As a health policy analyst, I have studied many reforms to our nation’s health care system since beginning my career working in the White House for President George H.W. Bush. I’ve watched as the Affordable Care Act has made a difference in the lives of millions of Americans, including young adults (some of whom have been my students) who can stay on their parent’s health plans longer.
Yet there are still hundreds of thousands of low-income adults in Virginia, working full time or multiple part-time jobs, who cannot take advantage of many of the law’s provisions. For them, the ACA’s proposed expansion of Medicaid coverage to adults with incomes up to 133 percent of the federal poverty level — roughly $15,000 for a single adult and $26,000 for a family of three — can provide needed health care access and financial protection to as many as 400,000 of the state’s approximately 985,000 uninsured.
The catch is that for this expansion of coverage to occur, our legislative leaders must agree to accept the federal funds that will finance it. Federal dollars will pay for 100 percent of the cost of expanded eligibility from 2014 to 2016; 95 percent from 2017 to 2020; and 90 percent in 2021and thereafter. In other words, starting in 2017, Virginia must pick up just 5 percent of the cost, and 10 percent starting in 2021.
This expense has emerged as a major political stumbling block. Yet if Virginia continues to balk at expansion, it will be a Catch-22: Fewer people will get insurance through Medicaid, the state will lose out on significant state budget savings and Virginia will get less federal funding for hospitals that treat the uninsured.
What we need, then, is a bipartisan compromise — inspired by pragmatic approaches to expanding Medicaid adopted in other states — made up of four potential provisions. First, Medicaid expansion could be made conditional. For example, if the federal government were to reduce the significant financial commitment made to states in the ACA, Virginia could halt further enrollment under the expansion in 2017 or withdraw altogether.
Second, new Medicaid enrollees could be required to pay more for health care. Virginia could create a cost-sharing arrangement whereby enrollees with higher incomes contribute up to 5 percent of their annual income (roughly $580-$775 for a single adult) toward co-payments and/or deductibles.
Third, while receiving increased access to primary care, preventive services, and wellness promotion programs, new Medicaid enrollees could be required to participate in a variety of initiatives to improve their health, such as smoking cessation programs.
Finally, all new enrollees should be covered by private health care plans, rather than traditional Medicaid. By combining expanded health insurance coverage with increased personal responsibility and a bigger role for private health plans, Virginia could (and should) join the growing number of states forging market-oriented Medicaid plans. If lawmakers pass up this sensible opportunity to get more Virginians health care coverage, we will effectively be subsidizing other states’ efforts, while receiving none of the benefits.
Rick Mayes is an associate professor of political science and do-director of the Healthcare & Society Program at the University of Richmond. Contact him at firstname.lastname@example.org.