At a strip-mall laundromat halfway between Washington and Richmond last week, the question in Virginia’s fierce struggle over expanding Medicaid was whether the government-backed health program should extend to the asthmatic in the black hoodie or remain reserved for the pregnant mom with a smiling frog on her sweatshirt.
The two Virginians loading laundry to blaring reruns of “Gilligan’s Island” and “Taxi” are at the heart of the fiscal and philosophical quandary that forced the General Assembly to adjourn without a state budget Saturday and now threatens weeks of uncertainty.
In a state that was cautious about expanding Medicaid long before President Obama’s 2010 health-care law offered billions of dollars in new enticements, the Republican-controlled House of Delegates and Democratic Gov. Terry McAuliffe are locked in a dispute over what government is for.
The value judgments embedded in Virginia’s current Medicaid system about who deserves coverage and who doesn’t — pregnant women do, childless adults don’t, for example — would be replaced by a standard set in Washington. That is seen as an unwanted intrusion by some and a welcome reform by others, leaving both camps claiming not to understand where the other is coming from.
While shifting demographics helped Democrats sweep all statewide races in November and the state twice voted for Obama, Virginia is experiencing a homegrown version of the divided government that has stymied Washington.
But at the Laundry Basket outside Fredericksburg, the debate in Richmond gives way to more concrete questions.
“A visit’s like $200. If you go to urgent care, it’s $80 for them to see you. If they give you a shot, it’s probably $130,” said X. Dee Boone, 20, whose job as a line cook grilling bacon-wrapped filet mignons and half-pound lobster tails puts his annual income just over the poverty line of $11,670.
Boone pays for his asthma flare-ups out of his pocket because he doesn’t qualify for Medicaid. But he wants to be insured. “I’d like to have it in case something does mess up. But now I can’t afford it,” he said.
Tabatha Weathers, 27, said the abuses she’s seen have made her wary of opening up Medicaid too broadly. “Somebody like me, I need it,” she said, folding warm clothes while her 11-month-old daughter wiggled in her father’s arms. Weathers’s second baby is due next month, and she couldn’t afford her obstetrician appointments without the Medicaid she receives, she said.
Added boyfriend Josh Nicholson, who has private insurance as a diesel mechanic: “I don’t think an average person like me, who can go out and get a job with insurance, should get it.”
Virginia has long been restrictive when it comes to who qualifies for Medicaid. Despite being among the 10 wealthiest states and receiving an outsize share of federal dollars that boost the local economy and help keep taxes low, the commonwealth excludes many people whom other states cover.
In Tennessee, a parent with earnings just above the poverty line can get Medicaid. In Virginia, the ceiling is half that amount. According to a legislative study last year, Virginia ranked 46th in per-capita Medicaid spending nationwide.
That means that Shannon Hays, 37, the mother of four boys, would qualify for Medicaid if she lived in Nashville and not near the Fair Oaks Mall in Fairfax County. She works with children at her day-care job, then comes home to do it again. She needs an oral surgeon for her broken and decaying teeth and a doctor for preventive care.
“I’m an older, aging woman,” she said. “I had four kids. I need to see a female doctor. . . . I’d like to get the breast thing as well, but I don’t do any of those things. I pray I don’t get a fever and get sick.”
Hays lost her job as an administrative aide when the recession hit. Her employers found someone who could do the job more cheaply, Hays said, and three months later the family was homeless.
“I was a regular person,” she said. “I know what it’s like to have insurance.”
Hays, the children and their father, who works at a call center, spent a year in a Fairfax shelter. They now live in public housing, and she tears up thinking about their return to some degree of stability. “Either you sink or you swim,” she said.
Medicaid has had a public-relations problem nearly from the start in Virginia. It was signed into law by President Lyndon B. Johnson in 1965, and the following year a front-page news service article in the Danville Register warned that the program “has grown astonishingly into a financial Frankenstein.”
Nearly 50 years later, under the Affordable Care Act, Virginia is eligible to receive billions of federal tax dollars to expand its Medicaid program — but only if it covers everyone earning up to 138 percent of the poverty line, including a young man such as Boone and a parent such as Hays.
Some have balked, notably Republicans in the state House of Delegates who are resolutely standing in the way of a proposal that was crafted by Republicans in the Senate and is backed by McAuliffe.
“You need to remember that when Medicaid was developed by Congress, it was for the elderly and the blind and the children. Medicaid expansion is basically for the able working man,” said House Speaker William J. Howell (R-Stafford), who has led the opposition. Howell argues it would be “incredibly foolish” to expand a program that is already growing at an unsustainable pace.
Enrollment in the state has grown by 53 percent in the past decade, to 887,000, and costs have doubled to a projected $7.8 billion this year, according to Virginia’s Department of Medical Assistance Services. Half of that is covered by the federal government.
McAuliffe has been barnstorming the state, stopping at hospitals and clinics from wealthy Loudoun County to much poorer Wise County, pointing to what he describes as the human cost of inaction. He also makes a pragmatic pitch: What would be foolish, he said, would be to turn away promised federal dollars collected in Virginia for which struggling hospitals and residents are hungry.
“It’s not like I’m asking anyone to raise taxes,” McAuliffe said. “This is different. This is bringing back your money.”
The expansion plan would use $1.7 billion a year to buy private insurance for an estimated 255,000 Virginians. The federal government has promised to cover the full amount for three years; after that, it would reduce its share over time to 90 percent.
For those who would be covered, the dispute reaches beyond government finances.
After Duane Darling, 45, who lives in the Washington suburb of Woodbridge, was laid off from his job as a Dell support technician in 2007, he went to truck-driving school “and learned to how to drive one of those bad boys.”
“I liked being out on the road, basically my own boss,” Darling said.
But last year, after driving a load to Alexandria, he found heavy pallets of two-liter Coke bottles knocked onto the truck’s floor. He restacked 12-bottle units into rows 16 units wide and seven units high.
“I’m thinking, okay, you’re in your 40s, you’re not in shape, of course your back’s going to hurt,” Darling said. “Then later on that evening I ended up in the emergency room. And here I am from there.”
The pain was constant.
“I was literally in 24/7 agony,” Darling said.
Last week, he inched out of the Prince William Area Free Clinic behind his walker. Volunteer doctors inject his spine every few months, which has helped with the pain. “The work they do is amazing. If I didn’t have them, I’d probably be going postal someplace,” Darling said.
They are “angels,” he said, but “if I was on Medicaid, I would actually be able to go to a back doctor and say, ‘I’ve got this situation, what can we do about it?’ ”
At the Laundry Basket, as a bank of industrial-size dryers whirred away behind her, Weathers said her skepticism has come from what she’s witnessed.
A woman she knows who is on Medicaid lies to her doctor about being depressed, then sells the pills she is prescribed, Weathers said. Another has plenty of money to buy a new car. “They know how to play the system,” she said before heading outside for a smoke.
A Virginia Medicaid administrator said Weathers should call the program’s fraud hotline. She said Virginia’s rate of improper payments is 0.47 percent and the national rate is 3.3 percent.
Boone went to community college to study business, but he dropped out when bills stacked up. The same thing happened with his backup plan to train as a barber. As he ate dirty rice from a Styrofoam cup, he wondered about the lawmakers opposed to adding him to the rolls. “I don’t know their background,” he said. Maybe they once struggled to survive on their own. “Maybe they forgot.”