Medicaid is one of the largest health care programs in the state of Ohio. This federal health care program for low-income families and children pays for more than one in five hospital visits and provides health care coverage for over three million Ohio residents–more than a quarter of the state population.
Medicaid was created over half a century ago as part of the 1965 Great Society amendments to the Social Security Act. Originally granting public health insurance coverage to children, pregnant women, retirement-age people, and people with disabilities, Medicaid was expanded in the 1980s to allow more state flexibility and expand eligibility to pregnant women and children regardless of welfare status.
While Medicaid dodged the chopping block that other public assistance programs faced during welfare reform in the 1990s, the 2005 Deficit Reduction Act introduced cost-sharing measures and gave states more flexibility to design benefits, allowing premium charges and service-specific copayments for some populations. The Affordable Care Act in 2010 expanded Medicaid to cover nearly all adults with incomes under 138% of the federal poverty level, but a 2012 Supreme Court decision relegated that coverage to state discretion.
All this has led to a system of low-income health coverage that is heavily dependent on decisions made by state policymakers.
In the state of Ohio, over half of the state General Revenue Fund is designated to Medicaid spending. This has made the program a focus for policymakers interested in reducing state spending.
In the proposed state budget, the Governor has included two provisions that could reduce the state’s spending on Medicaid.
Work Requirements
Medicaid has not traditionally been a program that requires its recipients to work. Since it was originally targeted at pregnant women, children, people with disabilities, and retirement-age people, work requirements were not much of a consideration even during the welfare reform era of the 1990s.
During the first Trump Administration, the Department of Health and Human Services started approving waivers for state governments to impose work requirements on Medicaid recipients. While the Trump Administration approved the request for 13 states, only Arkansas fully implemented the requirements before they were struck down by a federal judge. In Arkansas, about 18,000 people lost health care coverage under the requirements. About half of cases closed were due to problems with communication, with red tape causing thousands of Arkansas residents to lose health care coverage.
Ohio was one of the thirteen states that were approved by the first Trump Administration to impose work requirements on Medicaid recipients. More than a month before President Trump took office in January of this year, the state Department of Medicaid had applied for a waiver from the federal Department of Health and Human Services to impose work requirements on Medicaid recipients. The state estimates 61,000 Ohio residents could lose health coverage under the work requirements. The Center for Community Solutions, a Cleveland-based health and human services think tank, estimates the number of people who could lose their health insurance under work requirements could be as high as 450,000.
Medicaid Expansion Repeal “Trigger”
When Medicaid was expanded under the Affordable Care Act, one of the bill’s provisions was to have the federal government cover 90% of Medicaid spending for this newly-eligible group of low-income people. This was meant to ensure the group continued to receive medical coverage without overly burdening state budgets.
This provision became even more important when the Supreme Court made Medicaid expansion an optional element of the Affordable Care Act. One of the largest selling points for states deciding whether to allow coverage of these residents was that nine dollars would be coming into the state for every dollar they spent–a pretty good investment of state dollars.
A total of 41 states have now expanded Medicaid. Most of the states which have not expanded eligibility are in the South. Ohio expanded Medicaid under the Kasich administration and as of February 2025, 770,000 Ohioans receive health care coverage under that expansion program.
A number of states, however, have also adopted laws that make this health care coverage contingent on continuing support from the federal government. A total of 12 states have implemented “trigger language” that would automatically revoke health care coverage from people covered under the Affordable Care Act expansion of Medicaid if the federal match drops below 90%. About 4.2 million Medicaid recipients across the country would lose coverage if these trigger laws were invoked at the same time. Governor DeWine’s budget includes a provision to have Ohio join this list, making it the 13th state to include trigger language if the federal government reduces its match.
This is especially salient right now as Congress is debating an extension of the 2017 Tax Cut and Jobs Act, the signature legislative accomplishment of the first Trump Administration. Cuts to pay for federal spending increases would have to come from somewhere, and Medicaid is one of the top targets of Congress today. Reducing the federal match rate could be an easy way for Congress to cut spending on Medicaid across the country and free up space for federal tax cuts. This would mean removing health care coverage for 770,000 people in Ohio to pay for federal tax cuts.
What do these mean?
Both of these changes to Medicaid policy in Ohio would mean fewer people with health coverage in the state. Ohio currently has 94% of its residents with health insurance. Medicaid is the most common non-employer form of health insurance in the state, covering more Ohio residents than Medicare, individual insurance, and military insurance combined.
Both of these policies could remove coverage for the 770,000 Ohioans who receive health insurance due to Medicaid expansion. Medicaid expansion led to more preventative measures like colon cancer screening and HIV testing, so loss of coverage may lead to more serious disease among low-income state residents. It also led to less use of emergency room care, which suggests reduction of coverage may lead to more crowded emergency rooms and costs shifted onto the public. Loss of insurance also leads to financial instability. That is the purpose of insurance, after all: to pool risk and reduce financial exposure of people to one of life’s most dangerous contingencies–threats to our health.