Category Archives: Entitlements

Entitlements, Fiscal Limits and the Looming Age of Rage

Now that Democrats are close to parity with Republicans in the House of Delegates, there is renewed talk of Medicaid expansion in Virginia. Meanwhile, in Washington, President Trump and Republicans are pushing a tax-cut plan that would spur economic growth but, even with stronger growth, would increase deficits by $1.5 trillion over the next ten years. Nobody is talking about the $14.6 trillion national debt except as a cudgel against partisan foes. Even as Medicare, Disability, and Old Age and Survivors trust funds are projected to run out within a single generation, entitlement reform is not up for discussion.

Just a reminder… Here’s are U.S. budget deficits forecast by the Congressional Budget Office without counting proposed GOP tax cuts:

The “on-budget” deficit is what we conventionally think of the deficit. It does not include the draw-down of “off-budget” Medicare and Social Security trust funds. Data source: Congressional Budget Office.

Within eight years, the U.S. will be running $1 trillion-per-year deficits every year, pretty much forever. And the CBO forecast does not take into account the likelihood of a recession or two over the next ten years, in which case deficits will metastasize.

And here’s the off-budget forecast. Payouts for Medicare hospitalization, Social Security disability and Social Security old-age programs exceed tax revenues, but interest income on the assets will keep the respective trust funds in the black for the next couple of years. By 2020, however, the off-budget numbers shift  into deficit mode and plunge rapidly thereafter.

Barring major changes in U.S. spending programs or economic growth, here’s when the trust funds are expected to run out, according to Medicare and Social Security trust estimates:

  • 2028: Disability trust fund runs out of money.
  • 2029: Medicare hospitalization trust fund runs out of money.
  • 2035: Social Security trust fund runs out of money.

Back when the Simpson-Bowles commission tackled the deficit issue in 2010 — the last time Americans thought seriously about entitlement reform — the county had 25 years before keystone social safety net programs imploded. If Congress had acted then, it could have put the trust funds into fiscal balance with relatively minor tweaks (slightly higher payroll taxes, slightly reduced benefits, slightly older retirement ages) that had a large cumulative effect over many years. But a decade of delay will require more painful sacrifices, which means they likely never will be made.

If nothing gets done until the trust funds run out of money — what I call Boomergeddon — the programs will have to cut benefits to match revenues generated. We are only twelve years from massive dislocations to the Medicare program, and 17 years from disruptions to Social Security. Baby Boomers beware, your retirement will be a lot uglier than you realize.

As for those $1 trillion+ on-budget deficits every year, they put Virginia at special risk. Any Congressional effort to tame deficits without touching entitlements will require cuts to discretionary spending, the biggest pot of which is related to defense, intelligence and homeland security…. which happens to be Virginia’s biggest industry sector. Son of Sequester will subject the Virginia economy to chronic economic stress and fiscal pain. But instead of dealing with Virginia’s long-term structural issues, the next session of the General Assembly could well consume itself in a renewed debate over expanding Medicaid.

As Americans speak no evil, see no evil, and hear no evil, we hurtle toward an era of brutal fiscal limits, broken promises to millions of Americans, and polarization and rage that will surpass anything we see today.

How Medicaid Is Cannibalizing Virginia’s Budget

Source: JLARC

Three big trends are worth noting from the Joint Legislative Audit and Review Commission 2017 state spending update, a review of state spending over the previous 10 years.

First, General Fund spending has been constrained by limited revenue growth resulting from Virginia’s weak economy. The increase in spending has averaged 2.0% per year. Adjusted for inflation and population growth, General Fund spending actually declined 1% over the decade.

Second, the Medicaid program has crowded out spending for other priorities. Medicaid hogged 60% of all General Fund revenue growth over the decade. Medicaid’s share of the General Fund pie increased by 73%.

Third, the healthy growth in non-General Fund spending was driven in large part by tuition increases at Virginia’s colleges and universities. In other words, when faced by stagnant revenue and untouchable Medicaid spending increases, legislators cut what was cuttable. They reduced state support for higher education knowing that colleges and universities could fall back upon the expedient of raising tuition.

Cheerful thought of the day: As Virginia’s population ages, Medicaid spending will go one way — up — and it will continue to squeeze other spending categories. Here’s the spin that Republican legislators put on the JLARC report:

House Speaker William J. Howell, R-Stafford: “Once again, this annual report from JLARC shows that the increasing cost of Virginia’s current Medicaid program is crowding out needed funding for our public schools, colleges and universities, roads, and law enforcement officers. We consistently argued that Virginia can barely afford its existing Medicaid program, let alone the massive cost of expansion, and this report vindicates that position.”

Speaker-designee Kirk Cox, R-Colonial Heights: “It’s a simple proposition: if you cannot afford your mortgage payment, you don’t build a new addition to your house. Virginia’s current Medicaid program covers around 1 in every 8 Virginians, and as this report shows, the costs are staggering and continue to climb, despite ongoing reform efforts. It would be financially irresponsible to ask taxpayers to fund the massive expansion contemplated under the Affordable Care Act.”

Del. S. Chris Jones, R-Suffolk: “Even as we instituted major reforms aimed at bending the cost curve, and controlled spending growth in other areas of state government, Medicaid costs continue to increase dramatically. This growth eats into funding that could be used for our teachers, law enforcement officers, and hard working state employees.”

Bacon’s bottom line: Yeah, the Republican leaders are stingy bastards for not expanding Medicaid. But the alternative is worse. Latest news on the Boomergeddon front: The state of Illinois, which expanded its Medicaid program in 2013, incidentally, and now has to cover 10% of the expanded costs not funded by the federal government, has $16.5 billion in unpaid bills. The state also has $200 billion in total liabilities, including pension debt. Meanwhile, pundits are asking if debt-ridden Chicago will become the next Detroit. One good recession, and it will be.

To see what it’s like to operate a government bordering on insolvency, watch Puerto Rico flail as it tries to recover from Hurricane Maria. It’s not a pretty picture. It’s easy to be compassionate when you’re paying with other peoples’ money. When other peoples’ money runs out, everything goes all to hell.

Poverty and the Virginia Welfare State

Greetings from the Virginia welfare state

Greetings from the Virginia welfare state

Let’s say you’re a woman living in the City of Richmond. Let’s say you have two children, ages three and seven, but no husband. Let’s say you work 40 hours a week earning the minimum wage, or $15,080 per year. How much can you potentially receive in public benefits?

Sean Gorman, the Richmond Times-Dispatch PolitiFact reporter, added up the numbers based on a report by the Virginia Department of Social Services:

  • Welfare — $3,840
  • Food stamps — $2,268
  • Women, Infants and Children food basket — $600
  • Child care assistance — $12,468
  • School lunch — $1,296
  • Housing voucher –$10,692
  • Family Access to Medical Insurance Security Plan — estimated $9,807 (based on comparison to Medicaid)
  • Total — $40,971

Add that $40,971 to the wages the woman earns, and we’re talking $56,000 a year. Then consider that the $40,971 in benefits are not taxable income. To earn the same amount in take-home pay– accounting for social security, Medicare, federal income taxes and state income taxes — the same woman would have to earn $5,000 to $10,000 more, depending on what assumptions you make. (That is a back-of-the-envelope calculation derived from running numbers through a federal tax calculator.)

Thus, under the Virginia welfare state, a woman with two young children working for minimum wage enjoys roughly the same standard of living as a woman with two young children earning $60,000 to $65,000 a year. Then consider that the 2015 median household income in Richmond was $60,700, and consider the fact that the median household income includes many two-income families.

Discussion questions:

  • Income inequality. What do these numbers imply for the debate over income inequality in the United States? Does it make any sense to decry the disparity in income without taking into account benefits that low-income households receive from the welfare state?
  • Upward mobility. What do these numbers imply for social mobility? If a woman cannot better her material condition by working diligently and acquiring the skills needed to earn more pay, do welfare benefits act as a deterrent to self-improvement?
  • Poverty and marriage. Given the incentives of the welfare state, what reason do poor women have to get married and to raise their children in a stable partnership with their father? To what extent do welfare benefits render low- and working-class men economically peripheral and irrelevant for any role other than as sexual partners?
  • The nature of poverty. To what extent is the scourge of poverty in Virginia — substance abuse, domestic violence, child neglect, ill disciplined behavior, crime, dropping out of high school, out-of-wedlock births, and associated dysfunctional behaviors — the result of material deprivation or the consequence of welfare-induced family breakdown?

I would guess that the $40,000 tally of welfare benefits is a high number — not all similarly situated women apply for and receive the full gamut of benefits. Even so, the number is extraordinary. It is a testimony to the upward-striving nature of American society that anyone makes an effort to improve themselves at all.

Medicaid, the Blob that Ate the Budget

Medicaid, the blob that ate the budget

The Medicaid blob swallows all in its path.

Details on that runaway Medicaid budget…

Spending per Medicaid enrollee has been relatively flat the past five years, having increased less than 0.4% annually (adjusted for inflation) between FY 2011 and FY 2015. The cost driver has been enrollment, which increased 16.5% over the same period, according to a Joint Legislative Audit and Review Commission (JLARC) report, “Managing Spending in Virginia’s Medicaid Program.”

JLARC summarizes the consequences for Virginia’s General Fund budget:

Medicaid general fund spending has grown by an average of 8.9 percent annually over the past 10 years, while total general fund spending increased by just 1.3 percent. Medicaid spending comprised 22 percent of the general fund budget in FY16, increasing from 14 percent in FY07.

Chart source: JLARC

Chart source: JLARC

No wonder the Commonwealth can’t afford to give employees a pay raise and shore up their pension benefits (see previous post).

But there is potentially good news. The state still has room to squeeze costs by as much as $40 million per year.

In FY16, Virginia could have saved $17–36 million by not paying [Managed Care Organizations] for the inefficient provision of services. [Medicaid] also does not adjust administrative spending for enrollment increases, and these adjustments would have reduced spending by as much as $8 million in FY16.

Chart of the Day: Disabilities in Virginia

One in nine Virginians has a disability.

Source: StatChat blog

One in nine Virginians, nearly one million people, has a disability, according to numbers extracted from the 2015 American Consumer Survey by the Demographics Research Group at the University of Virginia.

The incidence of disability is strongly correlated with age — the elderly suffer a significantly higher rate of disabilities. But hundreds of thousands of the disabled fall into the 35- to 65-year-old age group, accounting for 9.3% of the working-age population. Of those disability_work_statuswith disabilities in the working-age population, most did not work, according to the SnapChat data, but about 44% of them did work full- or part-time jobs.

The snapshot in time is interesting, but not as interesting as the trend lines. As an aging population swells the number of elderly, one would expect an increase in the number of disabled. By contrast, with the decline of hard manual labor and continual advances in medicine, one would expect that the number of disabled in the working-age population would shrink.

But the number of disabled working-age Americans has steadily increased over the years. According to Social Security Administration (SSA) data, 5.3 million Americans were receiving disability benefits in 2001. That number increased relentlessly at a rate of 4% to 6% yearly through 2011. Then the rate of increase began slowing, and the number shrank by half a percent in 2015.

One theory to explain the increasing number of disabled is economic insecurity and unemployment. One might expect people to seek disability benefits during times of economic distress. Yet that is not borne out by the SSA data — there was only a modest increase in the number of disability applications during the recession and its immediate aftermath.

disability_trendline

The change that jumps out in this graph is the dramatic fall-off in the increase in Americans receiving disabilities in recent years. Has the “market” been saturated — have so many people been designated as disabled that there’s no one left who remotely qualifies? Alternatively, have the standards changed — has there been some kind of administrative crackdown that received no news coverage? I don’t know. But the change is dramatic, and it deserves an explanation.

Virginia Welfare Trends

I came across some interesting data on the Virginia Department of Social Services website showing the number of Virginians receiving social welfare benefits. I offer the data without commentary. — JAB

Temporary Assistance for Needy Families (TANF)

Temporary Assistance for Needy Families (TANF)

Supplemental Nutrition Assistance PrograM (SNAP), formerly known as food stamps.

Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps.

medicaid_enrollment

Medicaid

Children's Health Insurance Program (CHIP)

Children’s Health Insurance Program (CHIP)

Energy Assistance -- heating and cooling

Energy Assistance — heating and cooling

Energy Assistance -- crisis

Energy Assistance — crisis

Hospitalization claims

Hospitalization claims

General relief

General relief

Boomergeddon Watch: Student Debt Relief

debt_reliefby James A. Bacon

It should surprise no one that Hillary Clinton is advocating free college tuition and  loan forgiveness for millions of students in an attempt to appeal to the Millennial vote. But the pandering of presidential candidates doesn’t begin to plumb the depths of perversity in the American political system. Now industry is joining the cause. Reports the Wall Street Journal:

Real estate agents, farmers, architects, startup lenders, lawyers, tech companies, benefits administrators — even podiatrists — have sent lobbyists to Capitol Hill over the past two years to push for legislation to forgive or at least reduce what workers and consumers owe on their student loans. … Many industries argue that freeing up student debt, even for well-paid workers, would help the economy.

The proposal with the most traction, says the WSJ, would allow employers to contribute up to $5,250 a year toward an employee’s student debt without it being taxed.

The bald self-interest of these industries is appalling. To be sure, forgiveness of all or part of the $1.3 trillion in student debt would stimulate consumer spending — Millennials could buy more houses, more cars, more consumer goods. But such measures would pass on the cost to taxpayers, and it would ratchet up moral hazard to unprecedented levels.

It is mind-numbing to me that anyone is considering massive debt relief that would reward the profligate and irresponsible while punishing those who dutifully paid off their obligations. But why not? After all, we bailed out Wall Street after the real estate crash. We bailed out Detroit. We hand out tax breaks to big business like John D. Rockefeller tossed out dimes. We allow affluent home owners to deduct mortgage interest from their taxes. Now Donald Trump wants to hand out billions for a day care entitlement. There’s no end to the goodies we dispense, so what’s one more multi-billion-dollar giveaway?

The blindness is breathtaking. Despite sequestration, despite the expiration of the Bush tax cuts, despite a zero interest-rate monetary policy, despite continued (though tepid) economic growth, the Congressional Budget Office says that the post-recession trend of declining deficits is over, and that spending shortfalls will continue to increase every year, pretty much forever, and so will the national debt.

projected_deficits

Adding another entitlement — a higher-ed entitlement — rather than addressing the underlying problem of rising college tuition will only accelerate America’s march to Boomergeddon. This cannot possibly end well.

The New Idle Class: Men

fat_guyby James A. Bacon

Earlier this week, I noted that employers in Martinsville, a city with one of the highest unemployment rates in Virginia, have 1,400 unfilled jobs. Many jobs require skills that locals do not possess. But few aspiring workers are enrolling in courses at the region’s New College Institute that would equip them with those skills. Local officials bemoaned the lack of motivation of those out of work.  “We don’t have an employment problem,” said City Manager Leon Towarnicki. “We have a participation problem.”

It turns out that the phenomenon of unfilled manufacturing jobs is hardly unique to Martinsville. Openings for manufacturing jobs this year have averaged 353,000 a month nationally, but manufacturers struggle to find workers to fill them, reports the Wall Street Journal today. The Journal article emphasizes the mismatch between job requirements and worker skills.

In 2000, 53% of manufacturing workers had no education past high school. By 2015, that share had fallen 9 percentage points, while the share with college or graduate degrees increased 8 points. … The “upskilling” in manufacturing mirrors a broader bias in the economy toward more educated workers. …

Companies say education and training systems haven’t evolved with industry needs.

Perhaps there is something grievously wrong with the U.S. system for educating and training workers. That’s not hard to believe: The federal and state governments fund more than a dozen job training programs, which are notorious for their overlap, administrative inefficiency and lack of effectiveness. But, then, the nation does have a strong system of community colleges. And as the Martinsville case shows, many people out of work are unwilling to avail themselves of the opportunities to re-tool themselves.

In a separate WSJ piece, “The Idle Army: America’s Unworking Men,” Nicholas Eberstadt with the American Enterprise Institute focuses on the decline in workforce participation among American men. The fraction of American men age 20 and older without paid work rose from 19% to 32% over the past 50 years. “For prime working-age men,” Eberstadt wrote, “the jobless rate jumped to 15% from 6%. Most of the postwar surge involved voluntary departure from the labor force.”

Who are America’s new cadre of prime-age male unworkers? They tend to be: (1) less educated; (2) never married; (3) native born; and (4) African-American. But those categories intersect in interesting ways. Black married men are more likely to be in the workforce than unmarried whites. Immigrants are more likely to be working or job-hunting than native-born Americans, regardless of ethnicity. …

What do unworking men do with their free time? Sadly, not much that’s constructive. About a tenth are students trying to improve their circumstances. But the overwhelming majority are what the British call NEET: “neither employed nor in education or training.” Time-use surveys suggest that they are almost entirely idle. .. For the NEETs, “socializing, relaxing and leisure” is a full-time occupation, accounting for 3,000 hours  a year, much of this time in front of television or computer screens.

Part of the problem can be attributed to the workforce barriers encountered by America’s huge pool of ex-prisoners and felons, who account for one adult male in eight in the civilian non-jail population. Another is the increase in nonworking men who draw from disability and other means-tested benefit programs.

Meanwhile, writes Eberstadt, “the male retreat from the labor force has exacerbated family breakdown, promoted welfare dependence, and recast ‘disability’ into a viable and alternative lifestyle. Among these men the death of work seems to mean also the death of civic engagement, community participation and voluntary association.”

The assumption that “everybody wants to work” is no longer founded. That is an ethnocentric notion of U.S. elites, projecting their own values through an ideological filter upon an expanding underclass of all races. Economic policies that fail to recognize the new workforce reality, no matter how well intentioned, are a waste of time. Indeed, insofar as such policies distract us from the real issues and squander precious resources that our decreasingly affluent society can no longer afford, they do an actual harm.

The Student Indebtedness Dilemma

debtby James A. Bacon

The problem of student debt is finally getting high-level attention in Virginia, as evidenced by a panel discussion on the subject hosted in Richmond over the weekend. It’s less clear that anyone has a realistic idea of what to do about it.

Some one million Virginians owe a total of $30 billion in student debt. The indebtedness is disproportionately concentrated among African-Americans who tend to come from lower-income families, borrow more, take longer to graduate, are less likely to complete their degrees, are more likely to miss repayments, and are more likely to see their credit scores suffer as a consequence.

Although this was not a theme of the conference, as reported by the Richmond Times-Dispatch, I  would argue that, insofar as institutional racism is a reality today, the most oppressive institution in the United States is the system of higher education, which creates unrealistic expectations for poor, academically unprepared students and loads them up with life-crippling debt. While extremely liberal in ideology, higher ed is highly illiberal in practice, and it is creating a new class of indentured servants. Even in the early plantation economy of the American colonies, indentured servants could work off their debt in seven years. Student loan debt can last for decades.

Speaking at the Richmond event, Sen. Glen H. Sturtevant Jr., R-Midlothian, described his prospects as a Millennial with three young children. “By the time they’re ready to go to college, I’m going to be paying for them to go to college and still be paying off my student loan debt from when I went to law school.”

At least Sturtevant completed his law degree.

The underlying cause of student debt is the high cost of attending college. Due to escalating costs and stagnant contributions from the state, increases in college tuition and fees over decades have relentlessly outpaced the growth in household incomes of all but the most affluent Virginians. But that’s not all there is to the story. Colleges, driven by their commitment to racial and ethnic diversity, are especially aggressive in their recruitment of blacks with the consequence that blacks on average are less prepared academically than their peers, more likely to struggle, take longer to graduate (assuming they do graduate), and more likely to accumulate large debt obligations.

Another part of the problem is a powerful cultural belief that college is the only entry ticket to a middle-class life. Anne Holton, Virginia’s Secretary of Education, alluded to it in her panel remarks. “It’s a bit of a leap of faith,” she said, but research shows that the return on investment makes a degree worthwhile, resulting in up to $1 million in additional income in lifetime earnings.

Holton acknowledged that the $1 million figure is an average figure, and it does not apply evenly to everybody. Needless to say, a degree in engineering, computer science or business will lead to more remunerative employment prospects than a degree in education, social work, history or anthropology.

What Holton did not say (or was not quoted as saying) is that literally millions of jobs are going begging in the American economy that pay handsome middle-class wages and don’t require a four-year college degree…. Which brings us to a CNN Money story, referred to us by our friend Tim Wise (El Growler Grande), which says that the U.S. has a near-record 5.6 million job openings. American companies are looking for workers. The trouble is, they can’t find workers with the right skills — and those skills are not taught in four-year colleges.

While the number of students in college has increased from 15 million in 2000 to 20 million today (great news for the educational-industrial complex), what the economy needs is more truck drivers, electricians and plumbers. People may fret about the impact of self-driving Google cars on demand for drivers a decade from now, but the American Trucking Association says the economy could absorb 50,000 additional truck drivers today. The median annual wage for a trucker working for a private fleet is about $73,000.

Here in Virginia, 90% of all jobs in the future are forecast to require some education and training beyond high school but 50% to 65% will require less than a bachelor’s degree, according to “Workforce Credentials: The Pathway to Virginia’s New Middle Class,” a publication of the Virginia Community College System.

Put another way, for every one job that requires an advanced degree, there are two jobs that require a bachelor’s degree and seven jobs that require an associate’s degree or industry-recognized credential. The Virginia economy produces about 175,000 of those jobs each year.

Community college is cheaper than four-year residential colleges, it requires fewer years of study, and it provides degrees and/or credentials that lead to solid middle-class jobs. Lower-income students — especially those coming through school systems that did not provide them solid academic preparation — should consider an alternate, low-debt path to a middle-class life.

Nothing less than a wholesale reorientation of priorities is sufficient to fend off the social calamity of indebtedness.

An Alternative to Expanding Medicaid: Expanding Free Clinics

Del. John M. O'Bannon III

Del. John M. O’Bannon III

by James A. Bacon

With all the bad press that Virginia’s Medicaid program has been getting recently, the prospect of the General Assembly enacting an expansion of the health care entitlement in 2016 are just about nil. First came a report last month that the state wasted $21 million last year paying Medicaid benefits to recipients who no longer qualified. Then the McAuliffe administration revealed that the state share of funding Medicaid is forecast to surge in the next two-year budget cycle, boosting the annual cost from $7.9 billion in fiscal 2015 to $9.3 billion in fiscal 2018.

That’s without expanding Medicaid as allowed for in the Affordable Care Act. While the federal government has covered 100% of the cost for an introductory period, state governments will have to begin paying a share of the cost beginning in the next fiscal year, eventually topping out at 10% of the added spending.

Virginia Republicans have held fast against expanding the entitlement. Their primary argument has been one of fiscal responsibility: Every state dollar spent on Medicaid is one less dollar that can be invested in K-12 schools, higher education, and other pressing state needs. But Medicaid doesn’t exist in a vacuum. It needs to be seen against a larger backdrop of reforming a largely dysfunctional health care system and a tattered social safety net.

Yesterday I sat down with Del. John O’Bannon, R-Henrico, a practicing physician who happens to be vice chair of the House Health, Welfare and Institutions Committee, to discuss the wellness (or lack of it) of Virginia’s health care system. The thrust of my questions was this: It’s all very fine to oppose Medicaid expansion on fiscal grounds, but the health problems of poor and near-poor Virginians are real. What do Republicans propose as an alternative?

His answer comes in two parts. First, the General Assembly has steered more funds into the state’s mental health programs and into free clinics. Said O’Bannon: “We’re for strengthening the safety net.” But he prefers programs that Virginia can control without federal interference or that leverage private-sector philanthropy. Second, the state should do more to promote competition and transparency to contain medical costs and improve outcomes for all Virginians, including the poor. In this post, I’ll focus on the first approach.

In the current fiscal year, the General Assembly approved $125 million in new safety-net funding for mental health, free clinics and Federal Health Centers.

Of that amount $96 million is dedicated to SMI mental health, which, with an equal match from the feds, should treat 20,000 people with serious mental illness. (SMI stands for Serious Mental Illness.)

The balance of the new funds supports free and affordable clinics, which provide physician care, x-ray services, lab services, immunizations, preventive services, prescription drugs, and some dental care to Virginians lacking other health care coverage. According to FreeClinics.com, there are 254 clinics in the state of Virginia. Some clinics are federally sponsored Community Health Centers, which may charge patients a fee, depending on income, while others are entirely free. While coverage does not extend into every nook any cranny of the state, it is extensive. In Southwest Virginia, the mobile Health Wagon fills in some of the gaps by providing care services to residents of 11 counties.

State funds complement charitable donations and professional time contributed by doctors, nurses and other volunteers, while the Virginia Health Care Foundation works with pharmaceutical companies to contribute prescription drugs.

Although free/affordable clinics do provide primary health care to hundreds of thousands of Virginians, the health safety net is “stretched as never before,” states the website of the Virginia Health Care Foundation. “Free clinics reported up to a four-month wait for patients seeking a first appointment. Some have instituted lotteries to determine who can receive care. Other clinics are simply unable to accept new patients because of capacity and/or resource limitations.”

As imperfect as the safety net may be, Virginia’s dense network of free/ affordable clinics is “unique” in the country, says O’Bannon. By comparison, he says, Maryland doesn’t have a single free clinic. Instead of expanding Medicaid, with its arbitrary rules and fiscally unsustainable cost, Virginia should focus on strengthening its home-grown institutions that are inherently closer and more responsive to the community.