The ideas expressed in City club forums are those of the speakers and not of the City Club of Cleveland Ideastream Public Media or their sponsors.

Production and distribution of City club forums and ideastream Public media are made possible by PNC and the United Black Fund of Greater Cleveland, Inc.. Good afternoon and welcome to the City Club of Cleveland, where we are devoted to creating conversations of consequence that help democracy thrive.

It's Friday, May 16th.

And I'm Cynthia Connolly, director of programing here at the City Club.

And pleased to introduce today's forum where we will be unpacking Medicaid expansion.

Originally expanded in 2014 under the Kasich administration, Ohio is one of 41 states that has implemented Medicaid expansion under the Affordable Care Act.

However, if federal assistance for the program drops below 90%, trigger language recently added into the state budget bill would allow Ohio to dis enroll from the program.

The trigger language comes as congressional Republicans in Washington, D.C. consider cutting the federal match for Medicaid expansion.

This would leave states on the hook to cover the costs for Ohio.

It's a move that could ultimately strip health care access from over 77,077 Country 770,000 as a big number of Ohioans, including about 360,000 in rural Ohio counties.

Today, we will hear from leaders representing the health care sector, the insurance industry and the policy advocacy sector on what a rollback might look like, what work is ahead to ensure access to quality health care is for all Ohio families.

Joining us to discuss this on stage is Domonic Hopson, president and CEO of Neighborhood Family Practice.

We have yes, we have Dr. Beejadi Mukunda, vice President and market chief medical officer for Ohio.

For Ohio, for care.

Source.

And Amy Rohling McGee, president of the Health Policy Institute of Ohio.

Moderating the conversation today is Emily Campbell, president and CEO of the Center for Community Solutions.

Thank you, Emily, for being here.

And if you have a question for our speakers, you can text it to 3305415794.

Again, that's 3305415794.

And City Club staff will try to work it into the Q&A portion of the program.

Members and friends of the City Club of Cleveland please join me in welcoming all of our guests today.

Emily, thank you.

Thank you and good afternoon.

The conversation today could not be more timely.

Right now, there are closed door meetings happening in Washington, D.C., as the U.S. House of Representatives tries to figure out what will be in what's been called the big, beautiful budget bill to determine how to identify what's being called cost savings.

And Medicaid is certainly a piece of that.

Meanwhile, the state budget is currently sitting in the Ohio Senate where they are considering amendments and changes as we see what spending and policy will look like for our state over the next two years.

And so at this very moment, we are going to talk a little bit about what's on the table and what's at stake in terms of Medicaid, focusing on Medicaid expansion and state level policy.

We could spend all day working through all of the policy levels.

So it's rare that public policy changes have an immediate apparent and statistically significant impact on population level statistics and populate level conditions.

I've only seen it twice since the turn of the century in the last 25 years.

The most recent was during the pandemic, when the child tax credit was enhanced and improved, and for one year child poverty dropped by half.

When those provisions expired, went right back up.

The other time was ten years ago when Medicaid expansion went into effect in Ohio and the Full Affordable Care Act was implemented between 2013 and 2015.

The number and share of Ohioans who are uninsured fell by half, and it stayed there.

So today, 575,000 fewer Ohioans lack health insurance than they did before the implementation of the ACA, the Affordable Care Act and Medicaid expansion.

But all of the progress over the last decade is at risk.

We're going to specifically today talk about one very important word that's in the state budget, and it's the word shell.

Right now, the trigger, which we will be talking about, is in section one, 26.70 of the proposed fiscal year 2026 2027 budget, and it states this.

I'm going to read it.

If the federal Medicaid Medical assistance percentage for medical assistance provided to members of the expansion eligibility group is set below 90%.

The Ohio Department of Medicaid shall immediately discontinue all medical assistance for members of this group.

It's not a possibility.

It's a requirement that if the federal government changes their cost sharing in Medicaid, that Ohio has to continually, continuously and immediately discontinue the expansion population.

It's a subtle but clear message that even the slightest reduction in federal funds for Medicaid will trigger a drastic benefit cut for Ohioans.

That eligibility group, as was mentioned, is around 770,000 Ohioans, including close to 100,000 here in Cuyahoga County.

Today, we have an amazing panel of cross-section and expertise to talk a little bit about this issue and to bring their unique perspective.

And we'll start with Amy Rolling McGhee.

Amy, your organization, Health Policy Institute of Ohio, or GPIO, regularly publishes Medicaid Basics, which is the best explainer of this incredibly complex program.

Tell us a little bit more about GPIO and your work and to ground this conversation.

Please share briefly.

What is Medicaid and what's Medicaid expansion?

Thanks, Emily.

The Health Policy Institute of Ohio is a nonprofit, nonpartisan, independent organization based in Columbus.

It was created over 20 years ago by a number of foundations in our state, several from up here in the Cleveland area.

That includes the Cleveland Foundation, the George Gund Foundation, the Mount Sinai Health Foundation and others.

Our mission is to use data and evidence to advance policies that improve health, achieve equity, and lead to sustainable health care spending here in our state.

Thank you for mentioning Ohio Medicaid basics.

That's something we have created every two years since our organization began.

It's meant to be an explainer of this very complex program.

So to give you a little bit of information about what Medicaid is.

It was created by a federal law nearly 60 years ago, and it was meant to enable access to essential medical care for people with lower incomes.

Now, who exactly is eligible for Medicaid has changed over the years.

Currently, though, there are a wide range of people or types of people who are eligible for Medicaid coverage, including people who have disability.

These people who are older adults, some parents, people who are pregnant children and other adults, all with lower incomes.

And as was mentioned earlier, this is a state and federal partnership program, meaning the federal government pays part of the cost and the state pays the remainder of the cost.

Thank you.

And how does the Medicaid expansion fit into the program?

Yes.

So, as was mentioned, the Affordable Care Act and a subsequent Supreme Court decision gave states the option to expand Medicaid coverage to more adults.

So now adults between the ages of 19 and 64 in Ohio, who have incomes below 138% of the federal poverty level are eligible for Medicaid coverage.

And currently, that's about 770,000 Ohioans.

Thank you.

Dr. Mukunda Pterosaurs is the largest Medicaid managed care organization in the state, and sometimes members don't realize that the health coverage that they receive through care source is Medicaid is Medicaid coverage.

Please share a little bit more about care source and how managed care organizations fit into the broader Medicaid landscape.

And then if you could tell us a little bit about why having coverage in general is important and Medicaid expansion in particular is needed for healthy, thriving communities?

Sure.

Yeah.

Thanks, Emily.

So Care source is the largest Medicaid managed care organization in the state of Ohio.

There are other six organizations that are similar that also provide health insurance coverage.

What the what the difference in the between Kansas and the others is that care source is not for profit and care service is home grown.

This was started in Dayton back in the late 1980s and care service is very committed to working with the state leaders to find very innovative solutions that are very cost effective to provide the best outcomes to their members.

So when there is expansion, the Medicaid expansion, more Ohio and so able to find insurance and nobody disagrees that prevention is better than cure and more preventive care happens when you are insured, when you are uninsured.

The preventive care it's really hard to focus on.

And a lot of people end up in the emergency room with very late diagnosis and very bad complications.

I see my colleagues from Metro and all the folks that we work with every day.

You may have the best insurance, but if the emergency room is overcrowded, if the hospital is overcrowded, you're not going to get good medical care either.

So that increase in the uninsured affects everybody in the community.

It puts everybody backwards because there are more and more members that are not insured and not able to afford the preventive care.

All right.

Thank you.

Very important.

And Dominic, your organization, Neighborhood Family Practice, is on the ground really where the rubber hits the road, directly serving people in our local communities in Cleveland's neighborhoods.

Tell us a little bit more about neighborhood, family practice and the role that federally qualified health centers like yours play in the health care landscape.

Yeah, thank you for that.

And I have to go back to Amy's first point around the length and how many years Medicaid has been around.

Family qualified health centers were created in the 1960s with a clear goal to provide care to people navigating poverty.

So when you think about our Medicaid population and our uninsured population, that is truly who we were created to serve.

And in many cases, we serve as a safety net of the safety net and work with many of our hospital system, our partners to make sure that we meet that need for us here locally.

We've expanded over the years with the foundation in primary care and behavioral health and added additional services like our women's health and midwifery services and our podiatry, our HIV care, our pharmacy services, and of course for health.

And we've created that to meet the need.

We have so many great providers across our communities.

We've learned that people want to get care in their neighborhood, especially if you're navigating poverty because you don't have the resources to the transportation or those other barriers that you need to overcome to access care.

So when we think about Medicaid expansion, I just encourage everyone to continue to senator people, right?

These are our neighbors.

These are our family members, our cousins that we're talking about.

And those are the members that we currently serve and working with our partners, both our hospital systems and the unaffiliated providers, to make sure that we can meet that need.

And if anything happens with Medicaid expansion, that job just gets much harder than it already is.

Great.

Thank you.

So let's turn to the trigger, specifically in the proposal that's on the table right now.

So acknowledging that there's incredible pressures in all levels of government as we see potential cuts coming from the federal government, that A, we've it's way through our research found that about over $0.60 of every dollar in health and social services invested in Ohio come originates at the federal level.

So state policymakers have to make tough choices.

They're going to be on the hook if the federal government changes some of their matching.

But one of the concerns of advocates that they've raised is this word shell is a required it.

And a simple change to May means that we can study the problem, we can work on it, we can come up with innovative solutions.

We're not required to do things right away.

Without this change, this trigger language would initiate an extreme Medicaid cut for Ohio workers and families.

Amy Health Policy Institute of Ohio is in the midst of researching the potential impact of Medicaid expansion.

Trigger becomes law.

Can you tell us a little bit about what you're finding?

Sure.

Well, and first, I'd like to just build on something that Dominic mentioned, which is that these are our neighbors, our friends, our family members, and that's attached to one of our first findings from this research.

We looked at county level data, and I know the Center for Community Solutions just put out Senate district level data at both.

Both cuts of the data tell a similar story, which is that people with Medicaid coverage live in all parts of our state.

Yes, people with expansion coverage are more heavily represented in urban and Appalachian areas, but they're in rural and suburban areas too.

Chances are we ourselves have either benefited personally from Medicaid coverage, have family members who have have neighbors, friends, and other community members who we know who have.

So this is, you know, about a quarter of our whole population currently has Medicaid coverage.

It's a large proportion of our population.

So many of the folks who have Medicaid coverage likely would not have another source of coverage without this.

People with Low who work in lower wage jobs are more likely to not be eligible for health insurance through their employer.

So that's an important consideration and something that we're diving into more deeply in.

People can work in a lot of different types of jobs and still be eligible for Medicaid coverage.

So just to give you a point of reference, 138% of the federal poverty level is $36,777.

For a family of three, a person could be working as a home health aide, veterinary technician.

They could be working as an electrician or a carpenter and still be eligible for Medicaid expansion coverage depending on their family size.

And earlier research found that 94% of people in this group are working in school, taking care of family members or have a significant health condition that they're dealing with.

Thank you.

It's it's a lot of people.

And one of the things that we saw in Medicaid expansion is that many of the people who gained coverage were struggling with mental health issues, with substance use disorders, with chronic disease, people living with HIV and other chronic diseases that that weren't parents but didn't have access to health coverage because before Medicaid expansion, you could make no money and still not qualify for Medicaid depending on your family circumstances.

And so this was a change.

The other group that gained coverage are working parents because Medicaid expands expanded from 90% to 138% of that.

But through all this, more services available and more coverage available for people with mental health issues and substance use disorders.

Dominic, you have talked about the momentum that neighborhood family practice and others have gained over the last decade, thanks in large part to more covered people and more opportunity to address issues early and to continue to make sure people have the medical care and the health care that they need.

Integrated health care models, chronic disease management, Behavioral health.

How could the Medicaid expansion trigger impact those?

I think the first point to note is that we have made so much progress, but we still have so many disparities within our community.

But to your point, I think what we're seeing is more collaboration.

We have partners here in the room that we've worked so closely with to build ways to tighten up those gaps that we talk about in our safety net.

And so when we talk about the challenges that we face and what could happen, you would start to see some of those things degrade and you start to see us backslide.

At a time that we can't afford to do that.

And so I when I talk to our partners and our other organizations, we are finding better ways to make sure that patients get care across our organization or across our organizations.

And so that's collaboration, that's integration, that's technology investments and all those things now that we have to sustain those costs.

And as you look at some of those patients start to lose their coverage.

Organizations like NFP, we're still required to see them by statute.

We see everyone, regardless of your insurer status.

So just because you lose your health coverage doesn't mean that you're no longer a patient.

So how can we make that referral to our partner who may not have that same requirement?

And those are some of the concerns we have.

And we know that many in our community who have made success with managing their behavioral health or their substance use disorder, they are still dependent on those additional services and those resources.

So to take those away at this time is something that we just really can't afford to do because there's been so much progress and so much work continue to work in this space.

Thank you.

So building off that and turning to Dr. Mukunda, you know, you had touched on this a little bit earlier, the the layering and the balance and how having more people insured helps not only the individual, but the whole system.

Many of the cuts that are being proposed are being made in the name of efficiency In the case of Medicaid expansion, if the trigger happens and we lose that.

How might that impact the efficiency and the effectiveness of health care in providing health care?

Sure.

So to a large extent, when you're managing the members in the community, a lot of numbers help in innovation on providing the right resources to the right people.

For example, we touched upon rural areas, Appalachian areas.

It's hard to find home health agencies to go in and sort of one member because they have to drive 2 hours to see one member.

And if that number drops, if somebody has to drive for hours and they get paid for half an hour of service, it's harder to find those agencies to serve those members.

Similarly, efficiency is always better.

For example, the managed Medicare Medicaid plans.

They are not only helping with paying the providers, but they're also helping with the biggest challenges, which are food insecurity, housing, job, connect with a better job.

You know, we help members to get job training and get back into the job jobs that they like to do.

All of those areas become affected when the numbers drop.

So overall, the whole ecosystem not only in that there is less coverage, but also it puts additional strain on caregivers because they have less resources to get from the from the Medicaid managed care plans.

So it all adds up to bigger problems.

And again, in the in the numbers are lower.

It's hard to find that efficiency.

You can do a lot of innovation, do remote monitoring, things like that.

But that, again, increases the strain on the health care workforce.

And it leads to a lot of frustration because members are not now being engaged.

They are not getting the preventive care that leads to loss of workforce in sort of adding to the workforce.

So it's kind of a downward spiral when that happens.

Great.

Thank you.

One thing we haven't really talked about is the economy and the importance of Medicaid within our health care economy, which is, you know, one of the largest sectors in the whole state.

And certainly here in Cuyahoga County.

But let's think back let's think back ten years ago before Medicaid expansion, maybe 11 or 12.

And the arguments at that time for expanding Medicaid were made on human dignity grounds, on coverage grounds, on health grounds, and on economic grounds that this would be of benefit for thriving communities, for people being able to take care of their health and working.

And so opening it up to any of you, can you talk a little bit about some of those impacts of Medicaid and some of the things that maybe over the last decade we've taken for granted here in Ohio that are threatened now?

Well, one that immediately comes to mind is related to mental health and substance use disorders.

The data that we've looked at from the Ohio Department of Medicaid tells us that about 40% of people with expansion coverage have a primary diagnosis of a mental health or substance use disorder and having access to treatment and to medications has enabled folks with disorders to get engaged in their community again and to work again, which then contributes to the economy.

So that's just one example additional analysis that we plan to release in the next week or two will also look at the impact on jobs and the impact on the economy overall, and in particular the tax revenues that are generated from additional economic activity enabled by Medicaid expansion.

Yeah.

So in some ways it's a game of Jenga where things are stacked on top of each other and you can maybe pull some pieces out, but if you pull the whole row out, things topple.

Well, case in point, over $1,000,000,000 a year is being spent on treatment for mental health and substance use disorders for people in the expansion population.

This is enabling.

And in 90% of that is funded by the federal government right now.

So think about the economic impact and the impact on people of just pulling out 90% of that from our state.

And think about all the progress that will be lost, because now we have we've improved our infrastructure and our provider networks and access to care.

And that will will reverse course and all of that progress without it.

We've talked a lot about reversing course, about threats, about these negative changes.

But there's always room for improvement in public policy and in programs opening it up to any of you.

What are some things that you might have seen?

You know, if maybe once we're through, if some of these debates are the things that we'd like to see to strengthen the Medicaid program or to strengthen health care coverage for Ohioans, I can start I think the the biggest one and I think is the concern is is even larger now is the administrative burden on those who have coverage and the number of people who end up losing losing coverage, not because they're not eligible, because they moved and they didn't get the the notice or they changed their number and they didn't respond in time to to a notice.

So making that process easier, we talk about AI and all the technology that's out there these days, all the information that's freely available, using that to make sure that people maintain their coverage longer because this is so disruptive whenever they do present thinking, if they have coverage and now they have out-of-pocket costs that they can't afford.

So that is the one area that I'm hoping that we can see continue to see improvement on our because keeping that covers consistent.

It just means so much to many of the patients that we serve.

Thank you, Dr. Mukunda.

And so when we look at the health care systems, there are struggling since the pandemic.

Most of the health care systems are in red.

Medicaid may not pay similar to commercial payment, but Medicaid has a lot of innovation.

We always look at aligning our goal and focusing on the outcome under something you may have heard of something called a value based reimbursement.

Or also there is something called Accountable Care Organization here.

Source has built the largest accountable care organization for kids in Ohio, which has more than 600,000 kids.

Under the accountable organization that is performing way beyond the rest of the providers that are doing the similar type of work.

So there there is increased reimbursement to the providers because they are providing better quality of care.

So all of this take a backseat and that in what's league goes down when we don't have all those ways to do the innovation in Medicaid.

That's a great point that we don't always talk about is because Medicaid is a public program, we have a public good component to it that a nonprofit, you know, organization like CARE source might have.

But it's not profit motives.

It's truly motives of better health, which is something that not all coverage entities take a look at.

And one other thing of that is very unique to Ohio.

The Ohio Department of Medicaid has been very innovative in this space.

They are asking all Medicaid managed care plans to do collective impact instead of just me focusing on saying this is my kids lives member because the coverage may change.

So all plans are not working together.

There is something called org outcome acceleration.

And for kids that all plans are working together with all the children's hospital in the state to make sure that every child gets a wellness visit.

Attention to vaccination, school based health care, those things that make a difference, including behavioral health and something like asthma medication management, which is so important for the kids to maintain not being absent from the school, how the presents in the school.

So, yeah, these are all the things that we might lose if the numbers fall down.

Thank you for that.

So before we turn to the audience questions, one sort of final question for the panel from me.

If Medicaid expansion disappears from your perspective, what happens next?

Dominic, can we start with you?

I think, unfortunately, we're going to see people start to lose some of the progress they've made when it comes to managing chronic conditions.

We one thing that we haven't talked about yet is the covering the cost of prescriptions, all the advances that we've had over the years when it comes to managing both mental and physical health conditions, have a toxic prescription cost.

So those individuals now lose coverage for those prescriptions that have helped them manage and keep control over those conditions.

I think, unfortunately, you're going to see providers, both small and large, have to cut back on the amount of services, the volume of services that we can provide to our patients.

And unfortunately, that's something that we just cannot afford when we do the math on Medicaid expansion.

Our modeling says we're looking at 3 to 6% of our budget.

If you follow the news, there's no health care organization in our region who has that type of margin.

So that immediately puts you in the red or further in the red if you're not already operating that way.

So you have to make adjustments in the level and the scope of services that you provide, which is a very difficult decision.

So I think there's an employment and economic component to it.

And then you have the outcomes component.

And again, I have to take us back to our current disparities that we know exists across our communities.

When you talk about life expectancy, you can look at chronic conditions, maternal and infant health or viability, all of those things that are still problematic here.

So if we lose this, there's no way we're going to maintain that progress, and we'd likely start to move back in a direction that we don't want to go in.

And I think that's what we see if we see this coming to this actually happen.

It's powerful.

Dr. Mukunda, what happens next?

Yeah.

So similar to similar to what Dominique said, we already have what are called maternity care deserts within Ohio, where it is very difficult for women to find the right place to get their child, deliver their prenatal care, postnatal care, child's and wellness visits.

Those will become bigger.

There is going to be less health care providers that will be able to provide services for these members if the Medicaid expansion falls through just one of many, many, many areas of impact.

And Amy, from your perspective, what happens?

So access to care is a critical element of us being able to reach our full health potential.

It's not only thing, you know, being able to have healthy food to eat and a safe place to live, and all of that also contributes to our health.

But access is critically important If we're sick, if we experience an accident or an injury, if we're having a baby.

In those cases, we all appreciate and value having either insurance or some other means to be able to afford to get care when we need it.

I want to just share a quote from someone who has Medicaid expansion coverage and also has a mental health condition.

Now, I think you could you could fairly sub out mental health condition for any other health condition in this quote, too, whether it be diabetes or hypertension or something else.

But just think about what losing this coverage would mean for this individual and people like her.

She said as a working adult, having Medicaid is important for me because otherwise I would not be able to access most of my mental health meds or therapy or other appointments.

I just don't make enough to be able to cover living expenses, plus all my doctors and meds and therapist.

With Medicaid, I know I can get my meds and be able to get the care I need, and having access to that care has enabled this person to engage in her community, to work and to thrive.

Without that, to use Dominic's phrase, we'll be going backwards.

And just one word in the state budget puts it all at risk.

Thank you.

So we're about to begin the audience question and answer for our live stream and radio audience or those just joining.

I'm Emily Campbell and CEO of the Center for Community Solutions and moderator for today's forum.

We are talking the trigger language added to the Ohio State budget and what it means for Ohioans if state decent rolls from Medicaid expansion.

Joining me on stage is Dominic Hopson, president and CEO of Neighborhoods Family Practice, Amy Rolling McGhee, president of the Health Policy Institute of Ohio.

And Dr. Bijan Mukunda, Vice President and Market Chief medical officer for Ohio for care sauce.

We welcome questions from everyone City club members, guests, students and those joining via our live stream at City Club Dawg or live radio broadcast at 80 Nuts 89.7 W WKSU Ideastream Public Media.

If you'd like to text a question for our speaker, please text it to 3305415794.

That's 3305415794.

And City Club staff will try to work it into the program.

May we have the first question, please?

Hello.

Our first question is a text question.

It says, What can we do as providers?

Medicaid recipients.

Just regular people to help protect Medicaid expansion.

We are all here, but we don't know how to support our fight back.

This is a public health emergency.

Yeah, that's a great question.

And I think part of the answer is advocacy.

Amy, do you want to speak to that a bit?

Sure.

Now is the time to get involved and contact your elected officials.

In fact, there there is an amendment we've heard that has been submitted or will be considered in the Ohio Senate that would change this trigger language to May from show and make some other changes as well.

So if this is an issue that concerns you, that you think your state senators need to know more about, I would urge you to let them to contact them as well as to contact people in the Ohio House of Representatives.

Now, the federal government is a whole nother thing.

There's a lot going on with the federal government.

That's a forum, that's a different forum.

But also important to contact your your federal delegation as well.

And I think for people who are, you know, regular people that depend on Medicaid, their efforts through the Ohio Medicaid, some Ohio Medicaid coalitions to collect those stories to get connected.

But the time is now because if if policymakers don't hear from their constituents, they assume nobody cares and they want to hear from their constituents.

And remember, our elected officials are regular people just like the rest of us.

So, you know, don't be nervous or afraid to reach out to them.

They are there to serve us.

And they need to hear from community members about how issues like this impact the people in in their communities.

Thank you.

Next question.

Hello, my name is Kyle Williams.

I am a junior at the Time High School and I wanted to know that if the proposed cuts are made, what would this mean for the revenue that health care centers make, not just around Cleveland, but around Ohio?

And do you think this will be a detriment to the health care society as a whole?

Yeah, that's a great, great question.

Thank you for that.

Dominic, do you want to speak for.

Yeah, I have to just continue to come back.

That is.

And I don't use this word often, but it's catastrophic, honestly, to both our health care organizations, but also the populations that we serve.

And so, again, we've made progress and we have more progress to make.

But now is not the time.

And you can look at a number of factors economically, morally, all the things it makes sense to maintain this coverage.

And to Amy's point, please raise your voice.

Reach out to your representative.

But that's the impact.

It's both the health and an economic impact on our organizations, because, you know, the people, you know, we're able to provide and provide employment for many in our community who then serve our neighbors.

And so both of those things are impacted if this goes into place.

Yeah.

And if I could just add to that.

So we've talked a lot about the 770,000 Ohioans who currently have expansion coverage.

So analysis that we're going to release next week.

Finds that more than half well, more than half of those folks would likely become uninsured.

Now, some may be able to get coverage through another way, maybe through private health insurance, through an employer, but most likely that insurance would have premiums that people would have to contribute to deductable bills.

Cost sharing, which in a sense makes that insurance uninsured or underinsurance because you still can't afford to pay the bills.

And that will directly affect providers like Dominick's organization as well.

So there's lots of implications to providers in the community.

And I think an important point is that these decisions will be made in Columbus and in Washington, but it's up to us to figure out how to address them or to deal with it.

Mm hmm.

Thank you.

We have another question.

Hi.

We know the best scenario here is not to have this trigger language in the state budget at all.

Now, I know there's a group right now they are at a table seven.

They will accept your signatures.

We will have this letter and sent to Ohio Senate, even to the conference committee, even the governors.

However, the real question is we know it's hard to avoid having this language in there, no matter what forms.

So now how will we be able to cover the huge service gaps caused by this particular situation?

Because don't forget, even ambulance services will become optional for people.

And we have a lot of senior citizens right now.

They take care of their grandchildren as a kinship care caretaker if their health cannot be taken care of.

How will we be able to raise the healthy, younger generation to populate Ohio and get our glorious status back?

Great.

Thank you.

There's a lot in that question to unpack.

Well, let's.

Covered a lot.

Quickly.

Dr. Mukunda, can you can you speak a little bit to some of those challenges?

Right.

I mean, when we speak with providers similar to Dominique's organizations, there are over 158 hospital health care systems in Ohio.

There are a large number of community organizations that provide services.

There is all the Medicaid managed care organizations that are looking at this.

The concern is real.

We hear this from a lot of providers.

They are looking at how do we provide care for these members?

And like Dominick said, just because they lose their insurance, they do not become not for them.

They are still their patients.

So they still need to provide services for them, which means stretching the resources that are already scant.

So I think, you know, no matter what the health care system straight to do, it will be a very large wide that somebody can fail despite everybody putting their hands together.

So that's the that's the impression that we get from speaking with the providers.

And I'll add to that is there's not much we can do locally to account for that.

And there has to be a increase in an uncompensated care fund.

So you think about why not just keep the coverage in place?

Because many of our hospital partners, again, are going to have to still care for these patients when they show up to their emergency rooms as an organization.

After we see we still have to care for these patients so the care isn't going away, the dollars that reimburse the carriers.

And so we will be asking our leaders at the state level for it to created uncompensated care fund to help absorb some of this cost.

And if that doesn't happen, there's nothing that we can do locally.

We make an act as a foundation to bridge the gap, but they can't do that long term.

That may give us a few months to plan and strategize and lessen the impact, But there's nothing that we can do locally, our city, our county.

Nobody can kind of fill that gap.

It just can't It's not possible.

So it's a great question.

But ultimately, that the powers to be, you know, down in Columbus will need to help fill that gap.

Thank you.

Next question.

Well, that was a good segue way to my question, Dominic.

So thank you.

Heather Stoll with Catholic Charities.

And I'm also on the Center for Community Solutions Board.

I think you've nicely unpacked the great impact both on the health care side as well as the economic side for Medicaid expansion.

So I think would be helpful for this group and really is for Emily and Amy.

What are legislators asking?

Let us help us understand what are the questions that are being happen asked at the state level so we can help to respond?

Yeah, well, thanks for bringing the moderator into the into the conversation, calling me up by name.

I'd be delighted to answer.

You know, one of the things that I've heard from some state policymakers is skepticism as to whether the federal government will cut the federal matching percentage.

So they're saying it's not going to matter.

And, you know, last week there were public statements by leadership from U.S. House that made it seem like it may not matter.

This isn't one of the solutions today.

That's a different story as those negotiations happen.

And so, you know, a piece of what we're being asked to share is why does it matter some of the things that you've heard today?

Who in my district is covered by Medicaid?

What are the circumstances to sort of do some myth busting, but also talk about the underpinning of these things and to emphasize that, you know, if these changes come to pass and 770,000 Ohioans need to look elsewhere for their health coverage, all of a sudden you're not going to be able to blame the federal government.

And the federal government is not going to be able to blame the states.

It's all tied together and it will be our local, our local economy, our local people and our local agencies that are going to have to figure out how to address it.

Amy, I don't know if you have anything to add.

Sure.

I think one question that comes up in these conversations is if the federal match dropped and we were to keep Medicaid expansion.

How would we pay for the additional state cost?

And that connects to some analysis that we've been working on, looking at the sources of revenue that currently fund the state share of Medicaid expansion.

So it's not just general revenue funds that are funding our Medicaid expansion program here in Ohio.

There's other funding sources.

And the state would not be saving money if they took down Medicaid expansion because that additional revenue would go away.

Also, there are some costs that right now the state is only paying 10% of because of Medicaid expansion.

But if expansion went away, they'd have to pay 100% of the cost.

A great example there is care for people who are incarcerated.

So when someone is incarcerated in a state prison and needs inpatient care during the period of time that they're in an inpatient setting, that care is paid for by Medicaid.

But the state is obligated to pay for that care regardless of whether there's Medicaid expansion or not.

So those are additional costs that the state would incur without this.

So it's really important for our policymakers to take a comprehensive view of the lost revenues that the state would experience.

The additional costs that the state would experience, what additional funding they might want to put on the table, because we need a social safety net.

So funding for federally qualified health centers, funding for mental health and substance use disorder for charitable clinics, all of these other places, they will need additional funding.

So important to look at this with a full view rather than just looking at the state match.

Hey, Larry Heller with Nora.

So we've been discussing the impact of Medicaid expansion, the potential impact of losing it.

And we've primarily focused on the human impact.

As we all know, many decision makers and legislators may be moved by human impact, may be compelled to act.

But there are also some who may be moved primarily or exclusively by financial impact, by numbers and by dollars.

And my understanding and you touched briefly on the economic impact, my understanding is that Medicaid does, in fact, create tremendous cost reduction and cost savings.

You know, you mentioned some of the economic impact, but also without Medicaid, people may either delay care until the issues become catastrophic, both having human impact and financial impact, but also they'll access care only at the most expensive and least effective points.

So my question is, how do we more effectively advocate and target to the legislators and decision makers who are focused more on the economic impact?

Thank you.

I think it's important to share that data.

And we've talked about value based care, and a fee is one is an organization that is participating in a number of value based care contracts.

Specifically, when we look at our Medicaid population, we know that we reduce the costs of care for those individuals when they receive care for us.

So whenever we're meeting with our legislators, we share that information to say that ultimately the state is saving by investing in us to provide this care.

Because ultimately our system is connected.

So at the same time, at the same time that the state is looking to roll back Medicaid expansion, we see them looking to improve and expand Medicaid in other smaller or different ways.

Right.

We're talking about continuous coverage for infants and young children.

We're talking about an expansion of Medicaid in schools in this same budget.

And I'm wondering, given what we've heard from you about the great economic impact of Medicaid expansion, the great social impact of Medicaid expansion and the proof we have of this over the last decade plus?

I'd love to hear your reflections on what do you think is ideologically motivating the attack on this piece of Medicaid?

Well, it's a good question.

You want to take any?

Okay, I'll take it.

Yeah.

You know, I mean, I guess I can't speak for policymakers, but I can say some of the things that we've heard and some of the things we have heard is misunderstanding about who's covered through Medicaid expansion.

You know, at least 40% of people on Medicaid expansion are already working.

It's not enabling to stay at home or stay out of the workforce.

And I and I think one of the main motivations is, is a dollars and cents question.

You know, seeing a big price tag for Medicaid expansion, recognizing, however, that only $0.10 of every dollar of that is state dollars.

The rest, we're bringing in from the federal government and a concern that if the federal government changes the rules of the game and stop supporting Medicaid, that the state will have to make up the difference.

And they don't want to have to make those decisions.

So there are some things that are tough to wrap our heads around when they're suggesting things like like you mentioned, like increasing health care in schools via Medicaid and then talking about eliminating this large group of of coverage.

Amy, I don't know if you have anything else to share on that.

Sure.

You know, it's interesting because in the House passed version of the state budget bill, there was an amendment inserted.

It was a bipartisan it was supported by both Republicans and Democrats, which would require the Department of Medicaid to seek a waiver for to support people who are reentering from prison, recognizing that having access to health care when one is coming back into the community from being in an incarcerated setting, that having medications and other access to care is really important to being able to fully engage productively in your community.

So I think there's a lot of, as Emily said, kind of misperceptions of who Medicaid expansion helps.

The person who I mentioned earlier, kinship care providers.

We don't have firm data on this, but it's easy to imagine when this group goes up to age 64 that there are a fair number of people in the Medicaid expansion population who are caring for their grandkids, either full time or part time, and enabling the parents to get out and be involved in the economy.

So to the degree that we can put faces to these data and help policymakers understand that the the real life experiences of people in this group are much broader than the stereotype types that they are thinking about.

I think it overcomes it will help to overcome these political barriers.

Hi, my name is.

My name is Cheryl Prichard and I am with Noble.

Northeast Ohio Budget Legislation Equality.

And we have gone down to the statehouse and did the whole talking to the senators, the House of Reps. We as a matter of fact, we were just there this week.

I, too, am a I am that person that you read about.

Okay.

Receiving behavioral health as well as therapies for chronic, you know, inflammation and and these different things that are going on with my body.

So we do have that letter that Lou did speak about that we can ask you all to sign on that are to get rid of that trigger language.

My question is, as an organization and as a an individual, we have done things.

Is there something else that we can come together and try to do?

Or is there something specific that you would ask us to help you do?

Mm hmm.

Well, one word that comes to mind is persistence.

You're doing all the things you just got to keep doing all the things and keep persisting.

This is this is a rough road ahead.

And I think also being encouraging of one another is really important right now because this is an uphill battle and we need the support of one another.

We need to be encouraging of one another and we need to be working collaboratively so that we're bringing both data and real life stories from people who are impacted together to inform our policymakers.

So persist, persist, persist.

Greg Great.

And I know wonder, how would you respond if I mean, you still see patients, how would you respond if a patient brought this concern to you during one of their visits?

Yeah, I think it's very powerful.

You know what you said that you see a number of health care providers that are important to keep you functioning.

Talk to every one of them.

They all belong to peer groups.

They belong to associations.

They have lobbying.

They have ways at the state level.

The more we make it widely heard, if the provider thinks that the patient does not care, they are not going to spend more time advocating for the member because they're all busy.

But when they realize that this is very important for their patients, that will make a difference.

Even out of the ten, if one provider speaks up and if their organization represents, you got an additional advocate for you.

I think it's just like we are looking at it from the collective impact from what we can do.

I think the collective impact coming back from the customers will really help.

Thank you.

All right.

Thank you to Dominic Hobbs and Dr. Mukunda, Amy Rolling McGee and Emily Campbell for joining us at the City Club today.

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Today's forum is part.

The City Club's Health Innovation series in partnership with Medical Mutual.

A special thank you as well to Jodi Mitchell with the Center for Health Affairs, the Center for Community Solutions.

And the City Club health member committee for their programing support on today's forum, The City club would like to welcome students joining us from M.C.

Squared STEM High School.

Thank you again for joining.

We would also like to welcome guests to the tables hosted by the Academy of Medicine Education Foundation, the Center for Community Solutions, the Center for Health Affairs, the George Gunn Foundation, first year Cleveland, the Metro Health System, Neighborhood Family Practice, and Ohio Guide Stone.

Thank you all for being here.

We are off next.

Oh, yes, please.

We are off next Friday, May 23rd, due to the holiday weekend.

But be sure to join us just before on Thursday, May 22nd.

We are once again proud to partner with the Cleveland Orchestra as part of the third annual Jack Joseph in Morton Mandel Opera and Humanities Festival.

We will hear from museum leadership from Washington, D.C., New York City and right here in Ohio, and how American cultural institutions are charting a new path forward on reconciliation and repatriation.

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And that brings us to the Entities forum.

Thank you once again to our guests and to our members and friends of the City Club to the economy in this forum is now adjourned.

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