The current impasse over approving a state budget isn’t really about whether the Medicaid program will expand. It’s about whether Sen. Phil Berger’s influence will shrink.
Since taking control of the upper chamber in 2011, the Senate leader has not simply led. He has ruled. There are debates, but in the end only one man decides. Berger is North Carolina’s own Sen. Mitch McConnell. Everything goes through him. Nothing goes around him.
Berger’s power is based on a well-honed edge of grievance after years of being ignored in the minority, a deep knowledge of the legislative process and control of caucus campaign funds that Republican senators depend on. But now Berger faces great pressure to practice a political skill with which he is not familiar — compromise.
The Senate leader finds himself locked in a standoff with Gov. Roy Cooper over the budget and Medicaid expansion. The Republican-controlled General Assembly passed a budget without expansion. Cooper vetoed the budget saying it must include expansion. The Republicans don’t have enough votes to override the veto. Cooper doesn’t have enough votes to add Medicaid expansion.
So here we are, eyeball to eyeball. Berger has a strong position because he controls a majority of the Senate’s votes. But Cooper has a stronger one. He has the moral high ground in pushing to give hundreds of thousands of North Carolinians access to affordable health care. According to polls, Medicaid expansion is favored by more than 60 percent of the public and almost 80 percent of Republicans would support expansion if it included a work requirement. Cooper has the backing of the huge health care industry and corporate leaders. He has the example of 36 states that have expanded Medicaid, including ones controlled by Republicans.
And finally, he has the facts on his side. Studies show Medicaid expansion would create thousands of jobs, boost rural hospitals and improve the well-being on North Carolinians. Not expanding means. North Carolina taxpayers will continue to pay taxes to support a program from which they do not benefit.
In this struggle, Berger is increasingly on his own. He has his own rigid opposition and the votes he controls. But his arguments have grown increasingly thin. He says he is protecting the state from a time when the federal government may renege on its promise to pay 90 percent of the cost of expansion. It’s hard to see how Congress would do that with 36 states reliant on the payments. He says it will give free insurance to “able-bodied” people, but expansion might ultimately reduce health care costs through better preventative care and fewer uninsured people showing up at emergency rooms. It would also save lives.
There’s evidence that House Republicans are ready to compromise. A Medicaid expansion bill with work requirements — NC Health Care For Working Families — easily passed the House Health Committee. Most Republican lawmakers want to avoid running in 2020 with the baggage of having blocked Medicaid expansion in any form. Cooper prefers no work requirement, but would consider one. Berger said a work requirement wouldn’t remove his other concerns about expansion.
Berger and Republicans helped themselves by passing legislation in 2016 that allows recurring state funding to continue in the event of a budget impasse. That takes some of the pressure off both sides, but ultimately the momentum is with the governor. Berger may hold out on this one, but the strain of resisting the governor and keeping restive Republicans in line will test — and perhaps reveal — the limits of his power.