Republicans Cave on Medicaid Expansion

General Assembly Republicans have capitulated on the issue of Medicaid expansion. All that remains to be decided is the terms of their surrender.

Speaker of the House M. Kirkland Cox, R-Colonial Heights, has signaled his willingness to “dialogue” with Governor Ralph Northam about Medicaid expansion if the Governor is willing to accept the condition that would require able-bodied recipients to work or be actively seeking employment.

Wrote Cox to the Governor in a letter that House leadership distributed publicly:

The House is willing to begin a dialogue on health care that includes significant reforms and strong taxpayer safeguards, but I want to be clear that the 51-member House Republican Caucus has taken a binding caucus position against ‘straightforward’ Medicaid expansion.

If your position is to pass straightforward Medicaid expansion without work requirements or other reforms, then you will be responsible for the failure to provide health care coverage to more Virginians.

Republican bills, reports the Richmond Times-Dispatch, also would require periodic checks of the recipients’ household income, and would include exemptions for adults attending college, acting as sole caregivers for children under six, receiving long-term disability benefits or otherwise proved to be “physically or mentally unable to work.”

A spokesman said Northam was “encouraged” that Republicans were willing to begin discussion about Medicaid expansion but not happy with Cox’s proposed restrictions.

Bacon’s bottom line: Republicans have held the line against Medicaid expansion on fiscal grounds for four years. It’s difficult to imagine any explanation for the about-face other than fear and trembling over the 2017 election results, which came within a frog’s eyelash of evicting the Republicans from control of the House of Delegates. Cox has caved on the expansion and now he’s bargaining over the fine print. It will be exceedingly difficult politically for him to backtrack.

But Medicaid expansion still will be bedeviled with the same problems that afflicted it when former Governor Terry McAuliffe was pushing for it.

Even with the federal government funding 90% of the budget for expansion, Medicaid expansion still will cost Virginia nearly $190 million a year more by 2022, according to the Heritage Foundation, putting the squeeze on other budget priorities. All for what? Yes, expansion will provide “insurance” to more poor and near-poor people. But what quality of coverage will they receive? Will Medicaid expansion help them find a doctor in a country plagued with primary care physician shortages, or will recipients continue to clog emergency rooms? And who benefits financially? The patients themselves — or the hospitals that will see a great reduction in the treatment costs they have to write off as charity or uncompensated care? Will legislation expanding Medicaid ask anything of the hospitals, many of which, like Scrooge McDuck, are rolling around in piles of money? Or will they just fatten their profit margins? Finally, is there any evidence that Medicaid recipients’ health will improve? Or will physicians dish out more painkiller prescriptions, as is said to be the case in other states, and risk aggravating the opioid epidemic?

If past is prelude, it really doesn’t matter if Medicaid expansion actually helps anyone. People are suffering, and people want to “do something” — regardless of what it costs or whether it works.

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16 responses to “Republicans Cave on Medicaid Expansion”

  1. LarrytheG Avatar

    re: ” If past is prelude, it really doesn’t matter if Medicaid expansion actually helps anyone. People are suffering, and people want to “do something” — regardless of what it costs or whether it works.”

    If Conservatives had a viable alternative , where is it?

    you can’t have it both ways…

    Conservatives also blather on and on about the opioid crisis.. where is their solution on that?

    and the Heritage folks view does not agree with the view of the Commonwealth Institute.

    the basic problem is that Conservatives have no solution other than “let them die”… honest injun

    1. “If Conservatives had a viable alternative , where is it?” Hear, hear!

  2. In several prior comments I noted that McAuliffe had said on WTOP radio back in Nov/Dec on the Ask the Governor program that Medicaid expansion was almost a slam dunk given the Nov election results, he said enough Repubs supported that to make it near-definite.

  3. I have a hard time reconciling these recent comments from JB:

    “Will legislation expanding Medicaid ask anything of the hospitals, many of which, like Scrooge McDuck, are rolling around in piles of money?”

    “Many of Virginia’s rural hospitals are in trouble. When a hospital like Pioneer Community shuts down, thousands of people find it far more difficult to access health care.”

    Now, granted, JB has already given us the outline of his answer in the form of this rhetorical question, “Do we enact blunderbuss legislation (such as Medicaid expansion) under the pretext of helping rural hospitals even though most Medicaid dollars will go to urban and suburban hospitals?” Well of course much of the money will go to where the population is. But the poor are disproportionately represented in the rural population and will receive their share of the benefit accordingly. Besides which, the difference between increasing a urban hospital’s volumetrics and keeping the rural hospital open at all is qualitative, not quantitative.

    In addition, who is claiming that emergency room services provided to poor patients are a source of PROFIT even for urban hospitals? Rather, Medicaid will reduce the cross subsidy paid by insured patients. Shouldn’t we look for the source of those urban hospital profits in other areas than providing needed healthcare to the Medicaid-expansion contingent?

  4. Conservative health care alternatives:

    – Eliminate mandated insurance benefits; give insurers the option to provide insurance products tailored to lower-income individuals. (Alternatively, allow insurers to sell across state lines.)

    — Eliminate Certificate of Public Need, and open up the healthcare marketplace to more competition and innovation.

    — Scale back medical licensure requirements that have transformed the healthcare industry into a giant craft guild.

    — Get rid of the fee-for-service insurance model and allow providers to charge flat rates for a bundle of related procedures. (Need a triple coronary bypass surgery? We’ll charge you $30,000 for the procedure and all follow-ups visits.)

    — Make greater use of Health Savings Accounts, make medical prices more transparent, and encourage health care consumers to shop around on discretionary services. (I’m not talking about when someone has a heart attack and is being wheeled into the emergency room, I’m talking about when someone has, say, a hip surgery.)

    — Focus scarce public resources on public clinics and money-losing hospitals serving rural areas or inner cities instead of implementing blanket policies that benefit highly profitable hospitals.

    The list goes on. The idea that conservatives offer no alternatives is simply a LarryTheG canard that he repeats over and over until others start believing him.

    1. LocalGovGuy Avatar

      HSAs… I’m sure that the individual making $20K a year is going to jump on that.

      We know all too well how “allowing insurers to tailor their policies” went pre-ACA. Even ruby red area residents were complaining about the absurdity of exclusions in those “insurance” policies. Obama’s most compelling line in his 2008 nomination acceptance speech was talking about his mother who had “insurance” sitting in a hospital bed having to argue with her “insurance” company about coverage of various procedures. Yes, what great days those were.

      And, by all means, let’s scale back licensure requirements. Here’s a great book on “scaled back” licensure requirements:

    2. LarrytheG Avatar

      none of these are being enacted and even if they were – they are basically “beliefs” with no real models that do exist.

      these are “ideas” that Conservatives use as an excuse for doing nothing right now – like hospitals closing in rural areas. what is the Conservative response to that? let’s see , that long list of “ideas” that have never been done and never been proven and even when the GOP is in the majority – not enacted.

      like I said… Conservatives evade responsibility for doing what has to be done now.. by claiming their “ideas” have not been enacted…and that’s the reason they can’t do anything else…

      bullfeathers.. Conservatives have no real solutions.. only “ideas” and excuses.. and blaming others for what they won’t do themselves.

  5. LarrytheG Avatar

    The politics of it especially the GOP party line -these days is pretty much bogus to the bone… it’s all about their ideological beliefs and not about practical solutions to real world problems.

    If they wanted to go in a different direction with medical care for those without insurance, – then fine… especially if they are the majority. .. but all they wanted to do is sit on it. They had no other approaches other than “no” while people are literally going to die from a lack of access to BASIC medical care.

    The GOP seems oblivious to this or feigned it or worse they know and they don’t care.. no matter how you slice it.. the GOP is not going to lift a finger .. take the Opioid issue.. they talk the talk – they talk long and hard, but where is the “plan”?

    NOW … they’re talking about a “work” requirement. Jesus H. Keeeerist – the Medicaid Expansion is expressly about insurance for the working poor. They ALREADY work!

    I’m coming to the conclusion that what Conservatives are about is “ideology”. It’s what the believe. If what they believe doesn’t comport with the realities – they just punt… .. it’s a miracle even with gerrymandering and voter suppression that they can still maintain a majority. It’s not that people want left or right ideology; they want solutions to the issues. They do want the issues addressed.

    The Medicaid Expansion – in addition to health care is economic development for the rural areas.. of all the harebrained economic development “ideas” that have been pursued over the years, standing up rural hospitals, doc-in-box clinics, and primary care practices are the way to improve their economies. They ought to be using the tobacco settlement money for that purpose also instead of the scandalous ways they have been using it in the name of economic development.

    This is why Conservatives WANT to make it about ideology. As long as they can convince their base that it’s all about “leftists” and “snowflakes” and Antifas.. they can evade the actual problems that should be addressed AND accountability for them.

    we have people who don’t have access to health care… we have a solution in Medicaid expansion.. If that’s not the right way – then come up with a better plan but don’t play “see no evil”. Do something!

  6. TooManyTaxes Avatar

    Here’s a couple reforms. Any non-profit in the Virginia health care market must accept Medicaid patients or it looses its tax-exempt status for state purposes. And just like many of us who are lawyers devote considerable time to community and pro bono work, every licensed heath care professional in Virginia must take Medicaid patients. They don’t have to work for free, just accept Medicaid reimbursement for covered patients. I bet a good third of the Docs who are clambering for expansion expect others to provide the service and would refuse to accept Medicaid patients. Dirt bags.

    I would like to see some state official put in writing what the expected costs to the Commonwealth will be when the extra federal money ends and be fired without a pension if and when the annual cost exceeds 10% of the annual estimate. Let’s have a little truth in government spending instead of trying to mask the real costs. Should apply to all big government programs.

    Finally, watch for Democrats to clamor for further expansion to cover illegal immigrants.

    1. I agree with you. Really. Your comment only underscores to me the importance of pursuing reforms in the cost and transparency of health care before those costs fully devolve onto the States. We have limited time to accomplish that, and it’s not apparent to me that Congress is capable of even trying, under current leadership. But just because we would impose a deadline upon ourselves to take further action is insufficient reason not to do the right thing for our people now.

      1. TooManyTaxes Avatar

        I don’t believe the Democrats are any more interested in health care reform than they are at putting the rights of native born and naturalized American citizens about those of illegal immigrants. Northam is in the perfect position to achieve real and beneficial reforms given the GOP movement on Medicaid expansion. As a M.D. he clearly knows where waste, fraud and abuse exists as well as tremendous inefficiencies. But he won’t step on the toes of any interest group that makes campaign contributions to, or votes for, Democrats.

        It’s all about buying votes with other people’s money. I’d love to be proven wrong, but when he objects to having a limited work requirement for Medicaid, you know darn well he’s owned and operated by the standard Democratic Party interest groups. Watch for a major Virginia budget crisis once the extra federal dollars are gone.

      2. “It’s all about buying votes with other people’s money.” Campaign finance reform really is the discussion we need to have, now.

  7. There are many pieces to the health care jigsaw-puzzle.

    One of them is insurance: in that, we enacted a compromise (yes, 100% on Dem. votes but clearly full of Repub. input). Since then it’s become a partisan litmus test for conservatives to seek to dismantle Obamacare; but where have their alternatives ever been articulated where itcounts: in Congress? Instead, we have this last- minute provision in the Tax Bill to kill the individual insurance mandate, which will destroy the insurance pooling which is vital to keeping private insurers in the market. Conservatives could not have devised a surer way to force Congress to adopt a single-payer “socialized” insurance model in order to avoid a total collapse, especially in those marginal rural districts.

    After insurance coverage, or who can pay and how, another aspect is the quality of the health care delivered, and a third of course is cost. On both of the latter the nation has made hardly any progress since the 1960s! Where are the specific proposals — subject to hearings and debate in Congress — to achieve any progress on these fronts? For that matter, where are they at the State level, as regards permitted Obamacare modifications and exemptions, let alone starting from scratch ? Gov. Kasich, one of the few Republicans to step up to this challenge, has been talking about how to improve the ridiculously low efficiency and transparency of our current system now for a year, with virtually NO support outside Ohio. Where are everyone’s specific ideas? At least, where are they being discussed in Congress?

    Your list above is a good start, by the way, but doesn’t go nearly far enough. How do we decide (and who updates) the level of minimal care and drugs to be covered by standard health insurance? How do we achieve sufficient transparency for non-medically-trained patients to compare treatment and payment options apples-to-apples and intelligently? I am reminded of this column about John O’ Bannon’s views from not so long ago, just as McAuliff began his tenure in another health-care era:

  8. LarrytheG Avatar

    re: ” It’s all about buying votes with other people’s money. ”

    it’s certainly not true but even if it were.. Conservatives have had the ability
    to put forth their own ideas into legislation and the simple truth is they have not so their only response is to accuse the other side of “buying votes”. That’s not exactly a winning philosophy.

  9. djrippert Avatar

    Putting aside the humanitarian points … why does this surprise you from a political perspective Jim? The Republicans in Virginia live and die through the provision of transfer payments to their base in rural Virginia. The cities went “blue” years ago. The suburbs went from “red” to purple in recent years (even Henrico is now “blue”). The exurbs and rural areas remain “red”. While the RPV was busy insisting on trans-vaginal ultrasounds and suing public universities for providing health benefits to the gay partners of employees they were losing the state. They are the real social justice warriors in the state.

    Now the buffoons who run the RPV have a huge problem. They are losing on all fronts and their remaining constituents are fundamentally divided. The ex-urbanites are killing themselves with long commutes to get to jobs that barely let them make ends meet as the suburbs encroach and prices soar. They deeply resent the wealth transfers that have been foist upon them without any consideration as to cost of living. Meanwhile, the rural population is becoming as dependent on government handouts as the inner cities. There is no policy platform that can possibly satisfy both of these political bases.

    Virginia, due to its unique approach to political life, has no real cities like Baltimore, Chicago, Atlanta or even Charlotte. So, the cities were never going to decide Virginia’s political destiny. The population growth in Virginia has been in the suburbs and exurbs. This was always the real battleground with the suburbs (almost by definition) being far more populous than the exurbs. To win in Virginia you have to win the suburbs. The RPV failed to do so. They are doomed. Rural Virginia won’t save them. Gerrymandering won’t save them. They have no plan. So, their last gasp approach is to toss around freebies paid for with other people’s money in an effort to buy votes. Fiscally speaking, there is no conservative party in Virginia. Sorry Jim but you’ve been abandoned.

  10. LarrytheG Avatar

    The idea that a GOP facing a shrinking rural base would start giving goodies away like vote-buying whores to retain that poor rural base is – if true – would indeed be “big” news…. for a party that has been traditionally derisive about giving transfer payments to “takers”.

    Look at the states that have not expanded Medicaid … and then even look at the ones that have – across the board – in both red and blue states the GOP continued to resolutely oppose the expansion- NOT embrace it – and that’s not that surprising… it’s the same GOP that would gladly eviscerate Obamacare… opposes minimum wage, child care for workers, and on and on.

    They GOP / Conservatives have ALWAYS been about rewarding (and protecting) self-reliant “earners” not schmoes with their hands out wanting goodies…

    What they “give” to their “conservative” supporters is tax cuts , regulation cuts, vouchers for schools, tax credits , etc… it’s who they are politically as a party .. goodies to “takers” even to buy votes – NO WAY!

    The idea that now, they’d start competing with the DEMS as TMT says “buy votes”… is truly a revelation… !!! Hells Bells.. the PROVEN way to retain power is with gerrymandering and voter suppression. God Forbid you give those taker-schmoes MONEY! I’ll believe it when I see the GOP voting WITH the Dems on entitlements.. not before.

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