Virginia Is Close to Expanding Medicaid After Years of Republican Opposition

Elections have consequences, goes the old saw, and in Virginia a Democratic wave in November remade the political landscape on one of the state’s longest-running and most contentious issues: whether to expand Medicaid to 400,000 low-income residents.

Republicans lost 15 seats in the House of Delegates and, left clinging to a bare majority, did an about-face on Medicaid expansion — an issue that to many had smacked of “Obamacare.” But Republicans in the State Senate, who had not faced voters, blocked expansion last month, and lawmakers failed to pass a state budget because of the issue.

Now, as Gov. Ralph Northam orders the House and Senate back to the capital on Wednesday for a special session to fix the problems, what remains of Republican opposition to expansion appears to be cracking.

Two Republican state senators said this week they would accept some form of broader Medicaid benefits, as provided under the Affordable Care Act — enough votes to carry the day on an issue that is widely popular in state polls.

State Senator Frank Wagner said on Friday that he supported Medicaid expansion, drawing a strong rebuke from leaders of his fellow Senate Republicans, who currently hold a 21-19 majority. He joined State Senator Emmett W. Hanger Jr., who in recent years has been the sole supporter of expansion among his party members in the Senate.

“I feel strongly the timing is right to move forward with the Medicaid expansion,” Mr. Hanger said in an interview on Thursday.

Broadening Medicaid would give Mr. Northam, a Democrat who won by a landslide last year, a major policy victory, one that eluded and frustrated his predecessor, Terry McAuliffe.

Mr. McAuliffe, a potential Democratic candidate for president in 2020, spent years trying to wear down Republican lawmakers on the issue, with little success.

Mr. Wagner on Friday said he backed an expansion plan as long as it required able-bodied adults to work and taxed hospitals to pay the state’s share of the $2 billion yearly costs.

Both provisions are in the House-passed version of the expansion, which received Mr. Northam’s support despite liberals’ opposition to the work requirements.

“There were things we didn’t want to see in the deal but were important to Republicans,” Brian Coy, a spokesman for the governor, said. “He believes Virginians elected him to work with everyone.”

The House and Senate must reach a compromise to pass a budget by June 30.

Although the two Republican senators’ embrace of expansion seem to promise a speedy resolution, there are enough differences in the proposals that a deal could founder.

Medicaid is the public health insurance program for low-income people jointly paid by states and the federal government. Since expanding benefits became a state option under a 2012 Supreme Court decision that upheld the Affordable Care Act, 33 states have embraced expansion. Eighteen, mostly led by Republicans in the South and Midwest, have turned it down.

Currently, Virginia has one of the most restrictive Medicaid programs. Childless adults are not eligible and working parents cannot exceed an income of 30 percent of the federal poverty level, or $5,727.

Expanding Medicaid would cover families and single adults earning up to 138 percent of the poverty level, or $28,180 for a family of three.

The dam in the House began to break in February when an influential conservative Republican, Delegate Terry Kilgore, long an expansion opponent, announced his support in an opinion column in The Roanoke Times, saying: “It is time to act.”

Mr. Kilgore’s district in southwest Virginia is one of the poorest in the state, where each July thousands of people visit a free pop-up clinic at a county fairground.

Delegate Chris Peace, another Republican who favored expansion in the House, said he had changed his position in part because in his family law practice, he had come to see the dire effects that a lack of health care had on low-income families.

He called the House bill that includes work requirements “the epitome of the Republican conservative mantra of a hand up, not a handout.”

Ahead of the special session, activists from the conservative group Americans for Prosperity have demonstrated outside Mr. Peace’s office in Mechanicsville, trying to pressure him to change his mind.

He dismissed them as remnants of the Tea Party movement straining to remain relevant. “Half are 60-plus gray-haired white men who hate Obama,” he said.

Mr. Peace said there was little question that November’s ballot wave changed the minds of Republicans in the House, who he said wanted to get Medicaid expansion off the table as a political issue before the midterm elections this year and the next round of legislative elections in 2019.

Senate Republicans opposed to expansion risk being swept from office next year, Mr. Peace said: “They haven’t seen the wave that has come everywhere.”

Just as conservative activists have targeted Mr. Peace, liberal door-knockers are pressuring State Senator Siobhan Dunnavant, a Republican expansion opponent, whose suburban Richmond district was carried by Hillary Clinton in 2016.

Dr. Dunnavant, an obstetrician-gynecologist, said that she cared about improving public health and stabilizing the costs, but that expanding Medicaid would accomplish neither.

“You don’t fix health care by throwing money at it,” she said. “You fix health care by using evidence-based programs and having them accountable.”