By Rose Hoban

On Wednesday morning, a group of advocates who’ve been working to persuade the General Assembly to expand the state’s Medicaid program started their day with a prayer service. 

By the end of the day, they seemed closer to having their prayers answered.

After weeks of telling reporters that consideration of closing this health insurance coverage gap would be too heavy a lift for the end of this year’s legislative work session, House of Representatives Speaker Tim Moore (R-Kings Mountain) presented a plan from his chamber to counter the one presented in the Senate several weeks ago

Moore told reporters on Wednesday evening that he had been wanting to “crunch the numbers” on an alternate proposal. 

“I wanted to make sure we didn’t do anything that would be a disincentive to folks going to work that would encourage someone who was otherwise able-bodied, to try to avoid work and supporting themselves over something,” he said. 

The proposal from the House Speaker would create a path to provide health care coverage for 500,000 to 600,000 low-income North Carolinians who make too much to qualify for Medicaid but too little to qualify for insurance subsidies provided under the Affordable Care Act. 

But not right away. 

The bill creates yet another study group, the Legislative Medicaid Rate Modernization and Savings Oversight Committee, to examine Medicaid expansion. 

This comes a scant two months after the last meeting of a different Medicaid study committee that met through the winter and spring. It also authorizes the state Department of Health and Human Services to negotiate with federal regulators on details of the expansion.

Then the bill calls for legislators to come back to Raleigh in December — after this fall’s election — for the actual vote approving the changes to the Medicaid program.

Skeptics on the right

On Wednesday evening, North Carolina Senate leader Phil Berger (R-Eden) expressed initial skepticism of Moore’s proposal. 

“So, the House has gone from ‘No,’ to ‘Let’s study it again,’” he said in a statement emailed to reporters. “Remember, we authorized a study in last year’s budget. It is past time for action. The House should pass the Senate version of House Bill 149, or we should agree to incorporate it into the budget.”

House Bill 149, the Expanding Access to Healthcare bill, came out of the Senate in early June and includes that chamber’s version of Medicaid expansion. 

When arguing for the bill on the Senate floor, Berger expressed full-throated support for the policy. “This is the right thing to do, and it’s not even close,” he said. 

The Senate’s version also includes a laundry list of proposals that Berger said enhanced the state’s ability to expand the program by addressing health care workforce shortages and the supply of hospital resources. But that bill also had items for many health care actors to hate: hospitals didn’t want the changes to the state’s certificate of need laws and physicians were unhappy with provisions that would give more independence for advanced practice nurses.

Moore’s bill lacks the pain for physicians and hospitals contained in the Senate bill. 

Both bills include changes to hospital financing that would amend how the federal government pays for hospital care for low-income patients, providing a higher pay rate to hospitals. 

But while Moore’s bill gives to hospitals, it also takes away. 

Hospitals would find themselves facing a new tax, leaving them to foot the state share of the cost for these new Medicaid beneficiaries, about 10 percent of the cost for their coverage. 

Usually, federal dollars only pay about two-thirds of the cost for care with state taxpayers picking up the rest. Under the Affordable Care Act, the federal government would pay 90 percent of the tab for those people who receive Medicaid under an expansion plan.

“The hospitals are fine to pay that because they’re going to get 90 percent of something instead of zero,” Moore said, noting that hospitals often end up picking up the tab when uninsured patients show up at their doors. 

Pathway to work for new beneficiaries

Medicaid expansion bills previously proposed by a small group of House Republicans in 2017 and again in 2019 both contained work requirements, and legislative leadership said the only way they would consider expansion would be to have such a work mandate. 

But courts and federal regulators have consistently struck down work requirements created by other states that have sought to impose them as part of their Medicaid expansion plans.  

Part of this new House proposal would create a program similar to one created in Montana which has been helping out-of-work adults eligible for expansion coverage find work by creating a job services program that connects the new Medicaid enrollees with workforce training, employment services, and job openings.

The program outlined in the House’s new bill would create the “Seamless Statewide Plan,” a  workforce development program that would combine other existing programs in the state to get job training, placement, resources and support for people who are out of work. 

On Thursday morning, Moore admitted some members of his Republican caucus are not yet ready to vote for the measure. Meanwhile, some Democrats have expressed frustration that this bill kicks the can down the road yet again.

“I don’t put bills on the floor that don’t pass,” Moore told reporters after a House Health Committee meeting where no vote was taken on the bill.

“I feel solid in the House, but you know, we’ll get a vote count on that,” he said.

Prayers and more

Erica Palmer Smith heads the Care4Carolina coalition that hosted Wednesday morning’s prayer event. She could hardly contain her excitement at Wednesday evening’s news. 

“We have been seeing the answer to all of these prayers over the last few weeks, as we have seen, first the Senate and now the House, push forward plans to close the coverage gap in North Carolina,” she said. 

Palmer Smith is likely getting some help from Washington with those prayers. 

President Joe Biden has made it a priority to get the last dozen states that have not expanded to adopt the policy. To answer those prayers, his administration has been dangling a hefty incentive of a one-time infusion of $1.5 billion in federal dollars that could be used for, essentially, anything. 

Both Berger and Moore note this time-limited offer as part of the reason they’ve opened the door to expansion at this moment.

Moore proposes that a billion of those dollars be used to address the state’s need for mental health services and treatment for substance use disorders. 

“I don’t even know if that’s enough money, but that’s pretty significant,” he said. “There’s not been that amount of money appropriated for that, that I’m aware of, really, anywhere. 

“We have to get a handle on that.”

DHHS Sec. Kody Kinsley told NC Health News in early June that there’s an expiration date on that money. 

“Right now, the money that is earmarked for North Carolina is nothing more than, you know, some print on a piece of paper,” he said. “It would not be hard for Congress to take that off the table.

“We cannot wait.” 

This story has been updated to add the timeline for the bill.

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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...

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