Finally, Medicaid Expansion

By: 
Sen. R. Creigh Deeds

Richmond

June 1, 2018

On Wednesday, May 30, the Virginia General Assembly adopted a budget two and half months late. The budget expands access to healthcare through Medicaid to roughly 300,000 low income Virginians. For over five years advocacy groups and some legislators have been fighting to reach this goal. The accomplishment is significant in many ways.

  In 2013 when the Senate of Virginia was evenly split between Democrats and Republicans, we had bipartisan consensus to expand Medicaid. At that time, the House majority was absolutely resistant to the idea. As a middle ground we included language in the budget to reform Medicaid in advance of expanding the program. Those measures were implemented, but in subsequent years, the resistance to Medicaid grew, in part due to the retirement of two Republican senators who favored expansion. Resistance to expansion in the Republican majority in the House remained firm until they nearly lost control of the House of Delegates during the 2017 elections. Eager to put the issue behind them, House Republicans adopted their own approach to Medicaid expansion. The resistance of the Republican majority in the Senate remained.

Throughout the process, Emmett Hanger, a senator from Augusta County and co-chair of the Senate Finance Committee, expressed his openness to finding a way to access the federal dollars available to Virginia through Medicaid expansion. After the session adjourned in March without a budget and the impasse continued for weeks, Senator Hanger, along with Delegate Chris Jones, the Republican Chair of the House Appropriations Committee, worked with the Governor's office to produce a consensus budget. Their work bore fruit on Wednesday.

Senator Hanger in particular deserves a great deal of credit. He consistently has spoken about gaining access to additional federal Medicaid dollars -- roughly $2 billion annually --  in order to provide access to healthcare for more Virginians and to free up state general fund dollars for other priorities. Through his candor and his fortitude, he maintained his position from 2013 to the present. During the debate this week, his Republican colleagues shot arrow after arrow at him. He maintained his good humor and eternal optimism throughout the fight. In the end, Senators Frank Wagner of Virginia Beach, Ben Chafin of Russell County, and Jill Vogel of Fauquier County voted for the budget. All of these votes took a great deal of courage in the face of criticism and opposition from their colleagues.

The nuts and bolts of Medicaid expansion are relatively simple. Virginia will have to submit waiver requests to get approval for our plan. The effective date is Jan. 1, 2019. Medicaid will be available to those who earn up to 138 percent of the federal poverty level. This covers people who make too much to qualify for Medicaid now but cannot afford their monthly premiums for an employer based plan or do not make enough to qualify for subsidies on the federal health insurance marketplace. The plan includes co-pays as well as premiums for this coverage based on a sliding scale not to exceed two percent of income.

The most controversial component, as I've discussed before, is the work requirement in the bill. Able-bodied adults will be required to work, look for work, or participate in job training or education programs. While I appreciate many Virginians wanted expansion without a work requirement, the inclusion of these provisions was essential to passage of Medicaid expansion. The impact is also limited because 75 percent of the Medicaid expansion population either works full time or lives with someone that does. The work requirement is waived in areas of high unemployment (150 percent of the statewide average). The work requirement, in my view, is not onerous.

A second controversial component of Medicaid expansion is the state match, which is capped at 10 percent. Virginia must invest $1 for every $9 we receive from the federal government. The compromise addresses the cost in two ways. First, the plan levies a tax on hospitals, a provider assessment, to cover the state share. A second provider assessment will provide additional funds to increase reimbursement rates to hospitals in order to offset some of that burden.

Since the fall of 2013, I have focused on improving mental health services in Virginia. The budget approved this week will have a tremendous impact on mental health services in the Commonwealth. While we have worked in recent years to provide coverage to the uninsured population with a serious mental illness through GAP, many uninsured Virginians who struggle with anxiety, depression, and other mental health diagnoses did not qualify. Medicaid expansion will expand access to all health care -- behavioral and physical -- to every low-income Virginian.

In addition, the final budget includes additional investments to build on the work and to support the priorities of the Joint Subcommittee to Study Mental Health Services in the 21st Century. In total, the budget adds, over and above the Medicaid expansion dollars, nearly $192 million general funds over the biennium to assist individuals with mental illness, substance abuse disorders, and intellectual and developmental disabilities. This includes over $84 million to implement new provisions of STEP-VA ahead of schedule.

You will recall the legislature passed legislation last year to redefine the mandated services provided by the community services boards. The General Assembly staggered the implementation of the bill over several years because of the cost. Through this budget, we ensure all CSBs provide same day access and begin implementation of the provision of detoxification and outpatient services, as well as primary care outpatient screenings. The budget also includes funding for discharge planning services at rural jails, housing for people discharged from state facilities, and an alternative transportation system for individuals subject to a temporary detention order. This infusion of funds seeks to reduce recidivism, relieve pressure on our public hospitals, and free up law enforcement to promote community safety. The final budget also provides additional funding to increase telemental health services.

Despite the historic investment in mental health this year, we still have work to do. We have to figure out what our system of CSBs and hospitals should look like. We need a comprehensive approach to workforce development and training so that we have competent, compassionate staff to provide the services. We have to develop a concrete plan for the remaining stages of STEP-VA.

The General Assembly is scheduled to meet on June 11 to consider any amendments the Governor offers to the budget. As the budget agreement was developed in consultation with his office and was adopted in toto, I do not foresee any recommendations from the Governor. We will have to stay tuned.

It continues to be my high honor to represent you in the Senate of Virginia. If I may be of assistance, do not hesitate to contact me. I can be reached at district25@senate.virginia.gov or by phone at 434-296-5491 or 540-839-2473.

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