By Rose Hoban
Large majorities of voters in North Carolina favor the state adopting a policy that would get access to health insurance to more low-income workers, according to a new poll released Wednesday morning.
The poll, sponsored by Care4Carolina, an advocacy group pushing for the General Assembly to pass Medicaid expansion, found three-quarters of North Carolinians favored the policy, which was made possible through the Affordable Care Act.
Majorities of Republicans and Democrats supported the policy, even after hearing arguments against it from the pollsters.
Usually, Medicaid primarily covers low-income children, some of their parents, people with disabilities and poor seniors, with the federal government paying about 66 percent of the cost for every dollar spent in North Carolina. The expansion policy would sweep in hundreds of thousands of low-income people, many of them workers, with the federal government picking up 90 percent of the tab. Under proposals that have been floated in the General Assembly over the past few years, large providers such as hospitals would pick up some of the remaining 10 percent of the cost for care, with new assessments on insurance companies covering the rest.
But leaders in the General Assembly, particularly in the state senate, have staunchly opposed the move since it was first available to states in 2013. At this point, 38 states and the District of Columbia have chosen to expand the program. The policy became one of two flashpoints in a protracted political battle over the state budget last year, which led to a prolonged standoff between the legislature and Gov. Roy Cooper, who refused to sign the state budget without expansion included.
“There are a number of reasons that Medicaid expansion is not the right answer for North Carolina,” said senate leader Phil Berger (R-Eden) at a press conference last week when asked about the policy.
“This is not the time for us to take on a new program with the expense of the new program all at a time when we are just now trying to get the Department of Health and Human Services not only to deal with coronavirus, but to deal with a major shift in how we deal with our current Medicaid population,” he said, referring to a separate Medicaid policy to transform the program from one run by the state to one run by insurance companies.
Lawmakers have mandated that DHHS move forward with that transformation to managed care with a deadline of next summer.
“Now is not the time, it is not the right policy, in my view,” he continued. “I certainly understand and some folks who have been agitating, advocating for expansion a long time would continue to see this crisis as an opportunity to move forward with something that’s been rejected multiple times.”
The poll, conducted over two days in late August by Harper Polling, found that nearly two-thirds of state residents had a favorable impression of the Medicaid program, including a slim majority of Republican respondents. More strikingly, majorities of respondents of every political stripe supported expansion, with 60 percent of those identifying as “very conservative” along with 89 percent of those who identified as “liberal.”
Before the pandemic, advocates, along with DHHS leaders estimated that somewhere between 400,000 and 500,000 uninsured North Carolinians would qualify for the program. But with mass job losses created by the COVID-19 pandemic, Care4Carolina estimates that as many as 178,000 additional low-income workers might qualify.
Currently, it’s essentially impossible for a childless adult to qualify for Medicaid unless they have a disability, and a non-disabled parent with one child looking to get onto Medicaid would need to earn less than about $5,200 each year.
Expansion would open up eligibility to workers – with and without children – earning between 100 percent of the federal poverty level ($17,240 for a family of two) and 138 percent of the federal poverty level ($23,791 for the same household). Above that income level, people qualify for subsidies on the Affordable Care Act (Obamacare) marketplace, and people earning just a little bit more than the threshold are eligible for enough subsidy to cover almost the entire cost of insurance.
Legislators have made multiple arguments against expansion, including the contention that Congress might remove the generous federal match to support the expansion population. Despite this and other negative messages presented to people being polled, majorities across all demographics continued to support the policy.
Doing well fiscally
Since the start of the pandemic, two Republican-led states have made moves to enact expansion: Voters in Oklahoma chose to expand in a statewide referendum in July; Similarly, Missouri voters opted for expansion in an August referendum in that state.
States that have expanded the program have done well fiscally, noted Robin Rudowitz who leads a research program on Medicaid and the uninsured for the Kaiser Family Foundation. In a literature review she and her team update almost annually, they reviewed more than 400 studies on health outcomes, the costs of insurance, provider reimbursement and the effect on state budgets of expansion.
“By and large, states that expanded experienced net fiscal benefits related to expansion,” she said. “That was tied to increased economic activity, additional federal dollars coming into the state for providers. In that economics bucket, there were reductions in uncompensated care and additional, you know, revenues from Medicaid.”
The research also finds that insurance rates remain more steady in states that have expanded.
COVID a wildcard
One of the biggest effects, during the pandemic, is people in expansion states are more likely to have insurance coverage, Rudowitz said.
“More people have coverage, and then as people lose jobs related to the economic effect, more people will have coverage options in expansion states,” she said.
Matt Salo from the National Association of Medicaid Directors said that it’s still too early to tell what the effects of the pandemic will be on expansion states versus non-expansion states. He said that economic signal is only now coming into view.
Medicaid is what’s known as a countercyclical program, meaning that when the economy flags, enrollment climbs, and with it, costs.
“We would have expected to see a much, much higher rate of growth in terms of Medicaid enrollment and spending. And we haven’t seen that to that degree yet,” he said. “The Medicaid expenditure data isn’t as robust. It isn’t telling us as clear a picture as we would have thought.”
But he did say that one strain of thinking around the fact that enrollment hasn’t spiked the way it did during the Great Recession in 2008-2009 is that most states have already expanded.
“A lot of the people who were kind of low-ish income, going to zero income they were already on Medicaid,” he said. “And going from 120 percent of poverty to going to 50 percent of poverty, this is no change, they’re still on Medicaid.”
The only change is that the federal government is picking up more of the tab for those expansion enrollees, making it cheaper for the states.
Rudowitz also said it’s too early to tell how the pandemic might affect finances related to Medicaid expansion. Many states are experiencing budget shortfalls related to slowed economic activity and business closures during lockdowns. She reiterated that many states that expanded have accrued financial benefits from doing so and that their cost for care will be less than covering uninsured people.
“It’s just where those costs show up, either in the Medicaid program, or it might be individuals paying out of pocket or providers bearing costs for individuals that can’t pay,” she said.
It could also show up in state subsidies to hospitals that have been clobbered with high numbers of uninsured patients with COVID-19.
In March, the General Assembly sent about $95 million to bolster the bottom lines of hospitals to weather the pandemic. That’s in addition to tens of millions of federal dollars that came for hospitals through the federal CARES Act and an additional $20 million appropriated last month to cover facilities who treated large numbers of uninsured.
“With the studies, pre-pandemic, we did see that some of those costs were states where paying for uncompensated care costs, and other indigent care and other programs, some of that was able to be offset by additional funding through the Medicaid expansion,” she said.