Medicaid Expansion in Virginia–Working on It

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