NC Senate Republicans back Medicaid expansion, overhaul of hospital regulations
Senate Republicans proposed an overhaul of the state’s health care industry Wednesday, a plan that would expand Medicaid to provide taxpayer health insurance to hundreds of thousands of the state’s working poor and to roll back regulations that conservatives have wanted removed for years.
The multi-faceted bill would end more than 10 years of fighting over Medicaid expansion in North Carolina. Support for the measure is a reversal for some of the state’s most conservative politicians. Senate Republicans said Wednesday that the time has come to move ahead with an Obama-era proposal that only about a dozen states have not embraced.
Their bill would give Medicaid coverage to adults up to 138% of the federal poverty level. That's about $38,300 for a family of four—generally too much money to be on Medicaid as it exists now, but not enough to afford health insurance through the federally subsidized Affordable Care Act exchanges. Those people have been left in the so-called coverage gap.
House Bill 149 started moving through committee Wednesday in the state Senate, but it faces long odds in the House. Both chambers have Republican majorities, but Speaker of the House Tim Moore said last week that there weren’t enough votes in the House to pass expansion. On Wednesday, his spokeswoman that position hasn't changed—even after other health care reforms were added to the package.
"Many of our members are concerned about a massive expansion of an entitlement program during record inflation and economic uncertainty," Moore spokeswoman Demi Dowdy said in a text message. "Attaching controversial, unrelated topics to expansion does not help the bill’s prospects for this short session."
Expansion has been a top priority for Gov. Roy Cooper and other Democrats for years. Some Democratic lawmakers were happily incredulous Wednesday to hear arguments they’ve made repeatedly come directly from Senate Republican leadership.
Concern over rollbacks
Several healthcare industry groups are concerned with a major regulatory rollback included in the bill, one that would allow medical groups to expand ambulatory surgery and other facilities without having to first get sign-offs from the state. Hospitals for years have used the so-called certificate-of-need process to hold back competition.
Among other things, hospitals argue that allowing doctors to split off profitable services would leave hospitals struggling to offset costs from their emergency rooms.
Conservatives have long called for certificate-of-need reforms. Senate President Pro Tempore Phil Berger and other Republican supporters said the reforms are needed to boost the supply of health services in the state, given that Medicaid expansion may provide new insurance for so many people.
The measure also incorporates the long-discussed SAVE Act, which would let nurses provide more services with less supervision from doctors. That's something doctor's groups have worked against for years, and the pushback against this section of the bill was particularly intense over the past week as Republican senators assembled the bill.
Several Republican lawmakers said their constituents received anonymous text messages urging them to lobby against the bill, calling it a "push by liberal Roy Cooper." The texts featured former President Barack Obama in a doctor's white coat.
"Hundreds have gotten them in my district," said state Sen. Kevin Corbin, one of the few legislative Republicans who has backed expansion for years.
Berger, R-Rockingham, said the Senate would push forward and worry about convincing others—most importantly the House—along the way. He and other key lawmakers have said several times that they hope the legislative session that got underway this week will wrap up by July 1, leaving relatively little time to get a complicated measure over the finish line.
Those targets often go out the window, though, at the statehouse. Republican Sen. Ralph Hise, a key budget writer in the chamber, said senators may add the bill to the annual state budget, which would increase the pressure on House Republicans to take the deal. Cooper has vetoed past budgets at least in part because they didn't include Medicaid expansion, and the budget is frequently a negotiating tool at the legislature.
There are enough votes to pass the bill in the Senate, but that support is not complete. Sen. Michael Lee, a New Hanover Republican who serves on a special committee reviewing expansion and other health care issues in the state, said Wednesday that the bill goes “many steps too far.”
What the bill does
Medicaid as it exists now in North Carolina primarily helps children, disabled people and senior citizens, though the universe of people on the plan ballooned during the pandemic to more than 2.7 million people, according to the North Carolina Department of Health and Human Services.
That figure includes 400,000 people, though, whose only benefit is $10 a month benefit for contraception, according to DHHS.
But the full Medicaid plan added a large number of parents and adults during the pandemic, and Sen. Joyce Krawiec, a key Senate Republican on health care issues, said it's likely that about 300,000 of the estimated 500,000 to 600,000 people who would be served by expansion are already on the state's Medicaid rolls, and early in the pandemic the federal government forbade states from dropping people from the coverage.
There's also more money available now from the federal government to expand. Funding that was approved in recent legislation—laws meant to entice states that have not expanded Medicad—amounts to an extra $1.5 billion over two years for North Carolina, Berger said. The Senate leader also said he's convinced that expansion and the Affordable Care Act it was part of aren’t going anywhere. Conservatives have tried to kill it in Congress and through the courts since it passed in 2010.
Berger said a federal promise to fund 90% of expansion costs also seems to be here to stay. If the money does go away, the bill includes a trigger that would end expansion and remove people from the Medicaid rolls. The other 10% would be raised through hospital taxes.
"First, we need coverage in North Carolina for the working poor," Berger said Wednesday, after acknowledging few in North Carolina have spoken louder against expansion than him. "Second, there is no fiscal risk to the state budget.”
“We are not likely to ever get a better deal than we are being offered right now," said Krawiec, R-Forsyth.
There's also evidence that Republican voters have come around on expansion. GOP county commissioners in Corbin's western North Carolina district have passed resolutions calling for expansion. The Carolina Partnership for Reform, a dark money group with ties to Berger, released polling data Monday that indicated a majority of Republicans in the state back expansion.
Many Republicans represent rural areas with struggling hospitals and poorer populations. Sen. Danny Britt, R-Robeson, said during a press conference announcing the bill Wednesday that his district has the highest infant mortality rate in the state. “Medicaid expansion is what we need," Britt said.
Wish list of reforms
But instead of backing expansion on its own, Senate Republicans loaded the bill with a wish list of other health care reforms.
The bill does not completely repeal the state's certificate-of-need laws, but it rolls back several key rules, allowing medical groups to expand their services and open new ones without the lengthy government review usually required. The changes would also make it harder for hospitals to block expansions still subject to government review.
It empowers nurses to provide more services without a doctor's supervision, which has been pitched for years as a way to boost the number of patients that can be seen. Rep. Gale Adcock, D-Wake, said the bill's language is identical to the SAVE Act that she and others have supported for years.
Chip Baggett, chief executive of the North Carolina Medical Society, said his group has "significant reservations" about this part of the bill, which does "significant harm" to the legislation and "potentially to the citizens of North Carolina."
The bill also requires insurance companies to pay for telehealth visits, though not necessarily at the same rate they pay for in-person doctor's visits. Those rates would be negotiated by insurers and providers, Hise said.
And the bill seeks to ban surprise medical billings that require patient notice and a cost estimate at least 72 hours ahead of an appointment if services will be billed at out-of-network rates. "No one will be surprised by a bill that they receive in a hospital," Krawiec said.
Hise, R-Mitchell, acknowledged that mashing all these issues together means there's probably "nobody 100%" for the bill. He also said these ideas won't pass on their own and that the combination "takes the reality of all the issues."
"There’s not going to be a day where Medicaid expansion alone comes, where the SAVE Act alone comes," he said.
Hise also predicted that there are enough votes to pass this measure in the House, if leadership in the chamber will bring the bill to the floor for a vote.
Work requirements
The bill includes work requirements for people getting Medicaid expansion, even though a federal court decision, as well as the Biden Administration, have said those can't be required.
The bill has them anyway, but they are essentially optional, with the state allowed to add people to the Medicaid rolls without insisting they have a job. The idea, Hise said, is to have the requirement in place "when the courts come to their senses." As written, the requirement has exemptions for people with children under a year old, people getting unemployment benefits, and people who can't work for physical or psychological reasons.
GOP leaders acknowledged Wednesday that most of the people expansion would apply to are already working—something Democrats have said for years in arguing against including work requirements in the bill.
Clarification: The post has been updated to clarify the total state population served by Medicaid.
