With the adoption of Medicaid Expansion by the General Assembly earlier this year (following four years of denials), Virginia joins 33 other states in fully implementing the Affordable Care Act (ACA), otherwise known as Obamacare. It has never been widely understood that the ACA is composed of two separate but related provisions: (1) providing low-to-middle income uninsured greater access to subsidized coverage in the individual insurance marketplace; and, (2) at each state’s option, expanding the Medicaid program to include all adults – even the “working poor” – with incomes at or below 138 percent of poverty — about $16,700 for an individual.
Alexandria’s Department of Community and Human Services estimates that between 4,700 and 6,000 uninsured adults (about 300,00 to 400,000 in the Commonwealth) are expected to qualify and enroll in the expanded Medicaid program following implementation beginning Jan. 1, 2019.
Studies have shown that in states with more than two or three years experience with Medicaid expansion, eligibility has improved access to care for most and has generally improved overall quality of care. A Health Affairs study found that in states that expanded Medicaid, there was a 40 percent increase in patients filling their diabetes prescriptions – which is highly significant as untreated diabetes can lead to more severe complications such as heart disease and kidney damage.
That’s the good news; the “not-so-great” news is that there are formidable challenges ahead to a smooth implementation of the expanded Medicaid program and to maintaining or even expanding insurance coverage for low-to-lower middle income through the Individual insurance market. Immediately following its failure to “repeal and replace” Obamacare late last year, the Trump Administration launched a number of administrative, regulatory and judicial strategies to undermine the law’s implementation – “death by a thousand cuts” as it has been described. Among those initiatives are:
- Repealing the individual mandate as part of last year’s tax cut ;
- Refusing to protect the ACA against legal challenges to its legitimacy by several Republican state attorneys general;
- Slashing budgets for Navigator programs established to help individuals enroll in the ACA;
- Encouraging the sale of “short-term, limited duration” (sometimes referred to as “bare bones”) insurance plans that provide limited coverage and fewer consumer protections,
- Supporting tightening of Homeland Security regulations that could deny immigrants who legally use such public benefits as food stamps and housing vouchers from obtaining green cards or permanent legal status. Finally, it must not be forgotten that while Medicaid expansion offers the hope of improved health and well-being for thousands in the city who have long been denied such hope, there will still be a significant number of low-to-lower middle income individuals in the community who will not qualify and will therefore continue to face daunting financial and other barriers to accessing the city’s health safety net. (The Commonwealth Institute estimates slightly more than 12,000 adults in Alexandria with incomes below three times the poverty rate – about $48,000 for an individual – will not likely qualify for Medicaid. Approximately 25 percent of the total or around 3,000 adults have annual incomes of less than $17,000.)
Significantly, the large majority of this “uninsured but not likely to qualify for Medicaid” population are Hispanic or Latino (48 percent) or Black or African American (30 percent). Non-Hispanic Whites constitute only about 12 percent of the group. Because of their uninsured status research informs us that they are all at increased risk of premature death. However, Blacks or African Americans within the city face a “double jeopardy” of increased risk for premature mortality – as data from annual County Health Rankings surveys indicate a significant disparity in the number of premature deaths among African Americans compared to Whites in the City of Alexandria between 2000 to 2015.
Happily, the decision by the Governor and General Assembly to finally expand the Medicaid program moves the principal of health care as a right, not just a privilege, much closer to reality in the Commonwealth. The City of Alexandria can be proud of its long-standing support for a strong and connected safety net. That commitment was well manifested just three years ago, as the mayor and City Council, by a unanimous vote, agreed to raise the cigarette tax by 11 cents a pack and devote all the new revenues toward increasing the capacity of Neighborhood Health — the nationally recognized, federally qualified community health center in Alexandria — to serve the primary care needs of more than 800 very low-income uninsured — many the collateral damage of the General Assembly’s refusal to expand the Medicaid program.
Our foundation’s mission has been “to bring health and hope” to Alexandria’s low-income uninsured, and that mission will continue so long as residents (including undocumented immigrants) face financial or other barriers to obtaining timely and affordable health care.
Dan Hawkins and Richard Merritt are co-founders and co-directors of Alexandria Cares for the Uninsured, a non-profit with ACT for Alexandria.