RALEIGH — After a decade of vigorous opposition, most Republicans in North Carolina have now embraced the idea of expanding the state’s Medicaid program to cover hundreds of thousands more low-income adults. Legislative approval finally seems within reach.
During the General Assembly session that ended July 1, the GOP-controlled House and Senate passed separate, bipartisan measures by wide margins that would put the state on the path to Medicaid expansion. Some details remain to be worked out, but there is a real opportunity to find a compromise by the end of the year.
It’s a remarkable policy shift in North Carolina, one that’s sure to be analyzed in the dozen or so states that have yet to accept the federal government’s offer to cover people who earn too much to be covered by traditional Medicaid but too little to benefit from subsidized private insurance.
“If there is one person in the state of North Carolina who has spoken out against Medicaid expansion more than I have, I would like to meet that person,” Senate Leader Phil Berger said when he sought to explain his reversal during a press conference in May. “We need coverage in North Carolina for the working poor.”
The two chambers were unable to settle their differences before adjourning, and talks between legislative leaders and Democratic Gov. Roy Cooper – a longtime supporter of the expansion – have remained dormant since then, at an impasse over other health care reforms the senators are seeking. But Berger remains optimistic about ultimate success. “I think we’ll get there,” he recently told reporters.
“There’s a lot of work to do…but overall we feel extremely encouraged by how far we’ve come,” said Erica Palmer Smith, executive director of Care4Carolina, a coalition of 150 groups that has worked to expand since 2014. .
Other defenders are tired of waiting. They say too many working poor are uninsured, risking their health and their lives. Others on traditional Medicaid fear that without expansion they will no longer be covered if they make too much money.
“I don’t know what to do,” said Courtney Crudup, 32, of Oxford, a mother of three and currently unemployed cosmetologist. She spoke this week outside the Legislative Building at an event urging lawmakers to act. “Listen to our stories. Listen to regular people like me and people who want to work.”
The apparent change of heart follows years of GOP suspicion about the 2010 Affordable Care Act, which Republicans called “Obamacare” only to see the label, as well as the program, become very popular.
For years, Republicans have said they can’t trust Congress to deliver on the federal government’s promise to pay 90% of expansion costs. They said the state’s Medicaid program — which now has 2.7 million enrollees — had been overspending for years and ill-prepared to take on more.
And basically, they argued that more people would become dependent on the government if they were allowed to get Medicaid, which now primarily serves poor children and their parents and low-income seniors.
Republicans say Medicaid spending in North Carolina is now largely under control and they don’t think Congress will increase the state’s cost share beyond 10%. The state’s share — perhaps as much as $600 million a year — can be covered by assessments on hospitals and state insurance plans.
Interest also increased when the 2021 federal COVID-19 relief package offered a financial sweetener to encourage remaining states to accept the expansion. For North Carolina, whose tax coffers are already full thanks to a booming economy, that would be an additional $1.5 billion over two years.
“This is an opportunity to take federal dollars, actually introduce an economy to the state of North Carolina, and increase access to health care,” said House Speaker Tim Moore. , to his colleagues in June. “I would call it a really good trifecta for doing these things.”
Cooper can also take credit for his perseverance. He has pushed relentlessly for expansion since taking office in 2017, citing the economic boost federal money would bring to rural hospitals, communities and the families of the 600,000 residents who may qualify.
Cooper went so far as to veto the 2019 state budget because Moore and Berger would not engage in Medicaid talks. He signed this year’s, saying “we’re closer than ever to an agreement on expanding Medicaid” and that a veto “would be counterproductive.”
A pivotal moment came after the 2020 election, when Cooper convened a bipartisan commission of medical, business and nonprofit leaders and state lawmakers who proposed “guiding principles” to improve health care coverage.
“People with quite different political views were willing to listen to those who approach these issues from different backgrounds and different concerns,” said Mark McClellan, director of the Duke-Margolis Center for Health Policy at Duke University, who has convened the committee.
Another influencer was former Ohio Gov. John Kasich, who told a joint House-Senate committee in March how the expansion had worked in his Republican-leaning state. The committee focused on the details, including how to increase the number of nurses, hospital beds and services in the state.
Negotiations slowed this summer between the House, Senate and Cooper, largely because the Senate wants regulatory changes to provide even more access to services that it says will drive down costs.
These include giving nurse practitioners, certified nurse midwives and others the ability to work independently of doctors, and reducing “certificate of need” laws that critics say allow medical providers to limit competition that could lower their revenues.
Berger criticizes the hospitals for refusing to accept a compromise. The North Carolina Healthcare Association, representing hospitals and health systems, said it raised concerns about Berger’s bill but remains an advocate for the expansion.
“It’s positive that both chambers are now supporting the expansion, and right now hospitals hold the key to making that happen,” Cooper spokesman Ford Porter said.