After five years of fierce, partisan battles, amid chants of “Yes we did” from the crowd of spectators, Virginia Gov. Ralph Northam signed a bill Thursday afternoon that will expand Medicaid under the Affordable Care Act to cover up to 400,000 more low-income people in the state.
“It has been a long road to get here,” Northam said. “It took longer than we would have liked. But I couldn’t be happier to sign this and give Virginians access to the care they need to live healthy and successful lives.”
Citing the Founding Father who designed the capitol building behind him, Northam thanked the lawmakers and advocates who made the passage of Medicaid expansion possible: “As Thomas Jefferson said, ‘Without health there is no happiness.'”
But the triumphant bill signing on the capitol’s steps in Richmond will not be the culmination of the state’s Medicaid wars, but rather the beginning of a new chapter. The bumpy road ahead includes requesting permission from the Trump administration to implement work requirements and to require that Medicaid beneficiaries pay premiums. Those conservative policies won the GOP votes necessary to get the bill over the finish line, and, if approved, are likely to be the stuff of political and legal battles for years to come.
Under the new Virginia law, starting next January, state residents with incomes up to 138 percent of the federal poverty line will be able to enroll in Medicaid, massively boosting coverage among the currently uninsured.
Some time later, depending on when the Trump administration approves the state’s waiver, Virginia will require those who depend on Medicaid to prove they are employed, studying or volunteering and to pay premiums for their health care. The work requirement will start at 20 hours per months and slowly ramp up to 80 hours, and will have a “three strikes and you’re out” enforcement approach — anyone who fails to certify for three months that they’ve met the work requirement will be booted from Medicaid and barred from reenrolling until the following year.
“That’s about as strict as you can get,” said Jill Hanken, a health law attorney and leader of the Health Care for All Virginians Coalition that campaigned for Medicaid expansion. “There are elements that are extremely punitive. Since most Medicaid enrollees are already working, we think setting up a whole new program for a very small slice of population isn’t the best use of those dollars, and we are quite concerned that people will lose benefits that they are entitled to because they get caught up in the red tape or make a small error.”
As this process moves slowly forward, expansion advocates tell TPM they plan to make their voices heard on every step — lobbying the governor as he drafts the waiver, submitting comments to Trump’s health department as they weigh its approval, pressuring the state as it decides how to implement and enforce the rules, potentially challenging the measures in court, and launching education campaigns to help Virginians navigate the process.
“If it’s approved, we’ll do our very best to make sure people eligible for coverage don’t lose coverage,” said Hanken. She added that should the balance of power shift in the state legislature, where Democrats came within one vote of controlling the lower chamber last year, groups will be calling on lawmakers to amend or scrap the restrictions.
“Even if the federal government approves the waiver, the state can come back later and request any amendments they believe are necessary,” Hanken said. “Virginia has done that many times before with existing waivers.”
A senior Democratic state lawmaker, speaking on background to TPM, confirmed that his party has already begun discussing that exact scenario, saying of the work requirements: “All of this stuff we’d return to if we got the majority in the next two years.”
The Affordable Care Act, passed in 2010, mandated that states expand Medicaid coverage, and included federal dollars to pay for it nearly all of it. But in 2012, the Supreme Court ruled that states must affirmatively approve the expansion for it to go into effect. Many red states, including Virginia, declined to do so.
The bill that finally passed in late May was a compromise struck in the Republican-controlled state Senate to ensure the passage of the expansion. Nearly all of the Republicans who crossed the aisle to back the bill cited the Medicaid work requirement as the reason they felt comfortable coming on board.
“We’re going to make sure they’re working, and they’re not going to get a free ride,” Republican Sen. Frank W. Wagner told the Washington Post. “[T]here are people out there who need help…who could be working and choose not to…I shouldn’t ask other people out there to pay for their lifestyle.”
The fate of the rule could also hinge on the outcome of a lawsuit against Kentucky’s work requirement — the first state in Medicaid’s 50-year history to be approved to implement such a policy — which goes before a federal court in D.C. in mid-June. A ruling in that case may only impact Kentucky, but it could also serve as a legal precedent and basis for challenges in other states.
But Hanken says all the looming battles ahead do not detract from her joy as the expansion is signed into law.
“We are so thrilled to have the coverage expanded,” she said. “We’ll cross those other bridges when we get to that.”