Impact Budget with Health and Human Needs

by Judith Tieman Bird

Grassroots advocacy around Ohio's two-year budget has never been more critical than it is now. Crafting the budget is by far the most important work the General Assembly does every two years, because the appropriations shape what state government can and cannot do. This year, Ohio faces the major challenge of adequately and equitably funding primary and secondary education, in light of dramatically declining revenues, while meeting other social needs.

In late March, the Governor announced that because of lower than projected tax collections the budget he presented the General Assembly at the end of January is now underfunded by over $500 million. This is in addition to the $500 million to $2.2 billion legislators are seeking to increase school funding.

All this adds up to significant cuts, likely in the range of 15-20 percent, to all other programs of state government. That is, unless the Governor and legislative leaders can agree on measures such as delaying already approved tax cuts or using the Rainy Day Fund or delaying implementing quite all the school increase at once or.

Relative newcomers to the state policy arena are making these decisions. Term limits have given Ohio a large pool of legislators who have not had to address economic downturns, who were not part of historic "understandings" about putting people first in recessions, or who actually want government reduced by whatever means accomplishes that end.

So what does this have to do with health care in Ohio? As the second largest expenditure of state funds, Medicaid, in the eyes of many new legislators, is a prime source of needed funds. Hence, comments about last year's CHIP expansion being "on the table" in budget discussions or Medicaid's "rich benefits package" being curtailed.

Already, the safety net program for single adults and childless couples, the Adult Emergency Assistance program, has been cut by 50 percent in the next budget. (In Fiscal Year 2000, 13 percent of this program's $4.2 million went to medical services.)
It also means that needed expansions, such as a Medicaid expansion to low-income working parents up to 150 percent of poverty or increased funding for the federally qualified health centers may not happen.

This is not the time to give up, however. This is the time to crank up efforts. Uncertainty over the budget's final outcome can't stop communications. The story about the needs of Ohio's low-income working families and individuals must be told time and again. And then againand again.

Why? First of all, the budget process does not end until June 30, 2001. The funding picture may improve. Second, advocates must protect current programs from cuts. Third, even if health care expansions are not obtained this time, legislators will be educated about health care for future budgets.

Legislators need to hear from people in their own districts. They learn about the importance of health and social service programs when they see how these programs help people in their own districts. Legislators can and do come to understand and support safety net programs ­ witness the come-from-behind increase, in the last budget, of family coverage to 100 percent of poverty. That happened because legislators came to understand that people leaving welfare for the workforce need health coverage to succeed.

But, with the new legislature, understanding the importance of health coverage will happen only with ongoing and persistent efforts by constituents in all corners of this state. Educating legislators can't be left to activists in Columbus. It must happen in the communities. And, it can't wait until tomorrow, because decisions are being made today.

Judith Tieman Bird is the Director of Public Policy for Ohio United Way.

From the Director, Larry Bresler

A critical but little known program that enables hospitals to provide medically necessary free care to the uninsured is Ohio's Hospital Care Assurance Program (HCAP). Through the program, about $530 million is allocated annually for uncompensated indigent care. HCAP is funded by a combination of 59% federal Medicaid dollars and 41% state dollars. The federal match is money budgeted for hospitals serving a disproportionate share of uninsured poor (DSH funds). In Ohio the state match is provided through an assessment, based on size, to the hospitals.

Because the state assesses the hospitals, it has allowed the Ohio Hospital Association (OHA) to propose the formula by which the HCAP funds are distributed. As the trade association for the hospitals, the interests of the OHA are for the financial well being of its hospitals, not for maximizing free care to low income uninsured persons.

Consequently, the distribution formula passed last year saw the greatest increase of HCAP funds going to hospitals that provide the least uncompensated care, and the greatest losses in HCAP funds to hospitals that provided the most uncompensated care. The formula also provided for a pool of $92 million (representing 17% of the HCAP allocation) to be set aside to ensure that all hospitals received a return of at least 50% of their HCAP investment. Thus funds from what is called the Disproportionate Share Limit Pool were returned to each hospital regardless of how little uncompensated care was provided.

After having no meaningful opportunity for input into the HCAP formula process last year, UHCAN Ohio, together with other groups, successfully advocated with the state for a more open process. As a result, this year we have a real opportunity to address the distribution formula.

Our recommendations are threefold:

• The Disproportionate Share Limit Pool should be eliminated. Returning assessments to the hospitals is clearly not the intent of the HCAP Program.
• The HCAP formula should be prioritized so that HCAP funds are used first and foremost to reimburse care for the neediest patients. Under the current formula, some reimbursement is allowed at any income level. Consequently, HCAP can be used as a vehicle to write off bad debt rather than provide free care.
• Hospitals that have closed should not be eligible to receive HCAP reimbursements. Currently they are. For example last year, Mt. Sinai Hospital in Cleveland, which had closed early in the year, received, nevertheless, $10 million in HCAP reimbursements for its bankrupt owners.

Ultimately, we need to reexamine the whole HCAP Program. In other states, federal DSH dollars have been used creatively to expand health insurance coverage to more uninsured people or to encourage hospitals to provide more community based primary and preventative care. We in Ohio should take stock of these examples and explore alternative uses of our DSH funds to maximize access to health care for the uninsured in our communities.

Hospitals Respond to UHCAN Ohio report

Columbus-area hospitals have responded positively to UHCAN Ohio's report, "Holes in the Safety Net," on difficulties finding out about hospital free care (the full report is available on UHCAN Ohio's web site).

In recent months, UHCAN Ohio's free care committee has been meeting with representatives of all four Columbus nonprofit hospital systems. The report, released last December, urges hospitals to take steps necessary to inform patients and the public that free care is available to those in need and to enroll eligible patients before they leave the hospital.

"Free care" is defined as care provided by a hospital to low-income, uninsured people for which the hospital does not expect to be paid. Ohio's statutory Hospital Care Assurance Program (HCAP), and status as non-profits give hospitals the obligation to provide free care.

As a result of the meetings, hospitals are implementing many of UHCAN Ohio's recommendations. Various hospitals are:

• printing simple written materials, in different languages, and placing them in accessible locations;
• producing new signs describing HCAP and charity care programs; UHCAN Ohio has provided training for one hospital system and is working with the others on education for staff members;
• examining and refining current procedures for educating uninsured patients about, and enrolling them in free care programs (including Medicaid and Alien Emergency Medical Assistance, or AEMA); and,
• developing strategies for training hospital patient care staff about free care.

The free care committee is planning, in late April, to bring together representatives of all the hospitals to look at standardization of free care policy and collection of data on uncompensated care. The meeting will also offer hospitals to share best practices and resources.

UHCAN Ohio will release a follow-up report in June, documenting the progress on improving free care policies and identifying changes still needed. Based on their collaboration thus far, the free care committee and the hospitals will have a lot to celebrate about in the report.

Coalition Organizes to Preserve Services

A coalition of eighteen community groups, organized by UHCAN Ohio in Columbus, presented recommendations to hospital system OhioHealth, which is planning to cut back on services provided at Doctors North Hospital. In February, OhioHealth announced that an internal task force would propose changes to stem recent financial losses, especially at Doctors North. OhioHealth representatives have suggested that likely changes at Doctors North include closure of the emergency room and termination of inpatient hospital services.

The coalition, drawn from the community served by Doctors North, stressed that the community needs the Doctors North emergency room, which is the only source of basic care for many area uninsured and underinsured residents. The closest area hospitals would be difficult to reach for those who have transportation problems.

Last year, Doctors North had 20,000 emergency room visits, including 2,500 admissions. Community leaders wonder whether the other hospitals can absorb these patients. Data on emergency runs presented to OhioHealth by the coalition showed that other hospital emergency rooms were sometimes full and diverting non-critical patients.

The coalition strongly recommended that, if the Doctors North emergency room closes, OhioHealth must add other services to meet community needs, such as an urgent care clinic open up to 24 hours. The group also wants a commitment from OhioHealth that Doctors North will remain open indefinitely.

UHCAN Ohio has organized several meetings between the coalition and OhioHealth leaders, and representatives of OhioHealth have assured the coalition that concerns have been heard. As a result of the meetings, OhioHealth announced plans to meet with Columbus Neighborhood Health Centers, which operates St. Mark's Health Center in the Doctors North area, to explore a possible collaboration for providing more primary care in the area. OhioHealth leaders have also expressed interest in the coalition's recommendations to hire an outreach worker to link people in the community with health services and to expand educational outreach efforts in the community. Transition plans for Doctors North will be announced in early April.

Making Connections

Jim works in the cafeteria at Cleveland State University. He brings home $600 every two weeks. His employer does offer him a health plan, but he would have to contribute $140 monthly and make hefty co-pays -- for an inadequate plan without prescription drug coverage. Jim can't afford the plan and remains uninsured. As do 28 of his 30 coworkers.

That's why UHCAN Ohio staff and volunteers joined Cleveland Jobs with Justice in support of Jim's union's demand for a new contract with good benefits, including comprehensive and affordable health care. At the April 4th rally, UHCAN Ohio staff and volunteers made the link, through speech and demonstrations, between worker justice and health care.

That same concern about uninsured working families is being channeled into action for a statewide Medicaid expansion to cover more working families. The Health Care Working Group of Jobs with Justice, chaired by UHCAN Ohio, is educating the labor, faith, and community groups that make up Cleveland Jobs with Justice about the need for the proposed expansion, and is organizing activities in Cleveland and a Lobby Day in Columbus. The campaign for the expansion is spearheaded by the Ohio Family Coverage Coalition.

Ohio Legislation Highlights

For more information on pending bills, see the legislative summary on UHCAN Ohio's website.
For questions, call Cathy Levine, policy director, at (614) 253-4340 or e-mail her at uhcanohio@ee.net.
Full texts of bills are available on the state's website: www. legislature.state.oh.us.

HB 33 (Olman, R-Maumee), the Mental Health Parity bill, would prohibit discrimination in health care coverage for persons with mental illness and substance abuse or addiction. Status: Referred to House Insurance Committee; hearings underway.

HB 4 (John Hagan, R-Alliance) would create a prescription drug discount program, under the Department of Aging, for Ohioans who are age 60 and older or who are disabled, i.e. bearers of the Golden Buckeye Card. Governor Taft announced this proposal in his State of the State speech. Status: referred to House Health and Family Services Committee.

SB 23 (Fingerhut, D-Cleveland), House Bill 32 (Barrett, D-Cincinnati) would create a home and community-based services waiver for assisted living for Ohioans who are eligible for Medicaid. Under current law, Ohioans who are sixty-five or older or disabled and are eligible for Medicaid have only two choices: one of Ohio's home health care options, such as PASSPORT or move into a nursing home.

HB 38 (Metzger, R-NewPhiladelphia) would require that young adults, ages 18-21, receive "independent living services," including Medicaid and workforce development services, as they move from care under a public children's services or private child placing agency toward independence. Status: referred to House Health and Family Services Committee.

SB 45 (Armbruster, R-North Ridgeville), HB 86 (Beatty, D-Columbus), HB 100 (Schneider, R-Cinci.) would require most health care plans to pay for diagnosis, treatment, and management of diabetes, and for diabetes self-management education. Status: referred to Senate Health.

Fighting Pharmaceuticals

BuSpar

Through the work of Gray Panthers and the SPAN (Stop Patient Abuse Now) coalition, Bristol-Myers Squibb was forced by a federal court to ask the U.S. Food & Drug Administration to de-list the new patent it received for the anti-anxiety drug, BuSpar. Less costly versions of the drug are now on the way to consumers, including AIDS patients, Alzheimer patients, and one-in-10 nursing home patients who rely on the medication.
During BuSpar's four additional months of patent protection, the company reaped nearly $200 million in sales, and consumers were forced to pay artificially high prices for the drug as a result of the company's apparent unlawful action. The Gray Panthers and Span are considering several options to help patients recoup their losses including joining in a class action suite.

Persons who have purchased or received BuSpar since November 2000 are encouraged to contact the National Gray Panther office immediately (1-800/280-5362 or tfuller@graypanthers.org). 

K-Dur

The Pharmaceutical Access Litigation Project is looking for users of the drug K-Dur, also known as Micro-K in connection with a class action suit. K-Dur is a drug often used by individuals with hypertension (high blood pressure). PALP is a collaborative venture with consumer health law programs throughout the country to bring class action lawsuits against drug companies that engage in illegal practices to prevent generic drugs from being made available to consumers.

Persons taking K-Dur, please contact the Health Law Program at 1-800-838-0388 and ask for Peter or Jon. Or e-mail Jon at jbolton@mainecahc.org. 

Are you a UHCAN Ohio member?

Not yet, you say? Please hesitate no longer. Join UHCAN Ohio now and help us work for comprehensive, affordable, and publicly accountable health care for all. We look forward to welcoming you into the UHCAN Ohio family -- and the movement for health care justice!