The Virginia state Senate adopted an expedited framework for expanding Medicaid to cover up to 400,000 Virginians who lack health insurance, but the more conservative House stuck with its slower timetable as two differing versions of the state budget won passage.
The Senate budget, with its more generous Medicaid expansion timetable, passed on a 36-4 vote. Its House counterpart passed 74-22.
That's the first step in what leads to high-level, mostly closed-door negotiations by a dozen senior legislators beginning late next week that will reconcile differences in the two versions of the $88 billion two-year state spending blueprint.
The only major tinkering with the budget bill was the Senate's Medicaid expansion floor amendment, which was approved over the objections of GOP conservatives. Neither the House nor Senate versions appropriate money for it, leaving that for the 2014 General Assembly.
The Senate is evenly split between Democrats and Republicans, while Republicans are the majority party in the House.
The Senate bill doesn't give the Medicaid expansion -- prescribed in the federal Patient Protection and Affordable Care Act -- an immediate or automatic go-ahead, but establishes criteria for expanding it as early as Jan. 1.
Senate Finance Committee chairman Walter A. Stosch's amendment would establish a new Medicaid reserve fund to capture hundreds of millions of dollars in state savings anticipated in the first five years of expansion when the federal government pays all or most of its costs.
Money from Stosch's proposed Virginia Health Reform Innovation Fund would be used after the first five years, when the states' share of expansion costs are expected to balloon.
The federal government would pay 100 percent of medical expenses for newly qualified enrollees from 2014 to 2017, then the federal share would drop to 90 percent by 2020, with each state paying the balance.
It also instructs the Department of Medical Assistance Services to negotiate for waivers to impose cost controls such as limits on patient benefits like transportation expenses, ensuring the benefits are commensurate with those that private insurers provide, some cost-sharing and greater use of wellness activities.
The amendment was adopted on a voice vote with Republican moderates joining Democrats in support while more conservative Senate Republicans argued for delaying expansion and questioned whether a federal government $16 trillion in debt can long be trusted to pay its share.
"I don't think we should put ourselves in that position. I can't imagine that the federal government is going to sustain this," Sen. Stephen H. Martin said in urging the floor amendment's defeat.
But Stosch (R-Henrico) found backing from Democrats, including Sen. Janet Howell of Fairfax and Henry Marsh of Richmond.
"We have over one million Virginians without medical insurance. This amendment would move forward about 400,000 of those, ...and who are these people?" Howell said. "They're the people who are cleaning our rooms in the hotel while we stay here in Richmond. They're the people working for fast food restaurants and other restaurants, and they're those people we're using for personal care assistance for our disabled."
In addition, it would accumulate about $5 million a day into the state and fund about 30,000 health professions jobs statewide, she said.
In the House, Del. Patrick Hope argued unsuccessfully for a faster track to possible Medicaid expansion. The House budget provides for expansion of eligibility to those within 133 percent of the federal poverty level starting on July 1, 2014, provided certain reforms in the system are approved.
Hope (D-Arlington County) said enrollment of new beneficiaries likely would not begin for another year after that.
"Over 18 months, we would miss out on $3 billion worth of benefits," he said. "That's money that's not going to go back to people treating the uninsured."
The Medicaid expansion amendment backed by the Senate's senior Republicans had a secondary effect: easing partisan resentments in the Senate by accommodating Democrats on Medicaid, a priority of theirs. Two weeks ago, hard feelings among Democrats over a Senate Republican ambush effort to muscle through a statewide Senate redistricting plan damaging to the Democrats threatened to kill major GOP initiatives, including the budget and transportation reform.
"It's helped a lot, no question about it,'' Senate Democratic Leader Richard L. Saslaw said after Thursday's budget vote.