The Unacceptable Human Costs of Virginia Rejecting Medicaid Expansion

Who's winning, who's losing, and why.
April 8 2014 5:43 PM

Virginia Is Broken

And low-income Virginians who fall into the Medicaid gap will suffer for it.

Virginia Governor Terry McAuliffe at George Washington's Mount Vernon Estate, February 17, 2014 in Mount Vernon, Virginia.
Virginia is modeling dysfunction yet again this month, as the legislature fights to the death over Gov. Terry McAuliffe’s proposed two-year, $97 billion budget.

Photo by Drew Angerer/Getty Images

If I lived in Virginia, I would be pissed. Wait. I do live in Virginia. And I am pissed. Because there is no excuse, not one, to block the Medicaid expansion, and no reason to shut down state government to do so.

Dahlia Lithwick Dahlia Lithwick

Dahlia Lithwick writes about the courts and the law for Slate. Follow her on Twitter.

The Commonwealth of Virginia is modeling dysfunction yet again this month, as the legislature fights to the death over Gov. Terry McAuliffe’s proposed two-year, $97 billion budget. The government is imploding in large part due to the fact that state Republicans in the House of Delegates have decided to fight tooth and nail—up to and including shutting down the whole government if this is not resolved by July—to avoid expanding Medicaid benefits to cover up to 400,000 lower-income Virginians who fall into the health care coverage gap. These are the folks who can’t afford to purchase health care under the ACA, but make too much money to qualify for Medicaid. The ACA would have taken care of those people through an expansion of Medicaid—money from the federal government to the states to cover the gap. The high court, in 2012, left it to the states to decide whether to accept the expansion. Virginia is one of the states having a hard time making up its mind. As with all government shutdowns, the answer to “why is this happening?” is “Republicans hate Obamacare.”

Last year, under the leadership of then Gov. Bob McDonnell, Virginia passed a controversial transportation bill that fractured the GOP by raising taxes to pay for new highways. The $6 billion transportation package also contained language sought by state Democrats that would create a bipartisan commission to explore Medicaid expansion and, at least the Democrats believed, would open the door to accepting the expansion. The commission did what it had to do and did it fairly well, but now finds itself gridlocked, since the Virginia GOP has pulled together to block the expansion. Sixty-six out of 67 Republicans in the 100-seat House voted against the Medicaid expansion, claiming that the federal government cannot possibly afford to pay the $2 billion bill when it comes due and also that the whole Medicaid program is broken. (The federal government only promises to pay for a limited time, then the state begins to incur some small obligation. Republicans don’t believe the obligation will be small, or that the program can stay solvent.) Last week McAuliffe proposed a two-year pilot expansion of Medicaid, which could be canceled if it proved unsuccessful. This seemed very reasonable. The House Appropriations Committee killed it. So yesterday, in Richmond, both the Senate Finance Committee and the Medicaid Innovation and Reform Commission met to argue and vote about stuff. Republicans blamed Democrats. Democrats blamed Republicans. Everyone blamed gerrymandering and gridlock and ideology.

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It’s worth at least pointing out here that the same House Republicans set on blocking the expansion represent 32 out of the 50 House districts with the most residents enrolled in Medicaid at current levels, at least according to this study from the University of Mary Washington. The representatives from the poorest districts, where residents who aren’t on Medicaid desperately need it, are fighting hardest against helping their constituents. As the Post points out, recent polls suggest that voters support the expansion more than they oppose it. So, as always, GOP politicians are banking on the fact that voters are more afraid of Obamacare in theory than they are desperate for health care in reality.

But have you noticed that all this debate has absolutely nothing to do with what happens if we fail to close the Medicaid gap? That GOP lawmakers can talk for hours and never once acknowledge what is actually happening to low-income Virginians who fall into the gap right now? Last weekend 60 Minutes did a terrifying segment on the Virginians who are unable to access affordable health care for diseases that range from cancer to epilepsy to black lung. Make no mistake about it: People without preventive care do die. According to the Virginia Poverty Law Center, the ACA establishes a new national Medicaid income eligibility level at 138 percent of the Federal Poverty Line. (That’s about $15,400/year for an individual; $32,000/year for a family of 4.) Virginia’s current program is very limited, and eligibility levels for adults are among the worst in the U.S. Parents’ eligibility is under 30 percent FPL ranking Virginia 44th in the U.S. Virginia is ranked 48th in per capita Medicaid spending.

Studies show that people will die because of states’ decisions to not expand coverage. The poorest are being cared for, the rest of us can buy insurance. The folks who fall into the gap get nothing. Of the 32,100 Virginia veterans who do not have health insurance, 12,300 could qualify if the coverage gap were closed. A quarter of the people who fall into the coverage gap are parents with kids under 18. An expansion would infuse significant mental health dollars into our system. These families are literally too “rich,” with their minimum wage jobs, to afford health insurance, and too poor to afford health insurance.

My friend Elizabeth Carpenter is a visiting home nurse who works with low-income and immigrant families here in Virginia. Here is what she experiences every single day:

Full time workers at minimum wage barely make $15,000. Here is the most common scenario I have come across: A family of four with an infant and a toddler, mom is staying home with the kids and dad is pulling $8.25/hr. Their yearly income is $17,160 or so. The kids qualify for Medicaid. If dad's workplace offers insurance it's $100-$150/month, or $300-$400/month if they want to add mom. That is waaay too expensive to purchase insurance. So the best I can do with them is to apply for coverage, so they get a denial letter from Medicaid then we can fill out a 6 page exemption form and mail it in, all in hopes that they get out of the shared responsibility fee when taxes are due next year. The fee in this case would be $171 for dad and $95 for mom. That fee will get significantly steeper over the next couple of years. Also, note that they still don't have health insurance.  

So here is a nurse, meant to be delivering health care to Virginia’s poorest (usually working) families and instead, she spends her days filling out forms that will hopefully get rejected so that she can fill out more forms that will possibly get her patients a tax refund, and also no health insurance and also no health care. The easy answer is to say that all this is the government’s fault; that the system is broken and we need to get the government out of the health care business. But that is the argument the House Republicans have taken to quasi-existential extremes: That government is broken today and certain to be broken in the future, that it can’t be trusted to keep its promises. So let’s have no health care.

At yesterday’s meetings, the Senate Finance Committee approved a plan for the private insurance marketplace. State Republicans offered the usual array of excuses for blocking the Medicaid expansion, some of which were laughably funny. One member of MIRC actually offered Obamacare as an alternative to the expansion for people between 100–138 percent of poverty. The same Obamacare that is purportedly unconstitutional and broken. Another speaker yesterday argued that the Department of Health and Human Services plans to punish Virginia and withhold all Medicaid reimbursements if the state ever opted out of expansion. Again the argument was advanced that it is immoral to offer programs that may not be funded in perpetuity. Better to suffer today than risk suffering tomorrow. And the GOP plan for alternatives to the expansion? Send the poor to emergency rooms and free clinics—free clinics they’ve attempted to shutter in earlier budgets. Pass more Good Samaritan laws! Tort reform! No, seriously. This is the alternative “plan.”

Government can only work if the folks running it at least pretend that it can work. But the sheer nihilism on display in Richmond shows what happens when you convince yourself that government can fix nothing. It’s not a coincidence that the end result of the impasse may be that the government shuts down altogether. It’s the Commonwealth that is broken here—not the Medicaid expansion.

Dahlia Lithwick writes about the courts and the law for Slate. Follow her on Twitter.

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