Medicaid and Bipartisan Cooperation in Richmond

For four years, Speaker of the House Bill Howell and his 66-member-strong Republican caucus in the House of Delegates was the GOP bulwark against the efforts of Democratic Gov. Terry McAuliffe to expand Medicaid in the commonwealth.

But then came the blue tsunami of Election Day 2017 when Democrats gained 16 seats in the the lower chamber of the General Assembly, battling to almost parity, 49 Democrats to 51 Republicans. Couple that with a new, more low-key governor (Democrat Ralph Northam) and a new speaker (Republican Kirk Cox), and the stage was set for dramatic change.

From the start of the 2018 Assembly session, bipartisan cooperation between Northam and Cox on a number of high-profile topics that had floundered during the McAuliffe/Howell era began to happen. First it was relatively small issues, almost exercises in trust-building, but leading up to the biggest issue of all that had bedeviled Richmond: Medicaid expansion.

Last Sunday, the House and Senate released their biennial budget documents, and the House budget included something that few people in the capital thought they’d ever see: a recommendation to expand Medicaid eligibility to 137 percent of the federal poverty line, allowing the state to tap into billions of federal tax dollars under the Affordable Care Act — tax dollars Virginians have been paying for years but that have been going to other states.

In many ways for Speaker Cox, it was a recognition of political reality in Washington.

Speaking to the Richmond Times-Dispatch, Cox was blunt: “My long-standing concerns about the cost of expansion aren’t going away, but unfortunately the ACA is here to stay, and the Trump administration is the best chance to secure conservative reforms. … Instead of fighting a losing battle against straightforward Medicaid expansion, I believe the House should lead by putting forward a responsible plan similar to what Vice President Mike Pence adopted as governor of Indiana.”

Primary to the changes Pence got approval for from the Obama administration was a work requirement for Medicaid recipients. In 2015, Indiana became one of the first Republican-led states to take advantage of ACA dollars for Medicaid expansion.

The House’s budget would accept $3.2 billion in federal tax dollars to pay for 90 percent of the cost of expanding Medicaid eligibility to persons at 137 percent of the federal poverty line beginning on Jan. 1, 2019. The remaining 10 percent of the cost would come from new “provider assessment” on the revenues of Virginia’s hospitals. Hospital leaders have calculated that this “bed tax,” as it’s sometimes called, would still be less costly for them than having to write off the uncompensated costs of care for uninsured Virginians. (That in itself would be a boon for the public as written-off costs wouldn’t then be calculated into charges Virginians with private insurance pay.)

Tapping into the ACA dollars — tax dollars Virginians are already sending to Washington, we want to re-emphasize — would provide more than 300,000 uninsured Virginians — children, the elderly and the working poor — with basic health care. Enacting the “provider assessment” on hospitals to pay the state’s 10 percent share of the costs would free up more than $420 million in state dollars to devote to other high-priority items that have been put on ice for years as politicians battled over Medicaid expansion: targeted raises for state employees, higher pay for teachers and increased higher-education aid for students.

The Senate budget, though, is starkly different from the House’s proposal. Medicaid expansion — with the influx of federal dollars and the state’s “provider assessment” — is out, creating a gap between the two plans of more than $400 million. Senate Majority Leader Tommy Norment, R-James City County, acknowledged “excruciatingly painful decisions” to make deep cuts across the board to fill the hole: Higher and K-12 education, public safety, student aid and mental health programs all went under the ax. The Senate budget even cut reparations owed to a man wrongly imprisoned for decades. Sen. Janet Howell, a Fairfax Democrat, was blunt in her assessment of the cuts: “And why have we made these cuts? We’ve made them to deprive low-income people of health care.”

In the next two weeks, House and Senate budget conferees will meet to hash out the differences between the chambers’ proposals. No one knows what ultimately will wind up in the final document the Assembly will send to Gov. Northam. And then, the governor has the power to amend the budget, subject either to approval or veto override by the Assembly.

What we are most happy about, though, is not the House’s Medicaid expansion or the Senate’s fiscal wariness of Washington but the fact that bipartisan governing seems finally to have returned to Richmond. That’s something that benefits us all going forward.

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