Medicaid expansion is here, but debate continues

When the Virginia General Assembly agreed on a balanced budget that included an expansion of Medicaid, a door opened for nearly 400,000 Virginians to have access to healthcare.

Throughout the state, localities have witnessed thousands of citizens becoming eligible to be covered by Medicaid; among those with more than 10,000 newly eligible citizens are the cities of Virginia Beach, Norfolk and Richmond and the counties of Fairfax, Prince William and Henrico, where about 10,800 are now eligible.

That signals a welcome change for many in the state and in the healthcare industry.

"The data is clear," said Julian Walker, vice president of communications for the Virginia Hospital & Healthcare Association. "States that increased health care access for the uninsured realized positive benefits."

But for others, like state Senator Siobhan Dunnavant of Henrico, the expansion is one full of risks.

“I hope that we're going to get preventative care, but I think that the way this was set up was short-sighted and flawed," she said.

Before the expansion, only disabled Virginians with an annual income of $9,700 or less, or a family of three with an annual income of $6,900 or less, were eligible to be covered under Medicaid, leaving adults without a child ineligible regardless of income.

But with the expansion, an uninsured-childless adult with an annual income of $16,750 or less is eligible to be covered under Medicaid, as is a family of three making $28,700 annually or a person with a disability whose annual income is $16,750 or less.

“In Virginia, the majority of the spending in the existing Medicaid program is driven by low-income elderly and disabled people, even though they represent the smaller share of program enrollment,” said Walker. He believes the expansion of the program will save the state millions of dollars that can be invested instead in education, public safety, transportation and other areas of need.

“In simple terms, savings are achieved because money Virginia now is spending on certain health care programs will be replaced with federal funding supported by Virginia tax dollars," Walker said.

Dunnavant, however, isn't convinced.

When the budget was on the floor, she proposed an alternative that would have expanded Medicaid to high-risk populations, such as those with disorders, mental illnesses or life-threatening and chronic illnesses. But her alternative wasn't considered. One of her concerns was that the proposal ultimately adopted in Virginia didn't utilize any of the knowledge gathered by other states that already had expanded their Medicaid funding – something she believed would have lowered the risk here.

She's concerned that the pressure to pass Medicaid expansion ultimately corrupted the process.

“It just went forward with such pressure and so rapidly," Dunnavant said. "I thought we were trying to change how we did things in politics and think things through more carefully, and not pass stuff and figure out what it means later. I'm disappointed that we didn't think this through better.”

Positive effects in other states
A Kaiser Family Foundation report analyzed 153 studies on the impact of state Medicaid expansions under the Affordable Care Act between January 2014 and June 2017, showing that Medicaid expansion results in significant coverage gains and reductions in uninsured rates, both among the low-income population and within specific vulnerable populations.

The studies also concluded that:

• Medicaid expansion positively affects access to care, utilization of services, the affordability of care and financial security among the low-income population;

• states have seen positive economic results associated, even when factoring in Medicaid enrollment growth that exceeded projections in states;

• Medicaid expansions result in reductions in uncompensated care costs for hospitals and clinics, as well as positive effects on employment and the labor market.

Research has also shown that states that expanded are less likely to see rural hospitals close, Walker said.

“Since January 2010, 83 rural hospitals have closed across the country, including two in Virginia; and 49 of those rural hospital closures since 2010 are in several rural southern states that have not expanded coverage,” he said.

Though research may seem to demonstrate the positive impact Medicaid expansion would have throughout the commonwealth, healthcare professionals also testify to its benefits.

“From a healthcare standpoint, it is a wonderful thing for the 400,000 Virginians that will get coverage under this expansion," said Danny Avula, the City of Richmond's public health director. "Medicaid covers things beyond direct healthcare services [such as home visitation, patient navigation and mental health services].

“There is plenty of data nationally to show that Medicaid expansion across the country has actually increased utilization of preventive and primary care services, and that's what we want. We want people to go to their doctor on a regular basis and to engage in prevention activities like screening, as opposed to them not ever intersecting with the health care provider and then showing up in the emergency room when they have late stage cancer, for example.”

Dunnavant expresses concerns
Dunnavant, herself a physician, was bothered by the influence of lobbyists in the process and concerned that lawmakers overlooked more prudent ways to address the issue.

“We expanded Medicaid through the state plan instead of through the waiver that we already have,” she said. “We already have a waiver. The safest way we could've expanded Medicaid would've been to expand it with the constraints and the improvements already built in instead of expanding Medicaid and hoping to get them later.”

It's still premature to determine the effects of Medicaid expansion and funding by the provider assessments, said Henrico, Parham & Retreat Doctors’ Hospitals spokeswoman Joanna Callaway, who also represents Hanover and West Creek Emergency Centers.

“Regardless of the impact, we are supportive of expanded coverage and believe it will improve the health of our community by providing increased access to necessary healthcare services,” she said.

That opinion is no surprise to Dunnavant.

“The hospitals really wanted this," she said. "They got not only Medicaid expansion but a raise in their reimbursement rate. And of the $3 billion that this is going to cost, there are projections that assert that $1 billion of that goes to the hospitals.

"Medicaid coverage in a practice, either by nurse practitioner or a doctor, is still only reimbursed at 67 cents on the dollar. Hospitals are making 88 cents to a dollar. So we created a $3-billion program that doesn't even encourage preventative care.”

But another local legislator who also is a healthcare provider disagreed.

In 2017, Del. Dawn Adams (D-68th) became the first nurse practitioner elected to the House of Delegates. (Her district includes several Henrico precincts, as well as portions of Richmond and Chesterfield.)

"I ran to create healthier communities through better policy, and this is a big step in the right direction," she said. "Medicaid expansion uses the money Virginians already sent to the federal government to help our citizens who fall into the coverage gap afford insurance through the state Medicaid plan. When Virginians have access to healthcare, more often than not they stay in our workforce."

U.S. Congressman Donald McEachin, who represents Virginia’s 4th District, issued a statement regarding the expansion of Medicaid while also thanking Governor Ralph Northam and other Virginians who called, wrote and rallied in support of Medicaid expansion.

“I am thrilled that my former colleagues in the Virginia Senate finally passed Medicaid expansion,” said McEachin. “With this landmark vote, more individuals and their families will be able to proactively visit their doctor before their medical issues worsen and become increasingly expensive, keeping people out of the emergency room and reducing healthcare costs across the board.”

State Senator Jennifer McClellan (9th District), who has consistently supported Medicaid expansion, echoed McEachin's comments.

“Nearly 300,000 Virginians postpone or forego needed medical care because they can’t afford preventative care. They are one illness or accident away from economic devastation,” McClellan said. “When they get sick or injured, they end up in the emergency room. When that happens, we all pay the price. The cost of that ER visit eventually leads to higher insurance costs for Virginians, and puts a strain on us, our hospitals, and our economy."