When the Affordable Care Act was passed, it included an option for states to expand Medicaid coverage to adults with incomes up to 133 percent of the federal poverty level, starting in January 2104. To date, 39 states have adopted the expansion, which calls for the federal government to pay 90 percent costs for registering new recipients, while the states are responsible for the other 10 percent.
North Carolina initially debated the expansion and decided not to participate for several reasons. The biggest one was that there was no guarantee that the 90 percent matchup would be permanent and that North Carolina would eventually have to recoup those costs. Also, legislators were concerned about the administration of Medicaid in North Carolina and wanted reforms, which they passed. So nothing happened. Roy Cooper made it a cornerstone of his 2016 gubernatorial campaign and has been galvanizing our legislators ever since.
More and more states, both red and blue, have decided to expand Medicaid, but our legislature has not budged. Why? Our lawmakers didn’t seem to care about people who couldn’t afford health insurance. Other states were signing on to the expansion, so why did North Carolina refuse to consider it? Then it dawned on me. It was political. The 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 confirm Obama.
Political polls have consistently shown that people support enlargement. A December 2022 poll found 78 percent supported expansion; as many as 64 percent of Republicans agreed. Hospitals across our state have agreed to provide the other 10 percent of costs, meaning Medicaid expansion would not cost North Carolina taxpayers a cent. Hospitals have admitted that people without health insurance show up in their emergency rooms to treat anything and everything. The emergency room is the most expensive of all treatments and hospitals have realized that it will save them money if more people have health insurance and go to the doctor regularly.
Finally, in 2021 (after more than half the states have used federal dollars to help poor people) there is a crack in the iceberg. Legislative leaders finally recognized the inevitability of Medicaid expansion. Each house of the legislature had a separate approach. One would expand Medicaid, but the state would in turn repeal certificate-of-need laws, which hospitals would not accept. Another chamber would expand Medicaid with a provision to expand the scope of practice for nurse practitioners and physician assistants, allowing them to have more authority to perform certain procedures. But the doctors would not agree with that idea. They argued back and forth, back and forth, refusing to just pass clean bill Medicaid expansion.
All the while, North Carolina lost an estimated $8 billion a year in federal funding — money that would improve the health of many and prevent them from clogging up our emergency services. You had to believe that if the House and Senate really wanted to expand Medicaid, they could fix the problem.
Finally, at the beginning of March, the deadlock was broken. Credit to Senate President Pro Tem Phil Berger for making it happen. Certificates of need laws would be amended. Expanding the scope of practice was not included, however, this is expected to be addressed later in the session.
There was widespread rejoicing. Finally, our legislature did the right thing and provided health insurance to 600,000 citizens who earn less than the federal poverty level. And hospitals will pay 10 percent in North Carolina, meaning state taxpayers won’t be on the hook for more money.
But before you get out the balloons, ribbons and celebratory cake, you need to hear what the late Paul Harvey said was “the rest of the story.” The measure lawmakers were considering is not a pure stand-alone law. There are caveats. The Medicaid expansion will be included in the budget draft, which must be passed by June 30. If the budget is not approved by that date, the whole problem of enlargement is dead.
Once again, our MPs are playing politics with people’s health. They are setting up Governor Cooper for a “truth or dare” scenario. You can be sure that the budget bill that comes across Cooper’s desk will contain many of their conservative agendas. It could be abortion reform, maybe more tax cuts, further cuts to executive powers… maybe all of the above or more.
Governor Cooper will face the real conundrum of signing a budget bill that contains many undesirable features, things that really shouldn’t be included in a document that is primarily about numbers. If he finds the budget harmful and vetoes it, he will shut down his signature campaign issue.
Furthermore, there are enough votes in the Senate to override that veto, and the House will only need one Democrat to join the override. Anyway, Governor Cooper is being installed. It’s party politics again.
I’d like to think I’m wrong and that our legislative leaders have good motives to help those less fortunate, but they call me a Doubting Thomas.
Tom Campbell is a North Carolina Hall of Fame broadcaster and columnist who has covered North Carolina public policy issues since 1965. He recently retired from writing, producing and hosting the half-hour NC SPIN TV program that aired for 22 1/2 years across the state. Contact him at email@example.com.