What took us so long?

Published March 16, 2023

By Tom Campbell

When the Affordable Care Act was passed it contained an option for states to extend Medicaid coverage to adults with an income up to 133 percent of the federal poverty level, beginning in January 2104. To date 39 states have adopted the expansion, which provides for the federal government to pay 90 percent of the costs to enroll new recipients, with the states responsible for the other 10 percent.

North Carolina debated the expansion initially and determined not to participate for several reasons. The biggest was there was no guarantee that the 90 percent match would be permanent and North Carolina might have to eventually pick up those costs. Also, lawmakers were concerned about North Carolina’s administration of Medicaid and wanted reforms, which they passed. So, nothing happened. Roy Cooper made it a cornerstone issue in his gubernatorial campaign in 2016 and has been prodding our lawmakers ever since.

More and more states, both red and blue, decided to expand Medicaid, but our legislature wouldn’t budge. Why? It appeared our lawmakers didn’t care about people who couldn’t afford health insurance. Other states were signing on to expansion, so why did North Carolina refuse to consider it? Then it dawned on me. It was political. Medicaid expansion had Barack Obama’s fingerprints all over it and North Carolina’s Republican leaders in the legislature didn’t want to do anything that might validate Obama.

Political polls have consistently shown that people support the expansion. A December 2022 poll indicated 78 percent favored expansion; even 64 percent of Republicans agreed. Hospitals across our state agreed to furnish the other 10 percent of the cost, meaning Medicaid expansion wouldn’t cost North Carolina taxpayers an additional cent. Hospitals acknowledged that people without health insurance show up in their emergency rooms for treatment of any and everything. ER service is the most expensive of most any treatment and hospitals realized it would save them money for more people to have health insurance and see regular docs.

Finally, in 2021, (after more than half the states had taken advantage of the federal dollars to help poor people) there was a crack in the iceberg. Legislative leaders finally recognized the inevitability of Medicaid expansion. Each house of the legislature had separate approaches. One would expand Medicaid, but in turn the state would revoke certificate of need laws, a provision hospitals wouldn’t accept. Another chamber would expand Medicaid with the provision that the scope of practice for nurse practitioners and physician assistants be expanded, allowing them to have more authority to perform certain procedures. But doctors wouldn’t agree to that notion. Back and forth, back and forth they argued, refusing to just pass a clean Medicaid expansion bill.

All the while, North Carolina was losing an estimated $8 billion a year in federal funding – money that would have improved the health of many and kept them from clogging up our emergency rooms.  You had to believe that if the House and Senate were really desirous of expanding Medicaid, they could have resolved the issue.

Finally, in early March the stalemate was breached. Credit Senate President Pro Tem Phil Berger for making it happen. Certificate of Need laws would be modified. No scope of practice expansion was included, however that is expected to be tackled later in the session.

There was widespread rejoicing. At last, our legislature was doing the right thing and would provide health insurance to 600,000 citizens earning less than the federal poverty level. And hospitals will pay North Carolina’s 10 percent match, meaning state taxpayers won’t be on the hook for any more money.

But before you get out the balloons, streamers and celebration cake you need to hear what the late Paul Harvey said is “the rest of the story.” The measure lawmakers considered isn’t a clean stand-alone bill. There are caveats. Medicaid expansion will be included in the budget bill that needs passing by June 30th. If a budget isn’t approved by that date the whole expansion issue is dead.

Once again, our lawmakers are playing politics with people’s health. They are setting Governor Cooper up for a “truth or dare” scenario. You can be sure the budget bill that lands on Cooper’s desk will contain lots of their conservative agenda. It might be abortion reform, perhaps more tax cuts, further reductions to executive powers…perhaps all of the above or more.

Governor Cooper will be faced with the real conundrum of signing a budget bill that contains many undesirable features, things that really shouldn’t be included in a document that deals primarily with numbers. If he finds the budget noxious and vetoes it, he will have killed his signature campaign issue.

Further, there are enough votes in the Senate or overturn that veto and the House will only need one Democrat to join the override vote. Either way Governor Cooper is being set up. It’s partisan politics again.

I would like to think I’m wrong and that our legislative leaders have good motives to help those less fortunate but call me a doubting Thomas.

Stay tuned.