hughes, acting director at the Ohio Department of Health, provided a letter of support for the grant request. She pointed out how welcome the funds would be – especially in the face of past and looming budget cuts that resulted in staff reductions – to help the department apply for various federal grants related to the Affordable Care Act.

The GIH grant is yet another example of public-private partnerships where government and private funders collaborate for the betterment of the state. It is also the first accomplishment for a larger, emerging coalition of OGF members, Ohio Funders Coalition Supporting Health Care Reform Implementation. The coalition began to coalesce last summer, when two foundations asked OGF to help convene funders from across the state.

There were two main reasons for bringing people together. First, funders wanted to educate themselves about the new health care reform law, the state’s plans for implementation and how it might impact their work. Second, they wanted to explore how they might work together to help implement the law in Ohio. The creation of this coalition in itself is an unprecedented effort among these health funders, with support from OGF: stay tuned for more about its work.