No state budget means no Medicaid expansion this fall

The failure of North Carolina’s legislature to finalize the state budget is profoundly affecting one of the most notable accomplishments of the 2023 session. The NC Department of Health and Human Services now says Medicaid expansion will not launch Oct. 1 as they had fervently hoped.

While a bipartisan majority of legislators passed expansion (HB 76/Access to Healthcare Options) in March with much fanfare, Republicans tied formal expansion and enrollment to passage of the state budget. Eight weeks into the start of the new fiscal year, the budget appears to be an afterthought.

Legislators are meeting in skeletal session this week, with budget negotiations focused on casino expansion not Medicaid expansion.

NCDHHS Secretary Kody Kinsley discussed the delay in an extended interview with NC Newsline.

“I think it is a shame that the current delays are causing us to lose hundreds of millions of dollars a month that could be coming into our healthcare system in this state,” said Kinsley.

“And because of some amazing work of our team, we’re going to be able to put 300,000 people on expansion Day One. Every month we delay, that’s a month that they go without access to primary care, access to the medications.”

Kinsley said the state’s delay is troubling for those struggling with diabetes, heart disease or other chronic conditions that have relatively low-cost interventions from the primary care perspective.

“But if you were to delay that and end up in, you know, a major catastrophic event, a stroke, a heart attack, a major disruption with your diabetes, the remedy of that tragic care in the emergency department in the hospital are so much more expensive. And guess who foots the bill? We all do.”

When it became apparent that the General Assembly would miss its deadline of passing a budget by June 30, he began working overtime to encourage lawmakers to decouple the Medicaid expansion provision from the budget.

“I struggle to find anybody who’s against [expansion] nowadays, and they were confident that we’re going to have the budget done in June. And now June is now August and maybe September and we’ve got to get it done,” he said.

The DHHS Secretary said his team has spent every day, including nights and weekends, trying to engineer the best approach to get resources to uninsured North Carolinians as soon as possible.

“But yeah, if this budget slides into September or later, we’re looking more like Dec. 1, or perhaps well into 2024,” Kinsley told Newsline.

Work is continuing behind the scenes with county and community partners to ensure they can implement Medicaid expansion as soon as possible.

But Kinsley acknowledges the delay is further straining providers who are gearing up to serve people who would be newly eligible. People in rural towns are three to four times as likely to be uninsured.

Earlier this month, Martin General Hospital announced it was filing for bankruptcy and closing its doors. For Williamston residents the closure means a trip to the emergency room will be 22 miles longer; the nearest emergency room is at ECU Health Beaufort in Washington, North Carolina.

Kinsley said the closure of Martin General is harsh reminder for rural hospitals and providers trying to operate a viable business.

A new report by the Georgetown University Center for Children and Families found that in states that have yet to expand Medicaid, the median income level for parents was about 35% of the federal poverty level, roughly $8,700 annually for a single adult in 2023.

In practical terms, that means a rural medical practice or hospital could survive for a while by adjusting the price upward that everyone pays.

“But eventually that stretches and stretches and stretches, and you just can’t afford to stay in business,” Kinsley cautioned.

Even more worrisome than rural residents driving further to seek care is the prospect they may delay care altogether.

“We were talking to a healthcare provider who was saying, people are just showing up in an active state of a heart attack because they have delayed all of the signs for the last several weeks,” Kinsley recounted. “Now here we are. That’s not the place to be for emergent care.”

On Monday, NCDHHS announced that after missing their hopeful target of Oct. 1 for Medicaid expansion, the agency would not issue a new launch date until the final authority and guidance is provided by the General Assembly.