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Virginians Push for Medicaid Expansion as Republican Opposition Softens

Kate Andrews

Republicans hope to tack on work requirements to expansion efforts that could put some families with dependent children in a coverage gap if they earn too much but don’t receive health benefits through work.

On an overcast Presidents’ Day afternoon, about 50 people from all over the state of Virginia gathered on the state capitol grounds to advocate for Medicaid expansion, joined by Democratic delegates who mainly represent districts in northern Virginia. The rally came as Virginia’s legislators edge towards expanding access to Medicaid for the approximately 300,000 Virginians who fall into the gap between those who don’t earn enough to pay for coverage under the Affordable Care Act (ACA) but make “too much” by the state’s standards to receive coverage under Medicaid.

Some of the advocates drove several hours as part of the People’s Caravan for Medicaid Expansion, organized by members of Indivisible groups in the state. They gathered as Republican lawmakers—long resistant to Medicaid expansion—warmed to the idea of expanding access to it now that they can force those seeking coverage to meet work requirements thanks to January guidance from the Trump administration.

In Richmond, Virginians told personal stories about neighbors and family members who fell into the health care coverage gap created by the state GOP’s steadfast refusal to expand Medicaid. Donelle Sawyer of Fairfax County said during a speech that she was there on behalf of her 54-year-old sister, who was diagnosed with mental illness at age 16 and lives on $14,000 a year in disability and other federal government income.

“She is put into a category called [Special Low-Income Medicare Beneficiary (SLMB)] that requires she pay an out-of-pocket threshold of over $4,000 before Medicaid will help pay her medical bills,” Sawyer told the small crowd of elected officials and constituents of all ages and different races. After county-subsidized rent, her sister has about $125 a month left for groceries, laundry, and other basics. For some people in the SLMB category, Medicaid expansion could eliminate that $4,000 deductible and allow them to receive full coverage.

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Lauralyn Clark, who lives in rural Caroline County and is a former health aide, told her story about caring for other people over the past 25 years but being unable to receive care herself because she makes too much money for Medicaid coverage. She uses a cane and can stand or sit upright for short periods.

“I’m going to be on the statistics list,” Clark said at the event. “I can’t work because I can’t stand very long. I can’t lift people. What am I supposed to do? That’s why I’m out here fighting. I’m tired.”

These stories are not new, and people like Clark—who says she’s been calling her representatives so often that they no longer return her calls—have asked for Medicaid expansion for years. Former Democratic Gov. Terry McAuliffe made it a personal goal when he took office in 2014, but hit a brick wall at the GOP-controlled General Assembly, which killed bills to expand Medicaid every session during McAuliffe’s four-year term.

That wall may be starting to crumble now that the Trump administration has signaled it would offer the green light to work requirements for Medicaid recipients. Del. Terry M. Kilgore, a Republican from Scott County in southwestern Virginia, announced last week that he was in favor of Medicaid expansion with some conditions favored by conservatives. Other GOP delegates have joined him. Kilgore’s district sits in a region of the state where 13.6 percent of nonelderly adults lack health insurance.

In an op-ed last week for the Roanoke Times, Kilgore wrote that he supports Kentucky’s expansion of Medicaid, which included a requirement that “able bodied adults receiving Medicaid assistance should work or seek opportunities to gain the work skills necessary to find and secure a job.” He said Kentucky’s policy was “a path forward, and one we can support” in Virginia.

Following this adjustment in some elected Republicans’ attitudes, the Virginia House of Delegates included Medicaid expansion for the first time in a draft state budget. In the plan set forth last Sunday by the House Appropriations Committee, couples making $16,000 a year and families of four earning $25,000 a year would now be eligible. Currently, non-disabled adults without dependent children are not eligible for Medicaid, no matter how low their income, and parents with dependent children are eligible only if their household income is up to 49 percent of the poverty line, or about $9,700 a year for a family of three.

The plan “would impose requirements that Medicaid recipients seek work training and contribute to their coverage through private insurers as a condition of receiving health coverage through the program,” according to the Washington Post.

While running for governor last year, Northam, a pediatric neurologist and former U.S. Army physician, promised to continue McAuliffe’s quest to expand Medicaid. He indicated support for the House’s move to expand Medicaid through the budget in a statement released last week. “I have long supported a simple and straightforward expansion of Medicaid. However, I respect the priorities of the House majority. We can and should expand coverage and provide significant training resources, counseling, and incentives to connect Virginians with employment opportunities.”

Northam told the Richmond-Times Dispatch in January that while he supports helping Medicaid recipients find work and receive job training, he “would not be in favor of a work requirement.”

Northam’s office directed Rewire back to the statement released by his office last week when asked to clarify his stance on work requirements.

In states with work requirements for Medicaid recipients, parents may find themselves uninsured because they earn more than the threshold to qualify for Medicaid—especially if a state chooses not to expand eligibility—but not enough to benefit from ACA assistance. This gap can also affect children, since they’re more likely to receive regular checkups and treatment if their parents do.

According to a recent issue brief on work requirements from the Kaiser Family Foundation, “Most nonelderly Medicaid adults already are working or face significant barriers to work,” such as an illness or disability. “There is a real risk of eligible people losing coverage due to their inability to navigate these processes, miscommunication, or other breakdowns in the administrative process,” the brief continues. “People with disabilities may have challenges navigating the system to obtain an exemption for which they qualify and end up losing coverage.

As of early this week, Medicaid expansion is not in the state Senate Appropriations budget, though those at the rally were optimistic the chamber could be swayed as negotiations take place between the governor’s office and legislators.

“We’re at a place—I’ve never seen this before—where there’s a meeting of the minds,” said Hala Ayala, a freshman Democratic delegate representing part of northern Virginia’s Prince William County. Ayala said in an interview with Rewire this week that she supports Medicaid expansion and noted that 1,200 of her constituents could benefit from greater access. As a former member of McAuliffe’s appointed Virginia Council on Women, she’s spent time at the state capitol lobbying for various causes, but she’s never seen this sort of openness on the part of Republicans.

She is a former recipient of Medicaid—once as a teenager after her father died, when her family couldn’t afford health insurance, and a second time as a new mother. “Medicaid saved my life and my son’s life,” Ayala said at the capitol rally on Monday.

Ayala, like many Democrats, does not favor a work requirement for people who receive Medicaid. Del. Jason S. Miyares (R-Virginia Beach) introduced a bill passed in the House in mid-February that would place work requirements on the state’s 1 million Medicaid recipients, except for children, pregnant people, the elderly, and others who are not considered “able bodied.”

“I have angst about that,” she said after the rally, especially the work requirement’s potential “subjectiveness,” Ayala said, referring to who exactly would be allowed a waiver to the requirement, or if volunteering and education could qualify instead of paid work. “What does that mean?”

Del. Lee Carter, another Democrat from Prince William County, said in a December 2017 interview with Rewire that a work requirement is “really not indicative of the voters’ will.”

“Voters in November were abundantly clear they want decisive action on health care, and they want it now,” he said, referencing the wave of Democratic legislators who won office in the 2017 elections.

The first self-described Democratic Socialist in Virginia’s legislature, Carter added that “Medicaid expansion is the bare minimum,” that can be done to expand access to health care in Virginia. Universal health-care coverage, he said, should be the end goal.

Carter is correct about the popularity of Medicaid expansion among voters. In a December statewide poll for the Virginia Hospital & Healthcare Association, 83 percent of respondents— Democrats, Republicans, and independents—said they would support a program to expand access to health care for Virginia’s 747,000 uninsured.

That popularity could make the difference in bringing Republicans to the table on expansion efforts.

Del. Jennifer Boysko, a Democrat who represents western Fairfax County, said at the rally that voters “have made my colleagues in the Republican party hear your voice. This is something that’s a win for everyone.”

Senior News Editor Dennis Carter contributed to this report.

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