Virginia lawmakers crossed an important hurdle Wednesday, ensuring that, despite years of resistance, the state will become the latest to expand access to Medicaid.
The move to broaden the federal health care program for low-income Americans comes as a direct result of the political fallout from last November's election.
Democrats came within one seat of drawing even in the state's House of Delegates in last fall's election. It was a stunning turn of events after decades of rule by Republicans. The GOP stranglehold on the House was the primary barrier to adopting the Medicaid expansion provision of the Affordable Care Act. Former Gov. Terry McAuliffe, a Democrat, spent all four years in office attempting to expand the program, to no avail.
In the 2018 legislative session, the first with the new House of Delegates, Republicans quickly worked with Democrats to negotiate a budget deal that included expansion. However, the leadership of the GOP-controlled state Senate (which was not up for re-election in 2017) remained resistant to the concept and used a variety of legislative tactics to stall the budget process.
Ultimately, a small cadre of pro-expansion Republicans teamed up with Senate Democrats to bring budget amendments directly to the floor that included expansion and had enough support to pass. The bill passed 22-18, with the support of three Republicans.
The final budget bill will still need to pass the House in its current form and be signed into law by pro-expansion Democratic Gov. Ralph Northam, but that is expected without complications.
Virginia's Medicaid expansion would be Democrats' first major policy victory to come as a result of the party's strength in elections that have taken place since Trump took office.
Democrats have largely been playing defense, using victories in congressional and state legislative special elections to make passing legislation a little tougher for Republicans. But in Virginia, Democrats have gone on offense.
"Today's vote in Virginia is a smack in the face to the Trump administration and the Republicans in Congress who keep pushing an out-of-touch, anti-health-care agenda," said Leslie Dach, chair of the advocacy group Protect Our Care, which supports the Affordable Care Act. "While they keep voting for health care repeal and sabotaging the system, Virginia voters demanded -- and won -- expanded coverage."
Medicaid expansion in Virginia, however, will come with strings. The deal calls for the state to apply for a federal waiver to allow it to implement work requirements, copayments and other measures. It also would place new taxes on certain private hospitals to cover state costs.
Work requirements and other policies could cause tens of thousands of residents to lose access to Medicaid coverage, according to the left-leaning Center on Budget and Policy Priorities.
The Trump administration took the historic step earlier this year of allowing states to require certain Medicaid recipients to work for their benefits. More than a dozen states have expressed interest, and the administration has already approved four states' waiver applications. Many of these states are targeting the expansion population -- often able-bodied, working age adults without dependent children -- in their work-requirement waivers.
The move to expand Medicaid means Virginia will receive an additional $2 billion a year in federal funding. The federal government picks up at least 90% of the tab in states that have expanded, though opponents worry that Washington could one day pull back on its support.
Proponents, on the other hand, have noted that Virginia has already missed out on more than $10 billion since the provision first went into effect in 2014.
Expansion is expected to add about 400,000 Virginians to the Medicaid rolls, according to state data. The uninsured rate would fall to 10.9% in 2019, down from 14.9%, an Urban Institute analysis found.
Virginia has among the most stringent eligibility rules in the country. Childless, non-disabled adults can't sign up currently, while parents can qualify only if their income is below $6,900 for a family of three.
Monthly enrollment averaged 1 million people, including 732,000 low-income families and children, in fiscal year 2017.
Virginia will join 31 other states and the District of Columbia in providing health insurance to its residents who earn up to 138% of the poverty level, or roughly $16,800 for an individual or $28,700 for a family of three this year.
Momentum is building in other states, as well. Voters in Maine approved a ballot initiative to expand Medicaid last year, though Republican Gov. Paul LePage has refused to implement it. Health care activists are suing the state in hopes of moving the process forward. At least 70,000 residents would gain coverage.
Advocates in Utah have collected enough signatures to put Medicaid expansion on the ballot this fall. Meanwhile, Utah Gov. Gary Herbert and state lawmakers are waiting for federal approval for a partial expansion, which would add adults making up to 100% of the poverty line, or about $12,100 per person.
Idaho activists are also gathering signatures to allow residents to vote on Medicaid expansion in November.