Northam Asks Good Questions About Amended Medicaid Budget

by James C. Sherlock

Governor Ralph Northam has raised an important issue relative to the budget negotiations. He has asked that the final bill not include an extension of a 12.5% increase in rates for Medicaid home- and community-based services for people with developmental and intellectual disabilities. The General Assembly put it in there anyway.  

That amendment, submitted by Sen. Emmett Hanger, R-Mount Solon, extends the expiration date for the increases from the end of calendar year 2021 to the end of the fiscal year on June 30, 2022. Hanger’s amendment claims that: 

“The costs of extending the rates are covered by the state savings in Medicaid from the 12 months of enhanced federal match for Medicaid Home and Community-based services included in the American Rescue Plan Act of 2021.”

That is a budget offset of “free” money from federal taxes and the deficit, but not defense of the program itself.   

The governor must have a good reason to have not only left that money out of the supplemental budget bill, but also to ask the General Assembly to take it out.

I’ll offer some thoughts on why he likely did so.

The governor’s liberal credentials and those of his appointees are hardly in doubt. The fact that they want answers to questions that they do not have in hand suggest they harbor significant doubts about patient results from the increases.

Especially because it would be politically easier to go along.


Financial questions:

  1. How much money is involved? Were there savings in Medicaid from less institutionalization?
  2. What are the terms and longevity of the extension?
  3. Was there a shortage of providers before the increase that was mitigated by the extra money?
  4. Is there a shortage now that could be exacerbated by a cut?

Policy questions:

  1. Did the extra payments to home- and community-based providers result in fewer patients institutionalized? 
  2. Did we see a downward or upward trend in hospitalization for non-COVID causes of patients in home- and community-based care?  How did the direction and slope of that curve compare to that for institutionalized patients?
  3. The state’s ability to inspect healthcare facilities and providers was compromised by chronic staff shortages long before COVID. Did the new money draw new providers about whom there may be questions and for whom the state lacks inspection capacity?
  4. Did the payments increases produce better outcomes for the patients? Worse?
  5. Were patients surveyed before and after the increase to gauge a change in patient satisfaction?


The dollar cost of the budget line item is certainly known. The answers to questions about the effects of the extra money on the supply of providers are discoverable if not already known.

Clearly, however, the governor doesn’t know whether the higher payments increased the health and well being of patients. And it clearly bothers him.

In the healthcare community such questions are featured in what is called a “patient-centered” approach. The answers to those policy questions are the difference between an effective healthcare measure and a mistake, whatever may be the costs or savings involved.

The governor wants those answers in a package on his desk before he supports the budget increase.   

Good for him. I support him. So should we all.

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6 responses to “Northam Asks Good Questions About Amended Medicaid Budget”

  1. Stephen Haner Avatar
    Stephen Haner

    Governor proposes. General Assembly disposes. Nobody in either body or party knows more about this part of the budget than does Emmett (Janet Howell, too), so I wouldn’t presume he is unaware of or uninterested in the answers to those questions.

    1. James C. Sherlock Avatar
      James C. Sherlock


      Hanger’s long time position as Chair or Ranking Member of the Senate Education and Health Committee is the source of his campaign money. But I was unnecessarily critical of him in this post, so I softened it.

      What do you offer as a reason for the governor to be so dead set against a provision that seems to benefit him politically? If the governor had positive answers to those questions, it would have been in his budget proposal.

      Certainly the VDOH and his budget director gave it to him as an option in internal budget discussions.

      If I remember correctly, the General Assembly Black caucus led the charge to pass the original bill that authorized the extra funding. So what made him back away and come out publicly against it?

      I credit concerns over the execution of the program. I can’t imagine what else would do it.

      1. Stephen Haner Avatar
        Stephen Haner

        No idea and it could be something totally unrelated. Things bump around in the dark over there. I haven’t been “on the ground” since March 2020. Two reasonable guesses: Didn’t want an R’s name on it, or has other plans for the dollars elsewhere.

        The game was supposed to be no amendments, leaving the House Ds and Gov stunned when the Senate R’s stuck on a few. ‘Twas a famous victory, if a small one.

        Hanger’s long effort to find a way to expand Medicaid is the reason for his heavy financial support, but remember — doing that has brought him internal primaries as costly as any general election. Having gotten him in that deep, no surprise the industry helped with those costs.

        1. James C. Sherlock Avatar
          James C. Sherlock

          The only time he was seriously challenged was in 2007 and he won by 5.5 points.

          I get your point, but the Virginia system of unlimited donations makes politicians’ dialing for dollars ever more demeaning and corrupting. I harbor distrust for those who overdo it. Looking at his fundraising history, he has raised 4 – 8 times as much as his opponents. So he would not have missed the difference if he had received $100,000 from VHHA rather than $217,000.

          He is boss hog at that trough.

          1. Stephen Haner Avatar
            Stephen Haner

            Nor would your opinion have changed had he raised that much less. You know I agree on the need for limits, but if you knew Emmett you’d know that he doesn’t actually try hard to raise money and the lobbyists (me included) have often had to call him and say, please ask us!! Never once had that discussion with Saslaw….

            Trashing somebody over the money is a reflex, even I do it, but its not always a sign of corruption. VHHA represents a huge industry, hundreds of companies, but encourages them all to give to the PAC and centralize.

          2. James C. Sherlock Avatar
            James C. Sherlock

            I take your experience with him seriously. I’ll keep it in mind.

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