Medicaid expansion in N.C. comes off the bench – Kirk Ross

Kirk Ross
Kirk Ross

Last week over the course of 48 hours about 200 bills were filed in the N.C. House of Representatives.

They join the dozens of others filed each day in the week prior as part of the final legislative sprint ahead of this session’s bill filing deadline.

The House bill count stands at 857. Though less populous the Senate has managed to file 657. I have not read every one of them, but have it on good authority that some will become law.

In a flurry like last week it’s hard not to be distracted by the bright shiny objects of General Assembly, even for those of us who preach restraint at such times. You probably heard reports about some of the more outrageous pieces of legislation. With so many eyes on this state there was certainly enough in the batch of filings to reinforce notions held round the world that several of the honorables now gathered in Raleigh reside comfortably outside the mainstream and at least one or two in the 19th century.

While it is difficult even for this old dog not to chase a squirrel every now and again, I’d rather draw your attention to one of the more rational items on the list.

As the legislature was wrapping up for a long Easter weekend, a break came in the long-running public policy disputes over how to increase Medicaid eligibility in North Carolina with the introduction by a group of GOP House members of a bill that would greatly increase Medicaid eligibility.

Since the passage of the Affordable Care Act the state has refused to buy into Medicaid expansion, one of the biggest carrots in the ACA, with most of the cost covered by the feds.

The arguments against expansion have been philosophical and ideological. The arguments for have been about sound fiscal and public health policy. So far, the ideologues have the upper hand, but there are signs that their more pragmatic collegues are starting to win out.

The recent failure of the hastily drawn up ACA repeal and replace plan fueled a push in the 19 holdout states, of which North Carolina is one of the largest.

The handful of House Republicans pushing the new legislation have billed the plan as uniquely tailored for the state and countered arguments about creating another handout by adding a work and job training requirement, a nominal annual premium and rules that recipients must schedule regular preventive care.

An estimate of the plan’s impact by the North Carolina Institute of Medicine says about 375,000 people could become insured. Locally, that would mean about 7,000 people in Orange County and 3,000 in Chatham County.

Also in the pragmatists’ favor is the reality that federal funding is not just a carrot under the ACA, but also a stick.

Next year, federal payments to hospitals for uncompensated care are due to sunset. North Carolina medical centers currently receive $320 million in federal reimbursements. While a large chunk of that goes to UNC Hospitals and the state’s other major hospitals, it is also a key source of funding for rural hospitals. That’s put a lot of pressure on legislators from rural districts where the hospitals and medical centers are also among the largest employers. Many are already under pressure and could be put out of business once the reimbursements end.

That’s given proponents a strong economic case in addition to the argument that growth in Medicaid rolls will translate to growth in health-care-industry employment as newly insured patients come into the system.

It’s unclear for now whether the current General Assembly leadership will allow any bill that greatly increases Medicaid eligibility to move forward. To some, it would be a capitulation and a stunning reversal to what they expected to see in the first 100 days of the Trump administration.

But they may have no choice.

Rather than destroy it, the failed effort against the Affordable Care Act helped to highlight not only its benefits, but the peril that awaits any politician attempting to undo a popular entitlement program once it’s entrenched.

Kirk Ross is a longtime North Carolina journalist, musician and public-policy enthusiast. Contact him at kmr@rossalmanac.com