Volunteer clinician Dr. Ernest Fonaris (standing, center) talks with Agoul Nangog and Deng Longar at CrossOver Healthcare Ministry as Chelsea Bodaghi (left), a VCU student intern, takes notes. (Photo by Jay Paul)
A year into Medicaid expansion in Virginia, and the numbers are impressive. As of Jan. 31:
- 383,544 more Virginians obtained health care coverage through the expansion, a number that includes 17,971 city residents, 14,723 people in Henrico County and 13,355 in Chesterfield County.
- 22,554 Virginians received treatment for substance abuse through Addiction and Recovery Treatment Services (ARTS). That number includes 1,791 in the city of Richmond, 916 in Henrico and 778 in Chesterfield.
- 45,720 received treatment for high blood pressure, including 2,441 in the city, 1,706 in Henrico and 1,359 in Chesterfield.
Many of the people who have gained access to medical care through the expansion previously relied on emergency departments or similar facilities, which are costlier, and had gone without regular treatment or medicines. Now, 86% of the newly enrolled have used at least one medical service.
“We’re very excited about the numbers,” says Karen Kimsey, director of the Virginia Department of Medical Assistance Services (DMAS), the agency that oversees Medicaid for the commonwealth.
DMAS is touting the expansion’s numbers through a dashboard on its website that allows visitors to delve into breakdowns of enrollment and services utilized by city and county. The statistics are updated regularly.
A survey of people who enrolled in health care coverage through the expansion conducted last year by Virginia Commonwealth University for the agency found that 25% of survey participants relied on emergency departments for medical care, and 19% got care through a free clinic. About 47% visited a regular physician, compared with a national average of 65%. About 95% of the new enrollees said they planned to see a primary care physician in the coming year.
Before Medicaid, 57% of survey participants said they had not had access to a regular primary care provider, 56% said they couldn’t afford basic medical care and 62% said they had unmet medical needs. Also, 65% went without dental care, and 49% said they could not get needed eyeglasses. About 72% cited cost as a factor in their inability to get care. About 68% were uninsured in the previous year.
About 47% of those surveyed said they had received treatment in an emergency room in the year before they enrolled in Medicaid, more than twice the national average (20%); 43% had two or three ER visits, and 24% visited four or more times (9% is the national average).
The report was released in October and was conducted by Virginia Commonwealth University School of Medicine’s Department of Health Behavior and Policy and the Department of Family Medicine and Population Health.
Most Americans receive health insurance coverage through an employer, but 68% of those surveyed said health issues prevented them from working or from keeping a job. Two-thirds of participants said they faced difficulties in the past year in paying medical bills, compared with 14% nationally.
Access to care may mean greater costs up front, but consistent access to health care enables people to manage chronic conditions and improve their overall health. It also diverts people from seeking help in a costly setting, emergency departments, and lessens the chance that someone will delay a treatment because they can’t afford it, and that their health will deteriorate until they do need emergency or costly care. For instance, someone with cancer who is uninsured typically delays seeking help until the cancer is in an advanced stage.
“Broadly, the value of having insurance coverage is that there are much fewer barriers to actually getting primary and preventative care. If you are not feeling well and don’t have insurance, odds are you will have to show up in ER, and at that point, it’s a much more serious condition. If have insurance, can get checked out much earlier in the disease process, so [there are] better outcomes,” says Danny Avula, director of the City of Richmond and Henrico County Health Districts. “The long-term benefits aren’t something we’re going to see immediately.”
Having access to primary care providers opens up more opportunities for the people who need to access the metro area’s safety net facilities, the nonprofits and ministries that have served the uninsured for years, including Daily Planet, Health Brigade and the Capital Area Health Network.
“Their patients go elsewhere, and hopefully that creates more capacity,” says Avula.
The uninsured population in the metro area is increasingly people who are without documentation and who don’t speak English, according to Avula.
Karen Legato, executive director of Health Brigade, says that the nonprofit has been thrilled that expansion occurred. “I’m so glad that Virginia has done it; it was the right thing to do,” she says.
Still, she notes, there are still several hundred thousand Virginians with too much income to qualify for Medicaid, but they make too little to pay for private insurance. There are also other obstacles, including a lack of familiarity with how to navigate insurance and health care, having no consistent access to transportation to work or to access health care, language barriers, or chronic health conditions. There also can be problems for new enrollees in finding a health care provider who is accepting new patients, which can lead to waits in accessing treatment, says Legato.
Health Brigade has made an aggressive effort to help people who qualify to sign up for Medicaid, about 900 so far, says Legato. That in turn freed up slots for others, those who didn’t have the option.
She notes that, for various reasons, people may get coverage, then lose it, then requalify, that there’s a churn. Expansion also has necessitated adding staff, even though Health Brigade doesn’t get extra Medicaid money, says Legato.
“We’re always going to be a clinic of last resort,” she says.
One nonprofit, CrossOver Health Care Ministry, has become a hybrid organization that serves the uninsured but also has begun to take on people with Medicaid, because of the expansion. The ministry, which serves many refugees, people from 118 countries and many who don’t speak English, says the expansion allows it to offer continuity in care, even as people move in and out of coverage. Also, children who may be covered may be seen along with their parents, who are uninsured.
“We made the decision to ramp up participation in Medicaid,” says Julie Bilodeau, CEO of CrossOver.
The ministry, which served about 6,500 patients in the 2019 fiscal year, now sees about 800 people through Medicaid, about 15% of its care recipients. Accepting Medicaid entailed changes for CrossOver including adding medical coding capability and adding navigators to its staff, says Bilodeau.
CrossOver offers comprehensive services, including primary and specialty medical care, prescriptions, obstetrics, mental health, dental, and vision care. “It’s kind of a one-stop shop,” says Bilodeau.
She notes that many people seen there may have chronic health conditions, may have experienced trauma and may have little fluency in understanding the health care system.
Continuity of care is important when working with people who have families that have fled violence. “Trust is really important,” says Bilodeau.
About 1.3 million Virginians were on Medicaid rolls last year. Federal money pays for about half the costs of those enrolled before the expansion, but pays for 90% of costs for Medicare expansion enrollees, which cost $3 billion in 2019, according to a Richmond Times-Dispatch report in November. The remaining 10% of expansion enrollment costs are paid by private hospitals.
Additional information is available through Cover Virginia on accessing health coverage through Medicaid and the FAMIS program here (in Spanish). Learn more about Medicaid expansion in Virginia here.
