He did so in a letter addressed to Gov. Ralph Northam (D), who made expansion the cornerstone of his 2017 campaign and greeted the missive as good news. But the letter reads like an ultimatum.
It warns the new governor that expansion could hinge on the fate of two bills to impose work requirements on existing Medicaid recipients. The bills, which come before the House Rules Committee on Tuesday, would require the state to apply for a federal waiver to impose work requirements on existing Medicaid recipients.
In his letter to Northam, Cox raised concerns about the governor's recent comments on seeking "straightforward" Medicaid expansion. Cox said he found those comments "disconcerting."
"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 healthcare coverage to more Virginians," Cox wrote.
The current program already excludes able-bodied people with the exceptions of pregnant women and single parents with young children. The vast majority of recipients are children, the elderly and people with disabilities.
"The response to this legislation will provide a good indicator of whether there is a path forward for further conversations on healthcare as part of budget negotiations," Cox wrote. "If there is significant opposition to the common sense concept of requiring able-bodied adults to work before receiving entitlement benefits, I fear the window on healthcare reform will narrow."
Northam has said that he does not favor work requirements, although he has said he could get behind a "work search" program. He has said that he supports other changes but would like those to be addressed apart from expansion.
Spokeswoman Ofirah Yheskel said the governor would not comment on the bills referenced in Cox's letter before passage. But she said Northam took the letter as a good sign.
"Governor Northam is encouraged that House Republicans are willing to begin the discussion about coverage expansion, though he believes the dialogue should begin with connecting more Virginians with quality health care, not less," she said. "He looks forward to working with the General Assembly on a plan that works for all Virginians."
House Democratic Leader David J. Toscano (Charlottesville) and Caucus Chairwoman Charniele L. Herring (D-Alexandria) issued a joint statement saying they were "encouraged that Republicans are ready to seriously address the health care needs of nearly 400,000 Virginians. However, we are disheartened that Republicans want to begin the conversation by reducing, rather than expanding, access to affordable health care."
There is little suspense about whether the bills will clear the Rules Committee; the panel is stacked with Republicans and chaired by Cox. They would also pass both chambers on straight party-line votes given that Republicans have narrow control of the House and Senate.
But Cox seems to be seeking at least some Democratic buy-in on work requirements before moving forward with talks about expanding Medicaid. Expansion under the Affordable Care Act has been a top Democratic priority since Terry McAuliffe won the governorship in 2013. The Republican-controlled legislature blocked expansion throughout his four-year term.
In addition to providing health care to uninsured Virginians, Northam says Medicaid expansion would create 30,000 jobs.
Over the years, Republicans have questioned whether Washington can afford to keep its promise to pick up most of the $2 billion-a-year tab. Some Republicans also have voiced philosophical objections to providing benefits to able-bodied adults — something the work requirements would help address.