June 25, 2022

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Medicaid

3 min read

By Rose Hoban and Rachel Crumpler

It finally happened.

In a move that many health care advocates have been pushing for years, the state Senate introduced a bill on Wednesday that would expand the state’s Medicaid program to some half million-plus low-income North Carolinians.

Until this point, Medicaid has been reserved mostly for children from low-income families along with a small number of parents in those families, poor seniors and people with disabilities. Since 2012, the possibility to sweep in many low-income workers has been on the table as a result of the Affordable Care Act, but Republican leaders in the state senate have been staunch opponents. 

Now, after years of saying no, powerful Republicans in the state Senate are saying yes.

“Why now? Why this? First, we need coverage in North Carolina for the working poor,” said state Senate leader Phil Berger (R-Eden), who admitted during a press conference Wednesday that he has likely been the most outspoken person in the state about his opposition to Medicaid expansion.

“Second, there is no fiscal risk to the state budget moving forward with this proposal,” Berger added, noting that the bill includes pay-fors that would have hospitals largely on the hook to pay the 10 percent of the costs for the expansion population not covered by an enhanced federal payment. There’s also a federal incentive that would total some $1.5 billion in extra funds that would flow to North Carolina over a two-year period.

Finally, he argued that since the state has moved Medicaid from being a state-run fee-for-service program to one managed by commercial insurance companies, the program has been “reformed and transformed.” 

“Medicaid expansion has now evolved to a point that it is good state fiscal policy,” Berger continued. “But again, I cannot emphasize this enough: Expanding Medicaid needs to happen with additional reforms.”

Those reforms could make the bill to be titled Expanding Access to Healthcare in North Carolina a hard pill for many to swallow. One aspect of the bill would set up a work requirement for the new beneficiaries, something that’s been repeatedly struck down in other states by federal judges. 

What really might jeopardize passage of the bill is that it contains provisions that already are raising hackles in some powerful health care lobbies, including those that advocate for the state’s physicians and hospitals. 

Resistance from doctors

One reform proposed in the 33-page bill would make it possible for advanced practice nurses such as nurse practitioners, nurse midwives and certified registered nurse anesthetists (CRNAs) to practice without having a contract with a physician for their supervision.

Physician and nursing groups have been divided over the so-called SAVE Act for years, with medical providers — led by the North Carolina Medical Society — usually being able to stop the nurses from having more leeway in their practices. At a Senate Health Care Committee hearing held after the press conference, several Democratic lawmakers also expressed reservations over this part of the bill. 

Chip Baggett, head of the

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Temp worker James Dickerson applied for Medicaid because it will be cheaper than his current health plan. Home health aide Sharon Coleman looks forward to having coverage that will cover a hospital stay. Incoming medical student Danielle Gaddis no longer worries a trip to the doctor will leave her in debt.

All three are among the roughly 490,000 people newly eligible for Medicaid after Oklahoma and Missouri voters in 2020 approved expanding the federal-state public health insurance program for people with low incomes. In both states, people who earn up to 138% of the federal poverty level — about $18,000 per year for an individual — can now get the free coverage even if they don’t have disabilities.

But the experience of the newly eligible in those two states — an estimated 215,000 people in Oklahoma and 275,000 in Missouri — has differed dramatically. Oklahoma has enrolled over 210,000 people, while Missouri has enrolled fewer than 20,000.

The difference comes down to the approaches taken by the two states, both of which are Republican-led and resisted expanding Medicaid for years.

Once Oklahoma voters approved the expansion, it was quickly embraced: The legislature appropriated $164 million in the state budget to fund it. Applications opened this June, one month before the program began, and within a month, 113,000 people had been approved.

In August, Oklahoma Secretary of Health and Mental Health Kevin Corbett told state lawmakers about one of those enrollees: a 62-year-old woman able to schedule appointments with a doctor and dentist for the first time in 20 years.

“Truly life-changing,” Corbett said. “We feel very good about what we’re being able to do.”

Other states that expanded Medicaid in recent years saw enrollment swell in the first month. Louisiana’s combined Medicaid and Children’s Health Insurance Program rolls grew by over 255,000; Virginia’s increased by almost 184,000; Idaho added about 45,500 enrollees, roughly half of the anticipated number of newly eligible people; and Montana added over 23,000, 51% of its expected total. Missouri, on the other hand, has enrolled only about 7% of newly eligible people in Medicaid.

“You can expand Medicaid on the books, but there are a lot of ways that you can throw up barriers to keep people from getting enrolled,” said Sidney Watson, director of the Center for Health Law Studies at Saint Louis University.

Expansion has been a slog in Missouri. The legislature refused to fund the voter-approved program, prompting Republican Gov. Mike Parson to announce in May that the state would “withdraw” its expansion plan. Then, in August, a judge ordered the state to start accepting applications, which it did. But Missouri could not begin processing them until Oct. 1.

That whiplash means many newly qualified Missourians are likely unaware they could be covered by Medicaid, according to University of Missouri-Kansas City law professor Ann Marie Marciarille.

Marciarille said that the state has a responsibility to get the word out about the program and that Missouri has done little more

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The White House-backed social spending framework will feature a pared-down expansion of both Medicare and Medicaid coverage as President BidenJoe BidenBiden administration takes aim at methane emissions McConnell blasts potential payments to separated migrant families Poll: 50 percent of Republicans don’t believe their vote will be counted accurately MORE seeks to secure enough support to advance the legislation.

The framework, previewed for reporters Thursday morning ahead of Biden’s meeting with House Democrats, would offer four years of subsidized private health insurance on the Affordable Care Act (ACA) exchanges for people with lower incomes living in states that did not expand Medicaid under the health care law.

According to the White House, the plan would provide $0 premiums for 4 million people in the “coverage gap,” meaning they don’t earn enough to qualify for ACA subsidies but, since they live in a nonexpansion state, also make too much to qualify for Medicaid. 

The temporary plan is more industry-friendly than the proposal offered by House Democrats in September, which would have created an entirely new “Medicaid-like” government program to provide coverage in the 12 nonexpansion states.

While many Democrats backed the idea, it was opposed in recent days by Sen. Joe ManchinJoe ManchinOn The Money — Presented by Citi — Progressives shrug off Manchin warning Cori Bush rips Manchin on spending bill opposition: ‘Anti-Black, anti-child, anti-woman and anti-immigrant’ Overnight Energy & Environment — Presented by The American Petroleum Institute — Glasgow summit kicks off MORE (D-W.Va.) and other lawmakers from states that have been paying for expanded Medicaid for years. They argued it wouldn’t be fair for their constituents if the federal government paid the whole cost of the holdout states to expand.

But at the same time, the temporary plan could be easier to set up and may avoid pushback from industry groups that worry a new federal program is a stepping stone to a larger-scale, government-run “public option.”

Backers of Medicaid expansion, including House Majority Whip James Clyburn (D-S.C.) and Georgia Democratic Sens. Raphael WarnockRaphael WarnockBiden reconciliation framework includes Medicaid workaround, no Medicare dental or vision benefits Senate GOP lines up behind Trump-backed candidates Perdue mulling primary challenge against Kemp in Georgia: report MORE and Jon OssoffJon OssoffBiden reconciliation framework includes Medicaid workaround, no Medicare dental or vision benefits Perdue mulling primary challenge against Kemp in Georgia: report McConnell backs Herschel Walker in Georgia Senate race MORE, wanted it to run for as long as possible.

On Medicare, the framework will expand coverage for hearing benefits, which is just one-third of what progressives were pushing for. 

Sen. Bernie SandersBernie SandersSanders hits back at Manchin’s spending concerns Manchin frustrates Democrats with latest outburst Democrats race to reach deal on prescription drug pricing MORE (I-Vt.) has drawn a line in the sand in recent days, saying that adding dental, hearing and vision benefits to Medicare in Democrats’ social spending package is “not negotiable.”

Progressives have long been pushing for expanding the Medicare benefits, but dental benefits

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