March 10, 2014
The 2014 Session of the General Assembly is over; we adjourned on Saturday. However, the main work, the budget, remains to be accomplished. The General Assembly will go back into session on March 24 to try to finalize a spending plan for the next biennium.
The big hangup, as I suggested from the beginning of the session, is the expansion of Medicaid. Opponents of expansion seem to be swayed by the argument that by refusing the federal dollars attached to Medicaid expansion, Virginia will send a message to the president and in some way rebuke the Affordable Care Act. The predominant concern is over whether the federal government can sustain Medicaid payments, despite the requirement that the feds fund no less than 90 percent of the cost of expansion. The argument ignores the fact that the feds have never failed to make their payments to Virginia under the original Medicaid plan, started in 1965.
There are at least three reasons why Virginia needs to move forward with the Senate’s approach, Marketplace Virginia.
First, ignoring the fact that a healthier population will result in a healthier community and a more robust economy, hospitals and insurance companies are already subsidizing the cost of providing health care to the uninsured. And thus, the people who pay the bills at the hospitals and the premiums to insurance companies are already picking up the tab. The people who will be covered by Marketplace Virginia are primarily the working poor, people who are already working but are not making enough money to afford insurance premiums and do not receive insurance through their work. For many, primary care is received through the emergency room, which cannot refuse care for a sick person. Those costs are subsidized by the hospital or other providers through increased costs for those who can pay and for insurance companies. We are already picking up the tab, and it just makes sense to provide coverage to the uninsured.
Second, the flow of federal money to Virginia, up to $1.8 billion a year, or about $5 million a day, is bound to have a positive effect on Virginia’s economy. Because the plan will provide healthcare coverage to over 200,000 Virginians, expanding coverage is expected to create as many as 30,000 jobs in the next six years. In an area where we need job growth, especially with a stagnant economy, this aspect cannot be ignored.
Third, we are paying for Medicaid expansion anyway. There is no doubt that fees and taxes went up at the federal level to pay for Medicaid expansion. In fact, Virginians are paying as much as $2.9 billion a year under the Affordable Care Act. Why should those dollars be spent anywhere but Virginia? It is true that we may not recoup all of the money Virginians pay the federal government under the Affordable Care Act, but why should we not receive as much as we can back from the federal government? Under the law, the feds have to pay 100 percent of the costs for three years and no less than 90 percent after that. What part of that deal is bad for Virginia?
Obviously there are people who disagree with my point of view. We will strive in earnest, I hope, to resolve the budget impasse as soon as practical. Millions of Virginians and hundreds of localities depend on Virginia getting its budgetary house in order.
Despite the budget impasse, the General Assembly did achieve some things this session:
A package of ethics reform bills passed, and, without question, raises the standard. For example, the new limit on tangible gifts to legislators is $250. However, for those looking for real reform, the legislation will not satisfy your hunger. One obvious flaw is that there is no limit on “intangible” gifts such as trips or sporting events.
Every year there seems to be an argument about the appointment of judges, where the judgeships belong, and who gets appointed. To satisfy many questions, in 2012 the legislature directed the Supreme Court of Virginia to develop a system to evaluate case loads and determine the appropriate use of resources in our judicial system. The National Center for State Courts completed the study on behalf of the court in November. The results show that we need about 28 judges more than we currently provide in the code. Because legislators from different parts of the state can pick apart just about every section of the report, particularly those that dealt with their region, the report was somewhat controversial. Nevertheless, the report provided us with a metric to use, and we finally agreed to increase the number of judges provided in the Code to 429. That does not mean all of the judgeships will be funded, but at least it gives us a point from which to work.
My personal goals with respect to mental health reform were met. I needed the strongest bill possible to leave the Senate to increase my negotiating power with members of the House of Delegates. The Senate supported legislation to establish a 24-hour emergency custody order period, a registry of psychiatric beds, and the establishment of state facilities as providers of last resort for any individual deemed to require hospitalization. While we did not achieve the 24-hour wait, the House agreed to the proposal to ensure that the state provide a bed of last resort. This is significant. It changes the paradigm. Under existing law, the issuance of a temporary detention order is triggered not by the need or behavior of the individual, but by whether a bed exists in which to place said individual. That makes no sense. The new process will effectively end what is known as “streeting,” where one in need of a bed is released at the end of the ECO period because a bed is not identified. We also lengthened the period of the temporary detention orders from 48 hours to 72 hours. These changes in the law will give the state enormous tools in mental health crisis situations.
But we cannot lose our urgency about the need for changes in our mental health system. We are still severely lacking, not just in Virginia but around the country, in our system of delivery of mental healthcare services. Importantly, my legislation creating a legislative study committee passed, and we will spend the next four years working to develop in Virginia a mental health delivery system that, I hope, can be a model for the rest of the country. In fact, I will not settle for less. I hope to examine and weigh the costs and benefits of every aspect of our system. Many argue that funding is the problem. I know that our system of community services boards has been underfunded and that the ones that work best are those that receive a significant amount of funding from local government. However, funding is not the entire issue. For example, a recent Inspector General’s report showed that one of the reasons we have a shortage of psychiatric beds is that the state hospitals are inefficient in the discharge of patients. I believe that we can squeeze inefficiencies out of the system and ensure that money is spent on effective, patient-focused care.