In a Capitol where Medicaid expansion came about only after a pitched five-year battle and a blue wave in the House of Delegates, the higher-than-expected enrollments have been seen in starkly different ways — either as proof of how desperately expansion was needed, or as a worrisome sign the program could swell beyond expectations.
“There’s a lot of demand and need out there for this coverage,” Jennifer Lee, director of the state’s Department of Medical Assistance Services, said in an interview.
For Republicans who opposed expansion, the higher enrollment added to frustrations about a separate Medicaid issue: a $460 million cost overrun in the state’s current Medicaid program. That is due in part to start-up costs as the state converted care for elderly and disabled recipients to a managed-care system.
That problem is unrelated to expansion, but some Republicans noted faulty estimates were at the root of both.
“We can’t even get the numbers right for the regular Medicaid program,” said Sen. Ryan McDougle (R-Hanover). “Now as we move into the expanded population, my concern is that the estimates for those numbers are not going to be accurate.”
Legislators and Gov. Ralph Northam (D), a pediatrician who ran on expansion, will have to find a way to cover the $460 million in the two-year budget during the 46-day session that begins in January.
But the extra Medicaid enrollments will not affect the state budget, since the federal government covers as much as 90 percent of the cost and Virginia hospitals cover the state’s share through a hospital tax.
The Virginia Hospital & Healthcare Association sees the higher expansion numbers as positive, spokesman Julian Walker said. Hospitals backed expansion — and swallowed a “bed tax” as part of the deal — partly on the notion that broader insurance coverage would allow more people to seek non-emergency care in doctor’s offices, rather than in costly emergency rooms. Hospitals, which by law cannot turn anyone away from their ERs, have had to write off those visits as charity or “uncompensated” care.
“This will reduce uncompensated care, which is a strain on hospitals,” Walker said. “The fact that people are signing up for coverage, we view that as an encouraging step.”
Advocates for expansion have always estimated as many as 400,000 Virginians would be eligible if the state raised income limits for the government health insurance program, as allowed under the Affordable Care Act. But they also said some people who are eligible would choose not to enroll.
Lee said the 400,000 estimate has not changed. She said the state has simply enrolled residents more quickly than expected, in part because it found a way to sign up some people automatically. In some cases, the state knew certain people were eligible because they already receive other forms of public assistance, such as a program for residents with serious mental illness. The state also has streamlined the application for enrollees in other programs, including SNAP, the Supplemental Nutrition Assistance Program commonly known as food stamps.
The 375,000 enrollment figure is a projection, based on the number of Virginians who have signed up since enrollment opened Nov. 1. More than 117,000 had enrolled through Wednesday, Lee said. Medicaid coverage for the new enrollees will begin Jan. 1.
“We’re in this big push right now,” Lee said, describing advertising campaigns in the mail, on radio and online. In December, the state will make a special effort to reach rural Virginians with billboards and even ads plastered on gas station pumps.
Virginia’s traditional Medicaid program has been one of the least generous in the nation. To be eligible, a disabled individual can make no more than $9,700 a year. Able-bodied, childless adults have not been eligible, no matter how poor. About one million Virginians are currently receiving health coverage through Medicaid.
Under the Affordable Care Act, Washington allowed states to open their Medicaid rolls to people with incomes up to 138 percent of the federal poverty level, which is $16,750 a year for a disabled person or able-bodied adult, and $28,700 for a family of three. The federal government pledged to pay at least 90 percent of the cost, which in Virginia would amount to about $2 billion a year.
The Republican-controlled state legislature refused the offer for years. GOP leaders said they feared the federal government would renege on its funding promise, sticking Virginia with a crippling tab.
But opposition in the House crumbled after Democrats nearly won control of the chamber in November 2017, amid a blue wave widely viewed as a rebuke to President Trump. House Speaker Kirk Cox (R-Colonial Heights), seeking to rebrand Republicans as results-oriented pragmatists, came out in favor of expansion if work requirements, co-pays and other conservative strings were attached.
With the legislature’s vote in May, Virginia joined 32 other states and the District in expanding Medicaid coverage. Since then, the number of states has risen to 37.
Residents can sign up online at coverva.org or by calling 855-242-8282. The call center, which first opened in 2001 to handle children’s health insurance, has been flooded with inquiries, Lee said. On Monday alone, she said, it received a record 7,000 calls.