Over the course of the last few months, the Center for Community Solutions has regularly written about and advocated for policies that enable our mission to improve the health, social and economic conditions of Ohioans. From improving maternal and infant health, to advancing the well-being of older adults, to supporting sound Medicaid policy, there is much that advances that work in the state biennial budget and much which also hinders progress. This budget, arguably more than any in recent memory, has provided incredible challenges as a global pandemic complicated the economy of Ohio, the safety of its citizens and the role of the federal funding in managing the crisis. We ask the conferees to consider the following as they deliberate the remaining decision points for the upcoming biennium.

Medicaid

For years, The Center for Community Solutions has written about Ohio’s managed care program, with pieces outlining federal standards, current performance and value-based contracting. And, when Ohio Medicaid announced they were rebidding the contracts, we paid close attention, monitoring the feedback process, providing written comment and reviewing, in detail, the hundreds of pages worth of documents outlining the proposal. That’s why we and many other advocates across Ohio were dismayed when a last-minute amendment was offered to derail Ohio’s efforts to improve its managed care system. But it may be helpful to dispel some common myths and fact check what is happening in the statehouse around this issue.

Managed competition is about achieving savings through performance-based contracting and this ensures underperformers could get taxpayer money. Ohio has worked hard to end pharmacy benefit manager grift and end the custody relinquishment of special needs children and this provision puts that work at risk. Procurement efforts also save the state money and make it easier to be a provider in Ohio, reducing regulation. The provision rewards companies based in Ohio, but doesn’t require them to serve the whole state, allowing them to cherry-pick which Buckeyes they want to serve. Terminating the Ohio managed care procurement leaves behind rural Ohioans, is anti-competitive and dismantles the years-long legislative work to stop pharmacy middle-manning, end custody relinquishment and save significant dollars in reduced overhead. We are asking conferees to remove the amendments which would rebid Ohio’s procurement.

Finally, in the executive version of the budget, we saw incremental, optional opportunities to improve quality, safety and cost-efficiency of Ohio’s nursing facility providers. And, in each step, these provisions were eroded, with diminishing oversight of these critical institutions, including the elimination of Ohio’s participation in the Special Focus Facility Program. In the end, these providers not only represent a significant and ongoing fixed cost by ensuring reimbursement in statute, but have eliminated provisions which safeguard compliance with the bare minimum of patient safety expectations. The House and Senate should remediate these issues and instead focus on developing policies which not only ensure the sustainability of the industry, but support their workforce needs and protect the older adults and their families who count on their effective clinical management.

Maternal Health

For the past several years, Community Solutions has been committed to analyzing Ohio’s escalating maternal and infant health crisis to raise awareness and pursue policy solutions to improve outcomes for families in our state. For this reason, we were incredibly pleased to see one of our primary recommendations included in the Senate passed budget – allowing all individuals whose pregnancies are covered by the Ohio Department of Medicaid to be able to maintain their Medicaid coverage for at least one year after giving birth. This coverage, penned as “fourth trimester” care by The American College of Obstetrics and Gynecologists, will include coverage for services like case management and outreach, lactation consulting, substance-use disorder treatment and mental health screening and treatment. Research has shown that extending Medicaid coverage does help to eliminate preventable maternal deaths. While Medicaid is required to cover pregnant individuals with incomes up to 200 percent of the federal poverty level for 60 days following birth, in West Virginia, for example, 62 percent of all maternal deaths from 2007-2013 occurred more than 60 days after birth.

Elderly/Disabled Simplified Application Project (EDSAP)

Both the Ohio House and the Ohio Senate passed budgets included requiring the Ohio Department of Job and Family Services to pursue the Elderly/Disabled Simplified Application Project waiver allowed by the U.S. Department of Agriculture Food and Nutrition Service. This waiver, also known as EDSAP or ESAP, is utilized by several other states including Alabama, South Carolina, Pennsylvania and Massachusetts, to keep eligible seniors and individuals with disabilities connected to the Supplemental Nutrition Assistance Program (SNAP) as long as they remain eligible. An EDSAP demonstration, which requires federal approval, allows states to make the following changes only for households with elderly and/or disabled individuals without earned income, approximately 1/3 of Ohio’s SNAP caseload:

Extend SNAP certification periods to 36 months (current maximum for these households is 24 months)
Eliminate paper-based interim reporting and rely on electronic data matching to update cases, which is more accurate and efficient
Waive recertification interviews, unless requested by the household, to avoid cutting off eligible households simply because they couldn't get through to a caseworker. (Keep in mind, call wait times are often 2-3 hours long in some parts of the state.)Not only will these changes that require no appropriation save county’s countless hours in caseworker time, they will assure churn is avoided in a population that is already highly susceptible to food insecurity. Because this package of waivers has been pre-sanctioned by FNS, Ohio is expected to receive approval should the provision remain in the budget.

Supplemental Nutrition Assistance Program and other safety net programs

Provisions added in the Senate version of the budget threaten access to the Supplemental Nutrition Assistance Program (SNAP), but also other safety net programs, for thousands of Ohioans who are eligible. The provisions:

Require change reporting for all SNAP households, a practice which no other state in the country uses. This means that families must report any change in income of at least $500, which would be a challenge for individuals who work hourly and/or fluctuating positions.
Threaten Ohio’s ability to exercise SNAP state options relating to Categorical Eligibility. This provision would require Ohio to reinstitute an asset test, which would prevent families from having assets over $2,250 and a car that’s valued over $4,650. It would also prevent Ohio from ever raising SNAP’s gross income limit above 130 percent of the federal poverty line.
Make child support cooperation mandatory to participate in SNAP. This would take food away from families with children who are victims of domestic abuse and do not want to pursue a formal child support arrangement to protect their safety. It would also be expensive to administer.
Gives the Department of Medicaid only 60 days to use third-party data to conduct an eligibility redetermination of all Ohio Medicaid recipients after the conclusion of the COVID-19 emergency period.

Ohio, along with all other states, already engages in a robust process to protect the integrity of SNAP. In 2018, Ohio reported using 19 different electronic data sources – including 14 national data sources and five state data sources – to confirm SNAP eligibility. In fiscal year 2019, Ohio’s payment error rate remained low and in alignment with the national average. SNAP consistently delivers the right benefits to the right people at the right time, due to the program’s rigorous quality control and accurate payment system.

The provisions in the Senate-passed budget are unnecessary and administratively burdensome, not to mention would threaten access to families that are eligible. We encourage the conferees to stick with the House version of the budget, which does not include these provisions.

Adult protective services

Both the House and Senate versions of the budget provide an increase in funding for adult protective services. Community Solutions has a long history of advocating for a strong adult protective services system in Ohio. Prior to the pandemic, older Ohioans were more susceptible to unjust circumstances such as financial exploitation from scam artists friends or family; as well as physical, sexual or emotional abuse. The pandemic restrictions, including social-distancing guidelines, non-visitor policies and capacity mandates meant older adults, like all of us, have had less interaction with society, reducing the likelihood that mandatory reporters of elder abuse were able to recognize and report it. We are concerned in the coming months there will be a caseload uptick in each county as restrictions are lifted and vaccines becomes more widely available. The increase included by both chambers will bring each county to $65,000, enough to support at least one full-time dedicated APS caseworker per county. We encourage the conferees to maintain this increase that was supported by both the House and the Senate.

Thank you all for your important work. We are here to answer any questions or provide additional information.

Sincerely,

John Corlett President and Executive Director The Center for Community Solutions

CC: Governor Mike DeWine Senate President Matt Huffman Speaker of the House Robert Cupp

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