MARCIA DAY CHILDRESS: Good afternoon.
I'd like to welcome you to the Medical Center Hour.
I'm Marcia Day Childress from the Center for Biomedical
Ethics and Humanities.
We produce the weekly Medical Center Hour.
Delighted to see you here.
"Medicaid Expansion in Virginia - Working on It".
This June, Governor Ralph Northam
signed a budget bill that gives 400,000 low income
Virginians access to government health
insurance through Medicaid.
This action, as those of us who've
been around Virginia for a while, was a long time coming.
Four years, in fact, and it marked
an upbeat bipartisan close to a bitter battle
in Virginia's General Assembly.
An option under the Affordable Care Act, Medicaid expansion
makes additional low income persons
in participating states eligible for care that's funded chiefly
with federal dollars.
Virginia's decision to join 32 other participating states
hinged on a bipartisan legislative compromise
to impose work requirements on the Medicaid recipients.
A few other states have taken similar positions,
but debate about work requirements
continues in government, in policy circles,
and in the courts.
Our Medical Center Hour today examines Medicaid expansion
in Virginia, something that will be implemented this January.
From the policy, political, and health care
perspectives with a focus, especially,
on what it means locally to us in Charlottesville
and central Virginia.
The hour is short, but we've tapped three experts
to efficiently unpack this important matter,
and to do so, we trust, with time left for your questions
and discussion.
In order of presentation, let me welcome Professor Carolyn
Engelhard on my immediate right, Health Policy
Analyst in the Department of Public Health Sciences
here at UVA.
In the center, the Honorable David Toscano,
delegate for the 57th district, and Minority Leader
in the Virginia House of Delegates.
And on my far right, Dr. Chris Ghaemmaghami,
UVA Health Systems' Chief Medical Officer and Senior
Associate Dean for Clinical Affairs.
None of our speakers, I'm happy to say,
had any conflicts of interest to disclose.
So now, please welcome Professor Carolyn Engelhard,
and we're going to work our way through "Medicaid Expansion -
Working on It."
CAROLYN L. ENGELHARD: So hi, everybody.
Can you hear me OK?
Good.
I'm so happy to be here.
I want to thank Marcia for the invitation.
I want to thank Dean Wilkes for supporting this program,
and I want to say a big hey to all my former students
and colleagues.
I love it that you're here, because it
means that you think this is an important topic,
and it is a very important topic.
So let's get going.
My job today is to give you the big picture,
is to paint the national landscape,
and then we'll zero in on what it means to Virginia, and then
to the University of Virginia Health System.
So Virginia is the latest state to expand their Medicaid
program.
It was a bit long in coming.
This topic was very contentious under the previous governor.
I'm sure David can touch on that more if you
want to talk about it, but this is
a map of the states that have expanded to date.
You can see the ones in dark blue have expanded.
As Marcia mentioned, in Virginia, the governor
signed it into law in June.
It rolls out January 1, 2019.
Interestingly, in Maine-- this just gives you
a little bit of flavor of just how political this program is.
Maine voters, through referendum,
passed Medicaid expansion multiple times.
The governor refused to implement it.
They sued the governor.
They took the governor to court, and the court
ruled now that Maine has to do Medicaid expansion.
And the governor, LePage, actually in the application
for Medicaid expansion to the federal government, to CMS,
actually asked the federal government not to approve it.
So we'll see what happens.
Medicaid expansion is on the ballot this fall
in four states.
You can see here, Utah, Idaho, Montana, and Nebraska.
In Virginia, up to 400,000 Virginians
will be eligible under the Medicaid expansion program.
Virginia is a state that has a very lean, traditional Medicaid
program.
If you are a parent in Virginia, you
are not eligible for Medicaid if you make more than 30%
of the federal poverty level.
The federal poverty level is about $12,000,
so you would have to make less than 30% of that, as a parent,
to get Medicaid in Virginia.
Now, with the Medicaid expansion, these parents
and childless adults, up to 138% of the federal poverty level
will be eligible to get health insurance through this program.
This is a map of sorts, of the states that have applied for
or received approval for work requirements
in Medicaid expansion.
Indiana and New Hampshire plan to implement their requirements
in 2019.
They have approvals.
Kentucky was the first state to receive
approval, a waiver approval, for the work requirement.
Immediately, that was challenged in federal court,
and a federal judge stopped the implementation of the work
requirement, saying that it was at odds
with the intent of the Medicaid program.
Arkansas's work requirement did go forward,
just completed its 90-day review.
And of the 26,000 people who are required in Arkansas to fulfill
a work requirement, over 4,000 have lost coverage
as a result of not fulfilling the work requirement.
There is a lawsuit pending, just as there
was in Kentucky, and that lawsuit will go before,
actually, the same judge that heard the Kentucky case.
The Virginia Medicaid expansion program
was passed with the understanding
that Virginia would submit to the Centers for Medicare
and Medicaid Services an 1115 waiver requesting
work requirements.
That document, a draft of that language,
came out just last week.
It's now up for public comment, and there
needs to be a report on the status of the waiver
application by December 1.
I'm sure that David will talk about that.
So what are the promises and the perils of work requirements?
We have enough data now about states
that have expanded their Medicaid program to know
that it has been successful.
It is expensive.
Health insurance is expensive.
Health care is expensive, but self-reported health status
is up.
Medical bankruptcy is down.
Patients have established connections with primary care
providers, and they've been better able to integrate
behavioral and physical health.
By and large, Medicaid work requirements are popular.
70% percent of Americans support them.
I think it just is sort of intuitive
that we believe that able-bodied people should work.
People should take individual responsibility
for themselves and their families.
And so, at least theoretically, it
sounds like a really good idea.
But as always with health policy, and you
all know that, the devil is often in the details.
If all states enacted work requirements, only 3%
of the over 70 million people on Medicaid
would immediately lose coverage.
That's because a significant number of folks are exempt,
and most folks on Medicaid already work.
However, when the work requirements come
in, because of some of the documentation requirements,
because of the way people work-- seasonal workers may not work
80 hours in a month--
because of inability to document your hours and submit that,
another 25% to 40% could lose their Medicaid coverage.
In Arkansas, of the over 4,000 who lost Medicaid
just this month as a result of not being
able to meet the requirements for work,
surveys indicate that the folks who lost it
said they didn't have good communication about it.
They didn't have a computer.
You have to submit your documentation
through a portal called Arkansas Access,
and most were just generally unaware there was even
a requirement.
So it sort of begs the question about how
we can do work requirements so that it actually
fulfills the intent, and there isn't
all of these sort of negative externalities as a result.
The Arkansas experience may be a cautionary tale for Virginia
and for other states looking forward
to implementing work requirements in their Medicaid
expansion programs.
All right.
So with that, I'm going to turn over
to my friend, David Toscano.
I like this picture of you, David, much better
than a head shot, because most of you
probably don't know David actually
has a PhD in sociology.
He was a professor before he became a politician.
He does best, I think, when he sits in groups of people.
This was at a town hall.
David and I have known each other for over 30 years,
and the last time we were on this program
was the day after Donald Trump was elected,
so I like to think we come at very exciting times.
DAVID TOSCANO: That's sweet, Carolyn.
I tell you, it looked like I was in a men's room.
I don't know what that says.
CAROLYN L. ENGELHARD: You were in a school cafeteria.
DAVID TOSCANO: Yeah, OK.
Thank you for clarifying me.
It's really great to be here today.
It's really daunting to be right in the middle of two experts.
You know, Carolyn is such a policy guru,
and of course the doc is on the front lines of providing
services to people.
You know, what do I know?
I'm just a small town country lawyer
trying to do the best I can representing Charlottesville
and Albemarle in the General Assembly.
MARCIA DAY CHILDRESS: Is your wireless mic on?
DAVID TOSCANO: Oh my god.
You can all hear me though, right?
Can't you?
OK.
Now is it on?
OK.
Now you can hear me.
I just told a joke, and now it's not
going to be picked up on YouTube.
The other joke, of course, is that over the last four years,
I've given so many speeches on the House floor
about Medicaid expansion that I have enough
to fill my own YouTube channel.
This year, actually, I only gave one,
and that was at the very end.
Sometimes lawyers know that you keep
your mouth shut if you think things are going your way.
We thought things were going our way.
The only speech I gave on the House floor
was the day the House passed a budget that
included Medicaid expansion, which was probably
the most consequential vote that I
have taken in my 12 years of service
in the General Assembly.
When you think about 400,000 people getting access
to health insurance with one vote,
that is a pretty good feeling about what happened.
Now, so let's go in.
It's a long and winding road, but you make no wine
before its time.
And you'll see later, we've been talking about making this wine
for years and years and years.
At the same time, as Stevie Winwood once said,
"when you see the chance, you take it."
And Jackie Robinson took that chance,
and who knows who this person is on the right-hand side?
Amy?
Abby?
Is that her name?
Abby Wambach?
Oh, OK.
You all know.
So here's a long and winding road.
Starts in 2010 when the Affordable Care Act is passed.
No Republicans vote for that bill.
It had to get put through by shenanigans
involving what's called reconciliation,
but it did pass.
In that bill, two things were really important.
Well, a number of things were important,
but included was a requirement that everybody
have health insurance, and two, that Medicaid
be expanded in every single one of the 50 states.
All right.
But then, June 28, my birthday, 2012,
along comes a court decision out of the Supreme Court,
strikes down the requirement that states
have to expand Medicaid.
Now it becomes optional, and that's where the fight begins.
So the first debates in January and February.
My hair is darker.
I probably have fewer pounds, but I did give those speeches.
Expansion was rejected in that first General Assembly session.
We did create, however, a commission to study it,
and supposedly to implement it if all these Medicaid reform
efforts were effective.
In point of fact, there were a lot
of reforms that were enacted in our Medicaid system designed
to provide better service and bring down costs,
but it didn't matter.
After all those reforms, the legislature
continued to say no to Medicaid expansion.
In 2014, Terry McAuliffe was sworn in.
He ran on Medicaid expansion and tried
to get it done for his four years.
We had a number of initiatives proposed,
including this thing called Marketplace Virginia.
The irony about Medicaid expansion
from a political standpoint is that initially, it
was the state Senate who was very much pushing
for Medicaid expansion.
The Democrats had control of the state Senate
at a point in time.
They were pushing this.
They had Republican moderates with them at the time.
The House was controlled by conservative Republicans,
and they weren't having anything to do with Medicaid expansion.
This year, however, it's flipped.
It was the House that made the difference on Medicaid
expansion, and the Senate, which has now flipped a little bit
to Republican control.
The moderates are gone.
They were brought, I could say, kicking and screaming
to the table to get a budget that had Medicaid expansion.
So, you know, wait a few years, things change in politics.
Boy, do they change.
And so, there are a number of things
that happen along the way.
You can read about it in my book when I publish it.
It's called "Medicaid Wars."
That's not the book.
That's a chapter in the book.
But there are all these machinations
that go on in politics.
And things that you think are going
to turn out the way you thought they would,
don't happen that way.
We thought we had a real shot of getting
Medicaid expansion in 2014.
We had everything lined up, and then, all of a sudden, Senator
Puckett, who is a senator out of southwest Virginia,
decides he's going to resign just before we
had the vote on the budget.
And when he was gone, we lost a vote
and we couldn't get it passed.
It was very, very discouraging.
OK.
January and February of 2015.
Now, there are a lot of players involved in this process.
A lot of lobbyist groups, a lot of activity, a lot of push.
And frankly, thank you all for all of your work
in trying to get this done.
We could not have done it without the medical community
and activists around the state pushing for this.
But there was a lot of activity.
But Republicans controlled the House
of Delegates and the Senate, and the General Assembly
stripped McAuliffe's Medicaid expansion language
from the budget.
McAuliffe kept putting the language in.
The Republicans keep taking it out.
You know, again, Medicaid expansion
was not a, quote, "bill."
It was in the budget because it has
to do with an appropriation.
House and Senate reject Medicaid again
along party lines in 2016.
And then in 2017, Medicaid expansion failed again.
But what was happening at the same time,
was we were expanding the more traditional Medicaid
to other groups of people.
So we were bringing more people into the system,
but the reimbursement, as you know, on old Medicaid
was 50/50 In other words, every dollar
we put up as a state, the feds only matched with a dollar,
so it's 50/50 split.
New Medicaid has the feds paying, originally,
100% of the costs of expansion, and then it
dropped down to 90% in 2020.
So we were expanding old Medicaid,
but we weren't expanding new Medicaid.
People wondered why we were doing this.
This didn't seem the most efficient use
of taxpayer dollars, but we still couldn't get it passed.
All right.
Then, the United States Senate says
no to the repeal of the ACA.
Senator McCain's infamous [THUMBS DOWN]..
Then, the earthquake.
November 17, 2017, Democrats win 15 seats
in the House of Delegates, most of whom
ran on Medicaid expansion.
Republicans said, uh oh.
There's something going on here.
We better alter our plans.
So the Republican leadership in the House
decided to work with Governor Northam
to come up and support a program to expand Medicaid.
Now, it wasn't unanimous on the Republican side.
All 49 Democrats voted for the bill,
but only about 17 or so Republicans out of the 51
they had.
And so now, 2018, we're working on this budget,
and we get the 18 Republicans to join us.
This took a while, because we didn't get
it done in the regular session.
It took some time, but, you know,
sometimes good things come to those who wait.
And we finally got it, and finally, on June 7,
Northam signed the budget with a work requirement.
Now, no one is quite sure what's going to happen with this work
requirement.
There are core challenges to it.
There are so many exemptions in the work requirement,
that most people will not likely be affected.
But one of the concerns is that, in the process of implementing
the work requirement, you will knock off people
who formerly received Medicaid.
That's where the court fight is going to happen,
whether you knock off people who formerly received it.
OK.
Now, September 20, we put in our waiver form on the work
requirement because it has to be approved
by the federal government.
We don't know when that will happen.
It could take months before they approve it.
Here are the population served by Medicaid.
Of course, most people on Medicaid
are kids, people who are disabled, and elderly folks.
There are, in Virginia, very small numbers
of people who could actually work anyway.
And here are some of the breakdowns for who can qualify,
and I'm going to go through this real fast.
We can come back to it.
Good coverage benefits for people
is really going to help a lot of people to get on.
There are some cost sharing in situations
here with the Medicaid program that we're
expanding in Virginia, and they call
the work program called TEEOP.
I don't know why they came up with that,
but everything has to have a bunch of letters in it.
And remember, the old traditional Medicaid
was a 50% federal match.
The new Medicaid is going to get to 90%.
The feds will pay 90%.
And you guys can study this at your leisure
if you want to know the cost.
It's always interesting to see how we save money by embracing
Medicaid expansion.
In point of fact, we couldn't have
passed the budget we passed this year without Medicaid
expansion.
Because what happens is, you take a lot of federal dollars.
You're bringing them into the state
to replace money that you otherwise
would have paid for a different thing, like indigent care.
$100 million we spend on indigent care.
But once we take in the federal dollars,
and we have Medicaid expansion, we're taking federal dollars
and we're using it to help fund the cost of indigent care
like at UVA, and that frees up that $100 million--
well, it's not totally $100 million that gets freed up,
but it frees up a bunch of that money that
then goes into teacher salaries, you
know, public safety, environmental protection,
other places.
And we were always arguing that we would save money
that we could invest in other places
if we took the Medicaid funds and, in point of fact,
it was like a $500 million difference in our budget
this year because we took the Medicaid funds.
That's a big deal because it helps
people other than those who really need the health
insurance.
OK.
So now I get to turn over to someone
who actually really does work as opposed to talking like me.
And you're going to explain what's happening next.
Right, doctor?
CHRIS GHAEMMAGHAMI: OK.
Good afternoon.
I'm glad everybody could make it here.
So just by way of introduction, it's
sort of funny to hear them referring to me as an expert,
because I think I'm the local color here.
I'm the color commentary guy, because I
serve as the Chief Medical Officer of the health system,
and work for Dr. Wilkes in the dean's office as well.
And, you know, so what does that mean?
Well, it means that we actually run
the operation of the hospital and the clinics.
I'm an emergency physician by trade,
and still see patients every Friday in the ER
here in Charlottesville.
So I've had a long career of taking
care of people who are uninsured and under-insured.
And you know, I think you really realize the impact of either
having health insurance or health care
coverage versus not when you see these people who have really
tried their best.
They've worked hard, but the expense and the hassles
of trying to get health care are sometimes
very, very large barriers to many people.
And in the emergency department, we
see people whose problem solving has basically failed.
They've tried to do what they can,
but they end up seeing us for sometimes very,
very serious issues that could have been taken
care of at an earlier state much more
easily at much less expense.
But sometimes, it's very simple things
that they just need some access.
And so by law, in an emergency department, we see all comers.
It doesn't matter if you have the ability to pay or not,
which is a great, great thing.
That's my commercial for emergency medicine
as a specialty for the students in the crowd.
But in terms of a societal impact,
you know, let's talk about what having coverage means
and who's affected.
You've seen a couple of slides already.
Their slides were much nicer than mine,
but these are very basic.
So just one thing to remember.
So in current condition, if you are
a resident of the Commonwealth of Virginia
and you are a childless adult, you basically
don't qualify for Medicaid.
All right?
So, you know, we do have an uninsured population
that we deal with.
Now, if you have people who are working,
they're the working poor, it is very difficult,
as we know, to buy insurance on the public exchanges.
And because of legislative decisions and court decisions
since the Affordable Care Act has been passed,
we have a lot of uncovered people still.
And so this is a big, big problem.
But many people don't realize what Medicaid really does cover
and what it doesn't.
Most people think Medicaid, and they think, well
that's, you know, poor people's insurance.
And it's like, well that's only partially true.
Not everybody even is eligible, and so this
is a great step forward for people in the Commonwealth.
This has been covered already.
So I was really asked to kind of talk
about how does this affect the patients in Virginia?
And then more specifically, what will be the impacts at UVA?
Because many of you actually are employees here,
and you're sort of saying, well this is interesting.
You know, we know that we are a safety net hospital.
What is this going to mean for our medical center
and for our clinics as well if all of a sudden, 400,000
residents of the Commonwealth suddenly
have some kind of health care coverage?
So let's start with the map.
So we're here in the star here, Charlottesville,
in the middle of that sort of upside down triangle
of Albemarle County, and what we consider our primary service
area, which is in red.
OK, so that is us as well as those five
surrounding counties.
So when we start thinking about who are we delivering service
to, and more concretely, who are we
responsible for delivering health care
for in our community?
This is sort of our community, and the near in community.
So any health care need that these people have,
we'd like to think that if they choose to come to UVA,
we can handle it.
So in that primary service area, we
are going to see some increased access to care,
but the people who live in this area
are, frankly, very fortunate.
Because of the support of the universities,
support of our state legislature and the governor
over the years, we've been able to be funded
to take care of all comers.
That's not true for other hospitals.
So we have, of course, one other community hospital
here in town, but in those other counties,
there actually aren't any other hospitals,
and you have to get to about a 60-mile radius
to start seeing where there are other hospitals impacted.
So there's access here, but as soon as you leave that red area
and go to the south of us, and especially
to the southwest of us, the access
is much more severely limited.
Sure, there are hospitals there and there
are hospital-based clinics, but if you
don't have any kind of health care coverage,
you may have trouble just finding a family doctor.
You may have trouble with the bureaucracy of getting
into a different hospital system,
and so it is not infrequent that in all of our clinics
and all of our inpatient facilities and even in the ED,
that you have somebody who's driven
from way down here in Wise County
or down by the panhandle of Virginia,
to come here just to get an appointment that might be
three or four months from now.
So that is really what a lot of people are dealing with now.
So here's my one Virginia fun fact for the lecture.
So see that point down there by Tennessee and Kentucky there?
If you look at the whole United States map,
and you just sort of look vertically,
that little point is actually west of Detroit.
So that tells you how much geography there is,
and how far these people are willing to go
to get here because of this economic disparity
that we have.
And so this is really great news that we're
going to improve on that.
So what it's really going to do is not so much
change our access to our local people
here, but really, access to some of these other areas.
Now of course, there's sort of the, what they're
calling now the urban crescent.
On the eastern part of the state,
there's a lot more access to care.
But south and southwest in particular, there
will be some big impacts here.
So I think that ultimately, the patients
will have better primary care access, hopefully
better preventative care.
And one of the great wins as Mr. Toscano
had mentioned, in this prior year,
there was significant expansion of mental health
services and particularly substance abuse treatment.
So these are very impactful for everybody.
As we know, if you pick up a newspaper,
if you read any medical journal, the opioid crisis is here.
It is in Virginia, and it is significant, and it is real.
And so the ability to provide those services
for a larger group of people is really
going to have a significant impact on our population.
So what about UVA?
You might say, OK, well this is great.
You know?
There's a lot more funding for all of these services.
Is that going to help with some of the UVA Medical Center's
sometimes financial issues?
And maybe.
The answer is not entirely clear.
As I said, we've been very fortunate over the years
because we are a safety net hospital in a very good state.
And what I mean by that is that through a number of mechanisms,
UVA is considered what they call a Type 1 hospital, where
we serve patients with a disproportionate share
of indigency.
And we're a GME hospital, so graduate medical education
hospital, where we receive additional funding.
And those are the ways that we've
been able to keep our doors open to everyone.
So our CFO, our Chief Financial Officer for the health system
likes to say, we had Medicaid expansion
before there was Medicaid expansion.
And that's kind of true.
So locally, we're probably looking at some offsets here.
So we'll probably do just fine.
We will be stable, but there's not
going to be some giant windfall financially for us.
What's going to happen, though, is that the people around us,
the providers around us, are going
to be able to fund programs for these under-served people.
And there will be a little bit of an offset in terms
of maybe some of those distances traveled
to come here just for a simple, lower complexity care.
And that will allow us to pursue our mission of being
the home of complex care in Virginia, so that way
we can deliver more advanced care with some of the capacity
that that will free up.
So you know, I think, if you look at the shift of patients,
it will be great for our local people who are basically
the working poor who now have broader choices for access.
I like to talk about urgent care.
One of the things that we've seen in the Medicaid expansion
states is there's pent-up demand.
So as soon as people start getting coverage,
they start signing up to see a doctor,
or they'll seek care in many environments.
And you start finding diseases, unfortunately,
and you have to take care of those disease.
So there's this pent-up demand in the beginning,
then it starts to level out.
But every state that's done this seems to confirm that,
and it's not a case of abuse.
These people need care.
One of the things that has been difficult in our area
and in Virginia in general, is because of decreased access
or because of lack of coverage, people
have used emergency departments a lot.
And interestingly, lots of providers
these days take Medicaid.
OK?
So private practice physicians may not necessarily
take on a whole lot of new Medicaid patients.
But now, because of consolidation in the industry,
you have large hospital systems.
They pretty much all take Medicaid.
And you have other entities like, you know, MedExpress
up on 29 that, actually, I checked.
I looked on their website before I came to give this talk.
They actually will accept Medicaid patients.
And so, in some respects, that's actually very, very good.
That's getting the right patient in the right care
environment in a timely fashion for a lower cost.
So you know, you're going to see alternate care models,
but you're going to see access to care.
And I think overall, that's going to be
very good for lots of people.
So here at UVA, you know, again, we're
not expecting to see anything big in terms
of financial changes in net.
We do hope that we will be able to see patients
earlier in the course of their diseases
and get them on the right track, open up
that access for some of our more complex services
by really allowing patients to stay closer to home
in facilities that are going to be basically better
supported and better funded in some of our rural areas.
Mr. Toscano mentioned the indigent care funds,
and so just two words on that.
Basically, this is a federal mandate
that indigent care funds flow through the states
and get to where the care is delivered.
In the original Affordable Care Act--
and I'm not the health policy expert, so I'll defer to Dr.
Engelhard--
there was a scheduled ramp down on what they call dish funds,
and so we don't know what's going to happen.
UVA, again, very fortunate.
We receive a fair amount of dish funding
for all of our operations and for our providers.
We don't know how that's going to work out,
and I think that's going to be an interesting discussion
to see how that turns out in the near future.
But overall, I think when I am back in the ED,
we will be keeping an eye out for people who,
as soon as this becomes live, we can direct towards enrollment
and try and allow them to have many, many different care
options, rather than just having to wait
months for an appointment with someone like us.
So I look forward to the questions and the discussion.
MARCIA DAY CHILDRESS: Thanks to all three of you,
we have a wonderful amount of time
to open a discussion with our speakers.
We have a couple of mics that we will bring to you
so that your comments and questions can be recorded.
As well, I'll ask that you please identify yourself
when you offer a question or comment.
You may want to indicate also to which of the presenters
you're directing your question, or you
could say all three or any of the three,
however you want to do that.
And we'll see where we go from here.
AUDIENCE: Thanks, Marcia.
I'm Susan Kirk.
I oversee the medical residents and fellows here,
and I have a question for Delegate Toscano.
So shortly after his election, we
invited Representative Perriello to come
give a talk about the ACA and Medicaid expansion.
And those empty rows that you see now
were filled by members of the Tea Party.
And it wasn't a public lecture, but somehow they showed up.
So my question to you, and we all know how that story ended,
do you see this as a real turning point,
or is there some risk for political backlash
for this decision?
DAVID TOSCANO: Great question.
You know, there's always a risk for a quote,
"political backlash" on any decision,
but if you take a look at the polling data on Medicaid
expansion, a great majority of people think it's a good idea.
I think that's one of the reasons why the dynamic shifted
in the last General Assembly session.
I think people began to see that there is a lot of support
for this all over the state, including places
that you wouldn't think--
well, places that don't vote, quote, "Democratic."
I mean, this has kind of been seen as a Democratic issue.
But if you look at the places that benefit most
by Medicaid expansion, a lot of the people
who live in those districts probably
haven't voted for a Democrat in 10 or 15 years
and may never vote for a Democrat.
But a lot of us thought, well, this is the right thing to do,
even if it would not affect our ability
to get elected to those places.
And I think that's part of the role of representatives
in ensuring that the Commonwealth is strong wherever
people live and whoever they vote for,
because after you get elected, you
try to represent the people.
Now, will this come back to haunt folks?
I don't know.
Let's see what happens in the next election
cycle, which begins in January of 2019
for Virginia state reps.
If a lot of the Republicans who voted for expansion
get primaried by Tea Party people and get defeated,
then you will know that there was a political backlash.
But so far, we don't see a lot of that going on.
We may see it, but we don't right now.
CAROLYN L. ENGELHARD: If I could just jump in real quick,
70 million plus people are on Medicaid in this country,
more than on Medicare.
And if the Medicaid expansion has done anything nationally,
is it's normalized what Medicaid is.
One in five Americans is on Medicaid.
What does this mean?
It means that every family now knows someone on Medicaid.
It's either your child, your parent in a skilled nursing
facility, someone who's receiving opioid substance
abuse treatment.
It is no longer a stigma.
It's no longer them.
It's us.
AUDIENCE: I'm Dr. Mary Preston, and I
work at the Greene free clinic, and also teach here.
I have two questions for Chris.
Sorry.
One is very tricky, and I have heard a rumor
that because people will have insurance, that UVA may not
have the financial discounts, and this would certainly
affect a number of the patients who perhaps do not even
qualify, who are making maybe $40,000 a year.
Second question is that, what is the primary care capacity
to take all these new patients?
We're not putting out a lot of primary care docs,
and so this is an advertisement too
for it's actually a fun specialty.
It's very-- you don't do the same thing every day.
Very much like ER, you never know
who's going to be walking through your doors.
And I love it, and I'm going to keep on doing it,
but these are some issues that I have.
CHRIS GHAEMMAGHAMI: OK.
Well thanks for the heads up on the trickiness,
and also, thank you for helping take care of my mother.
You're one of her doctors.
So I have not heard any rumor around removing discounts
for self-pay patients, or that we
would be changing the financial screening process where people
have different tiers, you know, all the way from some discount
to basically complete waivers.
I can get back to you on that one,
but I have not heard any rumor there.
I think we're a lot more pragmatic than that,
because, with all due respect to all of the work that's done,
you know, you never know how this is going to turn out,
and you never know exactly what the ultimate impacts
are going to be.
How many patients are going to come?
What's really going to change here on the ground?
And then, what are the revenues going to look like on that?
So I'm not aware of any proactive look on that.
I think that would be a pretty big leap to say, OK,
let's start planning ahead.
I mean, in terms of primary care capacity,
this is a tricky question as well.
We showed the map of what we consider
to be our primary service area and what I would say
is our commitment to care for our community.
Our access-- and you may disagree with this-- our access
for new primary care providers is fairly reasonable right now.
We're not the only player in town.
OK.
So there are other systems here who
also provide primary care, as well as individual practices,
but maybe not as many as there used
to be because there's been a lot of consolidation.
I think this gets a little bit more towards population growth,
honestly, in this area.
So who here has driven down 29 or on West Main Street
lately and found themselves going a little slower than they
used to go?
The population growth in this county is very high,
and I think that we're seeing some of the pressures
on our health care system just related to that alone.
Additionally, we've become a little bit of a retirement
community, and so we have an aging population.
And so, another plug for Dr. Preston,
we need more geriatricians specifically
to take care of some of our new primary care population.
So it's something I think we have to keep an eye on.
Just to answer your question more directly,
we don't have any plans to open up any new offices right now,
but we're looking at lots of ways
to increase access to our current offices
and how to provide the right care models.
This gets into a number of issues around team care.
So are you always going to see a physician, or sometimes
will you see a nurse practitioner or another type
of provider?
Particularly, this is important with the burden
of mental health issues where we need
to use lots of different team members, psychologists,
and licensed clinical social workers,
and people like that to help as well.
So we are looking at all of that as well.
AUDIENCE: Hi.
I'm Richard Ridge from Nursing Professional Development
over at the hospital in the School of Nursing,
and this is for Delegate Toscano.
For some of us, probably, 2020 can't come quick enough
in terms of the presidential election and what could happen.
But in terms of the funding, what
has to happen at the national level by 2020
to continue Medicaid period, Medicaid expansion?
If you can just elaborate on that,
what has to happen to continue funding after that point?
DAVID TOSCANO: Well, yeah.
I mean, you're the health policy guru,
you know, but it's all about appropriations.
You've got to have an appropriation bill that
passes that puts the money in, but I
think that they'd have a hard time not funding it
under the law.
And I think they could be compelled to fund it.
I think you might want to weigh in.
I mean, we know what's happening at the federal level.
The ACA, even though it's been any efforts to repeal it,
have been defeated, I don't know, 50, 60 times.
The Trump administration is trying to undermine it.
You know, I was going to comment on the question here.
They're undermining the insurance markets
by not enforcing the individual mandate.
They're undermining the exchanges
by not providing the CSRs that will help the insurance
companies.
And as a result, what we're seeing
is all this dynamic conflict within the insurance markets
now, and it's percolating in here to Charlottesville.
You can see what happened with the Optima rates,
and it gets into things about hospitals
and what they reimburse, the insurance companies, how that
affects the rates, et cetera.
The long and short of it is, you have to pass a budget,
because otherwise, you can't fund it.
CAROLYN L. ENGELHARD: So the two topics
used going into the midterm elections
are corruption in Washington and health care.
And specifically, under health care,
it's keeping the ban on preexisting condition
exclusions.
So there's a maxim in health policy,
and that is, it's much harder to take away
something you've already given.
So David is right.
Medicaid is an entitlement.
It's an entitlement program passed in the mid 1960s
along with Medicare.
As I mentioned earlier, as Medicaid expansion expands--
and clearly there is a demand for it,
we have it on four state ballots in the midterms
as a referendum--
the more groundswell there will be to offer these programs.
What I hope we see, because I think your question is really
good, and that is, how can we afford this
and where is the money going to come from?
And so I think it's really important
the next challenge that we have in this country
is to look at what we spend our health care dollars on,
and how we begin to control either the supply
or the demand, and certainly, the price,
particularly with regard to pharmaceuticals.
MARCIA DAY CHILDRESS: Other questions?
AUDIENCE: Hi.
My name is Morgan Taylor and I'm a social worker here
at the hospital, and I was wondering
if you could explain more about the work requirement that's
coming forward for Virginia.
If there's any ideas about what that would look like,
are you modeling after Arkansas?
And also, if there is a work requirement,
is there other funding for like child care assistance
and other things like that so people can work?
DAVID TOSCANO: Wow.
That second part of the question is very interesting,
because I think that one of the issues that the legislature
really didn't address was the cost of administering
this policy.
And the thinking is-- there's some thinking
that it costs more to administer a policy that
requires work and requires people to certify they're
looking for work or trying to or providing some community
assistance, than there is in just letting people enroll.
So that's the one question.
We think-- I can't remember what's
in our budget to do that, but a lot of people
are worried that it's not enough.
Then you've got the issue about what does it look like
and how is it administered?
We've got the waiver request out for commentary.
I haven't actually looked at the waiver request,
so I'm not sure exactly what it says.
But in the legislation, it exempts postpartum women,
it exempts people who are disabled,
it exempts pregnant women.
There are all these exemptions in there, and at one point,
I thought there were so many exemptions,
you could drive a Mack truck through the whole process
and it really didn't mean very much other
than an aspirational goal that you
would try to help people not have to qualify.
So until that waiver is approved,
we don't know exactly what the program is going to look like.
And then, how is it administered in terms of the cost?
That will be the second issue.
There's a lot of uncertainty right now with this,
and then there will be the legal challenges, because ours tends
to look more like Kentucky.
In Kentucky, we already have a court decision right now
that says it's not legal.
Whether it will stand or not, I don't know,
but there is a decision right now.
AUDIENCE: Now, the work requirement
was the result of a compromise in the legislature,
and you were a key player in that process.
I wondered if you might talk a little about the drama
that some of us followed last spring in the legislature
as you achieved that compromise with the Republicans
and with the Senate.
DAVID TOSCANO: There was a lot of drama,
and I hand it to my Republican colleagues.
It wasn't easy for them to take a vote like this,
because so many of them had voted
against expansion for years.
And so for them to reverse themselves,
puts themselves at risk of being primaried.
And I think that what happened over the course of the session,
is people began to say, we need some cover here.
We need to be able to tell our constituents that this isn't
a quote, "giveaway program."
This is a program that requires people who shouldn't
be on it to not be on it.
And that's why this work requirement came up.
So the Democrats generally don't like these work requirements.
They think they don't really accomplish what they're
supposed to be doing, and they cost a lot of money
in the process, and they discourage people
from getting benefits that they really need.
But we were willing to swallow that pill on our side, at least
most of us, for the sake of getting this 400,000
potentially on the rolls.
And that's how it works sometimes
in terms of compromise.
Would we rather have straight Medicaid expansion?
Yes.
Were we willing to do this in order
to get Medicaid expansion?
Yes, and that's where the compromise was struck.
AUDIENCE: Do you see that compromise
as sort of going forward as helping
to broker more bipartisan work in the legislature?
DAVID TOSCANO: Well, I'm an optimistic guy.
I always loved the idea of having more bipartisan work
happening in the legislature.
We're a fair-- we do pass a lot of bipartisan bills,
but the Washington disease sometimes
percolates across the Potomac, and we
have to guard against that because Washington really
isn't very bipartisan at all.
So I'm hopeful we'll be able to do some more things.
I think we needed, this is a Medical Center
Hour on Medicaid, but there are things
we can do on criminal justice.
There are things we can do on education.
There are things that we can do on energy where
I think you could get a broad bipartisan consensus on things.
You take tax policy, that's very difficult,
but some of these other things, I
think they're opportunities to work together.
MARCIA DAY CHILDRESS: Good, thanks.
Just to wrap up, do we have any other closing comments
or questions from anyone here?
Then I might-- oh, yes.
OK.
AUDIENCE: I can speak up.
MARCIA DAY CHILDRESS: No, no, no, no.
You go on the recording.
DAVID TOSCANO: You need to be on YouTube.
MARCIA DAY CHILDRESS: Oh.
There you go.
Tell us who you are.
AUDIENCE: A related topic--
I'm Danny Becker.
I'm a general internist.
Recently retired, and then more recently, rehired.
Part-time work, I'm an hourly employee.
Related to Medicaid reform, what about prison reform
in the Commonwealth?
DAVID TOSCANO: That's for me, right?
AUDIENCE: That's for all of you.
Well, I think it's for Carolyn, and then David, yes.
DAVID TOSCANO: I think you will get some reforms coming out
in the next few years.
I think from a conservative point of view,
I think people are beginning to realize that it is just
so expensive to incarcerate people for longer
and longer periods of time.
Without any kind of rehabilitation,
most people get out after they've served time.
And they get out often without the ability to work,
and then you've got a problem.
Either they have to go out Medicaid is they can't work,
or they have some other assistance that they get.
And I think people are beginning to realize the cost of prisons
are high, and the social costs are high too.
But particularly in the juvenile section,
that's where I think you're going to see more reform.
People now do not like the idea of warehousing kids,
because it trains them for criminal activity later on.
And so now, you're going to see a scaling
down of the size of these facilities,
and different kinds of programming
in these facilities that will speak to the conservatives'
desire to cut funding and the liberals' desire
to be more rehabilitative.
At least, I hope.
CAROLYN L. ENGELHARD: At least when
they come out of prison now, they'll
have health coverage with Medicaid expansion.
And for those of you who are interested in the work
requirement issue, you may want to look at Montana's Medicaid
expansion.
It's actually sunsetting.
They're going to go back and see if they-- it was like a pilot
and they're going to go back.
But one of the things Montana did
that the Commonwealth of Virginia may think about
is connecting Medicaid expansion work requirements
with funding for job training programs,
because they often work hand-in-hand.
And if the goal is to help people get out
of poverty or low income so they can enter the workforce,
then it might be helpful to have both health coverage to keep
you healthy to attend job training programs,
and then hopefully move off of Medicaid.
DAVID TOSCANO: And Carol, correct me if I'm wrong.
But if I'm not mistaken, that the Medicaid expansion here
in Virginia now is going to cover all of the prison
population, when before, a lot of the costs
were borne by the state directly.
So that's a place where the federal dollars
are replacing some of the state dollars and saving some money.
MARCIA DAY CHILDRESS: So it sounds like there's
lots of change afoot.
We'll all stay tuned for January 1, when some of this
starts to roll out.
Please join us next week, October 3.
We're going to have a Readers' Theatre here starring
four of the UVA medical students,
and also you, as the audience, discussing the play that they
perform.
So please join us for William Carlos Williams'
A Face of Stone in Readers' Theatre.
Thanks please to Carolyn Engelhard, David Toscano,
and Chris Ghaemmaghami.
And thanks to all of you for being here.