By Sarah Ovaska-Few
Now that some of the dust has settled after Tuesday’s election, the big question for many in the state’s health care community is whether North Carolina will expand Medicaid.
Here’s the unsatisfactory answer: Maybe, maybe not.
Tuesday’s elections brought significant change to the balance of power in the N.C General Assembly. Republican lawmakers, who started the 2013 legislative session by rejecting the expansion made possible by the Affordable Care Act, are still very much in power. But Democrats appear to have to picked up enough seats Tuesday in both chambers to break Republican super-majorities, meaning they can uphold any vetoes from Gov. Roy Cooper, also a Democrat.
Voters in three states – Idaho, Nebraska and Utah — voted Tuesday to expand Medicaid coverage to their citizens, a sign this piece of the Obama administration program is continuing to gain support in what are typically more conservative states.
Cooper, meanwhile, has not been shy about his desire to pull down available federal dollars and expand Medicaid for North Carolinians who would benefit, a number estimated to be around 339, 000 adults. Cooper could make expansion a point to negotiate when it comes to passing the state’s biennial budget this summer.
Cooper’s spokesman declined to speculate about the possibility of Medicaid as a budget bargaining tool, but said the governor is still focused on increasing coverage.
“This should not be a partisan issue and North Carolina should join leaders of both parties who have taken this step in states across the nation,” Cooper spokesman Ford Porter said about the appetite for expansion after Tuesday’s election.
What Republican state legislative leaders are thinking is unclear. House Speaker Tim Moore and Senate leader Phil Berger did not return calls from N.C. Health News seeking comment.
Just don’t expect a quick turnaround on their positions anytime soon, cautioned Mark Hall, a Wake Forest University professor who studies the health care insurance market.
“Since Republicans control both chambers of the General Assembly, [Medicaid expansion] seems unlikely to change in the near future,” Hall said.
It’s a view shared by state Rep. Darren Jackson, a Raleigh Democrat and House Minority Leader. As much as Democrats may want to see expansion, they simply can’t call the shots without bipartisan buy-in.
“I hope we can do it and get it done this year,” Jackson said. “But we still don’t control and we can’t push one single bill forward without at least some Republican support.”
For those in need of a quick primer, Medicaid is the federally mandated health care program that provides health care in North Carolina to 2.1 million poor children and their families, seniors and disabled persons. A key component of then-President Barack Obama’s Affordable Care Act was to bring uninsured adults too poor to afford health care of their own into the Medicaid system, but a 2012 Supreme Court ruling that states couldn’t be forced to expand led several Republican-led states such as North Carolina to reject federal money to expand the program.
Uninsured with few options
Jessica Oliver is one of those 339,000 people in North Carolina left in the lurch by the health care policy tussle.
The 36-year-old Caldwell County mother suffers from cyclic vomiting syndrome and gastroparesis, a condition where the stomach enters routine cycles of paralysis. She’s been largely untreated since 2015, when she married her longtime partner and subsequently found she lost the Medicaid coverage she received as a low-income unmarried mother to the couple’s 14-year-old daughter. To get insurance again, she’s been told by social service workers she would need to have a baby, separate or divorce.
“We thought about moving to separate houses, but paying the rent here and somewhere else would make it even harder,” Oliver said.
Nor can the family afford to buy health insurance for Oliver. The family has an annual income of about $18,000, all from disability payments her husband receives for chronic heart issues. The $1,500 they get monthly isn’t enough to cover basic expenses, with the family using food pantries to stay fed and an aunt paying their monthly power bill.
“It’s the only income that comes into our house of three,” she said. “But it’s too much, so I get nothing.”
Oliver said she’s unable to work because of her health conditions but that her diagnoses don’t quality as disabling events, which would make her eligible for Medicaid.
Since losing health care coverage in 2015, Oliver has stopped taking almost all her prescribed medications and making her doctor visits. She took out a gastronomy feeding tube she depended on because the $300 monthly cost was too much without insurance. Now, the only time spent with doctors comes when she heads to the emergency room for serious bouts of illness and malnutrition. Oliver estimates she has $50,000 to $60,000 in hospital bills that will go unpaid.
Alternate expansion
There could be some other relief for Oliver, if a small group of Republican state lawmakers can get their colleagues on board with a different version of Medicaid expansion.
A proposal called Carolina Cares would offer coverage to uninsured adults while removing requirements for the state to kick in money, a liability that’s hung up expansion in the past, said state Rep. Donny Lambeth, a Winston-Salem Republican, retired hospital administrator and backer of the program.
It differs from expansion in other states because it requires “skin in the game” with work requirements for most participants and premiums, said state Rep. Josh Dobson (R-Nebo), another Republican sponsor of the Carolina Cares bill filed last year in the legislature.
The proposal failed to get much traction when first introduced in 2017, and Lambeth suspects his Republican colleagues misunderstood the plan.
“It’s disappointing the leaders did not want to talk about it in the long session,” that took place in 2017, he said. He said he never got a chance to explain how his proposal differed from other expansion plans.
He hopes more lawmakers will listen this year and said Moore, the House leader, is willing to consider it. The real battle has been getting support in the state Senate.
The recent election results and the fact that North Carolina is well on its way to moving the $14 billion Medicaid program to a managed-care system may make the subject easier to broach this time around, Lambeth said. He’s also a House budget writer and plans on mentioning his pet issue when it comes time to hash out the budget.
But whether or not it will get a better reception in next year’s long legislative work session is still far from certain.
“It’s too early to tell,” Dobson said. “I know I’ll continue to advocate for it.”
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