Virginia is among 18 states that have not expanded Medicaid under the Affordable Care Act. But this year, the state legislature is going into a special session to continue discussions about whether or not to include it in its budget. By the time the regular session adjourned Saturday, members of Virginia's GOP-controlled House of Delegates and Senate could not reach agreement on whether or not to expand Medicaid.
Republican Delegate Barry Knight from the Virginia Beach area calls it "the 800-pound gorilla in the room." He's one of more than a dozen Republicans who voted to include Medicaid expansion in the House budget — along with a work requirement — this year.
It's a big shift in the House position on the issue and comes after 15 seats flipped in the so-called "blue wave" of last November's election, which also saw the election of Democratic Gov. Ralph Northam.
"On the big-picture issues, I think it was a re-awakening and a call to look at things from a different perspective," says Republican Delegate Chris Peace, from the Richmond area.
At a recent rally outside the state Capitol in Richmond, Northam continued his campaign message. "Are you all ready to get this done?" he called to the crowd's cheers. "Are you ready to expand coverage?"
A December poll showed over 80 percent of likely Virginia voters support an expansion.
"I think the House heard that message, loud and clear. I think the Senate still needs to listen a little bit," Northam says.
He's referring to a strong movement against expansion, led by Senate Majority Leader Tommy Norment from the Tidewater area in southeastern Virginia. Norment has come out against the House Republicans who want to expand. He reminds them that despite a slim margin, Republicans are still in charge and could stop Medicaid expansion.
"I do think that the House of Delegates is waiting for that moment of lucidity and epiphany to realize that their majority is 51 to 49," Norment says.
But President Trump has managed to mobilize Democratic voters, says Bob Holsworth, a former political science professor at Virginia Commonwealth University. He thinks expansion has a greater chance this year.
It could pass in the Senate, he says, because of a potential wildcard.
That wildcard is Republican Sen. Emmett Hanger, from mostly-rural central Virginia. Hanger has expressed support for some form of Medicaid expansion, and has a track record of voting independently, says Holsworth.
"What Hanger has said that's very interesting ... is that if he decides to support some version of Medicaid expansion, he says, 'There are a number of other Republicans who are going to go over with me.' "
However, Hanger isn't happy about a tax on hospitals that has been incorporated into the House's budget to help pay for the state's share of expansion costs. The tax accounts for about three quarters of the over $400 million Medicaid-related gulf between House and Senate budgets.
If legislators don't come up with a budget that includes Medicaid expansion, Northam has a plan B. He says he'll introduce an amendment to add it back into the budget. In the amendment process, the lieutenant governor, Justin Fairfax, gets a vote if the Senate ties. Fairfax says he'd be happy to vote to expand coverage to up to 400,000 low-income Virginians.
"There are so many people that we can help and we have the means to do it if we expand Medicaid. We just have to have the political will to do it," Fairfax says.
Among those expansion would help in Virginia: low-income adults without children.
"An adult who does not have children can have zero income — can be totally impoverished — and they cannot get Medicaid," says Jill Hanken with the Virginia Poverty Law Center.
And a family of three with a total income of about $10,000 doesn't qualify for Medicaid, she says.
"It's hard to explain to them that they don't have a choice, they're not eligible for Medicaid," she says, and they're not eligible for subsidies for insurance on the exchange, so health insurance is out of reach. "And the reason is because Virginia hasn't expanded Medicaid," she says.
The special session begins April 11. The state needs a budget agreement by June 30 to prevent a government shutdown.
This story is part of a reporting partnership with NPR, local NPR stations and Kaiser Health News.