Norfolk has Hampton Roads highest uninsured population, but Medicaid expansion could help

July 23--Norfolk has the region's highest rate of people without health insurance -- but there could be some relief on the horizon.

In Norfolk, 14.6 percent of residents are uninsured, about 4 percent above the state number, according to Old Dominion University's upcoming 2018 State of the Region Report.

However, experts expect Norfolk's number to shrink when the rollout of Medicaid expansion, passed earlier this summer, goes into effect Jan. 1, 2019.

"Medicaid expansion will have a huge impact on reducing uninsured Virginians," Deborah Oswalt, the executive director of the Virginia Health Care Foundation, said. "It could reduce the uninsured population by almost half."

That is, she added, if everyone who is eligible signs up. But getting everyone registered who qualifies isn't likely, said ODU economist Robert McNab. He estimated that between 45 percent and 65 percent of those eligible in Hampton Roads will sign up.

"The more of an outreach effort there is, the higher the take-up will be," he said.

But the budget for navigators, who help the public find the right plan, has been cut repeatedly. The Centers for Medicare & Medicaid Services announced it is slashing funding from $36 million to $10 million for the upcoming 45-day enrollment period.

Last year, President Donald Trump's administration decreased navigators' funding by 40 percent from $62.5 million. The administration also cut advertising and other outreach activities.

Hampton Roads' uninsured population is 8 percent, which is lower than the Virginia and federal rates, according to the forthcoming report. Medicaid expansion will have a lower impact on Hampton Roads because of the region's relationship with the federal government and military, McNab said.

He said 20 percent of people in the area have insurance through the military orVeterans Affairs. That figure is only 5 percent statewide and 2 percent nationally.

Norfolk is an anomaly for two reasons, McNab said: "First of all, you need to remember 60 to 70 percent of folks work in one community and reside in another. Second, we have to recognize poverty plays a role in having health insurance."

Norfolk also has the highest rate of people living in poverty in Hampton Roads at 21.3 percent, according to census data. That's almost double the state figure of 11 percent.

Medicaid covers individuals and families living at 138 percent of the poverty level. In 2018, that would be $16,750 a year for an individual and $28,700 for an adult in a household of three, which could put some individuals in a tough position, McNab said.

"They are stuck in this boundary where they don't want to earn too much to lose public health insurance," he said.

Ultimately, there is a gap. Seventy percent of uninsured Virginians are families with income at or below 200 percent of the Federal Poverty Level, according to a 2016 Urban Institute report.

The individuals who don't meet Medicaid requirements rely on charitable care.

For many patients at Sentara Ambulatory Care Center, it's not as simple as just hopping into a car, said Mary Blunt, interim president for Sentara Norfolk General Hospital. Since some rely on public transportation, a doctor's visit can become an all-day affair.

There were $325 million in uncompensated care costs for the clinic in 2017 -- a $15 million increase from the previous year.

"Having fewer uninsured people will help bolster the bottom line," said Michael Cassidy, CEO and president of the Commonwealth Institute for Fiscal Analysis. "When people don't have insurance, hospitals will have to swallow that."

One of the key appeals of Medicaid expansion is the high federal reimbursement rate. In 2019 the state will be reimbursed 93 percent, and then 90 percent in 2020 and beyond. McNab wonders if this reimbursement is sustainable in the long run.

"There hasn't been significant movement on that from Congress, but given the president's hostility toward the Affordable Care Act, one would say it's a possibility," McNab said.

Cassidy points out that federal share has survived through years of high-pressure battles.

"We've had cliffs, shutdowns and all kinds of high-stakes issues on federal spending," Cliff said. "Yet in the midst of all that over the years, what has remained untouched is the medicaid reimbursement rate under the Affordable Care Act."

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