UPDATE: Virginia: Medicaid expansion for 400,000 on the horizon at last?

Last November, along with voting to keep a Democrat in the Governor's office, Virginia voters also swept a huge wave of Democrats into office in the state legislature. They didn’t quite take a majority, but they came within a single vote of getting a 50-50 tie in the state Assembly. Instead, they have a two-vote shortfall (51-49), matching the same two-vote shortfall (21-19) in the state Senate.

New Governor Ralph Northam has solidly promised to finally push through ACA Medicaid expansion for 400,000 Virginians, but those two-vote margins have made doing so incredibly frustrating. Fortunately, it looks like the dam may have finally been broken:

A prominent Republican state legislator from southwest Virginia announced his support Thursday for expanding Medicaid, an about-face that could make it easier for other rural conservatives to get on board after four years of steadfast opposition.

Del. Terry G. Kilgore (R-Scott), chairman of the powerful House Commerce and Labor Committee, said his struggling coal-country district would get the “hand up” it desperately needs if more uninsured Virginians were made eligible for the federal-state health-care program.

“For my district, for my part of the state, it’s the right thing to do,” Kilgore said. “At the end of the day, I think you’ll see a lot of folks feeling that way.”

Kilgore’s announcement came a few weeks after House Speaker M. Kirkland Cox (R-Colonial Heights) began signaling a willingness to expand Medicaid if work requirements could be imposed on able-bodied recipients. Cox’s party nearly lost control of the chamber in the November elections in an anti-Trump wave, with many Democrats running on the issue of health care.

On the one hand, including a work requirement would suck, serving no useful purpose, being incredibly inefficient and costing the state far more than just, you know, expanding Medicaid...but it was a start. Hopefully this latest move by Del. Kilgore will make the "work requirement" Cox is pushing for a moot point anyway:

Kilgore is the first House Republican to explicitly call for expansion, doing so in a Roanoke Times op-ed and on a radio program. More were expected to follow, given Cox’s tacit support. House Republicans met in a closed-door session Thursday to discuss Medicaid.

With extremely narrow margins in both the state Assembly and Senate, Northam knows how delicate the situation is and is understandably treading gingerly:

“Governor Northam thanks Delegate Kilgore for sharing his ideas about how to expand health coverage for Virginians who need it,” said Northam spokeswoman Ofirah Yheskel. “He is encouraged by discussions with members of both parties on this important issue and believes we can reach an agreement that works for everyone.”

Expansion also was a top priority for Northam’s Democratic predecessor, Terry McAuliffe, who said it would provide health care to 400,000 uninsured residents and create 30,000 jobs. More recently, advocates have put the number around 300,000 because not everyone eligible would choose to sign up.

Hmmm...OK, I'm not an expert on Virginia demographics, but if the pattern from other states is any guide, the odds are pretty high that just about everyone eligible will enroll. Then again, that depends greatly on the "work requirement" issue.

UPDATE 2/19/18: Well, this seems to be happening quickly:

RTD Exclusive: The firewall against Medicaid expansion has fallen in the Virginia House of Delegates, budget proposal shows

The firewall against Medicaid expansion has fallen in the Virginia House of Delegates.

The House Appropriations Committee on Sunday will consider a proposed two-year budget that includes extending Medicaid coverage to more than 300,000 uninsured Virginians under the Affordable Care Act and using the savings to pay for a blockbuster higher education initiative in Northern Virginia, a big infusion of cash into K-12 and early childhood programs, and a targeted expansion of raises for public employees.

The catch, of course, is that yes, they're gonna try to bake in work requirements and the like:

...“My long-standing concerns about the cost of expansion aren’t going away, but unfortunately the ACA is here to stay and the Trump administration is the best chance to secure conservative reforms,” Cox said in a statement to the Richmond Times-Dispatch on Saturday, the eve of the annual release of the House and Senate budget proposals.

“Instead of fighting a losing battle against straightforward Medicaid expansion, I believe the House should lead by putting forward a responsible plan similar to what Vice President Mike Pence adopted as governor of Indiana,” said the speaker, referring to federal approval this month of a work requirement for the Indiana Medicaid program that Pence expanded with reforms in 2015.

Northam spokesman Brian Coy said in response to questions about the House proposal, “The governor supports the concept of expanding coverage to Virginians who need it and offering training and incentives to connect people with work opportunities.

And of course this is only half the battle; the barely-GOP-held Senate is still being kind of dickish about the whole thing:

The House proposal sets the stage for a political showdown over the next three weeks with the Senate Finance Committee, which already has said it will not include full Medicaid expansion in the budget it will propose later on Sunday, leaving a gulf of almost $400 million between the two spending plans.

Anyway, assuming it goes through via the compromise, here's what it'd look like:

The proposed House plan would accept $3.2 billion in federal money to pay for 90 percent of the cost of expanding the program on Jan. 1, 2019, while relying on a new “provider assessment” on hospital revenues to cover the state’s share of the cost of health coverage for currently uninsured Virginians whose care is uncompensated.

...The plan proposes a dual track for federal approval. The state would seek approval of an amendment to its state Medicaid plan to expand eligibility, while acting immediately under new language in the current budget to request a federal waiver to allow a requirement for Medicaid recipients to engage in some form of work, study or training, as well as other conditions for receiving health benefits.

It includes $22.4 million to administer the “Training, Education, Employment and Opportunity Program” the House adopted this month to impose work-related conditions on “able-bodied, working-age adults” who receive Medicaid benefits. The House approach is modeled after the Medicaid work requirement imposed in Kentucky and Indiana with the approval of the Trump administration.

The work requirement stuff is bullshit and counterproductive for a variety of reasons, of course, but that seems to be the general rule of thumb tradeoff that's developing for the 18 remaining non-expansion states (along with a few red states like Kentucky which already expanded): Medicaid expansion up to 138% FPL...but only with work requirements attached.

As Andy Slavitt put it:

Two things are clear:

1. The writing is on the wall for coverage expansion.
2. These conservative provisions are the difference between a 1 vote majority. 1 vote.

— Andy Slavitt (@ASlavitt) February 18, 2018

Every. Vote. Counts.