map shows 31 states have adopted the Medicaid expansion available under obamacare North Carolina is not one of them.
Current status of Medicaid expansion decisions, Jan. 2017 Map courtesy: Kaiser Family Foundation

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By Rose Hoban

More than 625,000 North Carolinians would gain health insurance coverage under the plans that the Department of Health and Human Services is drafting for federal regulators.

That number was quoted Friday during a conference call of the Medical Care Advisory Committee, a group of health clinic managers, doctors and administrator from around the state. Friday’s call was intended to give the advisory committee an update on what DHHS is doing to fulfill Gov. Roy Cooper’s call to expand the program, as allowed for under the Affordable Care Act.

Dave Richard heads North Carolina’s Medicaid program.

Despite votes in Congress last week, the ACA remains in effect and officials at DHHS have been scrambling to get draft proposals to the federal Centers for Medicare and Medicaid Services in the waning days of Pres. Barack Obama’s administration.

State Medicaid head Dave Richard said the estimates his department is giving federal planners is significantly higher than earlier estimates for the number of people who would be affected by expansion.

“A lot of the estimates have been around 500,000,” Richard said.

There’s doubt as to whether the plans will move forward. Late Saturday night, federal judge Louise Flanagan placed a temporary restraining order on the department, restricting DHHS from submitting the proposed State Plan Amendment. That means any submission of the request would go to a Trump administration hostile to the ACA.

The MCAC is required by law to advise DHHS on Medicaid policy, and they unanimously endorsed the plans described to them.

Prior experience

A new study done last summer by Washington-based think tank the Urban Institute put the number of potential Medicaid expansion enrollees in North Carolina higher than earlier estimates, based on the experience of other states that expanded the program. By and large, those states saw more people enroll in Medicaid than expected.

Analysts at the Urban Institute broke potential enrollees into two groups: Those making under 138 percent of the federal poverty level ($33,500 for a family of four) who are currently unable to qualify for Medicaid and make too little to qualify for subsidies to help pay for insurance purchased through Obamacare and those low income workers who are buying insurance in the online marketplaces now at full price.

Map courtesy: Kaiser Family Foundation

Cooper addressed the group at the start of Friday’s call, asserting that many of the North Carolinians who would qualify live in rural counties.

“We can insure hundreds of thousands of people,” Cooper said. “We can bring billions annually, tens of thousands of health care jobs particularly in the rural areas that need them the most.”

Jason Gray, an economist at the N.C. Rural Center, estimated that Medicaid expansion would mean about $3 billion in economic activity in rural North Carolina counties alone.

States such as Louisiana saw about 325,000 uninsured people flooding into that state’s Medicaid system when Democratic Gov. John Bell Edwards expanded the program soon after his election in late 2015. Louisiana has about half as many people as North Carolina.

Flooding the system?

Advisory committee members expressed concern to Richard about whether county social service workers would be able to enroll such a large and rapid influx of beneficiaries. Those questions come in light of continuing problems with county workers being able to enroll Medicaid beneficiaries in a timely manner.

Just last week, State Auditor Beth Wood released an updated report on the effectiveness of county social service departments where she found many counties had high error rates and issues with timeliness of completing eligibility applications.

Advisory committee members also worried about whether there would be enough rural providers to care for a new influx of patients.

“I think insuring access is going to be a huge issue, because we had a lot of providers that are not taking Medicaid or they’re taking such a low rate that it doesn’t even matter,” said Dave Tayloe, who runs Goldsboro Pediatrics. “That could be a huge issue.”

“We do believe as you begin to add ability for more people to have coverage, to have a payment mechanism for their health, that can drive the kind of economics that will help recruit [providers] to the areas that are hard to serve,” Richard responded. “When we bring on that large amount of new beneficiaries, certainly you  must look at infrastructure and network supports. That will be an initiative that we will be focusing on through the monitoring access statewide.”

The basics

Richard said these new enrollees would have different benefits from those currently on the state’s Medicaid rolls. The new enrollees would be managed differently by DHHS, with a benefit plan Richard called “robust” and the expansion would take effect in January 2018.

He said DHHS modeled their plans on the Blue Cross Blue Shield Blue Options plan, which covers services such as ambulatory services, emergency services, hospitalization, newborn care, mental health and substance abuse benefits, lab services, prevention and wellness, and services for chronic disease, among other benefits.

Currently, the federal government pays two dollars for every Medicaid dollar spent by North Carolina, but for Medicaid expansion enrollees, the federal government would pay 95 percent of the tab. The program would remain fee-for-service for now, Richard said, and eventually, these enrollees could be rolled under the Medicaid managed care program that’s being prepared for at DHHS. But that would take time.

Richard expressed hope that Cooper and DHHS would be able to “engage the General Assembly” in providing for some of that last 5 percent of the cost. He also said departmental planners believed that hospitals could absorb the costs of the expansion.

“It will be positive number on their bottom line if they meet the entire match for the state of North Carolina,” Richard said.

He has some reason for confidence: a report issued this month by the Ohio Medicaid Department to that state’s legislature found not only had expansion in Ohio improved health outcomes for patients, but that costs came in significantly under budget.

Since Cooper asked the department to draft documents for Washington, Richard said staff has been working overtime on the plans, including working through the holiday weekend.

In the wake of Flanagan’s two-week stay issued Saturday evening, it’s unclear whether the plans will be able to move forward.

Rose Hoban

Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...