Virginia is one of 19 states that has not expanded Medicaid under Obamacare, even though 83% of its residents support expansion. Expanding Medicaid would allow individuals with incomes of up to 138% of the federal poverty level to receive health insurance through the Medicaid program, and would lead to new coverage for 400,000 Virginians. Many of these currently uncovered individuals live right on or just above the poverty line and are in the “coverage gap”—meaning that they are not currently eligible for Medicaid in Virginia but also ineligible for premium subsidies. By not expanding Medicaid, Virginia is leaving federal dollars on the table; Virginia forfeits $142 million of federal funding every month and has missed out on over $10 billion since 2014. Health care was the #1 issue for voters in the November elections that swept Democrats to #BlueWave victories. Expanding Medicaid in Virginia is the first follow-up to those victories and this is a hugely impactful and winnable fight.
In this document:
- The state of play on Medicaid expansion in Virginia
- Why we can win this fight
- How we win
- Additional resources
We have been waiting in anticipation to see if the Virginia General Assembly would take up Medicaid expansion in this year’s budget. And the answer is… complicated.
The Medicaid expansion fight is in the budget.
While federal funds matched the cost of states’ Medicaid expansion at 100% initially, the match started decreasing steadily since 2017 and will rest at a 90% match in 2020. That means Virginia will have to appropriate 6% of the total cost of the expansion now, increasing to 10% by 2020. In December, outgoing Gov. Terry McAuliffe included Medicaid expansion in his proposed budget for the fourth year in a row. McAuliffe’s budget proposes covering the remaining cost through an assessment on hospitals and providers—a funding mechanism used in many other states. For example, an Oregon ballot initiative to fund their expansion through a similar mechanism just passed in January 2018.
The House wants expansion, but the Senate doesn’t.
During the regular legislative session that ended on March 10th, the General Assembly voted on proposed amendments to former Governor McAuliffe’s budget.
Having seen the results of the voters’ wrath firsthand in the November 2017 elections, the House of Delegates voted by an overwhelming margin (69-31) to include Medicaid expansion in their proposed budget, with 20 Republicans voting yes. The House budget calls for Virginia to institute a State Plan Amendment (SPA), which would allow Virginia to swiftly implement Medicaid expansion through a simple administrative mechanism. The implementation of the expansion would begin to provide health care coverage for almost 400,000 Virginians by January 1, 2019 at the latest. The fact that the House has voted for expansion for the first time is a clear sign that elections have consequences. The voters of Virginia spoke loud and clear in November and the members of the House of Delegates had no choice but to listen.
Meanwhile, it appears that Senators in Virginia have been living under a rock for the past year. They blatantly disregarded the will of the voters by omitting expansion from their proposed version of the budget and rejecting a floor amendment for expansion on a party line vote (21-19), with all Republicans voting against expansion. By not including expansion, which would save the state $422M, the Senate was forced to propose deep cuts to critical programs for education, public safety, student aid, and mental health.
Things are getting spicy.
The wildly different budget proposals led to an impasse between the two chambers, and things are getting heated. On March 9th, the Senate Majority leader gave a fiery speech calling for the House Speaker to resign. The General Assembly then adjourned on March 10th without passing a budget or making a decision about Medicaid expansion.
They are back now for a special session that started on April 11th and must pass a budget by a July 1st deadline.The House Appropriations committee met on April 13th and passed a budget including Medicaid expansion and the full House quickly followed suit on April 17th. The ball is now in the Senate’s court.
Here is what still needs to happen:
- The Senate Finance Committee will discuss the budget on Wednesday, April 18th. The full Senate must then vote on the budget on the floor.
- The House Appropriations Committee needs to hear and pass the House budget. This happened on Friday, April 13th.
- The House will vote on the budget on the floor on April 18th.
- The Senate needs to send their budget to Finance Committee and eventually also vote on it the floor. The Senate has no planned hearings or meetings scheduled so we have no idea when this will happen. The Senate Majority leader seems to be in no rush to get this done.
- The House and Senate budgets need to go to conference committee to negotiate the details.
- Both chambers need to vote on the conference committee budget and send it to the Governor.
- The Governor needs to sign it as is or send back amendments which also need to be voted on. (Note that the Lt. Governor can break ties on budget amendments but not the full budget itself).
You can see that there are still a lot of steps that need to happen to make Medicaid expansion a reality in Virginia. Things will be tense in this special session and it is important that your lawmakers hear from YOU!
The devil is in the details of the House budget.
While the House has passed Medicaid expansion in their version of the current budget, Republicans have also tried to include some problematic provisions that would erect barriers between people and the health care that they need.
In Virginia, the GOP is using work requirements as the “price of admission” for expanding Medicaid. The House budget includes a provision that directs the Department of Medical Assistance Services (DMAS) to apply for a federal section 1115 waiver to impose work requirements on Medicaid. Section 1115 waivers are granted by the federal government to allow states to implement the expansion in a different way than is outlined in the Affordable Care Act. This comes after the Trump administration indicated that they would issue waivers for states to impose work requirements for Medicaid. Kentucky was the first state to be granted such a waiver, but there is already a pending lawsuit against it.
Most recently during the special session, the House Appropriations Committee added a “lock-out period” to the work requirements so that any enrollee who did not meet the work requirements for 3 months would be kicked off Medicaid and could not re-enroll until the following year.
We know that work requirements don’t work; they serve only to make people jump through bureaucratic hoops to obtain the health care that they need. 80% of Medicaid recipients already work, and those that don’t are primarily people with disabilities or long-term injuries, or caretakers for other family members. Furthermore, the implementation of a work requirement system would cost the state $10 MILLION, money that could be better spent on providing better health care to Virginians.
We can win this fight, if we fight and fight hard. Democrats have tried for years to expand Medicaid without any success, but this year is different. We now have the political landscape to make this a reality.
The House of Delegates went from near supermajority Republican advantage (66-43) to a near split (51-49) that hinged quite literally on a random drawing. Beyond the 49 Democrats who support expansion, one Republican has come out in support of expansion, two others have supported it in the past, and there are several others who barely won re-election (by margins of less than 150 votes).
The State Senate also stands with a slight Republican majority at 21-19. All 19 Democrats support expansion, two Republicans have supported it in the past, and there are several vulnerable Republican members who represent districts won by Democrat Ralph Northam in the Governor’s race.
Two key Republican Senators (Emmett Hanger and Frank Wagner) have said they could be open to voting to expand Medicaid which could mean that we have enough votes to win this campaign. A third Republican Senator, Jill Vogel, seems to be on the fence. But we can only win if Virginians make it loud and clear that Medicaid expansion is a priority.
We win by showing up, just like we did in November. From now until the budget is passed, the fate of healthcare for almost 400,000 Virginians hangs in the balance. We need to send a loud message that Virginian voters have spoken, and the time for Virginia to expand Medicaid is now—with no strings attached.
The budget introduced by outgoing Governor McAuliffe included Medicaid expansion, which the House kept and the Senate stripped out. The two chambers were unable to come to an agreement before the end of the legislative session March 10th so they have returned for a special session that started on April 11th. It’s time to turn up heat up now that legislators have returned for their special session.
CALL YOUR STATE REPRESENTATIVES AND TELL THEM TO SUPPORT MEDICAID EXPANSION WITHOUT WORK REQUIREMENTS.
For Senators Hanger, Wagner, and Vogel (the swing votes that could change everything)
If Senator Hanger, Wagner, or Vogel are your Senators, please call them every day. They could be the swing votes that brings healthcare to 400,000 Virginians.
Caller: Hello! My name is _______ and I’m calling from [part of state]. I’m calling to let Senator <Hanger/Wagner/Vogel> know that I support Medicaid expansion and I am very happy to hear that <he/she> is considering voting for expansion. Please let Senator <Hanger/Wagner/Vogel> know that I support expansion and would support <him/her> if <he/she> voted for it.
Staffer: Thank you for your call. I will pass that information on to Senator <Hanger/Wagner/Vogel>.
Caller: Thank you. In November, Virginians have made it clear that we want to expand Medicaid and we have the opportunity to bring health care access to almost 400,000 Virginians. Please let Senator Hanger know that his constituents are watching and we will gladly vote him out in the next election.
For Senators/Delegates that voted NO on Medicaid Expansion
ALL REPUBLICAN SENATORS (except Hanger, Wagner, Vogel)
The Following Republican House Delegates: Adams, L.R., Bell, Richard P., Bell, Robert B., Brewer, Byron, Campbell, Cline, Cole, Collins, Fariss, Fowler, Freitas, Gilbert, Habeeb, Head, Hugo, Landes, LaRock, Leftwich, McGuire, Miyares, O'Quinn, Pogge, Poindexter, Ransone, Robinson, Rush, Ware, Webert, Wilt, Wright
Caller: Hello! My name is _______ and I’m calling from [part of state]. I’m calling to let [Senator/Delegate] know that I support Medicaid expansion and am severely disappointed in [Senator/Delegate] for voting against Medicaid expansion in the state budget. I expect [Senator/Delegate] to advocate for Medicaid expansion during the special session now.
Staffer: Thank you for your call. I will pass that information on to [Senator].
Caller: Thank you. In November, Virginians have made it clear that we want to expand Medicaid and we have the opportunity to bring health care access to almost 400,000 Virginians. Please let [Senator/Delegate] know that [his/her] constituents are watching and we will gladly vote [him/her] out in the next election.
For House Delegates that voted YES on Medicaid Expansion
ALL DEMOCRATIC DELEGATES
The following Republican House Delegates: Bloxom, Cox, Davis, Edmunds, Garrett, Helsel, Hodges, Ingram, Jones, Kilgore, Knight, Marshall, Miyares, Morefield, Peace, Pillion, Stolle, Thomas, Ware
Caller: Hello! My name is ________ and I’m calling from [part of state]. I’m calling to express my support of Medicaid expansion and gratitude that the House has included expansion in the budget. I expect [Senator/Delegate] to continue to strongly advocate for Medicaid expansion without work requirements.
Staffer: Thank you for your call. Work requirements are part of an ongoing negotiation to expand Medicaid in Virginia and will not affect that many people. This is the only way we will get expansion done this year.
Caller: If it will not affect that many people, then it makes no sense for the state to spend $10 million on a work requirement program. Most folks on Medicaid work already and those that don’t are usually sick, injured, or caregivers. We should not place any barriers between people and the health care that they need. I understand that there are negotiations taking place and I expect [Delegate] to fight for expansion that does not require any waivers from the Trump administration, including work requirements.
Wondering how your legislators voted last time?
Voted for Medicaid Expansion:
Barker, Dance, Deeds, Ebbin, Edwards, Favola, Howell, Lewis, Locke, Lucas, Marsden, Mason, McClellan, McPike, Petersen, Saslaw, Spruill, Surovell, Wexton
Voted against Medicaid Expansion:
Black, Carrico*, Chafin*, Chase, Cosgrove, DeSteph, Dunnavant*, Hanger*, McDougle, Newman, Norment, Obenshain, Peake, Reeves, Ruff, Stanley, Stuart, Sturtevant*, Suetterlein, Vogel*, Wagner*
* may be particularly vulnerable/ could be swing votes
House of Delegates
Voted for Medicaid Expansion:
Adams, D.M., Aird, Austin, Ayala, Bagby, Bell, John J., Bloxom, Bourne, Boysko, Bulova, Carr, Carroll Foy, Carter, Convirs-Fowler, Davis, Delaney, Edmunds, Filler-Corn, Garrett, Gooditis, Guzman, Hayes, Helsel, Heretick, Herring, Hodges, Hope, Hurst, Ingram, James, Jones, J.C., Jones, S.C., Keam, Kilgore, Knight, Kory, Krizek, Levine, Lindsey, Lopez, Marshall, McQuinn, Morefield, Mullin, Murphy, Orrock, Peace, Pillion, Plum, Price, Rasoul, Reid, Rodman, Roem, Sickles, Simon, Stolle, Sullivan, Thomas, Torian, Toscano, Tran, Turpin, Tyler, VanValkenburg, Ward, Watts, Yancey, Mr. Speaker
Voted against Medicaid Expansion:
Adams, L.R., Bell, Richard P., Bell, Robert B., Brewer, Byron, Campbell, Cline, Cole, Collins, Fariss, Fowler, Freitas, Gilbert, Habeeb, Head, Hugo, Landes, LaRock, Leftwich, McGuire, Miyares, O'Quinn, Pogge, Poindexter, Ransone, Robinson, Rush, Ware, Webert, Wilt, Wright