By Anne Blythe
Whether you believe that politics has become a blood sport or sports have become too political, it’s hard to dispute the long-standing comparisons between the two.
So on Tuesday, when key North Carolina lawmakers came together to talk about the state Department of Health and Human Services’ decision to put an indefinite pause on the long-awaited transformation of Medicaid to a managed care system, Rep. Donny Lambeth, a Republican from Winston-Salem, offered a sports analogy.
“It is unfortunate where we are, but we are there,” Lambeth said nearly an hour into a meeting of the Joint Legislative Oversight Committee on Medicaid and Health Choice. “It reminds me of the UNC game against Duke last weekend. … Up by 13. We’re playing well as a team. We have all of our momentum and it starts slipping away. Not just one, but two miraculous plays, and we lose the game.
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“And now, we’re in the locker room, wondering what happened. Why are we in this situation?”
The situation is tied to a standoff between Gov. Roy Cooper, a Democrat, and Republican lawmakers at the helm of the General Assembly.
Cooper vetoed the General Assembly’s $24 billion spending plan nearly eight months ago, in large part, he said, because he thought the budget should include higher raises for teachers and funding to expand Medicaid eligibility to potentially 550,000 low-income adults who could qualify for the federal aid.
The Republican leadership has resisted such efforts, digging their heels in against the expansion opportunity borne out of the Obama administration’s Affordable Care Act.
How’d we get here?
That political clash was part of the game-changer behind the Medicaid transformation launch. In November, 75 days before the state was set to abandon its fee-for-service Medicaid model and essentially turn the management of the $14 billion annual program to managed care companies that had been awarded contracts, the state secretary of Health and Human Services put on the brakes. Mandy Cohen, appointed by Cooper, said there just were not enough funds in the department’s budget to move forward.
Last year, before the General Assembly adjourned its session, Republican lawmakers assembled enough votes to pass one in a series of mini-budgets that would have released $502 million for the transformation project.
But Cooper vetoed that plan, saying he had hoped that lawmakers would have entertained a broader discussion about health care in North Carolina that also included Medicaid expansion.
Dave Richard, the deputy secretary for NC Medicaid, and Jay Ludlam, the assistant secretary for Medicaid and a key shepherd of the transformation project, told the Joint Legislative Oversight Committee on Tuesday, that planned budget cuts would throw a wrench in further plans for transformation. They mentioned $40 million in cuts that lawmakers had included in their overall spending plan as well as a proposal to move DHHS headquarters out of Wake County to Granville County.
The “mini-budget” resolved some of those issues, but DHHS leaders worried it failed to protect the department from the cuts had Republican lawmakers managed to find the votes to override Cooper’s veto of the full state budget.
The administrators also outlined work that continued on the transformation project even though it is uncertain whether a new launch date will be in two years, as several lawmakers speculated. It could be sooner if a compromise can be reached between the governor and state Senate and House leaders in an election year.
“I think it’s really important that we talk about what it is that a budget means to us,” Richard said. “There’s really not a chance for us to go forward with managed care if those cuts continue.
“I want to say that I know that your conversations with the governor and others continue to be much broader than that. So the right budget means not just the Medicaid part, but it means some of these other items that we will be talking about,” he said. “I hope personally, when y’all come back in April that there’s a chance to get that right budget moving forward.”
If that funding were to come, there still would be much to do to get the transformation to managed care systems flowing again.
Data would have to be refreshed.
Personnel at some of the managed care systems and other organizations involved in the planned launch have changed and the new people on board would have to be brought up to speed.
The state would have to update the waiver proposal that went to the federal government to allow for such a switch and then wait for the wheels of bureaucracy there to churn at whatever pace is set.
“None of us are pleased about the position where we are today,” Richard said. “What we’ve tried to do is do the things we can without spending money.”
Teeming with questions
Sen. Ralph Hise, a Spruce Pine Republican, again asked a question raised in November about whether suspending the transformation was legal.
Richard dodged that question, acknowledging that he was not a lawyer but that the department’s legal team had looked it over and opined that the authority to do so was there.
Hise also asked how the department prioritized what it decided to dial back on, given the funding shortages. Richard and Ludlow explained that the priorities funded were either already up and running or further along in the implementation process than the transition to managed care.
Other lawmakers raised questions about whether managed care companies that had been awarded contracts might have a claim against the state.
The state administrators told the lawmakers that the department had maintained close contact with the contractors and none had tried to jump ship yet.
The meeting ended after an hour and a half of discussion, with DHHS administrators agreeing to develop reports that attempted to address the cost of the indefinite stall on transformation as well as other data and analysis sought.
In closing, Lambeth sent the lawmakers and day’s speakers out into the world again with his reference to last weekend’s college basketball game when Duke topped UNC 98 to 96 in a nail-biter, in which the Tar Heels, with a 13-point lead, looked as if they might be cruising to a victorious conclusion.
“Well we need to put our uniforms on and get back out there and get going again, “ Lambeth said.
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If we’re going to use the basketball analogy, and people need to understand that players all have a role on the team whether you are a one or two guard or a stretch for, each player has a role to play on the team in order to run an efficient offense and a formidable defense. There needs to be a floor captain on the court in order to have a cohesive unit of five people playing as a singular unit. The problem is everyone is voting based on party lines and there is no one to take the lead does nothing gets done in terms of the budget. They had open enrollment start before physicians had time to contract with the five companies. Without a floor leader in order to have a clear-cut vision of the Medicaid transformation, how can anyone rollout a very complicated overall to the Medicaid system without anyone taking the lead? This is a very poor analogy.
The budget contains an additional 1,500 Innovations Waiver slots for individuals with intellectual and developmental disabilities. Each time this budget gets veto’d, 1,500 people have to continue living without the vitals services that make independence a reality for those people. The Governor is so hyper-focused on Medicaid Expansion because the election is in November and that sucks for those 1,500 individuals that could have already been utilizing those services. But those 1,500 votes don’t count as much as 550,000 low income adults. At least that’s how it seems to me. Just to put things in perspective, there are currently OVER 10,000 individuals on waiting lists for Innovations Waiver services. 1,500 isn’t going to solve all the problems for people in this community, but 15% is at least a start in the right direction.