For most local candidates in the House of Delegates 93rd and 96th Districts and the Senate 3rd District, the expansion of Medicaid is here to stay, they acknowledged.
What to do about it and how to manage its stay depends on who you talk to.
Support for Medicaid expansion was mostly along party lines, with all Democrats commending the expansion, with some wishing the expansion provided more comprehensive coverage.
Republican and independent candidates were more skeptical of the expansion and Medicaid itself, citing financial concerns and noting the absence of work requirements, which have yet to be put in place and have faced challenges.
When the General Assembly voted to expand Medicaid in Virginia last year, the expansion intended to cover 400,000 newly eligible low-income Virginians ages 19 to 64. As of August 2019, enrollment in the new plan had already reached 300,000.
The expansion covers people earning less than or equal to 138% of the federal poverty level. Childless adults and people with disabilities are eligible if they make an annual income at or below $17,237, while a family of three is eligible if annual income is at or below $29,436.
In 2018, Medicaid expansion in Virginia came about through a deal which promised to enforce work requirements for enrollees to continue enrollment. Virginia submitted its work requirement waiver proposal to the federal government’s Center for Medicare and Medicaid Services in November 2018. Known as Creating Opportunities for Medicaid Participants to Achieve Self-Sufficiency or COMPASS, the waiver is still pending approval.
The work requirement program under COMPASS, named Training, Education, Employment and Opportunity Program or TEEOP requires able-bodied adults with income up to 138% of the federal poverty level to be involved in employment, education, and other activities for 80 hours per month to stay enrolled in Medicaid.
But in September 2019, the Richmond-Times-Dispatch reported that CMS was unlikely to put federal funds into the program, which would mean that the state would have to spend around $50 million to implement it on its own.
Medicaid expansion on its own saves Virginia money because the government matches state funds, according to according to Christina Nuckols, Virginia Department of Medical Assistance Services media relations manager. Under pre-expansion rules, members’ coverage was matched half by state funds and by federal funds, and the expansion does not change this, she said.
For the newly eligible adults under the expansion, however, Nuckols said their coverage falls under a different formula in which the federal government pays more. Since Virginia expanded Medicaid in 2019, that rate is 93%, but will change to 90% for 2020 and all future years. A hospital tax is supposed to help pay for the state’s share on Medicaid expansion.
Had Virginia expanded Medicaid between 2014 and 2016, the federal government would have covered 100 percent of the cost; in 2017, they covered 97 percent, according to Nuckols.
93rd District
In his three years of service, Democratic incumbent Mike Mullin said that his vote to expand Medicaid has been one of the most important he has taken. Medicaid membership has extended into his district, he said, and the expansion is financially prudent.
“We have lost tens of millions of dollars as a result of not taking federal money to expand Medicaid,” he said.
Virginia cannot move forward with work requirements until permission is received on the federal level to enforce those requirements, Mullin said. “As of right now, it looks like that’s going to take some time,” he said.
Heather Cordasco said she does not doubt the importance of health care but worries about its financial impact. She added that the expansion of Medicaid cut into funding for Virginia’s community services boards, which provide services for mental health issues, substance use disorders and intellectual disabilities.
“When I get [elected], I can absolutely not live with the fact that the community service boards’ budgets are not being funded in the way they need to be because I think they’re a huge part of what we need to do in our community to address health as a whole,” she said.
In May, Northam vetoed SB 1689 and HB 2443, which would have let small businesses group together to buy less expensive employee health insurance plans, Cordasco said. She disagreed with the veto, saying it could have been an alternative solution to Medicaid membership for some.
“It was something that small businesses were really behind because that’s where the gap falls for a lot of people,” she said. “They may be working full time in a business that can’t give them any benefits.”
96th District
Amanda Batten said she believes Medicaid has the potential to become a long-term financial liability. After Virginia underestimated cost savings from pre-expansion program changes, she said she welcomed the legislation proposed by Hanover senator Ryan McDougle in February. SB 1352 adds oversight on the financial aspects of Medicaid through the creation of an independent state agency, Office of Medicaid Fiscal Oversight and Accountability.
“If [Medicaid] expansion is here to stay, which it is, then we need to make sure we’re looking closely at it and planning for the future, because it eats a large part of the budget,” she said.
Work requirements are a moot point, Batten said, because of the challenges in courts other states are facing because of attempts to impose them.
“No matter how you feel about [the requirements], the reality is they might not actually be able to be enforced,” she said.
Mark Downey said it is necessary for the state to improve future estimates of Medicaid costs. While he supports Medicaid expansion, he added that Medicaid needs to include dental and vision coverage.
“As a physician, I would like to see everyone covered, but Medicaid expansion is one piece of that puzzle and now we need to do more,” he said. “I think we need to look at making sure that we have dental and vision coverage [included], which isn’t part of Medicaid right now, [as] that’s an integral part of people’s health care as well.”
Under its preventative Early and Periodic Screening, Diagnosis and Treatment program, Medicaid provides comprehensive coverage, including for dental and vision services, for individuals under 21. However, adults under Medicaid can only receive dental coverage for diagnostic appointments associated with medically necessary oral surgery and the surgery itself, according to handbooks for families and older or disabled Medicaid members. Vision coverage for adults is not included.
Libertarian James Jobe noted that despite his party affiliation, he supported the increase in healthcare coverage.
“I think it’s good that we’re covering more people,” he said. “The goal here is to make sure that everyone is covered. It is sometimes difficult dealing with private insurance companies the way it is right now.”
He said he did not like that Medicaid increased the state’s budget and thought that the budget should be cut in areas like tourism to compensate. While Jobe said he did not know a lot about the cost underestimation last year, he said he was not surprised it occurred.
“It’s one of the consequences and one of the risks you take when you get the government involved in things.”
Senate 3rd District
Herb Jones said Medicaid can do more. Legislators should prioritize coverage for everyone over expressing concern about work requirements, he said. For Jones, Medicaid should cover people earning 200% to 250% of the federal poverty level.
“I think Medicaid expansion is a great thing,” he said. “I think we need to find a way to expand it for all Virginians, because still, there’s some Virginians that earn too much. They’re going to fall through the cracks.”
Incumbent Thomas Norment said he wants Virginians to have health care but has concerns on whether the state can afford it, noting that healthcare costs are the fastest growing section of the state budget.
“I still have reservations on Medicaid,” he said.
On work requirements, the process to approve them has become more complicated, he said, because TEEOP expanded to include volunteering and other community engagement activities.
Despite his reservations, Norment said he does not want to repeal Medicaid because it would feel wrong to take health care away from people who just received it.
Madeline Monroe, madeline.monroe@virginiamedia.com
