photo of crowd holding signs with the US Capitol in the background
Medicaid advocates rally in Washington, D.C., in June. (Phil Galewitz/Kaiser Health News)

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By Rose Hoban

North Carolina’s Medicaid advocates like Pamela Tripp have spent a lot of time in their cars this past week. Tripp, the CEO of CommWell Health, a community health center headquartered in Sampson County, drove back and forth to Washington, DC this past week to advocate for the defeat of the newest attempt for Congress to repeal and replace the Affordable Care Act.

The bill, known as Graham-Cassidy for Sens. Lindsay Graham (R-SC) and Bill Cassidy (R-LA), would radically change the Medicaid program, which covers what Tripp called the state’s “most vulnerable populations” – low-income children, pregnant women, people with disabilities and low-income seniors. The bill would return all of the money allocated in the ACA back to states in the form of block grants, lump sums of money for states to spend on providing health care services as they see fit.

The CommWell Health facility in Tar Heel is just across from the Smithfield hog processing plant. CEO Pam Tripp says many plant employees depend on their services. Photo courtesy: CommWell Health

Tripp said such a move would destabilize the lives of many of her patients at the 13 CommWell clinics spread across five counties in eastern North Carolina who depend on Medicaid.

“We are very rural,” Tripp said in an interview conducted as she drove back from Washington late last week. “We’re between chicken houses and hog houses, that’s where we live. So the population we serve is a rural population, a lot of agriculture, a lot of producers and growers.”

Based in Tar Heel, across the road from the Smithfield slaughtering plant, Tripp said her main facility, for example, serves many of those plant workers. In addition, CommWell  has thousands of working poor patients who fall through the cracks of the state’s loose safety net.

“I don’t believe that Congress understands how fragile health care is already in rural America, in rural North Carolina,” she said. “So, we know out of the 22,000 patients that we serve annually, that we literally have thousands of people… who have to decide whether to put food on the table or go to the doctor.”

And Tripp is counting the days because Graham-Cassidy bill only has a short shelf life. Members of the U.S. Senate need to pass the bill by Saturday, Sept. 30, before Senate rules force members of the Republican majority to negotiate with Democrats. If the bill doesn’t come up for vote before then, it’s likely to be dead.

Big money

During a meeting of the Medical Care Advisory Committee on Friday, a group made up mostly of small providers that consults with North Carolina’s Department of Health and Human Services, Medicaid head Dave Richard told members that the Graham-Cassidy bill would end up costing North Carolina about a billion dollars a year.

“We are taking it seriously,” said Richard.

“We are continuing our more detailed analysis of this, taking a look at every possible group’s estimates and what we see is what’s relatively consistent with what I’d describe as some of the more… moderate projections coming out of the think tanks.”

Dave Richard heads North Carolina’s Medicaid program.

Right now, the federal government matches two dollars for each one North Carolina pays Medicaid providers. It’s one of the highest match rates in the country, calculated from the state’s poverty level.

More than half the state’s Medicaid recipients are children.

Richard said that despite some analyses of the bill showing a “bump” in federal spending to North Carolina from 2020-26, those analyses neglect to note the dollars coming in during 2020 are less than what the state gets from the feds right now. And the money dwindles from there as the annual federal allocation shrinks further.

Putting federal money into block grants would put the problem of financing the care for North Carolina’s two million Medicaid recipients back into the laps of the General Assembly, he said. And the changes would take place just as North Carolina is converting Medicaid into a managed care program.

Richard explained that the cost to North Carolina would not only be the elimination of the federal match but also in the loss of subsidies the federal government paid to individuals who enrolled for coverage on the federal health insurance exchanges.

He said North Carolina would be a “loser” of funding compared to neighboring states.

“Other states around us lose, but they don’t lose as much as we do, and there are some states that are big winners,” he said. The bill takes away from states, like North Carolina, that were successful enrolling large numbers of recipients in the ACA, or ones that expanded Medicaid.

“Some of this looks a little bit like politics,” he said.

Hospitals at risk

Julie Henry from the NC Hospital Association says there would be no hospital in far western Murphy but for Mike Stevenson.

At Murphy Medical Center in far western Murphy about 70 percent of patients are on some form of government insurance. Photo courtesy: MMC

“Keeping that hospital open has taken ingenuity and perseverance and a lot of sweat,” she said last week.

Not every town has been so fortunate to have a Stevenson. In the past few years, four rural hospitals have shuttered in North Carolina and many more are at risk.

Stevenson is a little more humble about his role in keeping the hospital open, but he will say that keeping Murphy Medical Center open over the past 29 years has been a balancing act that’s largely dependent on Medicaid dollars.

He said the mix of payers at the 57-bed Murphy Medical Center, is about 55 percent Medicare, from all the retirees in the mountains, 8 or 9 percent of “no pay, indigent and bad debt” and 15 percent from Medicaid.

“Medicaid covers 90 percent, or a little more, of our births,” Stevenson said last week.

That leaves only about one in five dollars coming from commercial payers, such as Blue Cross Blue Shield of North Carolina or other large insurers.

To cover costs, Stevenson there’s always been cost-shifting from patients who have well-paying coverage to make up the tight payments provided by Medicare and Medicaid and the no-pay patients.

“There are a certain percentage of folks who are proud and responsible and poor and if they don’t have the money to pay, they won’t get those services,” he said. “I’ve seen it first hand, they delayed getting care until it’s too late and when they came into the emergency department, they were in advanced forms of cancer and it was too late.”

He’s frustrated by all of the repeal and replace bills that have emerged this year and said he has a hard time explaining to folks in his relatively conservative town why the bills are bad for the community.

“They either think you’re stupid or crazy or dishonest,” he said. “I think out of all of the ills of Obamacare, there are many solid concepts in it. But even Obama recognized there are fixes that need to be made.

“Why trash this whole thing, except for politics?” he asked.

Correction: This story originally stated that CommWell was headquartered in Bertie County.

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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...