In the early 1960s, Roe v. Wade had yet to legalize abortion, Medicaid didn't exist, and educating teenagers on issues related to women's health and sex was still considered taboo. Progressives often argue that society has made great strides on these issues since that time. But looking at the budget proposal passed by the Republican-controlled Ohio House in a 61-35 vote on April 18, there seems to be a strong reluctance by conservatives in power to accept the scientific and social progress made in the past few decades.
If the Ohio House budget bill is approved by the Republican-controlled Ohio Senate and signed by Republican Gov. John Kasich in the next two months, Ohio would forgo the federally funded Medicaid expansion and defund Planned Parenthood, while funding crisis pregnancy centers (CPCs) that focus on anti-abortion, abstinence-only education.
But the bill that made it through the Ohio House is actually more moderate than the bill that made it through the Ohio House Finance and Appropriations Committee on April 16. Before it was amended through a final round of votes in the Ohio House, the committee-backed bill actually banned comprehensive sex education in Ohio, touting fears of "gateway sexual activity." That ban prompted a harsh response from pro-choice groups.
Kellie Copeland, executive director of NARAL Pro-Choice Ohio, noted in a statement that the proposal seemed like a throwback to social and educational policies from decades ago.
"Today the Ohio House Finance Committee voted to send our state back to the 1950s," it read. "The Ohio House is doing everything they can to restrict access to reproductive health care and medically accurate information that help Ohioans live healthy lives."
The committee-backed bill also flat-out rejected the Medicaid expansion, while the final Ohio House bill asks for a waiver from the federal government that would give Ohio more time to mull over a Medicaid expansion and could lead to a revamp of the state-backed health care program and ensure health insurance coverage for 456,000 low-income Ohioans.
Still, even the revised budget bill has upset Democrats, women's health advocates, educators and hospitals, which collectively support the Medicaid expansion and funding for Planned Parenthood and oppose funding for CPCs.
Surprisingly, Kasich actually joined opponents of the budget bill through his support for a Medicaid expansion. The Republican governor was the one who proposed accepting the Medicaid expansion earlier in the year, and he's stuck by his support.
"We are pleased that the House backed away from its initial position and has listened to the governor and many, many others who have clearly demonstrated the advantages to businesses, Ohio's economic recovery and the health of our state of providing health care to low-income, working Ohioans," wrote Kasich spokesperson Rob Nichols in an email to CityBeat. "The process continues, and the governor is totally committed to extending health coverage to people who are battling mental illness and addiction, 26,000 veterans and other Ohioans for whom health care is a ladder up and out of poverty. We look forward to continuing our work with the House and Senate on this issue and to advancing the rest of our Medicaid and health-system reforms, which have already improved care and saved $2 billion."
But it's so far unclear where Kasich stands on the other provisions in the bill. When asked about defunding Planned Parenthood and funding for CPCs, Nichols wrote, "We don't comment on every provision in the House budget. There is a process currently at work; we're talking to the House and Senate about a number of provisions, but we don't do our negotiations through the media."
Without Kasich, opponents of the budget bill are left helpless as Republican legislators, who answer to very conservative gerrymandered districts, jam social issues into a budget that was initially dubbed "Jobs Budget 2.0" by Kasich and his supporters, leaving Planned Parenthood and Medicaid in the balance.
No more planning
In what Democrats have labeled a distraction from creating jobs, Republicans included a measure that would effectively defund Planned Parenthood by redirecting federal money elsewhere. The measure continues years of Republican attacks on Planned Parenthood and other family-planning services, which legislators have criticized for providing abortion services.
But supporters of Planned Parenthood emphasize that the organization provides much more than abortion services, and no public funding is used for abortions. Instead, all abortions are paid for with private donations, and the public funding Planned Parenthood receives goes to other medical services, including breast exams, prenatal care, family planning and sexually transmitted infection (STI) treatment.
Some legislators and supporters say the measure is not about abortions; they argue they're just trying to open up funding for providers that aren't Planned Parenthood. But at public hearings over the issue on April 12, Stephanie Kight, president and CEO of Planned Parenthood of Greater Ohio, pointed out those funds are already open to different providers. They just happen to lose to Planned Parenthood in the competitive distribution process because distribution officials deem Planned Parenthood's services superior.
Still, Kight did not back down when she was asked by Republican state Rep. Ron Maag why Planned Parenthood doesn't shut down its abortion services if they endanger the "good work" Planned Parenthood does elsewhere. Kight responded by saying she believes Planned Parenthood's abortion services are "good work," prompting Maag to cease further questioning.
A separate section of the budget bill also redirects federal funding to CPCs, which act as the anti-abortion, abstinence-only alternative to comprehensive family-planning services like Planned Parenthood. At the budget committee hearings over the issue, Denise Leipold of Right to Life of Northeast Ohio praised CPCs for promoting chastity and abstinence.
A study released by NARAL Pro-Choice Ohio found CPCs routinely mislead patients by instilling them with fears about false links between abortion and mental-health problems, breast cancer and infertility. In what NARAL Pro-Choice Ohio labeled an "undercover investigation," the organization found 47 percent of CPCs gave misleading information about abortions and mental-health problems, and 48 percent gave false information about abortions, breast cancer and infertility.
Leipold told CityBeat that abortion is a major factor behind her organization's support for the Ohio House budget bill.
"Our mission is to support the right to life from conception to natural death," Leipold says. "Abortion happens to be a big problem right now because in the past 40 years it's become part of the culture."
Copeland of NARAL Pro-Choice Ohio says the state should heed health-care experts, not social conservatives who are trying to push their own social agenda.
"They're trying to impose their morals on you," Copeland says. "These are not health-care experts. These are not people who are trying to find real solutions for the problems that real people face. These are people who want to impose their personal views, their personal morality on you."
More funding for comprehensive family services could save the state money. When looking at three ways to prevent unintended pregnancies for a 2012 study, the Brookings Center on Children and Families found the most cost-effective policy was to increase funding for family-planning services through the Medicaid program. In other words, if governments increased spending on family-planning services, they would eventually save money by preventing costly pregnancies and STI treatment.
For Ashley Hernandez, a 25-year-old Cincinnati resident and self-proclaimed "second-generation Planned Parenthood patient," the Planned Parenthood cuts would have a personal impact that goes back to her mother, who began using Planned Parenthood in the 1970s when she found out she was pregnant. Hernandez says her mom went to Planned Parenthood to get health care she otherwise had no access to because she was low-income and lacked health insurance.
Hernandez says she also has used Planned Parenthood since she began using birth control. She says she appreciates that the option has always been there, even when she didn't have access to health insurance.
"Whether I have health insurance or not, I receive the same quality of care," Hernandez says, citing "timely appointments, great doctor services and compassionate, nonjudgmental, medically accurate information."
Even though she has a job, Hernandez currently relies on her parents' health-care plan, but she says she's worried that once she turns 26 and is knocked off that plan, she will be left with no option, especially if there's no Medicaid expansion.
"If they defund Planned Parenthood and they don't expand Medicaid, there's pretty modest estimates of over 450,000 people being affected by this in Ohio," she says.
She adds, "The thing that Ohioans needs to understand and Gov. Kasich needs to understand is that the 800,000 people who go to Planned Parenthood in Ohio every year don't go to make an ideological or political statement. They go because it's the only place they have to go, and it gives them top-quality care. They may not have access to that anywhere else in their lives."
Let's not talk about sex, baby
When the budget bill first made it through the Ohio House's budget committee, it included an amendment that would have effectively banned comprehensive sex education. Rep. Lynn Wachtmann, a Republican from the small northwestern Ohio town of Napoleon, successfully proposed the amendment restricting sex education. He told reporters that the restrictions would have effectively shifted Ohio to "abstinence-only" education in schools.
The amendment was stripped after a 76-19 vote in the Ohio House, but not after garnering national attention for its reference to "gateway sexual activity."
The amendment would have banned any implicit or explicit promotion of "gateway sexual activity" in schools, disallowed individuals or groups to distribute contraceptives on school grounds, banned demonstrations with "devices specifically manufactured for sexual stimulation" in classrooms and forced teachers to emphasize adoption over abortion and teach that having kids out of wedlock could harm "the child, the child's parents and society."
The rejected amendment would have created a $5,000 fine that teachers would be subjected to if they explained the use of condoms, birth control or other basic sex facts in a way that promoted, implicitly or explicitly, "gateway sexual activity." The amendment did make some exceptions for medically correct information, but the information had to be given in a way that would not enable or promote "gateway sexual activity."
For many, the phrase "gateway sexual activity" raised more questions: What does that mean? Is it like a feared gateway drug, only it relates to sex? Why is the government dictating sexual activity?
The amendment defined "gateway sexual activity" by using Ohio's criminal code definition for "sexual contact," which is defined as "any touching of an erogenous zone of another, including without limitation the thigh, genitals, buttock, pubic region, or, if the person is a female, a breast." In other words, "gateway sexual activity" is practically any sexual activity.
The amendment would have allowed teachers to share basic facts about contraceptives, such as condoms reducing the chance of pregnancy or contracting HIV.
But if a student approached a health teacher, said he's having sex, and wants to know how to apply a condom or use any other form of birth control, the teacher would have not been able to offer guidance because an answer would enable "gateway sexual activity."
The amendment was eventually rejected, but it still represented the interests of the state's conservative warriors. Even Rep. Ron Amstutz, a Republican from Wayne County who later pushed to get the anti-comprehensive sex education language removed, actually voted for the amendment while the budget bill worked through the Ohio House's budget committee, which he chairs.
Meanwhile, Leipold of Right to Life of Northeast Ohio says abstinence-only efforts are needed
to tame a cultural movement that's gone too far.
"Now kids are learning that responsible sex means that you can have sex but just use birth control," she says. "That's not supposed to be the attitude. The attitude is supposed to be that sex is for a committed relationship between a man and a woman in a marital relationship."
But the research on abstinence programs has not been kind to that type of thinking. The most comprehensive research has correlated abstinence-only education to higher rates of teen pregnancy in comparison to comprehensive sex education programs.
A 2007 study published in the Journal of Adolescent Health found abstinence-only programs have no impact on rates for teenage pregnancy or vaginal intercourse, while comprehensive programs that include birth control education reduce rates.
A 2011 study from researchers at the University of Georgia that looked at data from 48 states concurred that abstinence-only programs do not reduce the rate of teenage pregnancy. The study indicated states with the lowest teenage pregnancy rates tend to have the most comprehensive sex and HIV education programs.
Still, abstinence-only programs have gained limited traction in some areas. In 2010, supporters of abstinence-only programs rejoiced when a major study from a University of Pennsylvania researcher finally supported their ideas. The study, which tracked black middle-school students over two years, found students in an abstinence-only program had lower rates of sexual activity than students in the comprehensive program. But the study did not look at longer-term effects, particularly when the students reached high school.
For Democrats, the perceived absurdity of the amendment quickly prompted a fundraising campaign. Following the amendment's passage through the Ohio House's budget committee, Ohio Democrats sent out a fundraising email mocking the bill: "Today, Republicans introduced a budget amendment to ban 'gateway sexual activity' (whatever that is). The GOP effort would prohibit all comprehensive sexual education from our schools, but that's not it! If an organization supports anything other than abstinence, they'd be banned from classrooms. And anything from distributing birth control to condoning pre-marital sex could carry a stiff $5,000 fine. Sometimes Republicans' 'laser focus' on job creation gets distracted."
The fundraising campaign prompted a response from Ohio Republicans that oddly referenced the terrorist attack on the Boston Marathon two days earlier. In an email to CityBeat, Ohio Republican spokesperson Matt Henderson wrote, "I mean we're partisan, heck, we created StopOhioJobKillers.com, but it's downright insulting that Ohio Democrats and Chris Redfern would rather play politics than show respect for those in Boston whose children were ripped apart by shrapnel less than 24 hours earlier."
Health care? No thanks!
On top of pushing for conservative social policies, the Ohio House budget forgoes an opportunity to provide health-insurance coverage to nearly half a million Ohioans, save the state money over the next decade and bring health-care jobs to the state.
When Kasich proposed the first iteration of "Jobs Budget 2.0," the bill asked for a full expansion of the state's Medicaid program, but Ohio House Republicans have since walked back that proposal to simply ask for a Medicaid waiver that would give legislators more time to work on an expansion and perhaps carry out even bigger reforms.
Under the Affordable Care Act ("Obamacare"), states are financially incentivized to expand their Medicaid programs to include anyone at or below 138 percent of the federal poverty level, or annual income of about $15,856 for a single-person household and $32,499 for a family of four. If a state expands its Medicaid program, the federal government would pick up the entire tab for the expansion for the first three years. Afterward, the expansion would be drawn down to 90 percent over the next decade, where it would remain.
If Ohio took up the offer, it would mean expanding a health-care program for low-income earners, impoverished children and non-workers with disabilities that currently includes one in six Ohioans, or 2.2 million people.
It may seem like a great deal, but state Republicans are not convinced it's a good plan for Ohio. It all started with a letter from State Treasurer Josh Mandel to state legislators, which warned Republicans of the potential financial consequences of a Medicaid expansion: "There is no free money. While expanding Medicaid may direct more federal dollars to Ohio in the next few years, in the long term Ohioans will have to repay the debt that is funding federal government spending… If Ohio's leaders take the bait today, I fear that generations of Ohio taxpayers will be on the hook for the long-term costs of expanding Medicaid."
The fear, which has been echoed time and time again by state Republicans, is that the federal government might pull Medicaid funds in the future, even though there has been no historical precedent in which the federal government failed to live up to its Medicaid commitment since the program was signed into law in 1965.
Kasich's proposal planned for a situation in which the federal government pulled funding. If that happened, an automatic trigger would have immediately halted and pulled back any Medicaid expansion.
But that didn't eased Republican legislators' concerns. Michael Dittoe, spokesperson for Speaker of the House William Batchelder and Ohio House Republicans, says Obamacare's massive commitment and the rapid growth of Ohio's Medicaid program are unprecedented, making them potentially bigger problems for both the state and federal government.
"(Republican House members) have a serious doubt that the federal government is going to be able to maintain its commitment," Dittoe says. "If the federal government can't live up to their commitment that they've made to the state of Ohio, what happens to the hundreds of thousands of people that are now on the Medicaid program?"
He adds, "Given that in the last decade the cost of Medicaid in the state has doubled, our members want to look at reforming the program and possibly seeking alternative solutions."
Instead of going for a full Medicaid expansion, Dittoe says legislators want to look at how Medicaid can be changed to insure more people at lower costs in a way that better fits Ohio. For this, he says legislators have been looking at experiments in other states, including Florida and Arkansas.
In Arkansas, legislators recently passed a plan that expands coverage of low-income people through a privatization scheme instead of a traditional Medicaid expansion. The Obama administration has so far supported the plan as a reasonable alternative, even though private insurance plans typically cost more than public health plans.
Still, Dittoe admits legislators could potentially do nothing - no reform, no expansion - but he says that's unlikely.
Distrust of the federal government is not new to Republican politics. Republicans at all levels of government have warned of a large federal government hindering state-based governance. But this time, the anti-government fervor may actually cost Ohio and its citizens money and health coverage.
A study from the Health Policy Institute of Ohio released in January and revised in March found the Medicaid expansion would insure 456,000 Ohioans by 2022. It would also save the state money - about $1.8 billion over the next decade - by creating jobs through more demand in the health care market and shifting health care costs from Ohio to the federal government.
In other words, the Medicaid expansion would save the state money by generating enough economic activity to create jobs, but the budget, which, again, is called "Jobs Budget 2.0" by supporters, is, at the very least, delaying that job-creating expansion.
The Medicaid expansion would also come with financial benefits for hospitals. As part of Obamacare, the federal government is making cuts to providers around the nation. The idea was that the provider cuts would be made up by expanded insurance coverage, which would lead to more paying customers and less uncompensated care in hospitals.
But that policy was built on the basis that the Medicaid expansion would be mandatory, which the U.S. Supreme Court altered in its 2012 decision on Obamacare. While the Supreme Court ruling did generally uphold Obamacare and its individual mandate, it also decided that a Medicaid expansion was too coercive because it was effectively mandatory through a threat that the federal government would pull all Medicaid funding if state governments didn't decide to expand. The Supreme Court decision made the Medicaid expansion optional, leading to Ohio's stalemate today.
The Ohio Hospital Association (OHA), which has supported Obamacare since it was first challenged in court, has been pushing state legislators to support the Medicaid expansion. John Palmer, spokesperson for OHA, says the rejection of the Medicaid expansion would force Ohio hospitals to endure the totality of Obamacare's cuts without anything to make up for them.
But he also makes a humanitarian plea for the Medicaid expansion.
"These are hard-working Ohioans that either have some support through a part-time job or are working to kind of get by," Palmer says. "When it comes to health care, they just don't receive it. This extension would help provide a safety net for those Ohioans from a health care standpoint."
Palmer says Medicaid isn't even a great financial deal for health-care providers. For every dollar in care provided, Palmer says hospitals get 83 cents back. That may seem like a bad deal, but it's better than an alternative in which uninsured people get treated and end up not paying for care at all, leaving hospitals to foot the entire bill.
OHA was among health-care providers and others that took part in an April 11 rally in support of the Medicaid expansion, making similar arguments to a crowd of 2,500. Kasich also supported the rally, but it clearly wasn't enough to convince Ohio House Republicans to include the Medicaid expansion in their budget bill.
Moody's, an independent credit and research agency, recently supported the warnings from health-care providers. In a statement for its March 14 report, the agency said either states or hospitals would face great budgetary strain if states reject a Medicaid expansion.
"States that opt out of Medicaid expansion will have to choose whether to compensate for the shortfalls with their own funds or leave hospitals to absorb the costs, which will increase rating pressure on the hospitals," said Nicole Johnson, senior vice president of Moody's, in a statement. "States that choose to fund uncompensated care costs themselves could face budgetary strain."
The report presents a stark reality for Ohio: If Republicans don't take federal funds that they fear will eventually vanish, the state government and hospitals will be forced to foot the bill anyway to make up for Obamacare's funding cuts.
For many progressive advocates, it remains a mystery how the state government keeps coming back to conservative social policies in a state that elected Democratic President Barack Obama twice and handily re-elected Democratic Sen. Sherrod Brown last year, particularly with the support of young and women voters who are more socially liberal. But the state's congressional district map may have some answers.
A July 2012 study from Fair Vote found redistricting is causing congressional districts to become more polarized. In other words, as state officials redraw congressional maps to benefit one party more than the other and build politically safe Republican and Democratic seats, they're also building districts that are becoming increasingly polarized.
When Ohio's Republican legislators go back to congressional districts that were redrawn in 2011 to heavily favor Republicans, they're finding constituencies that reward conservative policies and punish liberal policies and even political moderation.
The one exception in Ohio's legislative process is Kasich, who has to worry about voters around the entire state, not just polarized congressional districts. Whether that ultimately has a political impact will be seen in 2014, when Kasich will run for re-election.
But if Kasich keeps playing along, he'll continue supporting an endgame that is highly socially conservative - certainly more socially conservative than the state at large and a majority of Ohioans born after the 1960s.
The Men leading the way
Background on nine officials involved in the defunding of Planned Parenthood and potential rejection of Ohio's Medicaid expansion
State Treasurer Josh Mandel: Even though Mandel can't legislate from the state treasurer's office, he began the campaign against the Medicaid expansion with a letter to state legislators asking them to reject it.
Rep. Ron Amstutz (R-Wooster): Amstutz chairs the Ohio House Finance and Appropriations Committee, which originally passed a budget bill banning comprehensive sex education in Ohio. He later supported the amendment that got the language repealed.
Rep. Lynn Wachtmann (R-Napoleon): Wachtmann has been one of the strongest advocates against abortion in the Ohio House. He introduced the amendment that would have banned comprehensive sex education.
Rep. William Batchelder (R-Medina): As speaker of the house, Batchelder helped pass the Ohio House budget bill that defunds Planned Parenthood and forgoes the Medicaid expansion.
Gov. John Kasich: The governor will have the final say on whether the Ohio House budget passes. His position on defunding Planned Parenthood so far is unclear, but he's been a strong advocate for the Medicaid expansion.
Rep. Jeff McClain (R-Upper Sandusky): McClain is the vice chair of the Ohio House Finance and Appropriations Committee, which approved a budget bill that banned comprehensive sex education in Ohio. The rest of the Ohio House eventually stripped the amendment.
Sen. Bill Seitz (R-Cincinnati): Seitz will help rework the Ohio House budget bill to meet the Ohio Senate's wants and needs. In an email to CityBeat, Seitz said he supports the funding measures that decrease money going to Planned Parenthood and the plan to forgo the Medicaid expansion.
Sen. Keith Faber (R-Celina): As senate president, Faber will play a prominent role in the Ohio Senate budget process. Faber has been one of the strongest opponents of abortion rights, previously supporting the heartbeat bill, which would have banned abortions after a heartbeat is detected.
Rep. Ron Maag (R-Lebanon): As an opponent of abortion rights, Maag has supported measures that defund Planned Parenthood. He previously implied that Planned Parenthood should stop providing abortion services.