#vapolitics

The budgets passed by the Virginia House and Senate highlight two different pathways to improve health care access for the commonwealth: one concrete and funded, the other aspirational. While the House has welcomed federal funds to extend health insurance to hundreds of thousands of low-income Virginians, the Senate aims to prioritize individuals with intellectual and developmental disabilities (ID/DD). Unfortunately, the Senate does not have the funding to implement their priorities. But if the Senate agrees to the Medicaid expansion proposal put forth by the House, they could use the savings from that to also help more individuals with ID/DD. The budget impasse could transform to a win-win situation for both chambers.

Virginia currently has three waivers through the existing Medicaid program to provide home and community-based services for people with ID/DD. These waivers provide a variety of supplemental care and supports -- such as employment and day services, crisis support, assistive technology, nursing, and personal assistance -- to people who generally have basic health coverage through employer-based coverage, Medicaid, Medicare, or FAMIS. In order to receive these supplemental services through the Medicaid program, an individual must meet eligibility requirements and a waiver slot must be available.

The Senate claims to prioritize these individuals by including language in the budget, reflecting legislation by the Senate (SB915), to create a Priority Needs Access Program. This program would provide healthcare to people with serious mental illness making up to 138 percent of the federal poverty level ($16,643 for one person in 2018) and increase eligibility to others who have specific medical and mental health needs. But the program would be limited to 20,000 people. The bill and the corresponding budget language also direct the Department of Medical Assistance Services to add waiver slots to provide home and community-based services to nearly 2,300 people with ID/DD, contingent on available funding.

But there is no funding allocated to make this plan a reality. The legislation states that this program will become effective if funds become available. And here’s the thing: funds could become available if the Senate chooses to accept federal funding to expand the Medicaid program.

By accepting federal funds to expand Medicaid and using a provider assessment to cover the state’s costs of expansion, the House estimates a savings of $371 million dollars for the state over the next two years. With the savings, the House chose to invest almost $270 million more in K-12 and higher education than the Senate, as well as additional investments in state and local police departments and economic development.

The Senate has many options. One is to accept federal funds to expand Medicaid alongside a provider assessment. The savings from that could more than pay for the 2,300 waivers included in SB915 and at the same time would be providing access to quality healthcare to nearly 400,000 Virginians. The House and Senate could also recognize the strengths in each budget and distribute the estimated savings over many areas of investment -- funding additional waiver slots beyond the 825 already included in the governor’s, House, and Senate budgets, as well as additional investments in education and public safety as proposed by the House.

In other words, the Senate can not only fund its goal, it can do even more for more people. Think of Medicaid expansion like a curb cut -- the place in the sidewalk that serves as a ramp to allow easy access between the sidewalk and the street. Originally designed to help people in wheelchairs (one of the first ones was installed in Michigan in 1945 to assist WWII veterans), today, parents with strollers, small children, people with limited mobility, and others also benefit. Like a curb cut, Medicaid expansion would remove a barrier to accessing health care for low-income families, and it could also help people across the commonwealth in many ways. But only if lawmakers are willing to put money where their aspiration is.

-- Sherri Egerton, Communications & Research Assistant

Print-friendly Version (pdf)

While we wait for lawmakers to return to Richmond to take up the state budget and consider expanding Medicaid to hundreds of thousands of Virginians, the Brookings Institution has dug into a number of arguments opponents make about expansion -- projected enrollments are wrong, costs are bigger than expected, it’s a disaster for state budgets -- and asked the question: Do states regret expanding Medicaid? Turns out the answer is largely no, and that expansion has been good for states in a number of important ways.

Citing numerous analyses and reports, Brookings Senior Fellow Mark Hall gives the run down of how almost all of the purported threats from expansion share a few common threads that can be easily debunked when looking at the experiences of other states that have benefited from Medicaid expansion for years. Drawing on this analysis and others, here’s our short version:

Medicaid expansion has strengthened state budgets, and lawmakers in other states continue to support the program. Opponents of Medicaid expansion claim that it has been a disaster for state budgets, but here’s what’s really happening:

Every expansion state that has analyzed the comprehensive effects of expansion has seen improvements to their state budget balance as a result of expansion, even after accounting for higher enrollment.

Expansion in Arkansas, California, Colorado, the District of Columbia, Indiana, Kentucky, Louisiana, Michigan, Montana, New Mexico, Ohio, Oregon, Maryland, Pennsylvania, Washington state, and West Virginia has led to documented state savings and revenue gains.

Virginia can expect to see net savings from Medicaid expansion because we already offer services that would now be paid for with more federal dollars under expansion’s more generous match rate.

Across the political spectrum, states that expanded do not regret their decisions. Republican governors in Arkansas, Arizona, Michigan, Nevada, and Ohio, along with Republican legislative bodies in Arkansas, North Dakota, and New Hampshire have continued to endorse Medicaid expansion and oppose repeal efforts.

Cost estimates of Medicaid expansion have been largely accurate, and improvements to care contracts could reduce some spending. If lawmakers are hesitating out of fear of uncertainty and cost, they need to look at the experiences of other expansion states. Here’s why:

After learning from the experience of expansion states over the past several years, cost estimates and projections (which were mostly accurate before) are likely to be even more accurate now.

Virginia can learn from the mistakes of early expansion states when devising Medicaid managed care contracts. The federal government projects that improvements to these contracts could lead to a 20 percent reduction in spending from 2015 levels for new expansion recipients.

Expert analysis shows that state costs will only increase modestly as the federal government moves to paying a 90 percent share of Medicaid expansion costs.

Not a single state that has a legislative trigger to repeal expansion if projected costs are wrong has felt the need to use the option.

Medicaid programs in other states have not been overwhelmed by enrollment as some suggest. Here are the facts:

While some states did see larger enrollment than initially anticipated, this did not lead to major new costs since the federal government paid for almost all of the costs.

Expansion states like Indiana, North Dakota and Ohio have seen enrollment trends remain under or at expected projections. States’ projections for Medicaid expansion costs have largely been accurate.  

While some opponents of Medicaid expansion point to federal uncertainty as a reason to not expand, a closer look at the debate suggests that it would be more risky to not expand Medicaid. It would take legislation to undo the Affordable Care Act (ACA), but that is unlikely to happen.

Attempts to disband the ACA failed numerous times last year. Republican leadership has indicated they are not interested in bringing up the matter again this year. With this certainty, we should bring our federal tax dollars back to the state and shore up the state’s reserves to protect our bond rating -- which is at risk.

Most versions of legislation to repeal the ACA would have penalized non-expansion states like Virginia by locking in our current low levels of Medicaid funding with some form of a block grant, so doing nothing is a riskier move for Virginia than expanding now.

Extensive evidence shows that Medicaid expansion costs are largely predictable and modest. Assertions that they are out of control or significantly above projections have not stood up to objective analysis. In the long run, Medicaid expansion may eventually have some net costs for Virginia, but these costs are likely to be negligible when compared to the benefits -- expanded access to health coverage, and an increase in jobs and tax revenue.

-- Chad Stewart, Research & Planning Analyst

Print-friendly Version (pdf)

This past Sunday the House and Senate money committees put forward their proposals for the state’s next two-year budget -- amending what former Governor McAuliffe proposed this past December. And what a stark contrast they offer: House Appropriations invests hundreds of millions of dollars to improve vital public services with funds from accepting federal funds to expand health care coverage to thousands of Virginians, while the Senate Finance Committee proposes deep cuts to the introduced budget.

The House Appropriations proposal maintains or increases widespread investments in vital public services, including need-based financial aid for students; pay increases for teachers, school staff, and state workers; investments in K-12 schools and higher education institutions; more access to mental health services; and expanded health care coverage to hundreds of thousands of Virginians.

The Senate Finance proposal makes dramatic reductions in state investments compared to the introduced budget. The Senate proposal eliminates pay increases for teachers, school staff, and state workers; cuts new financial aid investments in half; provides less support for mental health services; reduces support for state and local police, and does not expand health care coverage to thousands of Virginians.

Accepting federal resources to expand Virginia's Medicaid program makes a dramatic difference on state fiscal resources. By pairing expansion with a provider assessment on private acute care hospitals, the introduced budget would save the state over $420 million. The House Appropriations Committee takes a similar approach, but assumes a later start date for expansion and requires the state to submit a waiver to the U.S. Centers for Medicare & Medicaid Services to implement work requirements and other changes to the Medicaid program. The House estimates $370 million in savings with the delayed start and a cost of $21.5 million to administer work requirements. Yet, this still leaves a substantial amount of savings for state lawmakers to invest.

As lawmakers continue their conversations on the budget, it is important to find a solution that both increases access to health care coverage and makes needed investments in our schools, higher education institutions, law enforcement, and communities.

-- Chris Duncombe, Senior Policy Analyst

Print-Friendly Version (pdf)

Additional details on the Governor’s, House Appropriations, and Senate Finance budget proposals are available here.

Tangier Island backed Trump last fall. Now residents hope one of his biggest foes can save their way of life.

TANGIER, Va. — Mayor James “Ooker” Eskridge swapped his usual “Trump: Make America Great Again” baseball cap for one stitched with a generic “Tangier Island” to welcome Sen. Tim Kaine to his vanishing island home. He didn’t want to insult the Virginia Democrat, who took a three-hour round-trip ferry ride to a splotch of marsh in the middle of the Chesapeake Bay where residents did not support…