Stuck in the Middle

Stuck in the Middle

Healthcare reform could leave Virginia with a widening Medicaid gap.

The Neighborhood Health Center at 2 East Glebe Road.

The Neighborhood Health Center at 2 East Glebe Road. Photo contributed


From left are Eduardo Mantilla-Torres, Dr. Basim Khan, Richard Merritt, and Dan Hawkins.In September 2016, Alliance for Alexandria's Uninsured, presented a check for $10,000 to Neighborhood Health to support expanding operations in Alexandria.

“Where people are desperately poor there’s been no Affordable Care Act.” —Sara Rosenbaum, Professor of Health Law and Policy at George Washington University

While the healthcare debate rages in Washington D.C., in Northern Virginia many of the most vulnerable are left wondering how the reform will impact their access to medical care. For 400,000 Virginians who currently fall in the gap between the poverty-level Medicaid and insurance markets, it means the end to any hope of expanding Medicaid in Virginia. For Alexandrians either on Medicaid or in the private insurance market, cuts to entitlement programs and federal subsidies for the insurance market could start to push them into the Medicaid gap.

“If the House Republican bill were to become law it would have an enormous impact on the poor and uninsured in [Northern Virginia] both short-term and long- term,” said Richard Merritt, co-chair of Alliance for Alexandria's Uninsured. “Short term, it would likely scuttle any possibility of the Virginia General Assembly expanding the Medicaid program, as permitted under Obamacare … Over the long term, if federal payments for Medicaid are block granted or capped to the states as the bill calls for, it will mean a huge shift in responsibility for the health care needs of the poor to states and localities, most likely leading to even greater restraints on access to care for the poor.”

Dr. Basim Khan, the executive director of Neighborhood Health Virginia, helps provide healthcare to residents of Arlington, Alexandria, and Fairfax County. Neighborhood Health provides primary medical care, internal medicine, family medicine, pediatrics, dental and mental health services.

“We have about 16,000 patients we serve every year with 50,000 visits,” said Khan. “The vast majority of are low income. About half are uninsured and the other half have insurance, primarily Medicaid, Medicare, and insurance.”

Khan said in Alexandria, Neighborhood Health Virginia is the only provider for many of these services, while in Arlington the Free Clinic also provides care.

“The biggest concern related to health reform is that if people lose insurance, it will increase the demands for our services, which are already pretty high,” said Khan. “We’re trying to grow to meet the demand, but if people lose insurance, it will reduce their access to healthcare. Specialty care in particular can be a challenge for someone without insurance.”

Because Medicaid never expanded in Virginia, Khan and Merritt both noted that those in the Medicaid gap are unlikely to see much difference, but that pool could start to get larger at each end as more restrictions are put on who can receive Medicaid and more people lose access to insurance plans from the Obamacare private exchange market.

“Things never got much better for [those in the middle],” said Khan. “The effect on Virginia might not be as large as other states, but frankly we were in a difficult position to start with.”

“There’s not much of an impact [for the working poor],” said Merritt. “You’re taking away something that was never granted to them. Even under Obamacare, these people never qualified.”

Merritt said the continued decision not to expand Medicaid in Virginia left those with an income above 50 percent of poverty level without coverage.

“That shows you how stingy Medicaid levels are in Virginia,” said Merritt. “This population is not going to be affected because they never had Medicaid to begin with. In the long term, the impact will be the same: they’re not likely to get it.”

Meanwhile, for the existing Medicaid budget, “Virginia could lose more than $314 million from its general fund budget if the new Congress and President make good on their promise to repeal the Affordable Care Act, according to estimates by Virginia’s Medicaid director: Cynthia B. Jones, director of the Department of Medical Assistance Services,” said Frank Shafroth, director of the Center for State and Local Government Leadership at George Mason University, in an email. “The estimated losses — $123.2 million in the next fiscal year and $191.2 million in the budget year that begins in mid-2018 — reflect an outright repeal of the healthcare law, without knowing what would replace it.”

According to Sara Rosenbaum, professor of Health Law and Policy at George Washington University, changes in healthcare legislation will have a rippling effect throughout the medical ecosystem.

“In terms of people who depend on federal exchanges, both the House and Senate bills would precipitously increase the price of insurance for older people,” said Rosenbaum. “Essentially in various ways, both bills permit states to price based on health status. Both would restore steeper age rating for older people. Both bills seriously reduce subsidies available. Both would result in a massive increase in cost of insurance for older Virginians reliant on subsidies.”

Like Merritt, Rosenbaum said the poorest populations will unlikely see much immediate change.

“For the poorest Virginians, it has been an unfortunate reality that the state has so far refused to expand Medicaid,” said Rosenbaum. “It has left its poorest residents with nothing. You can’t get tax subsidies until your income reaches poverty threshold. In places like southwest Virginia, where people are desperately poor, there’s been no Affordable Care Act. Nothing reaches them. Their legislators have worked against their interests. Elimination of additional funds for expansion doesn’t directly hit Virginia right now, although it makes it impossible to reverse course in the future.”

Even for those without reliance on government subsidies, Rosenbaum said the new legislation could have a dramatic effect on the average Alexandrian’s healthcare experience.

“We have different insurance, but we all use same healthcare,” said Rosenbaum. “We all use same hospitals, same emergency departments. As people lose insurance, it puts pressure on the rest of the system. In Alexandria, several thousand are uninsured already. If there are cutbacks to marketplace subsidies, older, sicker people will be the worst affected. Even areas like ours that are relatively well insulated will feel the economic fallout.”

Rosenbaum predicted that places like INOVA and the Virginia Hospital Center will begin to see more emergency marketplace patients, while Roenbaum said Khan will begin seeing more marketplace and medicaid patients going into his already overwhelmed clinic.

Finally, Rosenbaum said the healthcare legislation will have a residual impact on funding for the school systems.

“The entire special education system depends on Medicaid to run children with disabilities programs, generally the most expensive students,” said Rosenbaum. “Because we’re urban with large pockets of lower income families, we tend to see more with students with disabilities [in the public schools].”

Meanwhile, Northern Virginia hospitals are closely watching the discussion in Washington D.C. but say there’s still much to be seen as the bill works through the Senate.

“The honest answer is that it is too soon to tell,” said Robin Norman, senior vice president and chief financial officer for the Virginia Hospital Center. “The new direction of healthcare legislation is not clear at this time. Having said that, I will say that the anticipated impact on healthcare providers is that reimbursement will remain tight and at Virginia Hospital Center we will continue to provide the highest quality care at the best value for our community.”