A work requirement was just one of several strings attached by conservatives before Virginia’s Republican-controlled General Assembly would agree to expand the program in May 2018. Another would make certain recipients responsible for co-payments, deductibles and monthly premiums.
The state has been seeking the federal government’s permission — a “waiver” from the Center for Medicaid and CHIP Services — to impose those conditions. But in a letter Tuesday to Washington, the Northam administration said it wanted to hold off “in light of recent changes in our state legislature, which have generated dynamic policy conversations with regard to the . . . waiver.”
“Given the likelihood that the Governor and legislature will substantially modify these new waiver provisions in the coming months, the Governor has directed us to pause . . . until we have clear policy direction from our State leadership,” Karen Kimsey, director of the Virginia Department of Medical Assistance Services, wrote to Calder Lynch, acting director of the Center for Medicaid and CHIP Services.
Virginia also has concerns about the cost of monitoring recipients for compliance, Kimsey said in the letter, which was first reported by the Richmond Times-Dispatch.
Republican leaders howled at the turnabout, which outgoing House Speaker Kirk Cox (R-Colonial Heights) called “Governor Northam’s broken Medicaid promise.”
“I’m disappointed to say the least,” Cox said in a written statement. “The Governor and I made personal commitments to each other on this long-term public policy agreement. There wasn’t an asterisk that said ‘unless my party wins the next election.’ It’s a sad reflection on the value of integrity in modern politics.”
Under the Affordable Care Act, Washington allows states to open their Medicaid rolls to people with income up to 138 percent of the federal poverty level, which is $17,237 for an individual. 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 five years, with GOP leaders warning that the federal government would stiff Virginia on the promised funding, leaving the state with an unbearable 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. Cox, seeking to rebrand Republicans as results-oriented pragmatists, came out in favor of expansion in the following legislative session — with work requirements and co-pays. In the end, 19 Republicans in the House and four in the Senate joined Democrats to expand Medicaid in May 2018.
Under the deal, certain Medicaid recipients would be required to work or participate in job training, educational programs or community service at least 20 hours a week. They also would be responsible for co-pays of $5, deductibles up to $100 and month premiums ranging from $5 to $10.
Expansion kicked in Jan. 1, but without the work and other requirements because Virginia has been awaiting federal approval.
Democrats were never enthusiastic about the conservative add-ons, calling them expensive to administer and likely to result in interruptions in health coverage.
After winning control of the House and Senate on Nov. 5, Democrats have the political muscle to modify those provisions or scrap them entirely. Democrats picked up six seats in the House, giving them a 55-to-45 advantage. They flipped two seats in the Senate, resulting in a 21-to-19 edge.
About 65,000 Medicaid recipients would need case management or employment supports to implement the work requirements, according to Daniel Carey, Northam’s secretary of health and human services. He has been lobbying CMS to provide Virginia with money for that, so far without success.
Other states that have sought to impose work requirements have run into trouble. Federal judges have blocked worked requirements in Kentucky, Arkansas and New Hampshire, while Indiana and Arizona have suspended theirs amid legal challenges, according to the Commonwealth Institute for Fiscal Analysis, a liberal think tank in Richmond.
“A lot has happened since 2018,” said Michael Cassidy, president of the Commonwealth Institute. “States moving forward to try to impose these work [requirements] found out how problematic the policy really is. Tens of thousands of folks have been losing coverage in states, many through no fault of their own, not because they weren’t working, but because they were having trouble with the bureaucratic red tape of reporting their work hours.”