Yet another attempt to expand Medicaid in NC

Linda Rider

By Anne Blythe

For all those waiting with bated breath to find out whether Medicaid will be expanded to nearly 600,000 more North Carolinians, take a pause.

Republicans in the state House of Representatives are not ready to embrace the policy whole hog. Instead, there will be one more study and more planning, while the lawmakers campaign for elections in November.

The proposal to create a legislative committee with members from both chambers that will hear a Medicaid Modernization Plan to be developed by the state Department of Health and Human Services comes out of negotiations between state House and Senate leaders over a spending plan for the coming fiscal year. This committee would come on the heels of a different study committee that met six times from February to April this year. 

The new way forward toward embracing Medicaid expansion, according to SB 408, should:

  • Add Medicaid coverage for adults with annual incomes up to 133 percent of the federal poverty level, or slightly more than $17,000 in earnings for an individual.
  • Increase what hospitals pay for the expanded health care coverage. This means that hospitals will foot the bill for whatever share of the tab is not being picked up by the federal government.
  • Invest $1 billion in programs and treatment for the opioid, mental health and substance use crisis.
  • Include recommendations for increasing access to health care in rural areas.
  • Direct the secretary of commerce to collaborate with others to address the health care workforce shortage, amid predictions of worsening patient-to-caregiver ratios.
  • If the secretary of the state Department of Health and Human Services comes back from negotiations with federal regulators with a plan that the General Assembly is happy with, lawmakers have said they’d return to Raleigh no later than Dec. 15 to have the actual, final vote on the plan.

“In December, should this go into law, there will be a vote,” Tim Moore, the Republican from Kings Mountain who’s speaker of the state House of Representatives, told the House Rules committee on Tuesday. In the past, bills to expand Medicaid have made it through the House committee hearing process only to never reach a vote on that chamber’s floor.

This time, Moore says he’ll bring the bill to a vote in the House of Representatives.

“The bill will either pass or the bill will either fail,” he said Tuesday. “Those who wonder whether there is some kind of trick — there wouldn’t be a bill voted on — absolutely not. The bill will be voted on and it will either pass or fail at that time on its merits. Based on what people have told me where they are on it, if the plan meets that, I think it will pass.”

The call for further study comes after longtime advocates for Medicaid expansion have been on a rollercoaster ride, of sorts. First, they climbed the steep hill of winning over Senate leader Phil Berger (R-Eden), who stood in the way of the state Senate taking up the topic for close to a decade. That gave the advocates momentum until they hit another ascent after Rep. Donny Lambeth (R-Winston-Salem), who led a  Medicaid expansion study committee this spring, said many members of the House remained a tough sell.

“We’re not lukewarm in the House,” Lambeth told reporters in February after the first meeting of the Joint Legislative Committee on Access to Healthcare and Medicaid Expansion. “It is still rather chilly. It is a heavy lift to convince our House caucus that this is the right direction to go. Now is it impossible? No. I wouldn’t be here if I thought it was impossible.”

Roller coaster ride

At the start of this month, Medicaid expansion advocates thought they were getting ready for a downhill thrill ride when Berger, the longtime critic, introduced a health care omnibus bill that called for adding hundreds of thousands of low-income North Carolinians to the Medicaid rosters.

Berger’s proposal, which passed the state Senate with all but two votes, included several provisions that did not thrill hospitals and physicians. The Berger bill would change rules for how some health care facilities are regulated and give advanced practice nurses more autonomy from physicians that oversee them now.

Moore has said those provisions were difficult for some House members to endorse, and they were not part of the bill the full House passed Tuesday evening 102 to 4. The Senate had gone home for the night by the time the full vote happened around 7 p.m. It would need approval from the Senate to then move to the desk of Gov. Roy Cooper, a longtime expansion advocate.

Berger played it coy earlier Tuesday when asked about the prospects in his chamber for the newest Medicaid expansion bill proposal.

“Let’s see what the House passes and then we’ll figure out what the Senate’s response will be,” Berger said.

Moore, who was standing beside the Senate leader quipped: “We’re happy with that response. We’re going to send him a good product.”

Berger quipped back: “Not as good as ours.”

Preview of $27.9 billion spending plan

All of the back-and-forth between the House and the Senate over Medicaid expansion comes in the midst of the annual tussle over the state budget. While the General Assembly is dominated by Republicans in both the Senate and House of Representatives, each chamber has its own priorities and there’s always backroom dealing to see which will prevail in the final budget plan. 

Tuesday evening Moore and Berger spoke to reporters about their $27.9 billion spending plan for the fiscal year that begins on July 1.

Key parts of the plan:

  • Gives teachers pay raises of 4.2 percent, a number that includes raises already called for in the previous fiscal year.
  • Sets aside $1 billion for an “inflationary reserve” to help offset problems brought on by high gas prices and other problems from the current state of inflation.
  • Sets funds aside to expand the school resource officer program but did not commit to beefing up school counseling programs.
  • Dips into sales tax revenue to support transportation projects that have been underfunded.
  • It keeps $6 billion in revenue surplus, $2 billion of which will be recurring funds.
  • Sets aside funds for redeveloping legislative and administrative buildings, a Raleigh development plan that could further reshape the downtown.

Some of the health-related spending in the plan:

  • Provide $14.8 million for mental health resources;
  • Set aside $32 million for school safety projects;
  • Gives more support to the crisis helpline; and
  • Gives rural counties a better shot at school safety grants.

More will become clear about the budget as the budget is more fully explained on Wednesday at a Joint Appropriations Committee meeting. The lawmakers have said they plan to vote on the proposed budget by the end of this week.

“Medicaid expansion is not in the budget,” Berger acknowledged to a room full of reporters and TV crews.

The reason, Moore told his House members before the vote on Tuesday, was: “There are not the votes in this chamber right now to put an outright expansion on the floor.” 

Nonetheless, Moore was able to persuade all but four members of his chamber to take the only palatable path forward for skeptical Republican members of the House. One unwritten rule Moore has followed in the past has been to only bring legislation to the floor when a majority of his Republican caucus is in favor.

‘Not a trick’

Democrats, who have waited years to see progress from the Republicans on Medicaid expansion, voted for the bill that Moore shepherded through the House with hopes that it would not be the end of the discussion.

“This is not the bill I had hoped to vote on tonight,” said Gale Adcock, a Democrat from Cary and nurse practitioner. Adcock has been an advocate of giving nurses a broader scope of practice without the oversight of physicians, a proposal that often hits a roadblock among powerful health care lobbying groups.

“As we look at expanding access to health care we need to look at striking the balance of not just having the demand side addressed, but also the supply side,” she told the House.

Lambeth summed up his thoughts on the House Medicaid expansion bill by recounting a trip he and his wife took to Asheville recently. They took the backroads, a detour of sorts, that allowed them to see the beauty of parts of the state they might not otherwise have seen,

As Kinsley develops a plan to bring back to lawmakers, he will learn from the federal government and teams of lawyers if North Carolina can add a work requirement to the expansion rules, something that’s failed in every other state that’s proposed it. He can also figure out a parachute for the state to opt out if the federal government tries to cut back on its funding share of 90 percent for every new Medicaid expansion beneficiary.

“I kind of view this as we’re taking a little bit of a detour,” Lambeth said. “This gives us an opportunity to go down a path — we’re taking a little bit of a detour here — to get this right.”

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