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Judy Ford Wason Center for Public Policy

Wason Center

March 19, 2018

Can the Assembly Come to an Agreement on Medicaid Expansion?

Issue / State

Wason Center survey on Medicaid expansion. While 58 percent of voters support expansion, there are strong partisan divides.

Medicaid expansion has been one of the most watched issues to reach the floor of the General Assembly in the 2018 long session. Medicaid is a federal and state partnership that allows for health insurance for low-income families, the elderly, and individuals with disabilities. Individuals and families with annual incomes below 138% of the federal poverty level are included in the Medicaid program. All 50 states currently participate in the Medicaid program at the minimum federal requirements; however, some states go beyond the minimum requirements and expand Medicaid in their state. Several states have already expanded Medicare such as California, Kentucky, Pennsylvania, and more. Some states are currently implementing expansion through a CMS Section 1115 Waiver. Section 1115 of the Social Security Act gives the Secretary of Health and Human Services the right to “approve experimental, pilot, or demonstration programs that promote the objectives of the Medicaid…the Secretary may waive certain provisions of the Medicaid law to give states additional flexibility to design and improve these programs”. There are also several states that are not considering Medicaid expansion and for the past few years, Virginia has fit into this category. The General Assembly heard proposals of Medicaid expansion under former Gov. Terry McAuliffe; however, the expansion was voted against every year.  After years of pushback from the Republican party, the 2018 session showed a possibility of compromise between the Democrats and the Republicans. However, the session ended on March 10 without Medicaid expansion, and now a special session has been called by Gov. Northam to continue the Medicaid discussion. The Wason Center has covered and will continue coverage on the possible Medicaid expansion in Virginia.

In a recent survey released on February 7, 2018, the Wason Center asked respondents if they supported or opposed Medicaid expansion in Virginia. 58% responded that they support the expansion of Medicaid which is a slight increase from a 56% supportive response in 2014. Overall, Virginians are in support of Medicaid expansion and are receptive to potential expansion efforts made this year in the General Assembly.

Due to sharp party polarization in the United States and Virginia representatives, citizens and legislators have had to face the possibility that a compromise may need to occur in order to expand Medicaid. Student researchers asked respondents to consider this possibility, and if they would support a partial expansion, only a full expansion, or no expansion of Medicaid. 53% of respondents supported a partial expansion, 23% only supported Medicaid expansion if it was in full, and 19% of respondents opposed the expansion of Medicaid. These percentages illustrate how the majority of Virginians would still prefer some expansion instead of no expansion of Medicaid at all.

Wason Center survey regarding voters' opinions on an expansion compromise.  Overall, 53 percent of respondents support a partial expansions with 23 percent supporting only an expansion in full and 19 percent not supporting any expansion.

After years of conversation and debate about the Medicaid expansion in the General Assembly, it all comes down to the House and Senate budget plans. On February 20, the Virginia House and Senate both approved their budget plans, which included very different viewpoints of the Medicaid expansion. The House plan would allocate $21.5 million for the job-training program that would be enacted over the next two years and would allow Medicaid to be expanded to about 300,000 Virginia citizens who earn up to 138 percent of the poverty level. House Speaker M. Kirkland Cox (R-Colonial Heights) endorsed the plan himself which caused an upset with several other Republican members. Republican members, including Cox, say that they accept Medicaid expansion as long as there is some compromise among the parties, such as work requirement impositions. The House passed its budget plan on a 68-32 vote once 19 Republicans voted for the budget to pass. Del. Steven Landes (R-Augusta) expressed that it was his first time voting against a budget in 23 years and that he believes that Medicaid expansion leads Virginia to become a part of a “failed federal policy and the strings that come attached to it” and that the vote moves the Commonwealth farther from the “Virginia way” and more towards the “Washington way”.

While the House budget has passed, the Senate budget is very different and still faces opposition. The Senate budget allows for $421 million less than former Gov. Terry McAuliffe’s budget which paves the way for state-wide cuts. Additionally, the Senate plan does not include Medicaid expansion, which Gov. Ralph Northam is urging them to reconsider. Senate Majority Leader Thomas Norment (R-James City) stated that he does not want Virginia to have to rely on 90% of federal funding and a promise from Washington and that the expansion is too expensive to consider.

When the 2018 long session in the General Assembly officially came to an end on March 10, 2018, a possible Medicaid expansion had not been included. Medicaid expansion has been a top priority of Gov. Ralph Northam which is why a special session was called to continue the discussion even after the session ended. “We’ve left one of our largest missions unfinished….as you all know, I want to be done with health care expansion,” stated Gov. Northam in response to the special session. There is usually a large partisan divide on the issue of Medicaid expansion, Republicans are staunchly against it whereas the Democrats are all for it. Virginia Republicans have voted against the expansion for the past several years and won, but this session has shown a considerable amount of compromise. In the 2018 session, several House Republicans voted in favor of expansion once a work-requirement was included in the House budget which allowed for the budget’s success. However, Senate Republicans are unhappy that their fellow party members showed support for expansion. Senate Majority Leader Norment (R-James City) reminded his fellow Republican members that they can still vote against the expansion and stated, “I do think that the House of Delegates is waiting for that moment of lucidity and epiphany to realize that their majority is 51 to 49.” Sen. Emmett Hanger (R-Mount Solon) has been deemed the Senate “wildcard” who mostly votes independently and could change the balance in the Senate vote for Medicaid. Hanger has expressed some support for the expansion; however, he does not like the tax on hospitals that has been included in the House budget to help pay for the expansion costs. Every Senator’s individual vote is very important in this vote as the entire expansion could end up hanging in the balance of a few votes. Democrats are eager to see the expansion included in the budget but they are also getting increasingly impatient; Sen. Mamie Locke (D-Hampton) and Senate Democratic leader Richard Saslaw (D-Fairfax) blame the Republicans for “holding up the entire budget process for political reasons.”

Gov. Northam is seemingly satisfied with the bipartisan progress that has been made, probably due to the fact that Medicaid expansion has not reached this level of possibility in the past years it has been proposed in the budget. “Thanks to the political courage of many leaders in both parties and both chambers, we have made significant progress on the issue over the past several months,” stated Northam at the start of the special session. Gov. Northam has warned that if a budget is passed that does not include Medicaid expansion, he will include it in his funding plan which he believes has enough support from both sides to pass. Northam has also said that he would introduce an amendment that would add expansion back into the budget and has the support from Lieutenant Gov. Justin Fairfax if there is a tie-breaking vote in the Senate. The special session began officially on April 11 and if a budget doesn’t pass by June 30, there will be another government shutdown due to partisan divides in 2018.

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