(Cross posted at the Makeshift Academic)
Good news came out of Virginia last week, as enough Republicans in the House of Delegates seemed to have caved in to popular demands and backed expanding Medicaid. It would make the state the 34th to expand Medicaid under the Affordable Care Act, and get 300,000 people health insurance.
Of course, there’s a catch: Republicans have conditioned acceptance of the Medicaid expansion on the imposition of work requirements for able-bodied Medicaid recipients.
It looks like Democrats in the legislature and Gov. Ralph Northam would be willing to play ball. The question is, as I asked with previous alternative Medicaid expansion attempts during the Obama administration, are the trade-offs worth it?
My answer is: it depends.
Follow me below the fold for details.
I'd lay down a few general markers to help Democrats determine when they should deal and when they should resist:
1. Less restrictive conditions (like requiring five hours a month on job related activities instead of 20 hours a week, not implementing co-pays for people under the poverty line etc) would nudge me toward a deal
2. Submitting fewer people to restrictions (exempting pregnant women, children, disabled, those over 50, people earning less than the poverty line, students etc. from requirements) nudges me toward a deal
3. Imposing access conditions like work requirements only on people who’d otherwise have no access to insurance at all would nudge me toward a deal
4. Imposing extra conditions on people who already receiving benefits, especially onerous ones, would nudge me away from dealing
5. Democratic control the executive branch of a state would nudge me toward a deal, seeing as it would be in charge of enforcing any agreed-upon provisions, and could do so in the most humane, reasonable fashion
Hypothetically in Virginia, based on what I know, I’d hold my nose and say yes.
Where Virginia stands on the above parameters is currently unclear, according to current reports because we don’t have a specific proposal or agreement to expand Medicaid – including the expansion in the House of Delegates budget proposal is only the first step.
Point 5 is satisfied – and Northam ran hard on expanding access to insurance, so his people at the State Health Department would likely enforce any sort of restrictive rules as loosely as possible.
Points 1-4 are murkier because we don’t know the deal. But we know that in all states attempting to work rules for Medicaid exempt most vulnerable populations (though the paperwork burden introduced by proving this status will likely cut off a considerable number of people from insurance.)
Initial discussions indicate that some adults – like parents currently on Medicaid, might end up subject to restrictions.
In contrast, more than 300,000 adults would be eligible for help under the expansion. I’d have to see language, but I think it’s pretty likely that conditions 3 and 4 would satisfied.
That leaves conditions 1 and 2. And it’s unclear what’s in the plan.
Northam’s spokesman said the following to the Richmond Times-Dispatch:
“The governor supports the concept of expanding coverage to Virginians who need it and offering training and incentives to connect people with work opportunities.”
That language is a far cry from embracing work requirements and sounds more like Northam would like a Montana-style expansion, where adults on Medicaid get linked up with job search and support services from the state labor department, if they want it.
Republicans in the House majority, like Speaker Kirk Cox, want much stricter conditions. As he told the Times-Dispatch:
“Instead of fighting a losing battle against straightforward Medicaid expansion, I believe the House should lead by putting forward a responsible plan similar to what Vice President Mike Pence adopted as governor of Indiana,” said the speaker, referring to federal approval this month of a work requirement for the Indiana Medicaid program that Pence expanded with reforms in 2015.”
Bridging that gap is going to be a delicate and fraught discussion among Cox, his caucus, Northam and his legislative Democratic allies, but I think that any likely result would involve much more good than harm.
In contrast, Democrats should ferociously fight attempts to implement work requirements in states that have already expanded Medicaid or are trying to implement restrictions without expansion.
The ultimate lesson remains, as always, the following: Elections matter.
Imagine the conversation we’d be having if the Democrats had scraped up 200 more votes last fall and secured control of the House of Delegates?
(Or for that matter, imagine the depressing situation we’d be if the Dems only had picked up 2 or 3 seats instead of the 15 they ended up getting.)
The good guys will get another shot at the Virginia House in 2019, as well as an opportunity to flip the 21-19 GOP-controlled Senate. Flip 5-10 more seats across those two bodies, and the conversation about Medicaid expansion changes drastically again.