Virginia Is For (Healthcare) Lovers

Democratic Gov. Ralph Northam today signed into law Virginia's Medicaid expansion, after a long a brutal battle under the state's Republican austerity scolds of the previous general assembly, but the fight with the Trump regime is just starting, and there's every reason to believe that the expansion will be rejected by the White House.

After five years of fierce, partisan battles, amid chants of “Yes we did” from the crowd of spectators, Virginia Gov. Ralph Northam signed a bill Thursday afternoon that will expand Medicaid under the Affordable Care Act to cover up to 400,000 more low-income people in the state. 

“It has been a long road to get here,” Northam said. “It took longer than we would have liked. But I couldn’t be happier to sign this and give Virginians access to the care they need to live healthy and successful lives.”

Citing the Founding Father who designed the capitol building behind him, Northam thanked the lawmakers and advocates who made the passage of Medicaid expansion possible: “As Thomas Jefferson said, ‘Without health there is no happiness.'” 

But the triumphant bill signing on the capitol’s steps in Richmond will not be the culmination of the state’s Medicaid wars, but rather the beginning of a new chapter. The bumpy road ahead includes requesting permission from the Trump administration to implement work requirements and to require that Medicaid beneficiaries pay premiums. Those conservative policies won the GOP votes necessary to get the bill over the finish line, and, if approved, are likely to be the stuff of political and legal battles for years to come.

Under the new Virginia law, starting next January, state residents with incomes up to 138 percent of the federal poverty line will be able to enroll in Medicaid, massively boosting coverage among the currently uninsured. 

Some time later, depending on when the Trump administration approves the state’s waiver, Virginia will require those who depend on Medicaid to prove they are employed, studying or volunteering and to pay premiums for their health care. The work requirement will start at 20 hours per months and slowly ramp up to 80 hours, and will have a “three strikes and you’re out” enforcement approach — anyone who fails to certify for three months that they’ve met the work requirement will be booted from Medicaid and barred from reenrolling until the following year.

“That’s about as strict as you can get,” said Jill Hanken, a health law attorney and leader of the Health Care for All Virginians Coalition that campaigned for Medicaid expansion. 

“There are elements that are extremely punitive. Since most Medicaid enrollees are already working, we think setting up a whole new program for a very small slice of population isn’t the best use of those dollars, and we are quite concerned that people will lose benefits that they are entitled to because they get caught up in the red tape or make a small error.” 

As this process moves slowly forward, expansion advocates tell TPM they plan to make their voices heard on every step — lobbying the governor as he drafts the waiver, submitting comments to Trump’s health department as they weigh its approval, pressuring the state as it decides how to implement and enforce the rules, potentially challenging the measures in court, and launching education campaigns to help Virginians navigate the process. 

“If it’s approved, we’ll do our very best to make sure people eligible for coverage don’t lose coverage,” said Hanken. She added that should the balance of power shift in the state legislature, where Democrats came within one vote of controlling the lower chamber last year, groups will be calling on lawmakers to amend or scrap the restrictions. 

“Even if the federal government approves the waiver, the state can come back later and request any amendments they believe are necessary,” Hanken said. “Virginia has done that many times before with existing waivers.”

It's an ugly mess of an expansion, but it's better than no coverage at all for thousands.  However, the race will now be to throw as many of those 400,000 off the state's rolls as possible, and as quickly as possible, and the work requirements will unfortunately pare a big chunk of people from that group.

But it's a partial win, at least.