About 747,000 Virginians are without medical insurance, which equals 10.7 percent of the state, according to the Virginia Health Care Foundation, an organization founded by the Virginia General Assembly and its Joint Commission on Health Care in 1992.

Medicaid is a program jointly funded by states and the federal government that provides health coverage to low-income people and those with disabilities, according to Medicaid’s federal website.

It provides services such as hospital care, behavioral health services, treatment for acute illness, dental services, nursing facility services and more.

And it’s a program Democratic candidate Natalie Short wants to expand. She is running for the Virginia House of Delegates District 23 seat, which includes portions of Lynchburg, Bedford and Amherst.

“If we expanded Medicaid, we would get $6.6 million a day,” she said. “Right now, we’re just giving it away to other states.

The $6.6 million would come from the federal government, Short said.

“We’d be able to afford it,” she said. “We’d be able to give 400,000 Virginians Medicaid.”

The program, which is supported by a mixed of federal and state funds, cost Virginia about $8.56 billion in fiscal year 2016, according to The Henry J. Kaiser Family Foundation (KFF), a non-profit organization that focuses on national health issues and global health policy.

For all it costs, according to the KFF, Medicaid also is the largest source of federal revenues for state budgets, as it pays for 50 to 74 percent of the costs of the program.

Republican Del. Scott Garrett — who has headed District 23 since 2010 — summarized Medicaid as “broken.”

“It’s not meeting the needs of all Virginians,” he said. “… It’s grown 60 percent over the last decade. It’s the largest single item in our state budget; it’s $20 billion out of a $300 billion bi-annual budget.”

Instead of expanding Medicaid, areas should focus on increasing access to health care, such as increasing the number of free clinics, Garrett said.

“I think that’s a wiser path,” he said.

Garrett, a surgeon, serves on several committees and subcommittees, two of which are the House Appropriations Committee and the Health and Human Resources subcommittee. Through those groups, Garrett said he had a part in granting $32.2 million toward mental health initiatives and hundreds of millions of new dollars into the Medicaid system.

“We have been very, very focused on strengthening the mental health safety net; our Johnson Health Center, our free clinics. We put tens of millions of dollars of new funding into strengthening that health safety net,” Garrett said.

But Short said expecting free clinics to fundraise and be able to continuously serve their communities puts too much work on them.

“They need to be able to treat patients,” she said. “People need to be able to focus on providing health care and not having to worry about ‘Are we going to have enough money next month to stay open?’

Short wants to increase the number of people eligible, with her long-term goal to make sure every Virginian has medical insurance through a single-payer system.

Though Medicaid covers more than 1.3 million Virginians — with more than 50 percent being low-income children — Virginia has some of the strictest eligibility criteria in the United States, according to the Commonwealth of Virginia Department of Medical Assistance Services (DMAS), the organization which administers Medicaid.

Short wants to increase what is considered the poverty level, as she doesn’t think the current standards are realistic.

Almost a quarter of the city of Lynchburg lives under the Federal Poverty Level — which currently sits at $12,060 for a single person, according to VHCF. Almost 40 percent of all uninsured Virginians live below that level.

“We’re the second city in poverty in Virginia, and if we’re going to fix that we’re going to have to start supplying the resources to get our families to where they can actually thrive, to where they can actually survive.”

Short said she’s been in a position where she can’t make ends meet.

“I’ve been there for a long time, and it’s not — people just expect you to boot strap theory, but it doesn’t work that way,” she said. “You don’t have boots. You can’t even go to the store and buy boots.”

But the Medicaid expansion is something Short said she “wants to work across the aisle on.”

Garrett said there’s an additional 90,000 Virginians that qualify for Medicaid, but have not gotten covered under the program.

“Those folks are called woodworks because if they came out of the woodwork and became covered lives we’d have … tens of millions of dollars, if not several hundreds of millions of dollars, of expense that we haven’t already appropriated,” he said.

Unless the state raised taxes or somehow got new revenue, that would challenge the resources currently put toward public education, public safety and public works and transportation, he said.

“What I have repeatedly and consistently said is that simply insuring a cohort or a group of people does not, in and of itself, result in better health care outcomes,” Garrett said. “There’s no data, no supporting documents that I’ve been able to review in four and a half years … that proves simply giving them Medicaid insurance, in fact, is going to improve their health care outcomes.

“In fact, in some states, there’s data that shows just the opposite.”

Garrett said he doesn’t think the federal government is going to be expanding their state Medicaid funding, but instead is looking at block funding to allow for more flexibility in how the funding is allocated.

“Right now, Medicaid is about a $10 billion cost to Commonwealth of Virginia,” he said. “About $5.2 billion of that is federal and about $4.7 billion of that is state.

“If the federal government decided to block grant us at the $5.2 billion, my job’s easy: we just continue the same programs … on the other hand, if they block grant at us at a number significantly below that, at $3.5 billion or $4 billion instead of $5.2 billion, and they do that by the end of the year? We suddenly have a huge deficit in our projections we’d have to rebalance.”

But even if Medicaid was expanded to cover more people, there aren’t enough providers, Garrett said.

“The Gov. [Terry McAuliffe] has had this push for four years to expand Medicaid, and it’s a false commitment,” Garrett said. “If you say, ‘Well, we’re going to give you this insurance card’ but there’s nobody there willing to accept your insurance then we’ve got huge challenges.

“… We have that same issue here in Lynchburg. With the exception of the family practice residency program and the doctors that work at the Johnson Health Center — which is a federally qualified health center — we don’t have physicians that are taking and accepting new Medicaid patients.”

To help with the lack of providers, Garrett supported a budget amendment to increase medical residency slots, he said.

“To increase those by 25 residents statewide,” he said. “There’s very good data to show that physicians will choose to stay within a 100 miles of where they did their residency training, so we’ve been trying to get more physicians to locate and health care providers to locate in south side, southwest Virginia and along the valley”

Without those residency slots, the state is going to have a hard time increasing providers, Garrett said.

According to the amendment, which was submitted for the 2017 session, $1.25 million from the general fund and an equal amount from the non-general funds will be used to pay for the new slots over 2017 and 2018.

“Of the 25 new residency slots, 13 shall be for primary care and 12 shall be for high need specialties,” the Department of Medical Assistance Services Medicaid Program Services budget for fiscal years 2017 and 2018 states. “In addition, preference shall be given for residency slots located in underserved areas.”

Short said providing free higher education also could have an impact on the lack of providers.

“You have a lot of students who don’t want to go to med school because they don’t want to take up that student debt,” she said.

She’s heard students say they’re already paying for four years, ‘How in the world am I going to pay for medical school?’

“We would have to start off with supplying community college and then work towards four year, but if we were able to do that for free then it would allow these students to go to med school if that’s what they wanted to do,” she said.

In addition, Short said trade schools also should be free. It allows people to go in the direction that they really want to go in, she said.

That type of program can be paid for with tax and lottery money, Short said, adding that money needs to be going into education.

“We’re over $400 million short, and that’s because the lottery money isn’t going where it’s supposed to go,” she said.

When asked where the money is going instead, Short said to ask current legislators.

But that’s more of a long-term plan. The short-term plan is the expansion of Medicaid would create 30,000 more jobs, which would draw providers and staff to the area, she said.

Garrett said the greatest challenge for health care is the uncertainty of how the federal government will continue to fund these resources.

In addition to the cost of Medicaid, a hidden cost that needs to be accounted for is the multi-million dollar administrative cost of Medicaid expansion, Garrett said.

“But my bottom line is this, simply insuring folks doesn’t result in better health care outcomes,” he said.

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State House district 23 candidates on health care, Medicaid expansion