By Peter Galuszka
Could some seemingly small technical changes in legislative tactics and voting powers on an obscure commission clear the way for passing a state budget and expanding Medicaid in some form?
Sen. Emmett Hanger, a Republican senator from Augusta, thinks so. If he’s right, there could be a way out for both Republican House Speaker Bill Howell and Democratic Gov. Terry McAuliffe who are taking the stubborn impasse right up to the wire of June 30.
Hanger is proposing technically separating Medicaid expansion to 400,000 lower income Virginians from the budget debate, but with a twist.
There would be legislation linked to the budget requiring changes in the voting of a legislative commission known as the Medicaid Innovation and Reform Commission (MIRC) which was formed in 2013 and must agree that enough positive change in the Medicaid program is taking place to allow expansion. It would most likely occur through private insurance exchanges of some type.
“By October of this year we might be able to begin some limited enrollments,” Hanger told me in an interview.
I called him because, frankly, I didn’t understand media accounts of what he was proposing although the reports indicated that there could be some kind of breakthrough involved. My undergraduate degree is in international relations and I used to study diplomacy. I realize that such types of granular give and take can bring tremendous progress. I am intrigued.
Of course, I could be dead wrong and Virginia will not pass a $96 billion, two-year budget, the state will lose its good bond rating, government will shut down at least in part, teachers won’t get paid and those caught in health care limbo between Medicaid and Obamacare will remain there.
Talking with Hanger gave me some perspective that I didn’t have and haven’t read in the Mainstream media.
First, he said that the General Assembly has already approved Medicaid expansion. It did so last year with former Gov. Bob McDonnell in office. But it also created the 10 member legislative Medicaid Innovation and Reform Commission to identify problems and offer improvement suggestions for the state’s Medicaid program. No expansion can occur unless the commission approves. Hanger is chairman of MIRC.
By law, any expansion of Medicaid must be approved by a supermajority vote of the commission. That means that a majority of the five Senate members of the commission would have to say yes. Ditto a majority of the five House members.
Hanger’s proposal would make it a straight majority vote of six out of 10 members from both Senate and House sides. Plus, they won’t vote to approve expansion, only to disapprove it. In the meantime, MIRC would set clear metrics to benchmark what reforms are truly wanted.
Medicaid expansion would involve some kind of private health exchange (now dubbed “Marketplace Virginia”), and there would be added safeguards that there would be adequate copays by participants and ways to make sure that emergency rooms aren’t suddenly flooded with newly insured patients. He also wants a workable data system to keep track of patients and payments and other safeguards to prevent abuse. There are at least 17 categories of improvement areas.
The Senate would concede and use the House’s budget bill. The House would drop “Marketplace Virginia” from its bill and would concede that addressing additional Medicaid reforms would be required.
“Technically, it delinks Medicaid expansion from the budget bills,” says Hanger. But he adds that many seem to have forgotten that the General Assembly actually approved of Medicaid expansion last year “if a series of reforms were taken.” He says his plan would insure that just that happens and he believes it could happen quickly while the budget impasse is resolved separately.
He says that Howell, who has stubbornly resisted any Medicaid expansion this legislative session, seems amenable. So does McAuliffe.
The danger, of course, is that decoupling Medicaid from the budget bills takes away leverage points from both sides. Democratic Senator Dick Saslaw fears some kind of trick as do some Republicans.
My view is that sure there’s that risk, but it’s getting really late to keep playing chicken. My view also is that McAuliffe has done a hell of a lot more to compromise than Howell has.
Also, in my view, a private exchange is not the best way to go to expand Medicaid but the reality is that Virginia has a highly conservative legislature. Other conservative states such as Indiana have managed health care expansion through private exchanges, so I guess half a loaf is better than no loaf.
It seems that Hanger’s proposed deal might just get that, and not too late, either. It’s worth a look since the financial and health alternatives are truly terrible to contemplate.
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