The political battle is over, but the work is far from done in expanding access to health care for up to 400,000 uninsured Virginians.

Gov. Ralph Northam is expected to sign a pair of budget bills early next week that include expanding Virginia’s Medicaid program under the Affordable Care Act, marking the end of a five-year political war in the General Assembly.

The heavy lifting is far from done for lawmakers and state officials, who didn’t include money in the new two-year budget to raise Medicaid reimbursement rates for doctors and other front-line health care providers.

“I recognize that that is something that is critically important,” Sen. Emmett Hanger, R-Augusta, said moments before a decisive vote in the Senate on Wednesday to adopt a budget that will expand Medicaid eligibility on Jan. 1, pledging to work on a solution.

Medicaid expansion will rely on $2.5 billion in federal funding — representing no less than 90 percent of the cost — and more than $306 million from a provider assessment paid by hospitals to cover the state’s remaining share. It will include a second assessment on hospital revenues that will raise the Medicaid reimbursement for inpatient and outpatient hospital care.

But the higher reimbursement rate won’t apply to doctors, nurse-practitioners or others who bill Medicaid separately for the care they provide.

“This should have been addressed at the same time with the same funding,” said Sen. Siobhan Dunnavant, R-Henrico, an obstetrician who voted against the budget and Medicaid expansion under the federal health care law. “This is Medicaid expansion.”

Hanger, co-chairman of the Senate Finance Committee and one of the architects of the budget deal, discouraged a potential floor amendment by Dunnavant and Sen. Jill Holtzman Vogel, R-Fauquier, to address the issue with passage of Medicaid expansion hanging in the balance, but he pledged to work with the governor to resolve it by the next legislative session.

Northam, a pediatric neurologist, also supports the effort to raise Medicaid reimbursement rates for doctors and other health care providers, spokesman Brian Coy said. “The governor feels strongly about it — if you don’t have providers, you don’t have care.”

The problem was the late timing, as supporters of Medicaid expansion tried to maneuver the budget bills out of the Senate without amendments so they would be accepted by the House of Delegates and sent directly to the governor instead of a conference committee, which would have had to work out differences between the two chambers.

The other issue is cost, about $47 million in the second year to raise reimbursements for doctors to 88 percent of their costs. “It’s not as expensive as I thought,” Hanger said.

For primary care doctors and other physicians, raising Medicaid reimbursements is a critical part of expanding access to care for uninsured Virginians, who either go to hospital emergency rooms or delay treatment entirely.

“Just because you get insurance doesn’t mean you have access to a doctor,” said Ralston King, vice president of government relations for the Medical Society of Virginia, which supports Medicaid expansion as long as it includes higher reimbursements for physicians now paid about 67 cents on the dollar for treating patients in the program.

Finding a way to pay for it is the next challenge, King said. “Right now, we don’t have a funding mechanism.”

The Virginia College of Emergency Physicians supports both expanding Medicaid eligibility and raising physician reimbursements for Medicaid patients, according to Dr. Todd Parker, a member of the college board of directors who serves as an emergency department physician at Riverside Shore Memorial Hospital on the Eastern Shore.

“Access to health care is a huge problem up here,” he said.

Parker said the Virginia College of Emergency Physicians also supports other ways of helping Medicaid patients get treatment, including creating a network of community clinics to serve them.

“We are encouraged that along with this legislation, given the very low reimbursements that Medicaid provides providers, that legislators are considering ways to increase Medicaid reimbursements and otherwise help physicians who may see increased numbers of Medicaid patients,” he said.

The immediate challenge for state health officials is to move quickly after the governor signs the budget to begin seeking federal approval of an amendment to the state Medicaid plan to expand coverage and receive federal money to pay for 93 percent of the cost in the first year and 90 percent thereafter.

“Submissions should be completed within weeks, if not days, after the governor signs the budgets,” said Dr. Jennifer Lee, director of the Virginia Department of Medical Assistance Services, which administers the state Medicaid program.

Lee said the department also “will immediately open a dialogue” with officials at the Centers for Medicare & Medicaid Services about federal approval of a waiver. It would allow Virginia to impose a series of conditions on recipients of Medicaid services to share in the cost of their care, as they are able to afford it, and seek work, training, education or other types of service if they are able-bodied.

“As DMAS officials have made clear from the beginning, expanding eligibility to up to 400,000 Virginians is a massive project that will require at least six months of intensive work to ensure that all systems, programs, and contractors are updated and reflect the new policies and procedures,” she said in a written statement.

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