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.