Medicaid expansion

The Veto Budget Session

June 27, 2014 by David Toscano

We met again on Monday, June 23, 2014, to consider the Governor’s eight vetoes to the signed 2014-15 budget. There was no discussion about a government “shutdown,” because the budget is signed and takes effect on July 1. The only issues remaining had to do with whether the eight vetoes would be sustained.

As usual, hot-button issues were vetoes that the Governor made involving Medicaid. In procedural moves that are not unlike what happens in Washington, DC, the House Republicans made it impossible to have votes on several of the Governor’s vetoes, including one which involved Medicaid expansion.

It was my view that we should vote on each one of the vetoes. The body could either vote to overrule (a 2/3 vote) or vote to sustain (a 1/3 vote), but I believe that the Governor has a right to veto and constituents have a right to know where their legislators stand on those vetoes. In taking their actions, the House Republicans denied constituents the ability to assess our votes on Medicaid expansion and hold us accountable for them. This is happening with increasing frequency in Virginia, and it is yet another example of how Washington politics is spreading across the Potomac.

By day’s end the House had overruled one of the Governor’s vetoes, which dealt with funding the Ethics Reform Commission and did not contest five other vetoes, which were relatively uncontroversial.

By the time the vetoes arrived at the Senate, there was only one to consider, the Ethics Advisory Council funding. The Senate sustained that veto, meaning that there is no funding for the Council in the coming year. The Governor has indicated that he will propose a stronger ethics bill and will support funding for the Council in January when we reconvene in regular session.

Technically, we remain in “Special Session” and will hopefully reconvene in Richmond soon to discuss the one remaining issue that we have, the filling of vacant judgeships, including one in our area. I have received many questions about this vacancy, and have told constituents that it would be filled after the budget has been finalized. Well, the budget has now been finalized and it is time for us to fill the vacancy. It will be up to the Republican House to determine when we are called back to discuss judges. Hopefully, it will be soon because the citizens in our region deserve to have a full-time permanent judge sitting in the Charlottesville Circuit Court.

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 either at my legislative office, 434.220.1660, or at my law office at Buck, Toscano and Tereskerz, 434.977.7977.

Sincerely,
David Toscano

A Budget without Medicaid

June 13, 2014 by David Toscano

After seven hours of wrangling and a series of very close votes, the General Assembly passed and sent to the Governor a two-year budget. As has been the case for most of the session, the debates surrounding the budget were about Medicaid expansion and the extent to which conservative Republicans in the House would be able to threaten moderate Republican Senators into the passing a budget with language prohibiting any expansion in the near future.

When we arrived in Richmond on Thursday afternoon, we had been led to believe that the Senate would consider no further amendments to the proposed budget, which had been dramatically scaled back because of a $1.5 billion shortfall in tax revenues. That agreement quickly fell apart, however, under pressure from Tea Party Republicans in the House who threatened their counterparts in the Senate that they would reject the budget if their anti-Medicaid language amendment was not approved. By late evening, moderate Republicans in the Senate had capitulated and the budget, which included a further prohibition against Medicaid expansion, was adopted on a largely party line vote. This would not likely have happened had not Senator Phillip Puckett resigned his seat abruptly last week, handing Republicans a 20/19 majority in the Senate. On Thursday, I called for an investigation of the facts and circumstances surrounding this resignation, including an exploration of the extent to which he was offered a position with the Virginia Tobacco Indemnification and Community Revitalization Commission as an inducement for resigning his seat. You can read the speech I gave on the House floor here.

While I was not pleased with the original compromise budget, I initially planned to vote for it, largely because we needed a budget and I was concerned about how the failure to pass one might affect our Triple A bond rating. The Commonwealth’s financial situation had deteriorated over the last few months and we needed to have a budget so that our localities would have monies to fund the needs of their constituents. The Republicans’ efforts to prevent Medicaid expansion, however, changed all of that.

When the revised budget came to the House floor, I felt the need to oppose it for several reasons, not the least of which involved the language on the prohibition against Medicaid expansion. The budget plan eliminates pay raises that we had approved earlier for school teachers, college professors, and other state employees. While the money for schools reserved for educational “rebenchmarking” (i.e., inflation adjustments) remained, other discretionary K-12 spending was cut. Increases that we had previously approved for higher education were taken away. Monies for housing assistance were removed, as well as additional sums to create waiver slots to help those who are intellectually and developmentally disabled. Inflation adjustment for hospitals was stripped away. Monies previously approved for life sciences and research, as well as other economic development initiatives were also eliminated. While I understand how a revenue gap will prompt spending cuts, my view is that they did not need to be so draconian and that we could have found ways to enhance revenues by eliminating some of the tax preferences that are going to larger companies in Virginia. You can hear my argument here, but it fell on deaf ears.

At this point, the approved budget goes to the Governor, who has seven days within which to act. He could veto the budget, make certain line item amendments, or simply sign it. He has not yet indicated his position, but he will no doubt do that shortly.

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.

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.

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.