Wednesday's voting marked the end of a more than four-year battle over whether Virginia should expand the publicly funded health care program for the poor. A fight over Medicaid expansion led to a standoff over the state budget in 2014 and again this year.
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Virginia Democrats have argued the state should not pass up the roughly $2 billion in extra federal funding the program would bring to the state. Republicans had previously been near unified in blocking past expansion efforts, saying the long-term costs were unsustainable.
Those arguments were again replayed in the final hours before Virginia's partisan battle was finally ended.
Sen. Ben Chafin, a Republican lawmaker from Virginia's economically depressed southwest coal country, announced his support for expansion on the Senate floor. He said his rural area needed expansion to help bolster its hospitals and provide care for constituents in need.
"I came to the conclusion that no just wasn't the answer anymore," Chafin said.
But several Republican senators remained strongly opposed, saying Medicaid costs would eventually overwhelm the rest of the state's budget needs for schools and public safety.
"It is a ticking time bomb," said GOP Sen. Bill Stanley.
Expanding Medicaid to cover more low-income families was a key provision of Obama's Affordable Care Act. A federal-state collaboration originally meant for poor families and severely disabled people, Medicaid has grown to become the largest government health insurance program, now covering 1 in 5 people.
The GOP-controlled General Assembly's support for Medicaid comes despite Trump administration rejections.
President Donald Trump has vigorously sought to negate his predecessor's health law. And White House officials, including budget director Mick Mulvaney, have urged Virginia lawmakers this year not to expand Medicaid.
Yet ironically, his administration's embrace of work requirements for low-income people on Medicaid prompted lawmakers in some conservative states to resurrect plans for expansion.
Virginia GOP Speaker Kick Cox said the Trump administration's openness to conservative reforms, including work requirements, "was probably the biggest key" in getting Republican support for Medicaid expansion.