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Changes to Medicaid expansion could impact thousands of recipients in southeast Ohio
By: Amanda Pirani
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WILMINGTON, Ohio (WOUB/Report for America) – James McMullen was 13 when doctors removed his colon. Now he uses an ostomy bag and several medications to maintain his condition, both of which come with a hefty price tag.
His mother, Jen McMullen, said the cost would be impossible to cover without health insurance.
“The biologic medicine that he’s on, it’s a $28,000 per dose injection that he needs to take once a month,” McMullen said. “Just that alone, it would literally wipe us out in a month’s time, and that would be the end of it.”
When McMullen heard the One Big Beautiful Bill might include new work requirements for some Medicaid recipients, she began to worry. While she receives insurance through her employer, her 22-year-old son is covered by Medicaid expansion, a 2014 program Ohio opted into under the Affordable Care Act.
Beginning in 2027, most Ohioans covered by Medicaid expansion will be required to complete 80 hours of work or an alternative to work each month. It’s one of many changes to Medicaid in the budget reconciliation bill, known as the One Big Beautiful Bill, President Trump signed into law on July 4.
The legislation also includes more frequent eligibility checks and potentially more out-of-pocket costs. They’re decisions that have advocates concerned thousands in southeast Ohio will be at risk for losing their health insurance.
Work requirements could lead to loss in coverage
McMullen says she understands where supporters of work requirements are coming from. She depended on government assistance in her early adulthood, but worked hard to become financially independent. She owns her own home and has a stable income working remotely.
But now she worries the requirements could endanger her son and put the both of them in extreme medical debt. Her son wants to work, but his condition makes it hard to keep a job. His physical health varies, and it’s given him intense social anxiety.
“The struggle on the emotional and mental health side of it is a huge factor for him. I want to say that that kid’s been through … four jobs in the last year and a half, and he’s had bigger gaps in between them than what he was able to work,” she said.
James’ experiences are not uncommon for someone with ulcerative colitis, which causes ulcers and inflammation in the colon. Studies have found those with the disease are much more likely to experience depression and anxiety.
Right now, he works as a pizza delivery driver, and McMullen is hopeful it will stick. But she questions whether it would be enough to meet the work requirements, which will need to be fulfilled three months before one’s eligibility determination.
“What happens if they get slow … what if he has an episode and has to go be in the hospital for a week? That happens to him, unfortunately, probably every six months or so.”
Like James, many people on Medicaid work. An analysis of U.S. Census Bureau data from the Kaiser Family Foundation found 64% of those covered by Medicaid worked full time or part time in 2023. But reporting that work can come with challenges that lead to a loss in coverage.
That’s according to Rose Frech, the director of external affairs at Integrated Services, an organization that provides behavioral healthcare in southeast Ohio.
“What we know from other programs and other states, is that oftentimes it’s people who actually are eligible, who do meet the criteria, who lose coverage because they simply just can’t navigate all of the hurdles,” Frech said. “And so what that results in is a lot of churn in the program.”
According to the Ohio Department of Medicaid, 770,000 Ohioans are covered by Medicaid expansion — about one third live in Ohio’s mostly rural, southeast counties.
Medicaid expansion allows for a larger pool of low-income individuals to qualify for Medicaid, those whose household income is below 138% of the federal poverty level. Previously, only those whose household income was under 100% of the federal poverty level were eligible.
The implementation of requirements remains unclear
While often called a work requirement, the One Big Beautiful Bill actually mandates members of the ACA expansion group complete 80 hours of what it calls “community engagement” each month. This can look like a part-time job, but may also include 80 hours of volunteer work, educational programming or substance abuse treatment.
The federal bill’s language does carve out some exceptions to the requirement. American Indians, caregivers for children under 13 or for disabled individuals, veterans with disabilities, and those who are considered “medically frail” or requiring special needs will be exempt.
Some of those the bill considers medically frail are people with a substance use disorder, a physical, intellectual or development disability, or those with a “complex medical condition.”
Someone like James might meet these exemptions, but McMullen isn’t sure. Right now he does not receive Social Security Disability Insurance, benefits the federal government administers to those with disabilities. Whether he’ll be classified as medically frail — and who will make that determination — is not clear.
“What kind of documentation will count? What will they need? How hard will it be for people to actually get that information? Will they, for example, have to reprove that every six months,” Frech said. “When you take all of those things in combination, it makes sense that they’re saying that … people are going to lose their health insurance, not because of any big, broad-based cut to an entire eligibility group, but it’s just death by thousands of paper cuts.”
The Ohio Department of Medicaid did not respond to multiple requests for comment on the changes to Medicaid in the One Big Beautiful Bill.
Frech said she hopes the state will offer flexibility in its implementation of both community engagement requirements and the exemptions.
“These things are nuanced. The way a condition manifests for one person may look different than how it manifests for someone else,” she said. “I’m hopeful that we see as much flexibility as possible in the rollout of that, at least here in Ohio, to the ability that the state has some discretion there, that you see something that is encompassing all of the intricacies of being human.”
Communicating changes over the next year will be critical to preventing losses in coverage, Frech said. Many notices about Medicaid reach patients via mail, but she said this isn’t always the most reliable way to reach those who may have unstable housing.
While insurance navigation isn’t a major part of the work done by Integrated Services right now, she said they’re preparing for the possibility that patients will need more support.
“Our hope is that as a provider that really does come into people’s homes and help people in a much more hands-on way, is that we can kind of just be a partner in that,” Frech said. “Like, ‘OK, hey, you got this scary piece of mail. Let’s figure this out together.’”
Integrated Services isn’t the only provider in southeast Ohio preparing to help patients navigate the changes. Spokespeople at Genesis HealthCare System and Muskingum Valley Health Centers said they are planning to provide assistance to patients who are eligible under Medicaid expansion.
“Our goal and objective is to ensure that everyone continues to be able to access care in the way in which they access it today,” said Dan Atkinson, chief executive officer of Muskingum Valley Health Centers.
Get Covered Ohio, an insurance navigator service run by the Ohio Association of Foodbanks, can also connect patients to free assistance in a patient’s local area.
In Athens County, Job and Family Services Executive Director Jean Demosky said in an email that JFS will take its own measures to reach communities about the changes. In addition to sharing materials online, JFS will utilize its mobile units to connect directly with people where they live.
Those who need support with Medicaid applications can call Athens County JFS or visit in person at its Millfield and Nelsonville locations.
More changes coming for expansion group
In addition to the community engagement requirements, the bill also increases the frequency of eligibility redeterminations.
Right now, the state checks whether someone still qualifies for Medicaid every year. Starting in 2027, it will do this every six months for members of the ACA expansion group. It’s a process that asks Medicaid recipients to submit detailed documentation regarding income and employment to verify they are still meeting the program’s income requirements.
The majority of the patients Integrated Services serves are covered by Medicaid. Frech worries the increased frequency of Medicaid eligibility checks could result in gaps in coverage because of regional barriers.
In southeast Ohio, most people don’t have access to public transportation, and access to high-speed internet is limited.
“If you have, on some regular cadence, to log into a portal to report work or work activity, but you don’t have internet at your house, what does that look like,” Frech said. “If you have to more frequently get to your county JFS office, but you live in a very rural part of southeast Ohio, and much of our area is not served by public transit … can you navigate that the same way that somebody in one of the urban areas might be able to?”
Beginning in 2028, states will also have to require out-of-pocket costs of up to $35 for some services covered by Medicaid expansion. However, services such as primary care, mental health and substance use disorder treatment, family planning, hospital-based emergency care, and institutional long-term care, will be exempt.
Teresa Lampl, chief executive officer of a behavioral health organization called the Ohio Council, said these fees could impact the ability for some to access specialized care.
“We don’t know how that will play out operationally, but then that means people who have chronic diseases can’t see specialists unless they pay $35,” she said. “That’s a tank of gas, that’s their groceries, that’s a pretty big investment for a poverty-level patient.”
Losses in coverage could cost everyone
If her son loses his health insurance, McMullen said he’ll have no choice but to forgo changing his ostomy bag — which can quickly become life-threatening.
“The reality is that he’ll be in the hospital every other day when he needs to change his bag, because if we can’t afford it, the only option then is for him to go and admit himself to the hospital,” she said.
Lampl said the scenario McMullen described could become more common if people lose coverage due to the work requirements.
“If you have higher rates of uninsured people, you have more people delaying access to care,” she said. “Which means that they show up in the emergency room that’s uncompensated, expensive care.”
As hospitals absorb these costs, Ohio University professor and health policy expert Cory Cronin says it could lead to higher costs for all of the patients they serve — a scenario called cost-shifting. If a hospital expects to provide expensive care to a certain percentage of its patients without reimbursement, it may build those costs into its budget by charging more to those who are insured.
“So the cost of care then goes up for everyone,” Cronin said. “Because the hospital is trying to account for what they’re going to lose on people who get care, often through the emergency department, and are not able to pay the hospital for that care later.”
Cronin noted that there is debate around the prevalence of cost-shifting, and the alternative scenario is that hospitals cut costs by paring down on staff or services.
While she waits to see how the changes will play out, McMullen is doing her best to prepare. She’s sent emails and made calls to the offices of her state representatives, searching for some reassurance. She hasn’t received an answer.
“That’s really frustrating. I pay my taxes just like everybody else does,” she said. “This is home. My kids are here. It’s not like I can pick us all up and move us anymore … So how do I make this place feasible to stay, for them to live?”
Amanda Pirani is WOUB’s Report for America Journalist covering Economic Livelyhood. For more information about Report for America, you can click here.