David Toscano

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David Toscano
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General Assembly 2014

Pollin’ and Explainin’

May 16, 2014 by David Toscano

Earlier this month a poll from Christopher Newport University’s Wason Center has the Commonwealth’s political class in a “twitter.” Republicans argue that the poll is conclusive proof that Virginians do not favor Medicaid expansion, and some Democrats are choosing to ignore the poll on the theory that “if you are explainin’, you are losin’.” My take is that all polls are “data points” that need to be assessed at face value, and we have an obligation, as elected officials, to explain what policy choices are before us and how citizen views should be taken into account in making them.

All polls are surveys based on samples from a larger population. Polling is not a perfect science, and is subject to considerable error. A good poll should be both scientifically valid and reliable. To be so, social scientists first need to be sure that the questions test what they are designed to test. Second, the results should be capable of being replicated through another sample. So does the recent CNU poll pass the test? In some ways, yes; and in others, no.

First, to ensure a scientifically valid poll, the questions must first be worded in a clear and neutral fashion. Without clarity or neutrality, the results will be slanted. This is clearly where the CNU poll has problems. As Republican Sen. Emmett Hanger of Augusta pointed out, the poll’s statement “Democrats propose to subsidize…” is factually incorrect; there are three Republican Senators who developed and support “Marketplace Virginia” and that approach is not “strict Medicaid expansion”. There are several other words that could influence the outcome of a poll such as “subsidize, fear, waste, and abuse.”[1]

Second, the subject in the sample must be randomly selected; in this poll, that appears to be the case.

Finally, the survey must be sufficiently large to reduce the “built-in sampling error.” That usually requires about 400 or more subjects for a population the size of Virginia, something that apparently the CNU poll has met.

But the biggest issue in the use of polling data, and thus the biggest problem with the CNU poll, is the extrapolation from one data point of the survey results into suggesting the results suggest a “trend.” When the CNU pollster concludes, as a result of the survey, that “Democrats are losing the debate on Medicaid expansion,” he is making a jump not justified by the poll.

Although this is not really a “push poll,” you cannot infer a trend simply on the basis of these results. The only way you can discuss a trend is if the exact same question was asked to a randomized sample from the same universe at two different periods of time.[2] The CNU poll did not do this and any conclusions about “trends” are meaningless as a result.

As always, it is a pleasure representing you in the General Assembly and I hope that you will contact me with your views and comments about issues affecting the region and the Commonwealth.

David Toscano
[1] The actual poll question reads, “In [the Medicaid] debate, the Democrats propose to subsidize private insurance for 400,000 uninsured and low income Virginians by using federal Medicaid money that would otherwise not come to Virginia. Republicans oppose this expansion because they fear the federal Medicaid money will not come as promised, and also say the current Medicaid program has too much waste and abuse and needs reformed [sic] before it is expanded. I’d like to know where you stand, would you say that you generally [RANDOMIZE: “support using federal Medicaid money to expand health coverage” or “oppose using federal Medicaid money to expand health coverage”]?
 
[2] The February 3, 2014 CNU poll asked the question: “Medicaid is a health care program for families and individuals with low income that is funded by both federal and start tax dollars. Currently, Virginia is faced with decision about whether to expand the Medicaid program to cover an additional 400,000 mostly working poor Virginia who are uninsured. In general, do you support Medicaid expansion or oppose it?” 56% of the respondents said they supported expansion.

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Filed Under: General Assembly 2014 Tagged With: Affordable Health Care, Medicaid expansion, Virginia Health Insurance Marketplace

ICYMI: Senator McEachin Sends Letter to Speaker Howell

May 8, 2014 by David Toscano

Where are the promised alternatives?

Last week, Senator Don McEachin, Chair of the Virginia Senate Democratic Caucus, sent a letter to Speaker Howell simply asking to see the alternatives to the expansion of Medicaid as proposed by Speaker Howell in his January op-ed piece, and echoed by his House Republican Caucus members. You may read Senator McEachin’s letter to Speaker Howell here. I also share with you my latest comments on this issue.

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Filed Under: General Assembly 2014 Tagged With: Affordable Health Care, Medicaid expansion

Common Ground on Medicaid

May 2, 2014 by David Toscano

Is There A Reason To Be Optimistic?

As someone who has made enough speeches on the House floor this session on Medicaid expansion to have my own “YouTube” channel on the topic, I have listened intently to my Republican colleagues to see if there might be some common ground on this issue. If you were to count the number of times that Republicans rejected the so-called “Obamacare expansion of Medicaid,” you would think there was no opportunity for agreement. But beneath the rhetoric, I continue to believe there are certain principles upon which both parties can agree. I list them below and challenge my colleagues to reject them if they do not agree.

First, there is broad bipartisan consensus that we should attempt to protect the most vulnerable of our population. Otherwise, why would the House Republicans include additional funding to provide assistance to the intellectually and developmentally disabled (we call this “ID/DD waivers”) over and above what is required by federal law? This population is among the most costly to assist, and the expansion of this assistance over the last ten years is testament to Republicans and Democrats who seek to help those in need. But these efforts to increase the number of “ID/DD waivers” look much like an expansion of Medicaid, and to a more costly population that would be covered under present expansion proposals.

Second, it is in the interests of all Virginians to have as many citizens covered by insurance as possible. I say this not only because so many of my colleagues have enrolled in the Virginia state insurance plan (a $2.6 million yearly appropriation in our budget for us, our staffs, and the Clerk’s staff), but also because it makes sense. When people with insurance use doctor’s offices, instead of the ER, they tend to stay healthier…and, if more people have insurance coverage, those of us who have this coverage are not subsidizing those who do not. How we get there is another issue altogether; the best solution is for citizens to have a job that either pays a living wage and/or provides benefits. This is, of course, difficult for many, particularly the frail, the elderly, and the disabled. Our Republican colleagues have not presented an alternative to Medicaid expansion that can get this done.

Third, Republicans and Democrats alike believe that Medicaid dollars (and all government spending) should be spent in the most efficient way possible. Republicans argue that the expansion of Medicaid could eventually “crowd out” other needed services (after the federal reimbursement drops from 100% to 90% in 2020), but what they do not share is the fact that Medicaid is expanding with or without the Affordable Care Act (ACA), largely because our population is aging and because of other economic conditions. That is why Democrats and Republicans have pushed Medicaid reform. The numerous reforms over the last several years have generated millions in savings. It is anticipated that an audit of the Medicaid program will show that “waste” in the program is not as widespread as some Republicans claim, with the result that expansion will be easier for them to justify.

Fourth, hospitals face financial challenges because of how the ACA was constructed and interpreted. Medicare reimbursement rates to hospitals will decline as part of the ACA and the Supreme Court’s decision that made state expansion of Medicaid voluntary will affect their bottom line. You will occasionally hear Republican delegates criticize the “rates of financial return” of various hospitals, but, at heart, they understand the risks to teaching and rural hospitals that are brought on by decisions in Washington, even though they are not yet willing to accept the responsibility to really tackle it. Republicans restored some cuts proposed by Governor McDonnell, but those efforts pale by comparison to the dollars available to the hospitals if we close the coverage gap.

Fifth, there is bipartisan concern about the long-term commitment of the federal government to fund additional enrollees in the Medicaid program. At present, the federal government would reimburse 100% of the cost of the enrollees, which would decline to 90% in future years (the present reimbursement rate is 50%). Given this concern about the long-term federal government commitment, the Virginia Senate has installed, as part of its Marketplace Virginia concept, a Medicaid trust fund into which funds would be deposited and held so that, in future years, if the federal government reneged on its promise, there would be sufficient monies to cover the program. This proposal has largely been overlooked in the debate.

Sixth, if you ask them privately, most Republicans would acknowledge that it is in our interest to bring as many of Virginia’s tax dollars back to the Commonwealth as possible. Republicans have implicitly made that point every time they argue that we are a “net receiver” of tax dollars. I have heard no Republican dispute the fact that Virginia taxpayer dollars are going to Washington to help fund the ACA. This is $5.2 million per day, which, without some form of expansion, will otherwise not come back to Virginia. Republicans counter that much of the funds for expansion come from “borrowed money,” but there is no doubt that the monies flowing from Virginia taxpayers to Washington are not coming back to the Commonwealth without some form kind of Medicaid expansion.

Seventh, this debate should not just be about coverage, but about health. This has largely been ignored in the debate, but it is true that reforms in the Medicaid program will need to focus on “healthy outcomes” instead of simply providing “services.” This is one reason why there is so much discussion of “managed care,” a concept designed to provide better outcomes at lesser costs. Implicit in this discussion is the notion that a healthcare model which provides incentives for citizens to seek care in emergency rooms (where most uninsured go at present), rather than with private physicians, brings potentially less care at clearly higher costs. This dynamic leads inevitably to the hope that more physicians will accept Medicaid patients, even though their reimbursement rates for this population are lower as a result. This is a far larger problem than Medicaid expansion, but one that most policy makers understand will need to be addressed.

Eighth, Democrats and Republicans agree that reform of Medicaid is key. Otherwise, why would we have agreed, on a bipartisan basis, to support the Medicaid Innovation and Reform Commission, which has already approved substantial reforms and generated hundreds of millions of dollars in savings in the program? Certainly, much more needs to be done, but the opponents of expansion have not yet identified what specifically would need to be accomplished before expansion occurs. Instead, we merely hear comments that “we will not be pushed off of our position,” or “I am not in favor of Medicaid expansion, and I have never been in favor of Medicaid expansion, and never will be.”

I may be wrong; perhaps my Republican colleagues do not believe in all or some of the above principles. If they do not accept them, it is time for them to say why they do not. If they do, let’s get together to accomplish some good for our people. “Just say no” is not a policy that our constituents understand, nor that our Commonwealth deserves.

As always, it is a pleasure representing you in the General Assembly and I hope that you will contact me with your views and comments about issues affecting the region and the Commonwealth.

David Toscano

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Filed Under: General Assembly 2014 Tagged With: Affordable Care Act - Virginia, Affordable Health Care, Medicaid expansion

Budget Dispute Continues

April 11, 2014 by David Toscano

We returned to the General Assembly on Tuesday, April 8, 2014, to continue our debate over the budget. It was a very short session because House Republicans refused to consider a budget passed by the Senate which included provisions for closing the coverage gap for up to 400,000 Virginians. In early March, Governor McAuliffe proposed a new budget that added $225 million for education and public safety because of the expansion of Medicaid. These savings were generated by taking monies that our taxpayers have sent to Washington and bringing them back to Virginia, where they can work for us. With Medicaid expansion, the Commonwealth would receive federal monies to provide 100 percent of the reimbursement of costs of new enrollees. The expansion would create 30,000 new jobs while bolstering our hospitals which are facing large financial losses. We have lost almost $500 million since January 1 by refusing Medicaid expansion.

The McAuliffe budget proposed additional spending in critical areas such as jobs and economic development, public safety, and public education. Charlottesville and Albemarle school divisions would likely receive additional monies if the McAuliffe budget was passed.

There is substantial support from around the Commonwealth to close the coverage gap, not only because it helps real people address their insurance needs, but it makes business sense. Here is just a partial list of the editorials from newspapers across the Commonwealth on this issue:

  • Danville Register and Bee: Patient care, not politics, for Virginia
  • Richmond Times Dispatch: “Marketplace Virginia is the way to go. It is the type of alternative conservatives interested in governing and in serving the entire citizenry should embrace.”
  • The Roanoke Times:  “In January, Speaker Bill Howell penned a commentary calling for an “alternative approach” to expanding Medicaid. Nearly three months later, he has yet to offer any alternative of his own. Meanwhile, the Marketplace Virginia plan sits untouched, waiting for someone to show up at the negotiating table. Like a misplaced pair of glasses, it’s in plain sight.”
  • Loudoun Times-Mirror: Virginia should support Medicaid expansion
  • The Washington Post: “Using allocated federal money to expand the availability of health-care coverage for some of the most vulnerable is a cause worth fighting for — in Virginia and every other holdout state.”
  • The Virginian-Pilot: Good Sense and Medicaid
  • Fredericksburg Free Lance Star: Expand Medicaid
  • The Daily Press: “The best way forward is by using federal money to purchase coverage for the uninsured through a market-based private opinion. It is a plan similar to one in Arkansas, and which already passed the Senate. It is supported by the state Chamber of Commerce and many medical groups as a practical way to break the impasse in Richmond.”
  • Staunton News Leader: “Rather than accept a Republican-written compromise — one of our best of that rare breed, crafted in part by Sen. Emmett Hanger, R-Mount Solon — to accept federal money without expanding Medicaid, the House said no. This means Virginia continues to lose $5 million in federal dollars everyday, money that is supposed to go toward helping our poor get access to health insurance, money that Virginians are already sending to Washington in federal taxes, money that can keep our hospitals fully staffed.”
  • Culpeper Star Exponent: “Virginia should expand Medicaid, even if legislators don’t agree with the ACA.”

The Town Hall meeting held March 19, which Senator Deeds and I organized, was extremely successful. Many people came to support Medicaid expansion and even “Tea Party” opponents who were there raised good questions and debated the issue in a civil and respectful manner. I greatly enjoy having both the proponents and opponents of policy ideas in the same room at the same time because it gives both sides the option to hear the arguments of the other.

Right now, the House Republicans’ refusal to act has put us at a standstill. The Governor’s budget has made it plain; the Commonwealth will gain financially from Medicaid expansion and our localities, educators, and law enforcement personnel would benefit by the passage of a budget that includes it. With the exception of the “veto” session scheduled for April 23, no other meetings have been scheduled – which means another day leaving Virginia taxpayer dollars in Washington and another day without a budget for the Commonwealth.

As always, it is a pleasure representing you in the General Assembly and I hope that you will contact me with your views and comments issues before the Commonwealth.

 
David Toscano

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Filed Under: General Assembly 2014 Tagged With: Affordable Health Care, Medicaid expansion, Special Session, Virginia budget, Virginia Health Insurance Marketplace

Adjournment Without A Budget

March 14, 2014 by David Toscano

The General Assembly adjourned on March 8, 2014 without a budget. This is the third time that this has occurred in the nine years that I have been serving you in Richmond. We have until the end of June to have a budget in place, but most of us want this to occur as soon as possible because our localities need to have firm figures from Richmond as to monies that are coming to them so they can prepare their budgets. The budget impasse is tied up in the Medicaid debate. It is my view that you cannot separate Medicaid from the budget. If we can access more federal dollars as part of Medicaid expansion, we would not have to appropriate monies in ways set forth in the House budget. We could replace millions of dollars in state dollars proposed for indigent care and for hospitals with federal dollars, freeing up state dollars to be spent on education and public safety. This debate will continue to occur when we reconvene in a special session beginning March 24th.

While most press coverage focused on the Medicaid issues, there were several significant actions taken by the General Assembly this session. They include the following:

Mental Health Reform

I served on the Mental Health subcommittee in the House that was able to advance a number of reforms, including the extension of emergency custody orders for citizens in crisis from six to twelve hours, requiring the state hospitals to provide a bed in the event that no other beds are available, and the implementation of a psychiatric bed registry to more quickly find beds for people in need.

Ethics Reform

I was the chief co-patron on a bipartisan bill that enacts a $250.00 cap on tangible gifts, requires that gifts to family members be reported, and ensures that the gift disclosures be made online so that citizens can easily see them. There is still much to be done in this area, but this is the first overhaul of this statute in many years, and represents a good effort to restore some faith in our ethics laws in the aftermath of the McDonnell scandal.

Standards of Learning Reform

We have reduced the number of SOL “high-stakes” tests in Grades 3 to 8, and have created a new committee that will recommend additional reforms.

Transportation Reform

The hybrid vehicle tax that was part of the 2013 transportation reform measure that many of us opposed was repealed.

Utility Service

We passed a bill that will make the undergrounding of utilities easier to accomplish by spreading the costs across the ratepayers. This is a very important measure for older communities like Charlottesville where above ground power lines often fail when major tree limbs fall during storms.

School Reform

We delayed by two years the issuance of the “A-F” letter grades for schools.

Bicycle Safety

We provided some additional protections for bicyclists by enacting a 3-5 foot passing distance around bicycles.

A number of measures were either tabled or defeated that might have some interest. The Virginia Dream Act, which would allow in-state college tuition for children of Virginia immigrants, was defeated, as was an effort to increase the minimum wage. Efforts by conservatives to push a new constitutional convention were passed by the House, but defeated in the Senate.

There were no new attacks on women’s reproductive health passed by the General Assembly, but our efforts to rollback the forced ultrasound requirement were defeated. The proposal to transfer $3 million from the City schools to the County schools was defeated in the House Appropriations Committee.

We have not yet designated a new judge for the 16th Judicial Circuit, which has been pushed back to sometime in April.

We return to Richmond on March 24th to work on Medicaid and the budget. Debates on this issue will likely continue throughout the spring.

As always, it is a pleasure representing you in the General Assembly and I hope that you will contact me with your views on various issues in the weeks leading up to our next session on March 24th.

David Toscano

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Filed Under: General Assembly 2014 Tagged With: Affordable Care Act - Virginia, Affordable Health Care, Education, Educational reform, Ethics reform, Medicaid expansion, Mental Health Policy, Reproductive Choice, Standards of Learning, Virginia budget

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