Health Care

Expanding Medicaid in Virginia


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

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.

On February 18th, the House Appropriations and Senate Finance Committees released their proposed amendments to former Governor McAuliffe’s budget. Having seen the results of the voters’ wrath firsthand in the November 2017 elections, the House committee included Medicaid expansion in their proposed budget. The Senate committee did not include expansion at all.

The House released two bills: HB29, which covers the current budget through June 30th and would go into effect immediately, and HB30, which covers the budget for the next two years starting July 1st. HB29 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 included 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 have blatantly disregarded the will of the voters by omitting expansion from their proposed version of the budget, leaving $422M of projected savings from expansion on the table.

The devil is in the details of the House budget.

While the House Appropriations Committee has included Medicaid expansion in their version of the current budget, Republicans have also tried to include some problematic provisions in the next two-year budget that would erect barriers between people and the health care that they need.

On February 13th, the House of Delegates passed HB338 which would direct 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.

In Virginia, the GOP is using work requirements as the “price of admission” for expanding Medicaid. The House budget in HB30 (2018-2020) directs DMAS to apply for a section 1115 waiver to impose work requirements (as outlined in HB338), as well as premiums and co-pays for people that earn between 100-138% of the poverty threshold.

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.

Why we can win this fight

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.

These slim margins, as well as the momentum from November, make this a very winnable campaign. But we can only win if Virginians make it loud and clear that Medicaid expansion is a priority.

How we win

We win by showing up, just like we did in November. From now until March 10th, the fate of health care 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.

Because the expansion is being pursued through the budget, the key dates of the budget process will drive our action. The budget introduced by outgoing Governor McAuliffe included Medicaid expansion and the General Assembly finance committees have now released their proposals. Below is the timeline for our health care victory.

Now thru February 22: Tell your reps what you think about their budget proposals

This week, it is absolutely critical that we show up and make a lot of noise. The budget proposals have been released and the public needs to make their reactions known to the legislature. We need to express our severe disappointment with the Senate for neglecting the wishes of Virginians by omitting expansion, and thank the House for including Medicaid expansion, while making sure that they also know that we disapprove of their problematic conservative provisions.

Use the call scripts below to call your State Senator and Delegate.

Find Your State Senator and Delegate Here

For State Senators

Caller: Hello! My name is _______ and I’m calling from [part of state]. I’m calling to let [Senator] know that I support Medicaid expansion and am severely disappointed that it was not included in the Senate’s version of the budget. I urge [Senator] to introduce a floor amendment this week to include expansion.

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] know that [his/her] constituents are watching and we will not be afraid to vote [him/her] out in 2019 if [he/she] does not help Medicaid expansion happen this year.

For House Delegates

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 [Delegate] to vote YES on HB29. However, I am disappointed that the legislature is also trying to include work requirements as a “price of admission” for expansion. We know that work requirements only function to prevent people from getting the health care they need. I would like to urge [Delegate] to introduce a floor amendment to remove the inclusion of work requirements, premiums, and copays from HB30 when it comes to the floor this week.

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.

February 19: Join the People’s Caravan and Rally

Indivisible groups all over the state are coming together to lobby their legislators the day after the budget is released. On President’s Day, Monday, February 19th, our groups will join together in caravans from the four corners of the state, picking up folks along the way, and will converge on the state Capitol in Richmond for a rally for Medicaid expansion. You can either join the caravan or donate a message for the travelers to bring to lawmakers in Richmond!

Learn more about this mobile and impactful action Here

Learn more about this mobile and impactful action here. Post your photos and tag with #ExpandVAMedicaidNow!

February 22: Budget floor vote and time for accountability

On or around February 22nd, the budgets will be brought to the floor for possible amendments and a vote. We will update this explainer with more information but get ready to hold your representatives accountable for their vote!

Late February thru Early March: Budget in conference committee

After being voted on the floor of both chambers of the legislature, the budget will get sent to a conference committee to iron out the differences. We will be keeping a close eye on developments and will update as things unfold.

March 8: Budget reported out from conference committee

This is the moment of truth for what the the ultimate proposal will look like. Stay tuned.

March 10: Budget voted on the floor

When we fight, we win.

Additional Resources

Healthcare for All Virginians Coalition

KFF Virginia Medicaid Fact Sheet