In pushing for a large scale expansion of Medicaid eligibility, Democratic Gov. Terry McAuliffe isn't just up against House Republicans who are leery of supporting a key aspect of President Obama's signature health care law. He's also trying to upend the commonwealth's long tradition of resistance to public aid.
Virginia state Sen. Charles J. Colgan, a Prince William County Democrat who was first elected nearly four decades ago, remembers former Gov. John Dalton voicing concerns in the late `70s about the state's growing Medicaid budget.
Dalton was worried that state spending on the publicly funded health care program for the poor and disabled would grow to a point where it was same size as the rest of the state's budget, Colgan said.
Today, similar concerns are raised nearly every day by Republicans in the House of Delegates opposed a plan by Senate Democrats and McAuliffe to expand Medicaid eligibility to nearly 400,000 Virginians.
"It goes back so far,'' said Colgan of Virginia's fight over Medicaid spending.
Under the Affordable Care Act, the federal government has promised to cover the entire cost of Virginia's state's expanded Medicaid population through 2016, and no less than 90 percent of the cost in future years. States can choose whether to expand Medicaid. Most Republicans in Virginia and elsewhere, however, argue that federal government won't be able to afford its promise and could shift costs back to the states.
For several decades in Virginia, regardless of which party has been in power and despite the commonwealth's overall affluence, the default setting has been skepticism toward public assistance of all kinds, including Medicaid.
When Colgan was first elected, Virginia was one of 22 states to prohibit welfare payments to families with an able-bodied but unemployed father. In 1998, Gov. Jim Gilmore vetoed a bipartisan plan to expand Medicaid to lower income children, saying the proposal "affronts my philosophy'' and created dependency on the government.
"The fight over Medicaid expansion and the hesitation to move in the direction of Medicaid expansion is something that has very deep roots in Virginia political culture,'' said Stephen Farnsworth, a political science professor at Mary Washington University.
Virginia currently has some of the most restrictive Medicaid eligibility requirements in the country. The commonwealth ranked 48th in state Medicaid spending per capita, according to a report from the state's Medicaid office last year.
Non-disabled adults without minor children cannot qualify for Medicaid, no matter how poor they are. If Medicaid expansion passed, the state estimates this group of adults -- with incomes up to about $16,000 a year -- would account for about 70 percent of newly eligible enrollees.
Supporters of Virginia's wary approach to public assistance say keeping the state's safety net small helps ensure it will always be available for those who need it most, like the infirm or disabled.
But McAuliffe and his supporters are hoping the state is ready to abandon that tradition in favor of what they say is a more compassionate approach that recognizes that fewer employers are offering health insurance to low-income workers.
And those in favor of an expanding Medicaid eligibility are counting on federal assistance to help change minds. The state's budget office said that with Medicaid expansion, the new federal health care law would save the state $1 billion through 2022.
"It's common sense, morally, socially and economically,'' said McAuliffe.
The Democratically controlled Senate and GOP-Controlled House are locked in debate over expanding Medicaid eligibility, and there's been no sign a compromise will be reached by the scheduled end of the 2014 legislative session on Saturday.
Slightly more than half of the states have expanded or are considering expanding Medicaid eligibility. Most southern states have rejected Medicaid expansion.
To make a proposed Medicaid expansion more politically palatable in Virginia, the Senate plan emphasizes the continued use of private insurers and requires co-payments of up to 5 percent of some enrollees' household income.
Business groups including the Virginia Chamber of Commerce, which have traditionally allied with Republicans, have pushed hard for the state to take the federal money. An expanded Medicaid program, they argue, would help the state's hospitals and decrease the cost of health insurance premiums for those already insured.
And progressive groups have emphasized the large number of Virginians who would be eligible for an expanded program that are already employed.
One such individual is Pamela May, a 52-year-old from Gloucester County who works part-time at a gift shop and as a pizza delivery driver.
May said her income was about $15,000 last year, and she wouldn't be able to afford her prescription drugs for health ailments without a free clinic.
She said full-time jobs with benefits are hard to come by in the sparsely populated coastal area where she lives.
"I'm doing the best I can,'' said May. "I'm not sitting at home twiddling my thumbs.''
But House Republicans argue Virginia's conservative approach to public assistance is more important than ever. They have said the federal government won't be to afford to cover the bulk of the expanded coverage, and if those costs are shifted to state there will be less money for other types of public assistance.
"The more you expand the program, it does affect other areas of the budget,'' said House Majority Leader Kirk Cox.