By Rose Hoban

At the legislature, big events often happen not with a bang but with a simple voice vote that can nonetheless rock a room.

A vote Tuesday morning was one of those occasions, as members of the Joint Legislative Oversight Committee on Health and Human Services approved an amendment to gut subcommittee recommendations that were passed just last week.

The amendment, put forth by Rep. Nelson Dollar (R-Cary), changed a report that had been passed by the subcommittee on Medicaid Reform only last Tuesday (see original document below). Last week’s report included sweeping statements intended to form the framework of a plan to overhaul the state’s Medicaid system.

But Dollar’s amendment stripped out all the details in the subcommittee recommendations, leaving just five bullet points – 31 words – to serve as imprecise guidelines for changing the system that provides health care for close to 1.8 million low-income children, women, elderly and disabled North Carolinians.

“I have very serious concerns,” Dollar said at the beginning of a 13-minute explanation of his amendment, where he outlined his objections to the findings and the Medicaid plan created by the subcommittee.

After other legislators weighed in on the amendment, it was put to a voice vote that produced a loud chorus of “ayes,” which won out over only one or two reedy “no” votes.

Differences persist

The amendment vote indicated that deep differences between the House and Senate’s visions of Medicaid’s future that emerged during the most recent legislative session persist.

The Senate’s vision includes inviting commercial managed care organizations to North Carolina to run Medicaid, an aggressive timeline for transformation and moving oversight of the program away from the legislature onto an appointed board.

[pullquote_left]Is North Carolina Health News part of your daily news diet? Support us by making a year-end donation![/pullquote_left]In contrast, the House’s vision builds on the system of patient-centered medical homes already existing in the state by encouraging that those provider groups form into accountable care organizations over a longer time period. It’s a vision that’s shared by Gov. Pat McCrory and Department of Health and Human Services Sec. Aldona Wos and was outlined in the Medicaid plan delivered by the Medicaid Reform Advisory Group this past February.

It was those competing visions that proved to be a sharp point of contention between members of the two chambers during the summer’s short legislative session; those differences delayed the end of the session. Lawmakers such as Rep. Justin Burr (R-Albemarle) had expressed hope that subcommittee work during the legislative interim would allow for some of the differences between the two chambers to be ironed out.

But Tuesday’s vote, and the rhetoric during the debate, indicated the upcoming legislative session will likely contain a continued tug-of-war over Medicaid.

Near the close of the debate , committee co-chair Sen. Ralph Hise (R-Spruce Pine) called Dollar’s amendment one of many “attempts to sabotage this from across the board.”

Hise also said he didn’t believe the subcommittee recommendations could be characterized as a managed care model for Medicaid.

“All that is said here is that we have not excluded [managed care organizations] from participating in North Carolina,” he said.

After the meeting, Hise characterized Dollar’s amendment as an attempt to “maintain part of the status quo.”

Not so broken?

During the debate, several legislators defended the state’s Medicaid system, which for the past two years has been repeatedly called “broken” by the governor, Wos and lawmakers.

But Dollar pointed out that much of the budget overruns that have dogged the program in recent years could be attributed to a range of issues such as miscalculations of federal matching funds, problems with budget forecasting and poorly designed programs that were slowly phased out.

“We do know too that the overall Medicaid claims spend, if you go back to 2008, 2007… has remained consistently under 3 percent,” Dollar said. “I don’t know of any state that has performed any better.”

He also praised the state’s medical home model of care, recalling that during subcommittee testimony in October the Virginia Medicaid director “admitted that if they could start over from scratch, they would like to emulate North Carolina’s model of primary care.”

Dollar also defended the mental health managed care system that’s been in place since 2010.

“We started this process by saying the system is broken,” said Rep. Marilyn Avila (R-Raleigh). “I would venture to say it’s not broken because we have recipients getting service and providers getting paid.”

She argued that starting from scratch in remaking the system would be unwise. Instead, she said, lawmakers should tweak the system to build on its current strengths. Avila also argued that reforming Medicaid should be done more slowly than the subcommittee report proposed.

“Big arguments, big discussions take time. You’re not going to wave a magic wand,” she said. “Everyone has reached this mentality that if we can’t solve a problem in two years, it can’t be solved, and I’m saying, ‘No way.’”

It takes time

After the meeting, Wos expressed relief that the door remained open for the ACO option to move forward.

When asked her opinion before the vote, Wos expressed “grave concerns” that if the state were to adopt a managed care Medicaid model access to care in rural areas would be a problem. She expressed particular concern over access in sparsely populated areas in the eastern part of the state.

“I’m afraid that with an MCO model, we would have enormous obstacles, and I’m not quite sure that we would be able to get federal permission to do that in [the east],” she said.

Afterwards, she told reporters that while MCOs might allow the state to control Medicaid finances more quickly, ACOs would create longer-term savings and stability.

“It’s a different business model,” Wos said. “It takes time.”

After the meeting, a group of lobbyists who represent managed care companies gathered in the back of the committee room. None would comment on the outcome of the committee’s vote.

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