But Dunnavant, like many of the GOP candidates, opposes all things Obamacare. “I will be a constant voice against Obamacare; I'll be a constant vote against expanding our broken Medicaid system!” she says on her campaign website. “Everything I've seen in the data tells me Medicaid expansion in Virginia would be a mistake,” she said in an interview.
Repp takes the opposite view. “Frankly, it's beyond me how she can say we shouldn't expand Medicaid,” Repp said. “Our hospitals are suffering mightily.”
Last week, the Virginia Hospital & Healthcare Association launched a major multimedia campaign to highlight the key role of hospitals in the state's economy, the financial struggles its members are facing, and the need for legislative relief. The association reported that one-third of the state's acute-care hospitals had negative operating margins in 2013, the last year for which data are available. In rural Virginia, 17 of 37 hospitals operated in the red. Hospitals provided $627 million in free or discounted care in 2013, up 57% since 2008.
Hospitals' financial woes are only expected to worsen because federal budget sequestration cuts require a continuous 2% drop in Medicare payments for the foreseeable future. Those cuts come on top of the Medicare disproportionate-share cuts required by the Affordable Care Act.
At the hospital association's Sept. 16 news conference in Richmond, health system CEOs from around the state warned that without legislative relief from the state, cuts in services, layoffs or even closures could result. “There are a lot of hospitals and health systems in the state today that are bailing water pretty seriously,” said James Cole, CEO of the Virginia Hospital Center in Arlington.
Mark Merrill, CEO of Valley Health, based in Winchester, said his organization was considering closing its trauma center in western Virginia, which means some people in the area would have to cross into West Virginia to receive trauma care. “That trauma center is something that we are evaluating,” he said. “It's a very expensive proposition to maintain.”
Last year, the state hospital association pressed hard for Medicaid expansion. But at the news conference, none of the hospital leaders who spoke explicitly raised the issue. They repeatedly referred to a “Virginia solution” to address hospitals' financial problems. “Are you guys afraid to say Medicaid expansion?” one reporter asked.
“Let's be candid. We started out talking about solutions, and it hasn't really gotten us anywhere,” replied Mary Mannix, CEO of Augusta Health, Fishersville.
The hospital association's economic arguments are a smart approach politically, said Joshua Ulibarri, a partner at Lake Research Partners who is polling for the VA House Democratic Caucus and three Democratic state senators. Medicaid expansion trails behind jobs and education as an issue for voters, he said.
The key Virginia races to watch are in the Senate, because it's unlikely the Democrats can win a majority in the House, said Stephen Farnsworth, a political science professor at the University of Mary Washington in Fredericksburg. Democrats only need to gain a single Senate seat to create a 20-20 split and throw the tie-breaking vote to Democratic Lt. Gov. Ralph Northam. That scenario would put McAuliffe and the Democrats in a stronger position to push through Medicaid expansion, though it still would face a tough hurdle in the House, Farnsworth said. Republican House Speaker William J. Howell has vowed never to vote to expand Medicaid.
Making McAuliffe's task even harder is that the Republican primaries eliminated some GOP candidates who might have been open to some form of Medicaid expansion. In the 24th Senate District, Sen. Emmett Hanger, who proposed Medicaid expansion through a private-plan model, had to fight hard to beat back a primary challenge. “Just discussing the possibility of a Medicaid expansion put (him) at risk in the primary,” said Beth O'Connor, executive director of the Virginia Rural Health Association.
Dunnavant said she doesn't believe the Obama administration would give her state the autonomy it needs to create a uniquely Virginian approach to providing coverage to the poor. She's also concerned about expansion's effect on the state budget, even with the federal government picking up 100% of the cost through 2016, dropping to 90% by 2020.
Chris LaCivita, a veteran Republican political operative who is working on the state Senate campaign of Dr. Nancy Dye, a retired Roanoke surgeon, said it's possible Congress will reduce the federal contribution. “Anybody that believes this money will always be there is naive,” he said.
Republican state Sen. Bill Carrico in the 40th Senate District, opposes expansion even though a hospital in his district, Lee Regional Medical Center, Pennington Gap, closed last year, and residents in his southwest Virginia district have one of the state's highest uninsured rates. He argued that even his uninsured constituents oppose expansion. “The majority of people in my district, whether they have coverage or not, don't trust the Obamacare system,” he said.
Back at Mary Washington Hospital in Fredericksburg, Todd Welsh, 32, who works as a contractor and has no health insurance, says grueling hours and heavy lifting have taken a toll on his health. He suffers searing back pain that keeps him up at night. This is his 10th visit to the ED in two years for the same problem; each visit costs him $600 to $700, but he has been ignoring the bills for months. Welsh, who supports five children, said after paying household bills, he has nothing left.
But like Shana Cox, he had no idea that there was a political fight over Medicaid, and expressed doubt that he'll ever get coverage. “I don't feel like there is a light at the end of the tunnel for me,” Welsh said.
