As Kate noted yesterday, the NCGA is "off" this week, with public pinky-swear promises from Republican leadership that no votes will occur until Sept 30. The legislature "should" have ended this marathon session in July, save for the major obstacle of Medicaid expansion, so let's dig into where things stand with it. Quick background: Gov Cooper vetoed the NCGA budget on June 28 because it did not contain Medicaid expansion. The Republicans did not have the votes to override Cooper's veto until the Republican deceit in the House on Weds, Sept 11, when they took and passed a quick veto override vote while most Democrats were elsewhere - having been told it would be a non-voting session. The ill will and mistrust from that dark day remains. The Senate has not yet held a budget veto override vote, so it remains in limbo.

Interestingly, HB 655, NC Health Care for Working Families, again cleared a House committee a week later, on Sept 18, after languishing for a couple months. HB 655 is sponsored by Republican Rep. Danny Lambeth, who served in a variety of administrative leadership positions at Wake Forest Baptist Health and NC Baptist Hospital. Rep. Lambeth understands the issue of the coverage gap better than most of his colleagues, and he also knows what's needed for a bill to have any chance of passing. HB 655 is basically Medicaid expansion that would likely qualify for federal Medicaid funds, but with work and premium requirements. And there's the rub.

On the positive side, it would extend coverage to several hundred thousand NC citizens who fall in the coverage gap between traditional Medicaid and qualifying for ACA marketplace subsidies (50-133% of federal poverty level, ~ $6200-$16,600/year). It "would allow working people who make less than 133 percent of the federal poverty guideline to buy into Medicaid. For example, a family of four making less than $34,000 a year would be eligible." (WRAL). BUT they'd have to pay 2% of their monthly income as a premium, even if they earn just a few thousand dollars a year, pay co-pays for the services they receive, AND report at least 80 hours of work or qualifying volunteer activities/month. Those are the poverty-penalizing aspects that make the bill palatable to Republicans and hard to swallow for Democrats.

There are exemptions to the work requirements, i.e., caregivers for a relative, students, those in a substance use treatment program, women who are pregnant, and Native American tribe members who receive care from the Indian Health Service. It's difficult to estimate how many people would be affected by these work requirements, as many of the folks who would benefit are working already, just not getting employer health insurance.

The experience of other states suggests that work requirements and premium payments are not cost-effective because they cost more to administer and track than they generate. Eligible people who ARE working may get bumped off because of not meeting the ongoing reporting requirements, and many Medicaid recipients lack easy access to computers and the internet to comply with reporting requirements. Some state work mandates have been rejected by the courts, so it's unclear if that would pass legal muster in NC - but the bill covers that base by stating that if a court blocks the premiums or work requirements, the whole program shuts down.

Read more:
NC Policy Watch, Five simple truths about the Medicaid expansion debate
NC Health News, Bill to extend health insurance benefits to low-income workers finally gets started
NC Policy Watch, Medicaid expansion would profoundly improve physical, economic health of rural NC
WRAL, GOP Medicaid plan again advancing in House
N&O (limited free views), GOP Medicaid expansion compromise is back on the table after surprise budget vote.

NC health advocacy groups are not of one mind about this bill. Some see it as a step in the right direction, even with its undesirable elements. They point out that far more people would benefit from access to coverage than the number of people who would be affected by the work and premium requirements. Others remain opposed to the bill in its current form. It's possible (at least in 🦄-land) that there could be additional compromise around those requirements in the next week or two. The bill's sponsors hope it will come up for a full House vote in the next two weeks.

Even if the House passes it in some form, its future in the Senate is an uphill climb - although Sen. Berger was quoted at the end of August as saying he's recently had productive conversations with Cooper's secretary of Health and Human Services, Mandy Cohen, and he left open the possibility of some form of health care expansion measure. "There is some broad agreement that there are some folks in North Carolina that through their employment have no access for care and are not eligible for policies on the (ACA) exchange and Medicaid," Berger said. "I think there's a need for us to have a conversation and a solution for those folks." (Dawn Baumgartner Vaughan/N&O, Colin Campbell/The Insider, 8/28/19, paywalls). Sen. Jeff Jackson (Dem) reported on Facebook that many Republicans in both chambers support Medicaid expansion, but are afraid to vote for it because of possible far-right primary challenges.

So what can WE do?

  • Share and attend this event sponsored by Health Action NC on Tuesday, Oct 1, 9a-12N at the NCGA. "Join us in delivering a memorial luminary that has a photo of someone who died in the coverage gap to every legislator in the NCGA. Following the delivery, there will be a Legislative Hearing on Medicaid expansion hosted by Senator Dan Blue and Rep Darren Jackson in Committee Room 1128 in the General Assembly at 11am."
  • Contact your NC state senator to urge them to uphold Gov Cooper's budget veto unless Medicaid is expanded.
  • Contact your NC state senator and representative to let them know what you think about HB 655. Speaking for myself (not representing any groups I'm affiliated with):
    • I support closing the coverage gap with a "clean" Medicaid expansion bill such as that filed by the Democrats in January. This is based on meeting the health care needs of more people AND the increased cost and inefficiency of creating additional administrative bureaucracy to handle those aspects of HB 655, as has been reported by other states with these requirements.
    • Barring that, I support HB 655 with amendments to expand the work requirement exemptions (so fewer people would be affected) and reduce the premium and co-pay amounts.
    • My last choice is to pass HB 655 in its current form. I oppose the work and premium requirements, and I'm willing to accept a loathsome compromise temporarily (see next bullet point) to provide coverage ASAP to several hundred thousand people who need it NOW.
  • Work to GOTV in 2020 so we flip the NC House and Senate and can pass a clean Medicaid expansion bill or amend HB 655 to remove those requirements!


Tags: (NC Medicaid Expansion, Health Care, NCGA, NCPol)

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