The growing complex of health care facilities along Interstate 75 in Butler County takes another leap forward this month when Cincinnati Children’s Hospital Medical Center’s Liberty Campus opens its more than $120 million Proton Therapy Center, one of only two such sophisticated radiotherapy centers in the country owned by a pediatric hospital.

The Proton Therapy Center, part of the newly expanded Cincinnati Children’s Liberty campus, will treat pediatric and adult cancer patients across the region and the world, the hospital says.

The huge proton therapy machine, weighing as much as three jetliners, fires pencil-thin proton particles to more precisely target brain tumors, lymphoma, sarcomas and other cancers. UC Health is partnering with Cincinnati Children’s on the facility and will conduct cancer research as well.

But the dramatic growth of the hospital’s footprint and services in Butler County has caused some Hamilton County taxpayers to wonder if their tax dollars are being used to fund the hospital’s growth outside the county.

“It’s absolutely a fair question to ask. That was definitely something we looked into,” says Michael Wilson, chairman of the Hamilton County Tax Levy Review sub committee, which recommended county commissioners put the hospital portion on the county’s Health and Hospital Care levy in 2014.

“It’s definitely not [a windfall] from a direct perspective but you always have that argument that money’s fungible and if you fund one program that wouldn’t have been funded otherwise that helps in other areas,” Wilson says.

The 4.07 mill renewal levy, better known as the indigent care levy, was approved by 71 percent of voters in November 2014. It costs the owner of a $100,000 house about $51 a year and provides about $40 million annually to support care for the county’s indigent population.

Originally approved in 1966, the levy was created to support the then City of Cincinnati-owned General Hospital (now University of Cincinnati Medical Center). Cincinnati Children’s was added to the levy in 1976. Today, UC Medical Center and Cincinnati Children’s share about half the levy proceeds. This year UC Medical Center received about $14.9 million from the levy and Cincinnati Children’s about $4.7 million. The balance of the levy is used to fund a variety of other county health care programs such as the Sheriff’s inmate medical care.

A key element of the levy contract with the hospitals is that the funds pay for uncompensated indigent care for Hamilton County residents. Under their agreement with the county, each of the hospitals is required to certify that the levy funds are only used to pay for Hamilton County resident’s care and the cost of these services each year must exceed the amount the hospitals receive from the levy. The agreement also says the levy funds can’t be used to pay for abortion or abortion-related procedures.

In 2014, the most recent year for which data was available, Cincinnati Children’s provided $136.2 million in free or discounted services for those unable to pay, a spokesman says.

That includes the loss from providing charity care and the shortfall from Medicaid reimbursement after accounting for the indigent care levy and funds from the Hospital Care Assurance Program (HCAP), a federal-state program administered by the Ohio Department of Medicaid that provides funding for hospitals that have a disproportionately high share of uncompensated care costs for services to indigent or uninsured Ohio residents.

Likewise, a spokeswoman for UC Medical Center, says, “All patients seeking financial support from the levy are verified as Hamilton County residents based on their income, which must be at or below our charity program income, and their inability to qualify for a government-subsidized health plan.”

The 11-member tax levy review committee, composed of county residents appointed by Hamilton County commissioners, is charged with examining the county tax levies put before voters and balance the need for public services against the ability of the public to pay.

“With the indigent care levy one of the things that we were tasked with by the county … was to make sure that the various levies are generally going toward Hamilton County residents,” says Wilson. “One of things we looked into at both Children’s Hospital and [UC Medical Center] was how they were using those funds and how they were insuring those funds were for Hamilton County citizens. “

In addition, Wilson says, the review committee was asked to assure that the county is the payer of last resort, making sure the hospitals tapped other funding sources for indigent care where ever possible.

As part of its 2014 review, the tax levy subcommittee hired Health Management Associates (HMA), a Michigan-based health care consulting firm, to review the health care services provided by the levy and the impact of the Affordable Care Act (ACA) on those services.

Because of uncertainty about the impact of the ACA on indigent care, the county has reduced the length of the last two levy renewals from five to three years.

The HMA study concluded the ACA could have a bigger impact on UC Medical Center than Cincinnati Children’s. For fiscal 2013, the study says, 6.8 percent of UC Medical’s expenses were for charity care compared with 1.3 percent of Cincinnati Children’s.

However, the study says if the ACA has more than a minimal effect on Cincinnati Children’s charity care, it could jeopardize its eligibility for future levy funds.

The Children’s Hospital spokesman says because the ACA is focused on adults without health insurance it has little impact on pediatric care.

A spokeswoman for UC Medical Center says the ACA has reduced the amount of uninsured care “but there are still many more patients eligible for levy funding than funds available to pay for the services they receive.”

The county’s three-year cycle for the indigent care levy will begin again next year with presentations to the Tax Levy Review Committee. Both hospitals say they haven’t yet had discussions with Hamilton County officials about seeking funds in 2017.