The last major movement in health care policy in Virginia came last year when the state opened enrollment to its expanded Medicaid program, extending insurance to more than 340,000 people to date.

This year, Virginia Democrats say they want to use their new legislative majorities to build on that program to offer dental coverage to more adults, while also turning their attention to the state’s health insurance marketplace and high prescription drug costs.

Northam pushes for lower premiums on individual marketplace

Gov. Ralph Northam rolled out a high-profile push to get premiums down on the individual marketplace when he introduced his proposed budget at the end of last year, announcing he’d like to double the tax on cigarettes to 60 cents a pack to pay for it.

The state’s marketplace has been plagued by soaring monthly premiums, which were estimated at just under $800 a month this year. Officials estimated about 260,000 people are likely to buy health insurance on the marketplace, created by President Barack Obama’s signature Affordable Care Act, this year — an all-time low.

Under Northam’s proposal, that average would drop to $640 a month. He gets there by using cigarette tax dollars to subsidize the costs of private insurers’ most expensive customers. The approach, called reinsurance, has been used in 10 other states. In Virginia, Northam’s administration has calculated it needs to spend $73 million to push everyone’s premiums down by 20 percent.

If approved, Northam’s administration said the earliest consumers should expect to see costs go down as a result of the program would be open enrollment 2021.

A state-run marketplace

Northam also proposed dropping out of the federally managed Healthcare.gov exchange in favor of a state-run marketplace. The logic, as explained by his administration, is that the feds are collecting a 3 percent fee from insurance companies for every policy they sell. The money is supposed to be used for administration and marketing, but under the Trump administration, much of those marketing resources have been cut.

By opening a state exchange, the 3 percent fee would flow to the state, bypassing the federal government and allowing the state to take control of marketing and hiring health insurance navigators to help walk people through the process of picking a plan and enrolling.

While Republican members of the General Assembly’s Health Insurance Reform Commission sounded open to the reinsurance program, Sen. Ryan McDougle, R- Hanover, worried the state could be stuck with cost overruns by launching its own exchange if technology costs balloon. A representative of the health care industry told the panel that it was a risk (remember the botched launch of Healthcare.gov?) but one that several other states have successfully navigated.

Both the state-run marketplace and reinsurance program were recommendations of a state work group that looked at ways to push down health care costs for everyone. The group made other recommendations, including instituting a state-level individual mandate that every resident have health insurance. But the group acknowledged that such an approach would likely not be politically feasible, and Democrats, with their newly consolidated power, don’t seem eager to go down that road.

“I think that would be something we would need to study,” said Del. Mark Sickles, D-Alexandria, who is incoming chair of the House’s committee on Health and welfare. “That’s not going to happen in January or February, I can promise you.”

Dental coverage for adults on Medicaid

One area Democrats in the General Assembly might go further than the governor is teeth. Currently, the state provides dental coverage for Medicaid patients who are minors, but not for adults.

A group of healthcare-oriented Democrats has been discussing ways to change that, said Sen. George Barker, D-Fairfax, though he says he’s still trying to nail down the potential cost.

“It may have to be phased in over a period of time,” he said, “but I think we will be able to do that.”

He sees dental care as a growing need, particularly as the link between oral and overall health is better understood.

“If you go down to the Remote Area Medical clinics down in Southwest, they used to have people getting treatment for all kinds of conditions,” he said. “The vast majority now, it’s dental.”

He said funding for mental health services and dental care will likely end up being weighed against the reinsurance program proposed by Northam.

Taking on high pharmacy costs

There has been no shortage of horrifying stories about high drug costs—among them, the death of a 27-year-old Leesburg man who aged off his family’s health insurance and could no longer afford the $1,200 monthly cost of his insulin.

At least one lawmaker, Del. Lee Carter, D-Manassas, says he plans to introduce legislation capping monthly co-pays for insulin at $30 for a one-month supply.

He said the law was inspired by a similar cap passed last year by Colorado.

“I don’t feel like people should be paying more than a dollar a day for insulin,” he said. “It’s medicine that you can’t delay on. You can’t do anything other than pay whatever it takes.”

A public-option health care plan in Virginia?

Another lawmaker, Del. Ibraheem Samirah, D-Fairfax, introduce legislation that would create a public-option health care plan on the exchange for the sliver of the uninsured population that doesn’t qualify for Affordable Care Act subsidies but doesn’t have insurance through their employers.

“It would cover a good chunk of the remaining uninsured population,” he said.

The measure is modeled after a similar approach adopted in Washington state. His office acknowledges the measure is a long shot this year, but considers it an important conversation starter.

“I think we need to have the conversation at the state level,” he said. “Simply put, private insurance needs to have some competition.”

Surprise billing

Lawmakers say they also expect to address some leftovers from last year– in particular, surprise billing.

Often called balance billing in industry jargon, it’s shorthand for what happens when medical providers hit patients with unexpected bills because they were seen by an out of network doctor or other provider at an otherwise in-network facility.

Congress has also been seeking a solution, but has so far yet to reach a compromise between insurance companies, which want to fall back on set-rates in such scenarios, and doctor and hospital groups, which prefer resolving individual cases through arbitration.

Lawmakers in Virginia couldn’t work out a compromise last year, either.

Where Virginia will land this year, nobody knows. But lawmakers say they’re going to work on it.

“I think both sides understand it’s important to resolve this rather than drag out,” Barker said.