Why top NC Republicans changed their minds on Medicaid for ‘working poor,’ and what’s next
North Carolina should join most other states in the country in expanding Medicaid coverage to lower-income residents, some Republican leaders said Wednesday morning.
“We need coverage in North Carolina for the working poor,” N.C. Senate leader Phil Berger, formerly an opponent of Medicaid expansion, said at a news conference.
It’s generally estimated that expanding Medicaid coverage would extend health insurance to around half a million North Carolinians. Republicans have long opposed it, citing both philosophical and monetary concerns, so Berger’s about-face signals a significant change.
And it’s not only Medicaid expansion, which is a longtime goal of Democratic Gov. Roy Cooper and others, that’s in the new bill. The proposal, published Wednesday morning as House Bill 149, also contains several other changes to health care policy — like free-market “certificate of need” changes and looser regulations supported by nurses — that have previously withered in the face of opposition from groups representing doctors and hospitals.
Sen. Joyce Krawiec, a Kernersville Republican who leads the Senate’s health committee, said she thinks hospitals will support this bill not only for Medicaid expansion but also because it contains other things hospitals want, like increased telehealth options, even if it also has items they’ve opposed in the past.
“I think this bill is a rescue plan for our hospitals, especially our rural hospitals,” she said.
So why are Republicans suddenly in favor of a policy in Medicaid expansion that they have long, and vocally, opposed? Berger acknowledged it might surprise some people.
“If there’s a person in the state of North Carolina who has spoken out against Medicaid expansion more than I have, I’d like to meet that person,” he said. “In fact, I’d like to talk to that person about why my view on this has changed.”
Change of heart on Medicaid
Berger signaled his change of heart last year, saying it happened after he decided North Carolina no longer needed to worry about the federal government keeping up its end of the bargain.
Congress failed to repeal President Barack Obama’s Affordable Care Act — even when Republicans controlled both the White House and Congress — and the Supreme Court upheld the law as constitutional.
If that had gone away, costs for Medicaid expansion would have shifted from the federal government to individual states. Berger said that all along his main concern has been for the state’s financial health, so with Obamacare appearing to be here to stay, then Medicaid expansion “is now good state fiscal policy.”
Plus, GOP leaders said, the 2021 stimulus package passed by Congress and Democratic President Joe Biden offered a “sweetener” to holdout states — which for North Carolina would mean $1.5 billion extra in federal funding if the state expands Medicaid soon.
“We are not likely to ever get a better deal than we are being offered now,” Krawiec said. “Our state budget will be stronger, our rural hospitals will be better-positioned to stay open.”
Also contributing to his change in attitude, Berger said, is that the state’s own Medicaid program had long been mismanaged but has improved in recent years. The News & Observer reported last year that North Carolina potentially wasted millions of dollars due to poor oversight of the state Medicaid program that lasted years.
A landmark “Medicaid transformation” bill in 2020 also helped, Berger said.
Chances for Medicaid expansion this year?
When Berger was explaining his support of the bill, he gave a hypothetical example of a single mom who’s working full time and making $25,000, or the equivalent of $12 per hour: Not much money, yet still too much to qualify for Medicaid — unless expansion passes.
“She does not have any affordable health care options” Berger said. “So she’s faced with difficult choices every day. Food, clothing, shelter. Once she’s taken care of those things, the question about health care, there’s no money left for that.”
However, it remains to be seen how quickly the bill might move forward, or if it will pass. While Republican leaders in the N.C Senate are behind it, and said they’ve been in talks with Cooper as well, N.C. House Speaker Tim Moore has voiced skepticism of Medicaid expansion in the past.
Asked last week if it was on the table for this spring’s legislative session, Moore told reporters, “I would be surprised.”
Sen. Gladys Robinson, a Democrat from Greensboro, thanked Republican senators during a committee hearing on the bill Wednesday morning for not only supporting Medicaid expansion — which Democrats have sought for years — but also for explicitly mentioning that it will help the working poor.
”I hate to say I told you so, in terms of the working poor, but I have to do that,” she said.
Other parts of the bill
The lengthy bill contains more than Medicaid expansion — a fact Berger, Krawiec and others said was key for it getting their support. However, some of its extra pieces have been controversial in the past, failing to pass the legislature in the face of strong opposition from powerful interests in the health care industry.
For example, the bill wouldn’t entirely gut the state’s “certificate of need” law but it would institute significant changes including a partial repeal.
Hospitals are big supporters of the law, which limits how many new hospitals or even new pieces of medical equipment can be built or purchased in different regions of the state. Supporters say it keeps costs down by eliminating unnecessary spending, but opponents like Krawiec say it does the opposite, by eliminating competition.
The N&O previously reported on a lawsuit filed by an eye doctor stopped by certificate of need rules from getting equipment to perform certain surgeries at his own clinic. Instead, he said, he’s forced to do those surgeries at a hospital that charges patients three times what he would.
Certificate of need changes have failed to pass in recent years, despite support from conservatives. Similarly, a bill with broad bipartisan support called the SAVE Act that would reduce regulations on nurses has failed to pass on its own due to opposition from doctors, but it has now been wrapped into the broader Medicaid expansion bill.
Chip Baggett, CEO of the doctor lobbying group N.C. Medical Society, said at a committee Wednesday that they support Medicaid expansion but still oppose the SAVE Act.
Allison Farmer, CEO of Durham-based EmergeOrtho, said her statewide orthopedic group supports Medicaid expansion, plus certificate of need changes.
And Jordan Roberts, from the conservative think tank John Locke Foundation, said they oppose Medicaid expansion but support some of the bill’s other pieces.
Republican Sen. Ralph Hise, who co-chairs the Senate’s health committee with Krawiec, said such a wide-ranging bill is likely to never have complete support from anyone.
”I dare to bet this is a bill that’s been put together that there’s nobody 100% for it,” he said, adding that the goal is to hit “the sweet spot” of a middle ground that both works and can get enough support to pass into law.
Editor’s note: This story has been updated to correct the stance of EmergeOrtho.
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 May 25, 2022 at 11:02 AM.
