Since the Affordable Care Act became law in 2010, states have had the choice to extend Medicaid coverage to most nonelderly adults. Three-quarters of the states plus the District of Columbia have adopted the Medicaid expansion, while 12 have not. That may be changing in North Carolina.
Specifically, the debate over expanding Medicaid, the nation’s public health insurance program for people with low income, is evolving. Nationally, the Medicaid program covers 1 in 5 people, including many with complex and costly needs for care.
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North Carolina’s budding political and policy transformation stems from years of fruitless negotiations between the Republican-led state House and Senate and Democratic Gov. Roy Cooper over how to expand healthcare without raising taxes or lowering the quality of care for residents.
And if put into law, the compromise could set an example for the other states that have refused Medicaid expansion under the ACA, former President Barack Obama’s signature domestic achievement during his eight years in the White House. The model could quell concerns over state Medicaid expansion that the fiscal cost is too high. That’s become a familiar refrain in the remaining holdout states, along with North Carolina — Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming.
In North Carolina this summer, the state’s House and Senate passed separate bills on Medicaid expansion, though a sticking point remains over the state Senate’s proposal including a provision for the scaling back of “certificate of need” laws.
CON is a regulatory process to approve or deny the establishment or expansion of various healthcare facilities and services. The laws were created to control cost, protect quality, and avoid unnecessary “duplication of services” in healthcare. For example, with such a law, hospitals cannot add beds or open more rooms without the CON board’s approval.
CON critics reject the regulatory process’s legitimacy. North Carolina’s CON laws are some of the most restrictive in the nation and disproportionately affect rural health services.
Taking this point of view, in 2017, state Senate President Pro Tempore Phil Berger and state House Speaker Tim Moore filed a federal lawsuit against Cooper for his attempt to expand Medicaid without legislative approval.
But today, Berger is open to expansion. What changed was a Sept. 16 proposal for Medicaid reform to the legislature and governor by the North Carolina Healthcare Association.
NCHA suggested repealing CON laws for psychiatric inpatient and chemical dependency beds in exchange for Medicaid expansion. NCHA has long supported Medicaid expansion but has historically pushed back on CON reform. It represents over 130 hospitals, physician organizations, and other healthcare systems in North Carolina.
“In an effort to get stalled negotiations moving, and in response to Senator Berger’s and Governor Cooper’s requirement that Medicaid expansion be coupled with certificate of need reform, our board of trustees has made the difficult decision to propose certificate of need law reforms,” said the release from NCHA.
“CON law changes could threaten the survival of community hospitals if they are not implemented carefully. We are putting a lot of trust in legislative leaders to do this correctly.”
If the compromise is enacted, the expansion will increase Medicaid coverage to 600,000 North Carolinians. In North Carolina, currently, eligibility for Medicaid is based on income level, and recipients must also be pregnant, 65 or older, responsible for a child, have a disability, or care for someone with a disability. In comparison, the expansion would allow people to qualify solely on income.
The John Locke Foundation, a free market think tank in North Carolina, opposes Medicaid expansion.
“For years, most state senators have rightfully recognized that Medicaid expansion is bad medicine for North Carolina,” said Locke Chief Executive Officer Amy O. Cooke.
“The Senate’s Medicaid expansion bill includes some positive supply-side reforms, such as scaling back certificate-of-need restrictions and granting nurses full practice authority,” Cooke said. “We should exhaust those avenues before ceding control of North Carolinians’ health care to Washington, D.C.”
However, a letter written to leaders of the state from the secretary of the North Carolina Department of Health and Human Services, Kody Kinsley, shares an opposing view in support of expansion. Failing to act, Kinsley wrote, “will have significant health and financial consequences.”
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Kinsley cited the billions lost in federal tax dollars that have flowed to states with expanded Medicaid programs since 2009.
“We are ready to move forward with this opportunity to save lives, save rural hospitals, support mental health and bring at least $8 billion per year to North Carolina.”
