Vir­ginia elec­tions could sig­nal fu­ture of Med­i­caid ex­pan­sion

Modern Healthcare - - NEWS - By Vir­gil Dick­son

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.

Gov. Terry McAuliffe’s ex­pected 2016 push to ex­pand Med­i­caid in

Vir­ginia will ride on Dems pick­ing up just one more Se­nate seat.

At a news con­fer­ence, health sys­tem CEO Mary Man­nix, right,

said call­ing for Med­i­caid ex­pan­sion “hasn’t got­ten us any­where.”

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