After years of debate, Medicaid expansion nearly law in North Carolina

A bipartisan state Senate voted Tuesday to expand Medicaid in North Carolina, which would extend taxpayer-funded health insurance to hundreds of thousands of people.

The 43-2 vote came without debate, but just few speeches celebrating the decision. The lopsided vote was yet another signal that, after more than a decade of debate and years where the Democratic priority was looked like the longest of shots in a Republican controlled General Assembly, expansion is almost a done deal.

The Senate must take a second vote tomorrow, with roughly the same margin expected. Then the multi-billion-dollar compromise, House Bill 76, heads back to the House for a final vote – where bipartisan support also is promised – before the measure goes to Gov. Roy Cooper for him to sign into law.

The bigger hurdle is likely what comes next: Republican leaders dropped a caveat into this carefully negotiated measure. Expansion won’t become a reality until a new state budget gets approved, allowing GOP lawmakers to load that budget with policies Cooper and his fellow Democrats will have to stomach to achieve the Medicaid expansion they’ve sought for years.

“We have been talking about this for a long time,” said Sen. Joyce Krawiec, R-Forsyth and a Senate health committee co-chair. “Actually we’ve been talking about it since long before many of us even arrived in the Senate. But today is the day.”

From somewhere in the chamber a quite “woo hoo” rang out.

Thirty-nine other states expanded the program before Republican lawmakers in control at the General Assembly got on board with the idea, enticed in large part by the billions of dollars in federal funding that expansion unlocks. That includes an extra $1.8 billion enticement Congress included in pandemic-era legislation to tempt the remaining states.

“I think it’s a little late,” Sen. Gladys Robinson, D-Guilford, said Tuesday. “But we’ll take it.”

Expansion targets the working poor: People who make too much money to qualify for Medicaid now under North Carolina’s strict rules but not enough to afford insurance. It will cover adults up to 138% of the federal poverty level.

That coverage gap is thought to include hundreds of thousands of people who pay grocery and power bills instead of paying for a checkup. Their children may be covered by an existing Medicaid program, but they live without health insurance.

“They’re working very hard most of them,” Krawiec said Tuesday. “There’s just never enough money to pay all of the bills.”

Robinson said she appreciated Republicans “understanding, finally, who this impacts.”

Sometimes a lack of health insurance lands people in the emergency room, where care is more expensive, and where unpaid bills lead hospitals to charge paying customers more for routine care to make up those costs.

Sometimes people die. Dr. Eleanor Greene, an obstetrician and gynecologist in Greensboro, told WRAL News about a woman who put off doctor visits for a year, despite the fact that she was bleeding, because she didn’t have insurance.

“When I examined her, a large portion of her cervix had been destroyed already by cervical cancer,” Greene said.

Cervical cancer, for the most part, is preventable or treatable when addressed early, Greene said. But this patient’s tumor had metastasized into the liver, “and there’s not a whole lot that can be done,” she said.

In addition to expansion, the bill would unlock Healthcare Access and Stabilization Program (HASP) payments from the federal government, which are expected to pump billions of dollars a year into the state’s hospitals, shoring up their finances. The bill also starts a ticking clock on major rollbacks of hospital regulations that currently limit competition in the healthcare sector.

Changes in these certificate-of-need laws will phase in over the next three years, and the hope among supporters is that the increased ability to build new surgery centers, buy new imaging machines and expand other services without wading through a lengthy state approval process will boost the overall supply of healthcare options in the state as the number of people with health insurance increases through expansion.

As for the state budget that is part and parcel of this Medicaid deal, that process is moving along in the House, which is expected to pass its version of the plan in early April. Then it would move to the Senate, where leadership has said they hope to hammer out their version by mid-May.

Cooper is expected to release his budget proposal tomorrow, but Republican leaders in the two chambers are free to ignore it and write their own plan.

Medicaid expansion triggers a number of changes to the program, which is largely federally funded but managed by the state. Cooper’s administration will work with the federal Centers for Medicare & Medicaid Services on the nitty gritty of implementation.

The state’s Department of Health and Human Services said Monday that it plans to submit its expansion plan to CMS once House Bill 76 passes. CMS then has 90 days to review and approve the plan, or to issue a request for additional information, which would pause that clock.

WRAL Capitol Bureau Chief Laura Leslie contributed to this report.