Virginia elections could signal future of Medicaid expansion
Puffing a cigarette just outside the emergency department at Mary Washington Hospital in Fredericksburg, Va., Shana Cox, 23, bemoaned that she had to return to the ED again to receive urgent care for a medical problem, this time for a cold that wouldn’t go away.
She said she makes the trek there about once a month. She used to have Medicaid but lost it when she gave up custody of her children due to her depression, so she’s uninsured. As a low-income worker at Taco Bell, Cox almost certainly would qualify for coverage under the Medicaid expansion plan proposed by Democratic Gov. Terry McAuliffe.
In the Nov. 3 state legislative elections, Virginia voters like Cox will have the opportunity to express their views on Medicaid expansion. Most of the Republican candidates for House of Delegates and Senate seats oppose McAuliffe’s expansion proposal, while Democrats support it.
All 140 seats in both chambers of the Virginia General Assembly are up for election. Currently, Republicans control both the House and Senate. Democrats need to pick up only one Senate seat to gain effective control of that chamber, though Medicaid expansion would still face an uphill fight in the House, where the GOP holds a two-thirds majority.
Some observers say the Virginia state elections not only could swing the outcome of that state’s Medicaid battle but could affect expansion’s national momentum. A pivotal election also will be held in Kentucky, where the Republican candidate has vowed to roll back outgoing Democratic Gov. Steve Beshear’s Medicaid expansion. A new governor also will be elected in Louisiana to replace outgoing Republican Gov. Bobby Jindal, a strong expansion foe; all four leading candidates have said they would consider some form of expansion. The ballot results in these state races could send a message to GOP leaders in other states such as Florida, North Carolina, Utah and Wyoming, where expansion is being debated.
“The national implication of the Virginia races is that it could bring Medicaid expansion back into the national conversation,” said Geoffrey Skelley, a political analyst at the University of Virginia Center for Politics. “Virginia is a key swing state for the 2016 presidential elections.”
But Shana Cox had no idea there was a political fight over expanding Medicaid in her state. She just lamented that she was no longer eligible for Medicaid. “I was doing so much better when I had Medicaid,” she said. “I was able to get my medications and see a doctor regularly.”
The Virginia Medicaid battle is playing out in the 12th Senate District, which includes Richmond. There, Dr. Siobhan Dunnavant, an OB-GYN and a Republican, is facing off against registered nurse Deborah Repp, a Democrat. The seat they are vying for is being vacated by retiring state Sen. Walter Stosch, one of only three Senate Republicans who aligned with McAuliffe and the Democrats last year to support a private-plan Medicaid expansion proposal similar to Arkansas’ model.
It’s expected that McAuliffe will again try to pass his plan
in 2016, after failing this year. Dunnavant is firmly against expansion, while Repp is for it. The state’s hospitals, which pushed hard for Medicaid expansion last year, are taking a more cautious approach now, stressing the need for some type of legislative action to ease the financial stress on hospitals from uncompensated care and Medicare payment cuts.
If the state were to expand Medicaid under the Affordable Care Act, as many as 400,000 Virginians with incomes up to 138% of the federal poverty level could gain coverage, and the state could receive up to $14 billion in additional federal
funds by 2022, the Urban Institute estimated last year.
In an interview, McAuliffe stressed the importance of Medicaid expansion. “There is no question that failing to get this done will hurt our hospitals, particularly in rural areas,” he said via e-mail. “It will also be a missed opportunity to create jobs, increase budget revenues and build a healthier workforce. I am going to continue to make the case, and hope leaders in the General Assembly come to the table so we can do the right thing in the best way for Virginia.”
But Dunnavant, like many of the GOP candidates, opposes all things Obamacare. “I will be a constant voice against Obamacare; I’ll be a constant vote against expanding our broken Medicaid system!” she says on her campaign website. “Everything I’ve seen in the data tells me Medicaid expansion in Virginia would be a mistake,” she said in an interview.
Repp takes the opposite view. “Frankly, it’s beyond me how she can say we shouldn’t expand Medicaid,” Repp said. “Our hospitals are suffering mightily.”
Last week, the Virginia Hospital & Healthcare Association launched a major multimedia campaign to highlight the key role of hospitals in the state’s economy, the financial struggles its members are facing, and the need for legislative relief. The association reported that one-third of the state’s acute-care hospitals had negative operating margins in 2013, the last year for which data are available. In rural Virginia, 17 of 37 hospitals operated in the red. Hospitals provided $627 million in free or discounted care in 2013, up 57% since 2008.
Hospitals’ financial woes are only expected to worsen because federal budget sequestration cuts require a continuous 2% drop in Medicare payments for the foreseeable future. Those cuts come on top of the Medicare disproportionate-share cuts required by the Affordable Care Act.
At the hospital association’s Sept. 16 news conference in Richmond, health system CEOs from around the state warned that without legislative relief from the state, cuts in services, layoffs or even closures could result. “There are a lot of hospitals and health systems in the state today that are bailing water pretty seriously,” said James Cole, CEO of the Virginia Hospital Center in Arlington.
Mark Merrill, CEO of Valley Health, based in Winchester, said his organization was considering closing its trauma center in western Virginia, which means some people in the area would have to cross into West Virginia to receive trauma care. “That trauma center is something that we are evaluating,” he said. “It’s a very expensive proposition to maintain.”
Last year, the state hospital association pressed hard for Medicaid expansion. But at the news conference, none of the hospital leaders who spoke explicitly raised the issue. They repeatedly referred to a “Virginia solution” to address hospitals’ financial problems. “Are you guys afraid to say Medicaid expansion?” one reporter asked.
“Let’s be candid. We started out talking about solutions, and it hasn’t really gotten us anywhere,” replied Mary Mannix, CEO of Augusta Health, Fishersville.
The hospital association’s economic arguments are a smart approach politically, said Joshua Ulibarri, a partner at Lake Research Partners who is polling for the VA House Democratic Caucus and three Democratic state senators. Medicaid expansion trails behind jobs and education as an issue for voters, he said.
The key Virginia races to watch are in the Senate, because it’s unlikely the Democrats can win a majority in the House, said Stephen Farnsworth, a political science professor at the University of Mary Washington in Fredericksburg. Democrats only need to gain a single Senate seat to create a 20-20 split and throw the tie-breaking vote to Democratic Lt. Gov. Ralph Northam. That scenario would put McAuliffe and the Democrats in a stronger position to push through Medicaid expansion, though it still would face a tough hurdle in the House, Farnsworth said. Republican House Speaker William J. Howell has vowed never to vote to expand Medicaid.
Making McAuliffe’s task even harder is that the Republican primaries eliminated some GOP candidates who might have been open to some form of Medicaid expansion. In the 24th Senate District, Sen. Emmett Hanger, who proposed Medicaid expansion through a private-plan model, had to fight hard to beat back a primary challenge. “Just discussing the possibility of a Medicaid expansion put (him) at risk in the primary,” said Beth O’Connor, executive director of the Virginia Rural Health Association.
Dunnavant said she doesn’t believe the Obama administration would give her state the autonomy it needs to create a uniquely Virginian approach to providing coverage to the poor. She’s also concerned about expansion’s effect on the state budget, even with the federal government picking up 100% of the cost through 2016, dropping to 90% by 2020.
Chris LaCivita, a veteran Republican political operative who is working on the state Senate campaign of Dr. Nancy Dye, a retired Roanoke surgeon, said it’s possible Congress will reduce the federal contribution. “Anybody that believes this money will always be there is naive,” he said.
Republican state Sen. Bill Carrico in the 40th Senate District, opposes expansion even though a hospital in his district, Lee Regional Medical Center, Pennington Gap, closed last year, and residents in his southwest Virginia district have one of the state’s highest uninsured rates. He argued that even his uninsured constituents oppose expansion. “The majority of people in my district, whether they have coverage or not, don’t trust the Obamacare system,” he said.
Back at Mary Washington Hospital in Fredericksburg, Todd Welsh, 32, who works as a contractor and has no health insurance, says grueling hours and heavy lifting have taken a toll on his health. He suffers searing back pain that keeps him up at night. This is his 10th visit to the ED in two years for the same problem; each visit costs him $600 to $700, but he has been ignoring the bills for months. Welsh, who supports five children, said after paying household bills, he has nothing left.
But like Shana Cox, he had no idea that there was a political fight over Medicaid, and expressed doubt that he’ll ever get coverage. “I don’t feel like there is a light at the end of the tunnel for me,” Welsh said.