By Rose Hoban
In a much-anticipated move, members of the General Assembly’s Democratic caucus filed bills in both the state Senate and House of Representatives to expand Medicaid, the health care program that covers many low-income North Carolinians.
Since the beginning of the 2013 legislative session, Democrats have been frustrated in their desire to get coverage to more of the people left out after legal challenges to Pres. Barack Obama’s signature legislation, the Affordable Care Act. Initially, the law called for all states to expand Medicaid to low-income Americans who make too much to qualify for their states’ programs and too little to qualify for subsidies to buy health insurance policies made available under the law.
Legal challenges to that law lead to a Supreme Court ruling in the summer of 2012 when the high court decided that mandatory Medicaid expansion was a federal overreach and gave the option to states whether or not to expand. Since that time, 37 states have chosen to extend benefits to people earning less than 133 percent of the federal poverty level.
“It’s time to make North Carolina number 38,” said House minority leader Darren Jackson (D-Raleigh) during a press conference at the legislative building Wednesday.
“Three Republican, red states put it on the ballot this past November, all three states passed it,” he said, referring to ballot measures in Utah, Idaho and Nebraska.
In North Carolina, Medicaid covers more than 2.1 million low income children, some of their parents, pregnant women, people with disabilities and low-income seniors. Childless adults without a disability are unable to qualify for the program, and adults with disabilities can only remain on the program if they earn less than the poverty level of $12,140 per year.
This leaves out many low-income workers such as farmers, construction workers and daycare providers, said Senate minority leader Dan Blue (D-Raleigh).
“Expanding Medicaid would help a half million … North Carolinians get better access to affordable health care,” Blue said. “Those in the coverage gap are those that we interact with every single day.”
New energy
In the wake of the 2012 election when Republicans took control of the General Assembly with super majorities in both chambers, Democrats and health care advocates have been frustrated in their desires to expand the program. Senate Bill 4, passed early in the 2013 legislative session, placed the decision to expand solely in the legislature’s hands.
But advocates say this is the year they think they may make progress on the issue, in large part because of Democratic victories in the November election which eroded the super-majorities in each chamber.
Longtime lobbyist Peg O’Connell, who represents public health interests at the legislature, said when she first organized meetings around pushing for expansion, only a handful of people would show up.
“Coalition meetings, which started small three years ago, are now standing room only, literally. That’s because they didn’t have more than 50 chairs,” O’Connell said. “There’s real energy around this issue.”
That energy is more noticeable in the responses of providers who, in the past, have been more circumspect about their desire to see the program extended to reach more uninsured.
“We support closing the coverage gap through an appropriate fiscally responsible mechanism,” said Greg Griggs, head of the North Carolina Academy of Family Physicians. “People who have access to insurance coverage are able to get the right care at the right time early in a disease process, which avoids more expensive care later.”
(Note: the NC Academy of Family Physicians is a NC Health News underwriter)
Navigating costs
Another measure of energy for extending insurance to low-income workers via Medicaid comes from the fact that Republican lawmakers in the House of Representatives introduced the Carolina Cares bill during the 2017 session. Sponsors of that bill expressed their belief during 2018 that an increasing number of House Republicans would be willing to vote for the measure, but the bill never advanced through committee.
Under the Affordable Care Act, states adopting expansion at this point are only responsible for 10 percent of the cost of those additional beneficiaries on the program. The Carolina Cares proposal called for assessments on hospitals to pay for any costs borne by the state.
The current Democratic proposal would depend on the same funding, Blue said.
[sponsor]“The hospitals have for some time been working on a solution to this challenge, and they themselves willingly offered this as a way to get this funded so that there would be no state cost,” he told reporters.
The Carolina Cares bill included a requirement for new beneficiaries to work unless they were in school, caregiving or too sick to be in the workforce. The new Democratic proposal would not include such a work requirement.
“If you start putting those types of conditions on here, then that requires a waiver to be submitted to the federal government and that just delays the process 14, 18, 24 months,” said Jackson, who called the proposal his “number one issue for this session.”
“We’ve introduced something today that can take effect as early as November 1,” he said.
Fiscal realities
The roadblock to Medicaid expansion has been in the Senate, where leaders have firmly resisted considering the measure.
“I think that was some of the concern that House leadership had about passing [Carolina Cares] and sending it over to our side of the building,” said Sen. Mike Woodard (D-Durham).
On Wednesday Senate leader Phil Berger (R-Eden) indicated he hasn’t moved far off that mark.
“He has a hard time reconciling the idea of Medicaid expansion with the fiscal realities of adopting a budget,” wrote Berger’s spokesman Bill D’Elia in an email to NC Health News.
“Additionally, there is also the issue that expanding Medicaid would force traditional enrollees, low-income children, pregnant mothers, the elderly, blind and disabled, to compete with 500,000 able-bodied adults for access to healthcare,” D’Elia wrote. “If there is a proposal that solves these issues, then we are certainly willing to look at it, but we have yet to see a proposal that does.”
Providers expressed confidence that finding the capacity to provide for new beneficiaries would not be a problem.
Ben Money, head of the North Carolina Community Health Center Association, said providers in his members’ clinics are already providing for the people who would get covered under expansion, but he said they’re not getting paid for it.
“What [expansion] means is that there would be more resources available to serve those patients because they would now come with a funding source,” he said. “It would mean that clinics would be able to hire more providers, give more services such as [medically assisted treatment] services for individuals with opioid addictions, more integrated behavioral health services.”
“Having fewer people who are uninsured would mean that we have a stronger health care system, not a weaker one,” Money said.
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We can expand the medicaid programs to the rafters in NC and it won’t help. Until the fraud and payoffs in this system are eliminated, the money just continues to go to thieves.