Several North Carolina House Republicans who want to expand Medicaid renewed their pitch on Tuesday, now that the state legislature's changing political balance gives the proposal more leverage.
Their bill seeks to expand Medicaid coverage to more uninsured adults who can't otherwise qualify because they make too much money. It largely follows a 2017 proposal that petered out due to opposition from GOP colleagues.
But this year's proposal should get more attention because expansion supporter Democratic Gov. Roy Cooper has more negotiating power since his party gained legislative seats in November.
Medicaid expansion could become a linchpin of this year's North Carolina legislative session, especially if Cooper threatens to veto any final state government budget without it. More than 35 states already have expanded Medicaid eligibility in some form through the 2010 federal health care overhaul.
"Certainly we know where the governor stands," said Rep. Donny Lambeth, a Forsyth County Republican and chief sponsor of the bill. "We know the governor will be part of these discussions at some point as we wrap up the budget."
Lambeth's proposal could cover more than 540,000 people ages 19 to 64 making no more than slightly above the federal poverty level. Slightly over half of those who could qualify don't currently have insurance, according to figures Lambeth provided, meaning they would be added to the current Medicaid rolls. About 2 million people in North Carolina already qualify for Medicaid.
House Democrats offered a bill in late January that would have expanded Medicaid without any requirements upon enrollees. Cooper spokesman Ford Porter said Tuesday in an email that work requirements and premiums "for the working poor create unnecessary barriers to coverage." Although Senate Republicans remain strongly opposed to expansion, Lambeth's measure, could serve as a roadmap toward a bipartisan compromise.
Lambeth, a former hospital executive, and other GOP sponsors are taking a different tack than most GOP leaders, arguing the benefits of federal Medicaid funds untouched for years are too great to pass up. Still, they tried to distance their plan from traditional expansion, calling it simply "NC Health Care for Working Families."
The bill sponsors also agree with several lobbying groups, including the state's hospital association, which say it will create health care jobs, counter opioid addiction and reduce infant mortality by covering women of child-bearing years.
"The greatest opportunities to improve the health of a woman and her child during pregnancy occur before she becomes pregnant," said Michaela Penix with the North Carolina March of Dimes.
Like the 2017 proposal, enrollees would have to pay monthly premiums equal to 2% of their income and either work or participate in job-training programs.
North Carolina taxpayers wouldn't directly pay the local 10% share of the program's overall annual cost of more than $4.7 billion.
Rather, it would be covered largely by assessments, or taxes that hospitals and health care providers would be required to pay. Responding to critics who say the state could ultimately get stuck with the bill, Lambeth said the measure would cancel expanded coverage should the federal government stop paying less than a 90% share.
Senate Republicans remain skeptical, noting that President Donald Trump last month proposed doing away with it and sending Medicaid money to the states in block grants.
Senate GOP members have instead offered several other proposals to expand health care access. A measure scheduled for committee debate Wednesday proposes spending to cover more people with developmental disabilities and repealing certificate of need laws.
"With the current state of the federal government's fiscal health, paying for 90% of Medicaid expansion is unsustainable," Senate leader Phil Berger, a Rockingham County Republican, said recently in a news release.
Lambeth's bill would include one new initiative: a rural health grant program that could set aside tens of millions of dollars annually toward recruiting and retaining doctors, expanding telemedicine and mental health services and other efforts. The money would be paid through a new tax upon managed-care groups who will soon care for most of the state's Medicaid patients.
House Republican leaders are lukewarm at best to the expansion idea. Lambeth said he has spoken to Speaker Tim Moore and Majority Leader John Bell about it.
"Now can I stand here today and say it's going to fly through with flying colors over the next few weeks? No, I can't do that," Lambeth said.
During his State of the State address last month, Cooper acknowledged some of the Republican opposition to expansion but expressed hope for a deal: "Let's listen to each other and let's get this done in a North Carolina way."