Governor who expanded Medicaid in a red state pushes it in NC as GOP resistance thaws

Former Ohio Gov. John Kasich made an impassioned plea to North Carolina lawmakers to expand Medicaid, making an explicitly moral case for increasing access to health care.

Kasich, a Republican who also served in the U.S. House and ran for president in 2016, spoke via video Tuesday afternoon to a legislative committee studying health care access and Medicaid expansion.

“When you die and go to heaven, you’re going to see St. Peter, and St. Peter is not going to ask you, ‘Did you balance the budget?’ He’s going to ask you what did you do for the least of those,” Kasich said, recounting a conversation he had with the Ohio House speaker. “And that’s how I feel about it. And what I would say to the fine members of the legislature of North Carolina, to the people of North Carolina, is there’s a lot of people who need a lot of help.

“We have to open our hearts to those people. It doesn’t mean that when we do that, we put ourselves on the road to bankruptcy. It means that we have to have good management.”

Tuesday marked the third meeting of the committee, which was created as part of the budget passed in November. Democratic Gov. Roy Cooper has long advocated for expansion in North Carolina, one of 12 states — most in the Southeast — that have not expended Medicaid after passage of the Affordable Care Act in 2010. A standoff over expansion was part of the reason Republican lawmakers and Cooper never reached an agreement on a budget in 2019 or 2020 and contributed to long negotiations last year.

In the previous two meetings, presenters, including North Carolina’s Medicaid director, relied on fiscal arguments to push for expansion. Kasich said the expansion in Ohio, which was implemented in 2014, did not stop his administration from cutting taxes, investing in public education or replenishing the state’s savings account. But he made a moral case for expansion in a way that was different from other presenters — Tuesday or previously.

“It makes me wonder if part of the reason I was there (as governor) was to do this very act of expanding this program,” said Kasich, who served as Ohio’s governor from 2011 to 2019.

What happened in Ohio

About 700,000 people enrolled in the expanded Medicaid program in Ohio. Almost 30,000 previously uncovered patients were diagnosed with cancer in the first year of expansion, according to John McCarthy, the state’s Medicaid director. Indiana saw similar results with 18% of new enrollees considered medically frail, which includes those diagnosed with cancer.

“When you think about the decision you’re going to make, can you imagine being in a position with yourself or family where you just didn’t have the resources or the ability to access care and you had to live with this? Could you imagine that?” Kasich said, referencing the cancer statistics.

“If we have the chance to reach out and literally hand them a lifeline, where they can get treatment. Could you imagine, first of all, dealing with the problem of cancer and secondly just being out there alone, it’s just enough to break your heart. ... We all have to take into account the bigger picture of what it does for a state and its economic status, but boy, if we can figure out how to do this, we will have people thanking you forever, and that’ll be part of your personal legacy.”

In addition to Ohio, the 18-member committee heard presentations about expansion in Montana, Indiana and Michigan on Tuesday. Committee co-chairman Rep. Donny Lambeth, a Republican from Forsyth County, said previously he expects the committee will hold informational hearings throughout the summer. He hopes the committee will put forth a plan to the legislature in the fall.

The next meeting is March 29.

Uninsured in NC

There are approximately 600,000 uninsured North Carolinians who would be eligible for coverage under Medicaid expansion.

“I think there is a segment that resonates with,” Lambeth said of Kasich’s moral plea. “But let’s be realistic. I think realistically people are looking at what’s it going to cost, what’s the return on investment, how’s it going to benefit the taxpayers of North Carolina, and is it worth proceeding down that path? Because this is a big decision and if we go down it, it’s gonna be very difficult to turn back.”

Tuesday’s presenters said they saw positive benefits to health outcomes in their states as a result of expansion. For example, the infant mortality rate in Indiana reached its lowest level since at least 1900 last year.

It continued a pattern of mostly positive remarks about expansion from people presenting to the committee.

“I can’t necessarily comment on other states’ experience, having just the Indiana experience, but if you were to go to larger evaluations of expansion in general, you would find that the experience that you’ve heard thus far today ... are the global experiences: decrease in uninsured, decrease in uncompensated care, increased adherence to prevention services, access to physicians and increase in the workforce,” said Jennifer Sullivan, the former Health and Human Services secretary in Indiana and now the senior vice president for strategic operations at Atrium Health.

The costs in the first year of expansion have exceeded projections in many states, presenters said, because of the need for treatment of previously undiagnosed illnesses discovered when patients get health care.

“People were not getting care, even in this (medically frail) population. They came in with pent-up demand for health care coverage, that was initially very expensive,” Sullivan said, pointing to a lag in cost savings from expansion. “It underscores that fact that those included in Medicaid expansion have not been receiving care. This is not shifting a group from one type of care to another. It’s bringing a new population into health care access.”

There have been signs that the long, protracted fight over Medicaid expansion in North Carolina could be thawing. Senate leader Phil Berger, an Eden Republican, said his caucus would support expansion and offered to include it in the state budget if other Republican priorities were in there, too.

House Republicans, however, refused to put it in any budget deal. Speaker Tim Moore, a Republican from Cleveland County, said in November that he did not have the votes in his caucus.

House Majority Leader John Bell, a Republican from Wayne County, told an audience in Raleigh earlier this month that he wants to see the problem addressed. He was on a panel with Berger and Democratic legislative leaders Sen. Dan Blue and Rep. Robert Reives.

“Health care will be a major focus of the short session and even though I may not be 100% sold as these folks are right now, I do think there is a pathway to get there on the Medicaid expansion access to care, to actually address the problem, not just put a Band-Aid on it,” Bell told a group at the Raleigh City Council’s annual retreat.

“So I’m hoping with the oversight committees and the work that I know both parties in both chambers are doing, I hope we get to a good place that we can all be proud of and say, hey, North Carolina did it the right way.”

What that looks like is still uncertain. Lambeth said previously “this needs to be a North Carolina solution.” During Tuesday’s meeting, lawmakers heard about other states’ attempts to attach job training, work requirements and cost sharing to their expansion.

One of the most conservative members of the House, Republican Rep. Keith Kidwell, is a member of the committee. He said he is approaching the hearings with an open mind, but said any expansion must have guardrails.

“We definitely need to do something to fix the cost of medicine in North Carolina, in the United States. And I don’t have a problem if we’re on the cutting edge of that,” Kidwell said. “As I’ve told some of the lobbyists that have come to my office, I’m not for giving free medicine to people who simply won’t work.”

For more North Carolina government and politics news, listen to the Under the Dome politics podcast from The News & Observer and the NC Insider. You can find it at https://campsite.bio/underthedome or wherever you get your podcasts.

This story was originally published March 15, 2022 at 6:23 PM.