Medicaid expansion finally came to Virginia this week.
A few reminders: Medicaid is the federal government’s health insurance program for the poor. It’s often confused with Medicare, which is the federal program for the elderly. Medicaid is also partially funded and administered by states, so state governments have a lot of say in who is covered. One of the main provisions of 2010’s Affordable Care Act, or “Obamacare”, allowed states to apply for billions in additional federal funds to help cover more people under Medicaid. This is the “Medicaid expansion” that Virginia’s General Assembly included in the state budget that finally passed this week.
So, there was basically free money from the federal government to help the poor. Why did it take this long for Virginia to join the 30 other states who have opted in to this expansion? And why was it included in the budget only after a protracted budget battle that almost led to an unprecedented shutdown of state government?
The Republicans who blocked expansion for years offered pretty thin arguments, mostly suggesting that it would be financially careless to expect the federal government to keep its funding promises. Never mind that it’s a dumb argument to say, “Don’t give me money today because you might not give it to me tomorrow.” But also, as many Republicans admitted this year, many of the people who would be covered under the expansion are already being paid for by the state, so there actually would be significant cost savings to adopting expansion. It was always a good idea.
So why did it take almost a decade to adopt this reform? It’s not policy – just politics. Three different political battles shaped Republicans’ intransigence to expansion:
Virginia GOP vs. T-Mac
Former Gov. Terry McAuliffe really, really, REALLY wanted Medicaid expansion. McAuliffe also had a famously tense relationship with the state legislature. Mostly an outsider to the insular General Assembly, the Governor often had trouble brokering any deals and getting any of his priorities through the GA; he vetoed a record number of bills during his term in office.
So GA Republicans saw Medicaid expansion as a way to prevent T-Mac from claiming a political victory. But the General Assembly also had a model for their opposition to the Governor’s agenda, particularly on healthcare.
National GOP vs. Obama
Republicans in Congress decided even before President Obama took office what their political approach to his victory would be: oppose and obstruct. Everything. As Senator George Voinovich noted, “If he was for it, we had to be against it.” This was a cynical strategy, but a largely successful one, particularly when it came to Obama’s signature legislation on healthcare. Opposition to Obamacare defined the GOP during the Obama years.
This opposition trickled down to the states. Virginia Senator John Watkins, who supported Medicaid expansion back in 2014, noted that his fellow Republicans who blocked it were taking a page from their brethren in Washington. “They are trying to exhibit their disdain for the Affordable Care Act,” he said. “They feel if enough people refuse to use it, somehow it’s going to go away, that it will fail.”
In 2018, both McAuliffe and Obama are out of office, so it would make sense that Medicaid expansion finally was put on the table. So then why did the expansion require an extended budget battle that went almost down to the wire?
Virginia GOP vs. Conservatives
Last fall’s election brought a “blue wave” to Virginia, with Democrats sweeping the state-wide races and almost taking back the House of Delegates. House Republicans took away one big lesson: adapt to the changing political mood in Virginia or lose even bigger next time. It helped that new House Speaker Kirk Cox brought some fresh air and a new political approach to the Republican caucus.
But over in the Senate, Cox’s counterpart Tommy Norment drew the exact opposite lesson: continue to signal your opposition to liberal healthcare plans, or you’ll get outflanked by your right. I think the RTD’s Jeff Shapiro has it right: Norment is worried that his colleagues will face opposition, and possibly even primary challenges, from conservatives who have been trained to see Obamacare and its ilk as evil incarnate. Plus, Norment has to worry about hanging on to his party leadership position.
Still, some of Norment’s individual colleagues, such as Jill Vogel and Ben Chafin, threw their lot in with the House and supported expansion. We’ll see next year if their view of their constituencies is better than Norment’s.
The bottom line in all this? Just like at the national level, party and ideology – they’re really both the same thing at this point – drive almost everything in Virginia politics. As much as we might like to “vote for the best candidate” or expect “reasonable people” in office to compromise, the “D” or “R” after your elected official’s name probably matters more than anything else about them. Credit – or blame – for this goes to Republicans, both in Washington and here in Richmond. Compromise is rare because they’ve not only played this game more effectively than the Democrats, but they’ve essentially set up the rules and laid out the board.
This week the General Assembly created the conditions for almost 400,000 Virginians to get healthier. It was a reasonable and bipartisan compromise that still required a sweeping electoral victory for Democrats last fall. If enough voters connect the dots, we should see similar results this year, and maybe even next. Tommy Norment may have a lot more to worry about.