Although the Ohio House of Representatives removed Gov. John Kasich's proposal from its budget bill and the Senate isn't inclined to put it back, the expansion of Medicaid in Ohio isn't a dead issue.
An amendment was added to the House version of the bill to give lawmakers more time to study the issue and possibly use the federal subsidies that would have come with the expansion to purchase private insurance for residents who can't afford it on their own. And Democrats have introduced standalone measures based on the language in Kasich's original proposal.
But with only 39 members in the House and 10 in the Senate, Democrats will need some votes from across the aisle to pass the bill.
"They only need to find 11 House Republicans that are brave enough to stand up to the Tea Party," Rep. Debbie Phillips, D-Albany, said at the Washington County Democratic Party's spring dinner last week.
Kasich has indicated he's open to other approaches as long as the end result is the same.
"We care less about how it gets done - just get it done," Kasich spokesman Rob Nichols said Tuesday. "There are a number of routes you can take to get there."
By the numbers
$13 billion - Federal money the state would receive over the next seven years to cover the newly eligible under a Medicaid expansion.
366,000 - Approximate number of Ohio residents who would be eligible for health care coverage starting in 2014.
1,744 - Approximate number of Washington County residents who would be eligible for Medicaid under the expansion.
604 - Approximate number of Morgan County residents who would be eligible.
425 - Approximate number of Noble County residents who would be eligible.
Source: Associated Press; Robin Bozian, Washington County Free Clinic.
According to the Associated Press, the administration has been in talks with the federal government about the private insurance option. Arkansas' legislature recently approved such a measure and U.S. Health and Human Services Secretary Kathleen Sebelius has endorsed the concept without green-lighting the specific proposal.
"We are looking for options that allow for greater flexibility from Washington, ensure more personal responsibility and provide a ladder up and out of public assistance," Nichols said.
Kasich's proposal would have raised the Medicaid threshold to 138 percent of the federal poverty level - $15,856 annual salary for one person, $32,499 for a family of four - extending coverage to an estimated 366,000 Ohioans. Robin Bozian, president of the board for the Washington County Free Clinic, said around 300 or so of their clients and nearly 1,800 county residents would become eligible as a result of the expansion.
"The majority of these folks, by the way, are the working poor," she said.
Although the Medicaid expansion is part of the Affordable Care Act that President Barack Obama advocated and numerous Republicans vigorously opposed, Kasich has argued it's a way to recoup billions in Ohio tax dollars while helping residents in need. Many of his fellow Republicans in the General Assembly aren't swayed.
"We understand that he was trying to accomplish a goal, but our goal was to continue to reform Medicaid," said state Rep. Andy Thompson, R-Marietta. "We did not want to be part of the expansion of ... Obamacare and the Affordable Care Act."
Medicaid expansion had been mandatory under the law, but a Supreme Court decision left it up to the states. If Ohio agrees to the expansion, the federal government has pledged to cover all additional costs for the first three years and at least 90 percent for a few years after that.
That's expected to bring $13 billion into the state over the next seven years.
"I don't know why we would not embrace this," said state Sen. Lou Gentile, D-Steubenville.
But Thompson said he opposes accepting the money because "it's taking money from the feds that they don't have" to induce the state to do something it shouldn't. And he and others aren't confident all the federal money promised would materialize.
"Washington's financial promises expire often before they're complete," he said.
Bozian said if that happens, the expansion would have to end.
"Even if it stops in three or four years, it's better than nothing," she said.
Thompson said he's not sure that's possible.
"I think that there's an issue that once you get into it you can't get back out of it," he said.
People on both sides argue their approach will guard against health care costs going up for folks who are insured. Because the expansion wasn't originally an option, the law still cuts federal funds to hospitals, Gentile said.
"The costs of uncompensated care being reduced for hospitals, that is going to go down over time," he said, noting that burden would shift to the health care costs of other, paying patients.
Thompson said Medicaid doesn't always cover the full costs of care, so it, too, would shift expenses to other patients.
Kasich and others have cited statistics from the Robert Wood Johnson Foundation indicating the expansion would cover 24,600 veterans on Ohio. Thompson said that statistic was only introduced recently and he believes there are different options for veterans - and other individuals - to receive needed coverage.
"Our hope is that we will have some other proposals that will enable us to address the governor's concerns," he said.
Thompson said he also wants to see the state's approach address existing problems like unnecessary emergency room visits and help to get people off the Medicaid rolls instead of adding to them. At times, Medicaid can be a disincentive if individuals are afraid to get a better job for fear of losing the coverage, he said.
"Medicaid can be a penalty to people leaving and getting a better job," Thompson said.
Bozian argued expanding coverage would have the opposite effect.
"That gives people an opportunity to work and work more hours" without losing their coverage, she said.