ACA changes may cost NC and other states that didn't expand Medicaid

When the nation’s governors met with President Trump on Monday, North Carolina’s Pat McCrory was not one of them. He was missing, of course, because he lost his bid for re-election to Democrat Roy Cooper. But his absence nonetheless carried strong symbolism regarding a prime concern at the meeting – Medicaid funding.

McCrory and other Republican leaders in North Carolina who refused to expand Medicaid under the Affordable Care Act now find themselves left out as the president and Republicans in Congress weigh how to continue funding for states that expanded. As a result, North Carolina may find itself twice deprived. First, it gave up billions of dollars of extra federal funding for expansion. Second, it may be shortchanged if Congress alters how Medicaid funds are distributed.

Only 19 states refused to expand Medicaid. In North Carolina, that refusal denied nearly a half-million people health insurance. All this medical hardship and funding loss was justified by Republican leaders in North Carolina as fiscal prudence. By not participating, they said, the state wouldn’t be on the hook for higher Medicaid expenses should the ACA fail or the federal government reduce the support it promised.

But now all that Republican tough talk about repealing “Obamacare” is being replaced by worry. For one, 16 states with a Republican governor expanded Medicaid. Those governors don’t want the political cost of taking the coverage back from millions of Americans. Secondly, Medicaid expansion has gained popular support. A Kaiser poll this week found that 95 percent of Democrats, 84 percent of independents and 69 percent of Republicans said it was “very” or “somewhat” important to continue to provide federal funding for the Medicaid expansion.

The Republicans’ default solution appears to be freezing Medicaid in place. That means converting the funding to block grants roughly equal to what states are spending now. Those that chose to expand will get a bigger grant. Those that chose to leave hundreds of thousands of their low-income adults uncovered will get less.

To soften the blow to holdout states, extra money may be provided to their hospitals to cover indigent costs. But treating low-income people as indigent patients is much more expensive than providing Medicaid coverage that would have helped keep them out of the hospital in the first place.

In North Carolina, conservative Republicans sure showed President Obama they wanted no part of his “government giveaway” to poor people. Let’s hope they richly enjoyed their defiance because – thanks to possible Republican changes – North Carolina may soon pay heavily for being obstinate.