I started working on health advocacy at the North Carolina Justice Center back in 1997, a few years after graduating from UNC’s law and public health schools. As I move into a broader role working with a national child and family health organization, I have a few thoughts for North Carolina’s Gov. Pat McCrory and the General Assembly on the issue of health care for our lowest-income state residents.
Today in North Carolina we stand at an impasse on the Affordable Care Act. Out-of-state political groups are spending millions of dollars demonizing the health care coverage people are now buying from N.C. Blue Cross and Coventry Health Plans through the new law. Top state political figures complain repeatedly about the health care law even as mothers and children, small-business owners with pre-existing health conditions and many others sign up in our state.
Even with the recent good news about the ACA, including declining costs and exceeded enrollment goals – North Carolina has the fifth-highest enrollment in the nation – there remains a significant coverage gap in our state. People below the poverty line of $11,670 a year who are either single or no longer have kids living at home are literally “too poor” to qualify for affordable coverage and are turned away because McCrory and the N.C. General Assembly did not expand Medicaid.
This has been a surprise, perhaps because of my long history of health advocacy where I have been a part of the two Republican-driven efforts to expand health coverage to our neediest children and seniors. With the “party of no” reputation McCrory and the General Assembly have built for themselves the last two years, it is hard to believe that the two largest expansions of state health coverage in the last 20 years were largely driven and shaped by the same party that last year turned down $5 million a day in federal dollars to expand coverage to the poor. However, it is true.
To understand this, one needs to remember a little history. N.C. Republicans decisively won elections in 1994 to gain control of the N.C. House for the first time since 1894 and controlled the House until 1998 alongside a Democratic state Senate. It may seem quaint today, but then House Republicans were eager to prove that they could be for something as popular as good, affordable health coverage.
House Republicans proceeded to lead the passage of one of the biggest expansions of Medicaid in N.C.’s history: full Medicaid coverage to elderly and disabled people with incomes below the poverty line. This brought approximately 40,000 people into the program with literally life-changing results for many of the most vulnerable people in our state. Moderate Republicans and Democrats worked together over the objections of conservatives in both parties.
But these Republicans in the 1990s weren’t finished. A dismal lack of health insurance for children in the 1990s spurred Congress to pass the State Children’s Health Insurance Program where millions of dollars in federal money was provided to states to expand health coverage to children of working parents. States faced many choices for their children’s coverage from declining the money to simply expanding Medicaid to kids. Then-Gov. Jim Hunt wasn’t shy about his preference for Medicaid. When Republicans in the N.C. General Assembly wouldn’t expand Medicaid to kids, he barnstormed the state preaching the importance of health coverage for children and called the General Assembly back into a special session to consider the issue.
House Republicans wouldn’t back down and insisted on a more market-based solution. In the end, Republicans got their way, and kids in N.C.’s Children’s Health Insurance Program got their insurance – paid for by federal dollars – not through Medicaid but through N.C. Blue Cross Blue Shield’s state employee plan. The result? Eventually over 100,000 uninsured kids gained health coverage.
Republican governors in multiple states are sounding more like our 1990s N.C. Republicans these days. Utah’s Gov. Herbert in just the last few weeks has been discussing a market-based plan for Medicaid expansion with the federal government and recently was quoted: ““We were received very well” by the Obama administration on our unique plan.
Even holdouts Idaho and Wyoming are watching Utah’s expansion efforts closely and may move toward expansion. Pennsylvania’s Gov. Corbett is awaiting a ruling on his latest very conservative plan while Republican Iowa Gov. Branstad just got approval for his market-based expansion solution.
After presiding over the biggest expansions of health coverage in N.C.’s history, Republicans should have been eager to put a conservative spin on Medicaid reform and gain a reputation for solving major health care coverage problems as well. Maybe after 17 years I’m still naive, but as N.C. shrinks into the minority of states rejecting Medicaid expansion I can’t help but think McCrory would rather create positive change than continue to just say no.
Adam Searing is the former director of the Health Access Coalition for the N.C. Justice Center.