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Medicaid Expansion In Virginia

The Affordable Care Act (ACA) was first signed into law in 2010

The ACA provided that there would be subsidies for all people with incomes from the poverty level up to four times that amount, but not to people with incomes below the poverty level ($23,050 for a family of four) and that Medicaid would become expanded to include all people making between 100% and 138% of federal poverty level.

Initially, the Affordable Care Act included a universal Medicaid expansion. But on June 28th, 2012, the Supreme Court ruled the federal government could not penalize states that did not expand Medicaid by taking away existing federal Medicaid payments.

There was a lawsuit brought by 26 states, the National Federation of Independent Business, as well as some individuals to exclude the part of the law that mandated that all states must expand Medicaid to their residents who qualify as well as challenging the individual mandate in the ACA. The U.S. Supreme Court ruled that it would be optional for states to expand Medicaid to all of their qualifying citizens.

By the end of 2014, 28 states and the District of Columbia had expanded Medicaid. Even though the ACA had the federal government paying for 100% of the Medicaid subsidy until 2016 and 90% from 2016 on, the remaining states refused to expand Medicaid. The argument Republican legislators and governors gave were they didn't want to pay the administrative costs for Medicaid expansion along with the worry that the federal government would eventually cut off the funding.

Meanwhile, the federal subsidies to hospitals were being reduced. The majority of hospitals are non-profit and are required to accept all patients regardless of their ability to pay. Hospitals were forced to absorb the additional costs without the former federal subsidy. Because of this burden (in states that did not expand Medicaid) hospitals were forced to raise their rates for paying customers. Many hospitals in states that did not expand Medicaid were forced to close.

Virginia did not initially expand Medicaid. In 2010 The Virginia General Assembly passed legislation exempting state residents from the federal coverage mandate. The governor of Virginia, Republican Robert McDonnell, signed this into law. It was the first such legislation in the U.S. to take effect as a state law.

In March 2010, Virginia Attorney General Ken Cuccinelli acting for the Commonwealth of Virginia brought a lawsuit claiming that Congress didn’t have the authority to require citizens to buy health insurance or pay a penalty. Cuccinelli won a procedural victory at the U.S. District Court level which was tossed out in September by a three-judge panel of the U.S. Court of Appeals for the 4th Circuit in Richmond. The Court of Appeals found that Virginia didn't have standing to sue. Bypassing appeals, Cuccinelli and Gov. McDonnell asked the U.S. Supreme Court to review the case but the Supreme Court declined.

In 2013, Terry McAuliffe, a Democrat, was elected governor of Virginia. McAuliffe had made Medicaid expansion a key part of his campaign. The state senate was tied with 50 Republicans and 50 Democrats but with the election of Democratic Lt. Gov. Ralph S. Northam presiding over tied votes, the Democrats had control of the state senate. McAuliffe wanted to expand Medicaid in Virginia but the House of Delegates was controlled by Republicans who refused to allow Medicaid to be expanded in Virginia.

In June 2014, Democrats lost control of the state senate, when Democratic state senator Phillip P. Puckett resigned, giving Republicans the majority and control of senate committees.

Realizing that he could not expand Medicaid for Virginia as long as the General Assembly was controlled by Republicans who were opposed, Governor McAuliffe introduced program improvements for those currently enrolled through an executive order and a series of emergency regulations. He launched The Healthy Virginia Plan in September 2014. The plan provided medical and behavioral health care to approximately 20,000 uninsured Virginians with severe mental illness.

The Healthy Virginia Plan utilized federal and state resources to enroll additional children in FAMIS (Family Access to Medical Insurance Security Plan, is Virginia's health insurance program for children), Medicaid, and in the federal marketplace for health insurance. It included an outreach campaign to reach those qualified for Medicaid who had not yet enrolled as well as those who would be able to get premium subsidies available through the federal exchange.

Democrats campaigned to expand Medicaid for the Virginia election in leading up to the November 2017 election in Virginia. Democrats kept the governorship with the election of Dr. Ralph Northam and made major gains in the House of Delegates. In the Virginia election in 2017 Republicans retained a small majority. Republicans lost 15 seats to Democrats. The vote in the 94th District was tied between Democrat Shelly Simonds and Republican David Yancey. According to Virginia law, in the case of a tie, elections were to be decided by drawing the names out of a hat. David Yancey won. On January 6, Shelly Simonds conceded, giving control of the House to the Republican party

Though the Republicans retained a narrow majority, many changed their stance, recognizing that Medicaid expansion was favored by many voters. In April, the Republican-led House of Delegates approved a state budget with bipartisan support to expand Medicaid eligibility to about 400,000 low-income adults.

On May 30, 2018, the Virginia senate approved Medicaid expansion, allowing up to 400,000 Virginia citizens to obtain health insurance. The budget included work or volunteer requirements for non-disabled enrollees which was necessary to gain the votes of the four Republicans who voted for Medicaid expansion. The federal government would be asked to grant permission for the work requirements which might only be granted up to two years after Medicaid is expanded in January 2019.

The federal government would pay for 90% of the cost of Medicaid expansion. Virginia's plan would tax private acute-care hospitals to pay the remaining 10% cost.

On June 7, 2018, Governor Ralph Northam signed the state budget bill that expanded Medicaid for Virginia