By Rose Hoban and Rachel Crumpler
It finally happened.
In a move that many health care advocates have been pushing for years, the state Senate introduced a bill on Wednesday that would expand the state’s Medicaid program to some half million-plus low-income North Carolinians.
Until this point, Medicaid has been reserved mostly for children from low-income families along with a small number of parents in those families, poor seniors and people with disabilities. Since 2012, the possibility to sweep in many low-income workers has been on the table as a result of the Affordable Care Act, but Republican leaders in the state senate have been staunch opponents.
Now, after years of saying no, powerful Republicans in the state Senate are saying yes.
“Why now? Why this? First, we need coverage in North Carolina for the working poor,” said state Senate leader Phil Berger (R-Eden), who admitted during a press conference Wednesday that he has likely been the most outspoken person in the state about his opposition to Medicaid expansion.
“Second, there is no fiscal risk to the state budget moving forward with this proposal,” Berger added, noting that the bill includes pay-fors that would have hospitals largely on the hook to pay the 10 percent of the costs for the expansion population not covered by an enhanced federal payment. There’s also a federal incentive that would total some $1.5 billion in extra funds that would flow to North Carolina over a two-year period.
Finally, he argued that since the state has moved Medicaid from being a state-run fee-for-service program to one managed by commercial insurance companies, the program has been “reformed and transformed.”
“Medicaid expansion has now evolved to a point that it is good state fiscal policy,” Berger continued. “But again, I cannot emphasize this enough: Expanding Medicaid needs to happen with additional reforms.”
Those reforms could make the bill to be titled Expanding Access to Healthcare in North Carolina a hard pill for many to swallow. One aspect of the bill would set up a work requirement for the new beneficiaries, something that’s been repeatedly struck down in other states by federal judges.
What really might jeopardize passage of the bill is that it contains provisions that already are raising hackles in some powerful health care lobbies, including those that advocate for the state’s physicians and hospitals.
Resistance from doctors
One reform proposed in the 33-page bill would make it possible for advanced practice nurses such as nurse practitioners, nurse midwives and certified registered nurse anesthetists (CRNAs) to practice without having a contract with a physician for their supervision.
Physician and nursing groups have been divided over the so-called SAVE Act for years, with medical providers — led by the North Carolina Medical Society — usually being able to stop the nurses from having more leeway in their practices. At a Senate Health Care Committee hearing held after the press conference, several Democratic lawmakers also expressed reservations over this part of the bill.
Chip Baggett, head of the North Carolina Medical Society, also spoke out about the nursing practice language in the bill at the committee. He had a number of problems with the changes.
“The first is the foundational education that is received by APRNs, many of which are receiving online education right now, and we do not think that provides the foundation necessary for independent decision making,” Baggett added after the meeting.
Several decades of research, though, bolster the nurses’ contention that their practices are safe, and that patient satisfaction with advanced practice nurses is often better than for physicians.
Joyce Krawiec, a Republican state senator from Kernersville, noted that 137 health care facilities across North Carolina only have CRNAs to deliver anesthesia services and that 34 other states have already loosened the rules around nursing practice.
“My husband had a colonoscopy recently, and they can do it with the supervision of a physician,” Krawiec said. She recounted how she asked the physician leading the procedure if he was overseeing the anesthesia. He responded, “Heavens, no, I don’t supervise her. He said I haven’t looked at anesthesiology since I was in medical school. I wouldn’t know what to do. She does it all on her own.”
Sen. Ralph Hise (R-Spruce Pine) argued that making it easier for nurses to practice, particularly in rural burgs, needed to be included in any bill that would make it easier for more people to see those providers.
“Finding nurses in this state is becoming more and more impossible,” Hise said. “And so this bill, allowing the nursing profession to expand its scope, to have more upward mobility in the nursing program is what ultimately I think will allow us to provide a lot of health care that we currently just don’t do.”
Rep. Gale Adcock (D-Cary), who is also a nurse practitioner, said that increasing access to health insurance would require adding providers.
“The majority of folks clearly understand these things all need to happen at the same time, and I’m excited to see that it might happen soon,” she said.
Hospitals, House objecting?
One of the big obstacles to Medicaid expansion that Republican lawmakers have raised for years has been where the 10 percent of the expansion cost not covered by the federal government would come from. For years, lawmakers have argued that hospitals would be the main beneficiaries of more federal dollars for Medicaid flowing to the state, so hospitals could foot much of the bill in the form of an additional assessment.
Hospitals have said they lose so much on uninsured patients that they were willing to pay for some of the cost, but not the whole tab. In Medicaid expansion bills in other years, this cost was also borne by a new tax on commercial managed care companies providing coverage under the “transformed” Medicaid program.
Hise contended the proposal will definitely help hospitals’ bottom lines, with more federal money flowing into the health care systems than they’ll have to put out to cover the rest of the Medicaid expansion population.
A spokesman from the NC Healthcare Association, which represents the state’s hospitals, told NC Health News that his organization was reviewing the new bill and would wait to offer comment on its potential impact.
The other big obstacle to passage of the bill may come from the other side of the General Assembly building in Raleigh, in the House of Representatives. Leaders there have expressed hesitation about making such a big policy change during this year’s short legislative session.
“The position of the House is we have no plans to take up expansion in the short session,” Rep. Donny Lambeth (R-Winston-Salem) said in a text to NC Health News.
Lambeth has been leading a committee with members from the House and Senate since January that has been examining what it would mean for the state to expand Medicaid.
“The work of the committee has not been finished and the committee has made no recommendations,” Lambeth continued.
The line from Lambeth and others on the House side has been that they’d rather come back for a special session on health care access in the fall. That, however, has drawn misgivings from state health leaders.
“I mean, September sounds nice,” Health and Human Services Sec. Kody Kinsley said last week. “But here’s why I’m worried. First and foremost, this $1.5 billion dollar signing bonus that’s on the table right now. Right now, the money that is earmarked for North Carolina is nothing more than, you know, some print on a piece of paper. And it would not be hard for Congress to take that off the table, so they can invest it in other things they need to invest in. We cannot wait.”
On Wednesday afternoon, Rep. Tim Moore (R-Kings Mountain), the speaker of the House of Representatives, said he believed that money would be available next year.
“All indications are it would,” he said. “If that is going to go away, then that’s a problem with the premise of even doing this.”
Medicaid already expanded
Since the beginning of the pandemic, Medicaid rolls have ballooned to close to 2.7 million beneficiaries, up from 2.1 million enrollees since March 2020. That’s because in one of their early COVID-19 relief bills, the U.S. Congress ordered all the new enrollees who qualified for the program to stay on the program for the duration of the federal state of emergency created by the pandemic.
Advocates have pointed out that many of those folks were people who would have qualified had North Carolina already expanded the program.
North Carolina likely paid billions more to cover those additional 600,000 people than the state would have if they had already expanded Medicaid, as the Affordable Care Act allowed. Instead of getting the 90 percent match that the federal government would have provided, the state had to make up the difference, paying 27 percent of the cost.
“We’re actually looking at a situation where a lot of the expansion population are already enrolled on Medicaid,” Hise admitted.
Hise also talked about the anxiety that county social service leaders have around the requirement to “recertify” all of these new Medicaid enrollees once the federal emergency ends. If the state doesn’t expand, at least half of those new enrollees would be purged from the rolls in a time-intensive process that would take up to a year.
The process of recertifying these peoples’ eligibility would be much less cumbersome if they end up rolled onto the program via Medicaid expansion, Hise noted.
After years of waiting for such a bill to come out of the Senate, there was a palpable upbeat energy in the Senate committee room.
“Sen. Krawiec, I hate to say I told you so,” quipped Sen. Gladys Robinson (D-Greensboro), an advocate of expanding Medicaid for years. Laughter erupted.
That giddy feeling might not last long. Getting the bill across the finish line seems like a stretch, given the resistance from the House and from powerful groups.
Catawba College political science professor Michael Bitzer said that many details could be hashed out once the House rejects the bill and it goes to a conference committee with people from both chambers.
“You know, conference committees are typically called the third chamber of the legislature because that is where the true dealmaking has to occur within the legislative dynamic,” Bitzer said. “With the way the two chambers are, that could become the real power base of any type of legislation that’s gonna get moved from either chamber.”
That bargaining will come down to who is willing to give up what from their wish lists during negotiation, Bitzer added.
“I think oftentimes with this type of significant legislation, people are probably more willing to say, ‘I can live without this,’ rather than, you know, ‘this is what my final demands are going to be,’” Bitzer said.
This story was contributed to “The Holdouts,” a reporting project focused on the 12 states that have yet to expand Medicaid, which the Affordable Care Act authorized in 2010. The collaborative is a project of Public Health Watch.
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