Ohio ranks sixth in the nation for Medicaid spending. But how healthy are its residents?

As pandemic-era policies and benefits end, Ohio officials estimate as many as 280,000 of the 3.55 million enrolled Ohioans may lose Medicaid.

Approximately 1 million Americans have already lost coverage from the government-paid health insurance program for children, low-income adults, seniors and those with disabilities since federally mandated automatic re-enrollment in the program ended on March 31, including 24,000 Ohioans who have lost the benefit since the end of May, according to the Ohio Department of Medicaid.

Now, people must manually re-enroll to get coverage.

Meanwhile, Ohio is one of the states that spends the most on insuring its citizens, but it doesn’t measure up in terms of health care access and quality.

How Ohio's Medicaid spending compares to other states

Ohio spent $27.6 billion on Medicaid, ranking sixth in the nation for spending, according to 2021 data, the most recent available from the Kaiser Family Foundation, a nonpartisan health policy organization.

Ahead of Ohio in spending are California (ranking number one at more than $100 billion), New York, Texas, Pennsylvania and Florida. Each state ranks higher than Ohio when it comes to total population. Ohio's population is the seventh-highest in the nation.

Total Medicaid spending in the nation was $748 billion in 2021, according to the foundation.

But when it comes to the population's overall health, Ohio is almost at the bottom — 44th out of the 50 states, according to the Health Policy Institute of Ohio. This is measured by a number of factors, including physical activity of the population, consumption of alcohol, suicide, depression, infant mortality, life expectancy, chronic illness and more. By comparison, California is ranked at third best.

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“We have less healthy lives here in Ohio and we’re spending more on health care than people in many other states,” said Edith Nkenganyi, a policy analyst at the Health Policy Institute of Ohio, who worked on its 2023 Health Value Dashboard for Ohio. 

“That’s not good,” said Amy Rohling McGee, the policy institute's president. “We have a lot of room for improvement."

What is Medicaid and how many Ohioans have it?

Medicaid is a public health insurance program for those who can’t afford their own and, in Ohio, it’s the largest single insurer in the state, according to Policy Matters Ohio, a nonprofit research institute.

To qualify for Medicaid in Ohio, a one-person household would have to have an annual income of less than $19,392 before taxes.

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The Medicaid program, which is a partnership between states and the federal government, covers different things in different states, though all states are required to pay for certain federally mandated services for their residents.

About 3.55 million people, or 30% of Ohioans have Medicaid, making it “an essential way in which people are able to access care,” according to Rohling McGee and the policy institute's 2023 Ohio Medicaid Basics Report, released in May.

Most of those people, more than 1.33 million, are children.,

Medicaid also accounts for a large proportion of state money, with about 39% of the state’s $110 billion budget going to the program in 2022, according to the institute.

Why does the state spend so much money on Medicaid?

During the COVID-19 pandemic, from February 2020 to December 2022, Ohioans getting the federal benefit grew by 29.6%, from 2.5 to 3.3 million, according to the Kaiser Family Foundation.

That's in part because, when the COVID-19 public health emergency began, the federal government started automatically re-enrolling people on Medicaid, and many also became unemployed during the pandemic. Ohio's enrollment growth during the pandemic was the 6th largest, with 837,600 people enrolling.

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Beyond having one of the largest state populations to insure, Ohio also pays for some coverage beyond federal minimum Medicaid regulations. Those “optional” services include pharmacy benefits, physical therapy, ambulance transportation, chiropractic care, alcohol and drug screenings, podiatry, speech therapy, telehealth and dental care, which each state can determine if it will offer, said Rohling McGee.

Ohio also recently extended postpartum coverage for mothers from 60 days after birth to one year, a time for which infants are already covered.

Rohling McGee said the amount Ohio spends on Medicaid coverage has gone up over time, in part, because more people may end up falling into the eligibility requirements than planned in the state budget, which increases the actual amount spent.

Additionally, Ohio’s health care spending is mostly on costly individual care to treat health problems, said Amy Bush Stevens, vice president of research and evaluation at the Health Policy Institute of Ohio.

"Our health is shaped by many factors beyond clinical care, such as education, employment, access to healthy food and air quality," Bush Stevens said. "Ohio performs worse than most other states on metrics related to the social, economic and physical environments."

Some of these problems could be caused by the fact that there are many tobacco-users in Ohio, and smoking causes disease and disability, according to the Centers for Disease Control and Prevention.

Nearly 20% of Ohio adults smoke tobacco, according to the Ohio Department of Health.

"Tobacco use is one of the key factors contributing to Ohio’s poor performance on the Health Value Dashboard," according to the institute. "Ohio’s persistently poor rank on the adult smoking metric (44th in this edition) helps to explain why the state struggles to improve health and control spending relative to other states."

Ohio also has poor outdoor air quality, lots of toxic pollutants and a high overdose rate, all of which contribute to its poor health rating, according to the institute.

The state needs to focus more on prevention and drivers of health to strengthen Ohio's performance and help more Ohioans live healthily, Bush Stevens said.

Access to healthcare in Ohio

Ohio's access to health care does not rank as high as its spending, according to the policy institute.

The organization ranked the state's access to care at 20th out of the 50 states for 2022, due to a lack of mental health professionals and physicians for underserved communities, and a decrease in the number of children getting preventative dental care from previous years.

For 2021, the institute ranked Ohio seventh among the 50 states for the same metric, but much has worsened when it comes to health care access in the state since then. Access was determined by looking at how easy it is for Ohioans to get necessities like health care coverage, affordable care, ability to see a primary care provider and finding access to mental health care.

The institute’s dashboard also provides recommendations for Ohio to improve its residents' health, said Rohling McGee. Those include increasing people's ability to work with more career technical education and childcare; more attention to addiction and behavioral health, such as building a more robust workforce of treatment providers; and strengthening access to health care by offering more school-based health centers, and training more primary care workers.

What's next for Medicaid coverage?

As pandemic-era Medicaid coverage is "unwound" over a year-long period, advocates are concerned that even more people could lose health care coverage completely during the transition from automatic to manual enrollment, which could have an impact on their ability to access healthcare, Rohling McGee said.

“That’s definitely something we want to keep an eye on going forward, to see what the impact of disenrollment is on people,” said Rohling McGee. “There may be some who are able to get coverage through their employer or through a spouse's employer — although many jobs that pay lower wages often don’t offer insurance, or they offer insurance with a very high deductible and high cost-sharing.”

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The Ohio Department of Medicaid said it is referring those who lose benefits because they are being found ineligible post-pandemic to navigators and managed care providers who can help them find alternative health care coverage that is affordable.

Other pandemic-related programs are expiring or changing concurrently, Rohling McGee said, including food stamps, and that could also have an impact on people’s ability to access fresh and healthy food and increase financial stress.

“We want to make sure that programs like Medicaid do stay in place,” said Rohling McGee.

dking@dispatch.com

@DanaeKing

This article originally appeared on The Columbus Dispatch: Ohio's a top Medicaid spender. But does its overall health measure up?