Virginia decided today to expand Medicaid, which will allow the state to start to cover approximately 400,000 people who are unable to afford health plans yet too poor to get tax credit subsidies to buy insurance. This is a significant win for Virginians and for bipartisan cooperation in an increasingly partisan age as a newly-elected Democratic governor worked with Republican majorities in Virginia’s House and Senate on a compromise plan to make Medicaid expansion happen. Unfortunately, this win also includes a provision instructing the Governor after initial expansion of coverage to attempt development of a Medicaid waiver that would include more red tape and complicated work rule requirements for people needing health care. However, this Medicaid waiver provision did not play a decisive role in Virginia’s Medicaid expansion decision. Why did Virginia finally agree to extend health coverage to low-income residents? I see five main reasons:
Elections matter
Previous Virginia legislatures had rejected Medicaid expansion numerous times. However, in the 2017 state elections, Virginia Republicans lost 15 seats in their House of Delegates, retaining only a slight majority. The Virginia Senate Republicans hold only a 21-19 majority currently. In the election for Virginia’s Governor, Democrat Ralph Northam easily defeated his Republican challenger by 54%-45%. And a major reason for these electoral results was clear. Exit polls showed consistently that health care was the top issue in the races for Governor and state legislature by a wide margin – and Medicaid expansion was a key plank in multiple races from the Governor on down. Virginia polls, including those conducted by firms typically working for Republicans – gave Medicaid expansion huge majority support among both Democrats and Republicans with some pegging overall support for expansion at 83% of all Virginians.
In this environment, consideration of Medicaid expansion became fulfillment of a promise made by many newly-elected policymakers including the Governor and multiple state legislators. And the strong results for Democrats plus voter focus on health care meant even races that Republicans won became much closer in 2018 and dominated by health issues.
Community forums on Medicaid expansion in more rural areas of the state
While the metropolitan centers of Richmond and the northern Virginia area near DC (“NOVA”) are clearly influential, more suburban and rural areas of the state played an important part in the debate around Medicaid. Community forums on Medicaid expansion featuring bipartisan groups of legislators, local clinic and hospital doctors and directors, and other health leaders were held in towns like Bedford, Williamsburg, Fredericksburg, Staunton, and Virginia Beach. This had a huge effect. For example State Senator Frank Wagner, a Republican from Virginia Beach, said in early April that he was going to break ranks and support a compromise on Medicaid expansion. This followed the support of Medicaid expansion from Senate Finance Co-Chair Emmett Hanger (R), representing rural Augusta County including the cities of Staunton and Waynesboro. And after the razor-thin Republican majorities created by the election, a minimum of just two Republicans in the Senate were now needed to join Democrats on any compromise plan to expand Medicaid. The role of Medicaid is essential to rural areas and small towns and that made a difference in Virginia.
Obama who? Obamacare what? Medicaid is popular
After a presidential election, a year of political turmoil with President Obama out of office, and multiple failed attempts to cut Medicaid and repeal the Affordable Care Act, the politics of opposing Medicaid expansion became less attractive. Over the last year Republican voters and legislators in Virginia began to treat the issue of expanding Medicaid as a separate issue from the ACA and “Obamacare.” Refreshingly many people, regardless of party, seemed more focused on the issue of how to extend coverage than rehashing ideological battles. This came through for Republican legislators who started to express support for Medicaid expansion – stories appeared detailing how any political backlash they felt for their stance was “milder than expected.”
In addition, the political fight over Medicaid in 2017 seems to have only enhanced Medicaid’s popularity. Overwhelming support for Medicaid consistently shows up in polling – and this support remains steady regardless of political affiliation. My theory as to why this is has a lot to do with stories like Rebecca Wood’s and many, many others where families who rely on Medicaid explained to all Americans how Medicaid is a safety net for everyone and a key reason why millions of families can see the doctor when they are sick without going bankrupt.
More policy, less posturing
A telling political maneuver took place shortly after Virginia’s new Democratic governor was sworn in. With an almost 10 point win, Governor Northam was in a strong position. And Democrats in Virginia’s legislature were feeling strong too, blocking a bill that would have sent funding to a hospital in a Republican’s district. Why? The Republican legislator opposed Medicaid expansion but also wanted taxpayer funding for the hospital struggling in his district in part because the state hadn’t expanded Medicaid. Northam stepped in early in 2018, getting his fellow Democrats to back off and let the hospital funding go through. This built on the Governor’s record of being willing to work with all sides for common goals and generated goodwill from Republicans that the Governor would work cooperatively on Medicaid expansion as well.
Lots of very committed advocates
All this change didn’t happen in a vacuum. Virginia boasted a broad-based “Healthcare for All Virginians” coalition pushing for closing the coverage gap with over 100 organizations from the Virginia Rural Health Association to health clinics, and groups like the Leukemia and Lymphoma Society. Key groups like Virginia Organizing, the Virginia Interfaith Center, The Commonwealth Institute, the Virginia Poverty Law Center, and many more worked together to hold forums in every area of the state. These nonprofit advocates also personally talked to as many people as possible — from thousands of ordinary Virginia citizens to key political and business leaders in all areas of the state – both urban and rural. They worked across partisan and geographic lines to make it clear that extending affordable health coverage should be considered on its own merits and not on ideological grounds.
