Answers on Medicaid expansion waiting on Supreme Court

Posted February 5, 2015

— Gov. Pat McCrory did his best in Wednesday's State of the State speech to talk about expanding the state's Medicaid health insurance program for the poor and disabled without actually saying the words "Medicaid" or "expansion."

That rhetorical aversion has to do with both the dicey politics and uncertain legal future of any North Carolina effort to provide health insurance to those who make too much money to currently qualify for Medicaid but too little to qualify for subsidies on the health insurance exchanges set up by the federal Affordable Care Act, what some people call "Obamacare."

"As we continue to review health care options for the uninsured, we are exploring North Carolina-based options that will help those who can’t help themselves while also encouraging those who can," McCrory said during his address before the General Assembly. "If we bring a proposal ... to cover the uninsured, it must protect North Carolina taxpayers, and any plan must require personal and financial responsibility from those who would be covered. I will only recommend a North Carolina plan, not a Washington plan." 

When Congress passed the Affordable Care Act in 2010, federal lawmakers and President Barack Obama assumed that all states would be required to expand their Medicaid programs to cover people whose families earn up to 138 percent of the federal poverty mark – $27,310 for a family of three people. But a 2012 U.S. Supreme Court decision struck down the requirement, saying states had the option of expanding Medicaid in response to Obamacare but that the federal government could not require expansion.

The following year, North Carolina lawmakers acted to prevent McCrory or any other governor from expanding Medicaid without the legislature's permission. Since then, top legislative leaders have remained staunchly opposed to expansion.

However, that has left a coverage gap in the state. According to a recent Kaiser Family Foundation report, 357,000 North Carolinians are both ineligible for Medicaid but earn too little to shop for health insurance on the state's health exchange, which offers income-based subsidies to purchase health insurance. Other studies put that number closer to 500,000. Of those in the coverage gap, 62 percent are in what the foundation defines as a "working family." Three-quarters are adults without dependent children. 

When expansion isn't expansion

Democrats and progressive groups have continued to pressure McCrory to call for expansion. Federal tax dollars, they say, are leaving North Carolina and going to pay for Medicaid expansion in other states. Covering more people, they argue, would help the broader economy as well as doctors and hospitals, who currently end up writing off millions of dollars worth of care provided to those without insurance. 

"I wish he would have been more emphatic about that," Sen. Mike Woodard, D-Durham, said of McCrory's expansion-related remarks. "Maybe that would have nudged some folks, particularly in the Senate, to work toward expansion. But he didn't get quite there."

If McCrory does "get there," it's unlikely he'll couch his proposal as a Medicaid expansion. Just as Obamacare is unpopular with national Republicans, chronic budget problems with the state's Medicaid system have frustrated GOP legislative leaders over the past six years. Many still see the system as deficit-plagued and inefficient. 

"Until we get it under control, I'm not a big fan of expanding what we have," said House Majority Leader Mike Hager.

That may explain why Health and Human Services Secretary Aldona Wos went to great pains following McCrory's speech to say that the administration wasn't contemplating "Medicaid expansion" per se.

"What that would mean is that what we have now, you're making it larger," Wos said.

Instead, the McCrory administration is pondering a "different model" that would use federal Medicaid expansion money in a different way. The Affordable Care Act offered to pay 100 percent of expansion costs in the first three years of the ACA, and will pay 90 percent of expansion costs through 2022.

"What we're proposing is something different," Wos said. "It's providing health care to the uninsured – or an opportunity for that." 

She did not lay out specifics of what the proposal might be, but there are examples of alternatives to Medicaid around the country. 

For example, in Indiana, Gov. Mike Pence recently reached a deal with the Obama administration to allow Medicaid to function more like private health insurance for those earning 100 percent of poverty. That plan would require premiums and co-payments. Other states, such as Arkansas, have used expansion money to subsidize private health insurance for those who would otherwise have found themselves in the coverage gap. 

Court rulings could change McCrory's plan

But McCrory has not tipped his hand as to what sort of approach he might prefer, and top lawmakers say they've heard nothing to change their minds on expansion.

"He's not brought us and did not tonight say he was proposing Medicaid expansion," Senate President Pro Tem Phil Berger said after McCrory's speech. "If he brings that to us, then I think my position has been clear on that. I think the position of the Senate is clear." 

Don't expect to see those specifics until sometime this summer. 

A court case pending before the Supreme Court, King v. Burwell, would not only keep North Carolina from filling the existing coverage gap but would likely blow that gap wider. The plaintiffs in that case argue that North Carolina and other states that relied on the federal government to handle their health insurance exchanges – rather than creating their own state-based exchanges – should not be allowed to offer insurance subsidies. That argument is based on what is likely a drafting error in the complex and highly technical bill that was rushed through Congress. 

"We'll find out nothing until the Supreme Court rules, because that really will determine whether whatever we're proposing is a viable option," Wos said when asked for specifics on North Carolina's plan. 

Even if that ruling should leave federally run state exchanges intact, don't expect lawmakers to jump on the expansion bandwagon. While Obamacare promises to pay 90 percent of the expansion costs until 2022, Republicans say they want some assurance as to what will happen after that.

"Once the federal government quits paying for it ... who pays for it after that?" asked Hager, R-Rutherford.

If the state were forced to pick up more of the tab, he argued, that could put more pressure on North Carolina's budget.


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  • 68_dodge_polara Feb 7, 2015

    View quoted thread

    No one is stopping you from paying for their healthcare. You may scoff but your in a better position than the federal government as it's 18 trillion in debt.

  • heelzfan4 Feb 6, 2015

    "Once the federal government quits paying for it ... who pays for it after that?" asked Hager, R-Rutherford."
    While it is prudent to "plan ahead" - the playing field of Healthcare most like will look totally different 7 years from now. So, in the meantime, NC will lose out on the federal dollars that will pay for health insurance (health, food, dental, etc) for over 300K in NC alone! Shame on NC!

  • Bob Cooke Feb 6, 2015
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    View quoted thread

    It is very obvious that you know nothing about insurance companies and policies and why individuals policies went up.

  • skeeter II Feb 6, 2015

    Currently, every hospital HAS to treat EVERYONE WHO COMES TO THE EMERGENCY ROOM!!!!!!!! Even illegal immigrant who come in their ER! Who is paying for this?

    A quick FIX to the rising health car cost would be to change the law so that hospitals ER's could refuse to treat those who were not sick enough or injured enough to meet a minimum state of treatment. (yes, vehicle accident patients would be treated) -- thus allowing hospital ER's to stop being a doctor's office.

    Those coming in to the ER that did not meet the minimum need to treatment would be referred to clinical service centers that already exist, thus reducing the ER cost of treating patients. The ambulance drivers/EMS personnel would not bring to the hospitals anyone that did not need to minimum level of care that hospital when then be providing.

  • Flora Pinkham Feb 6, 2015
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    Since we're arguing on the basis of anecdotes, I'll add mine. We had decent (expensive) insurance which we paid for out of pocket because I am self-employed and my husband works for a very small company. We just signed up for insurance through the ACA, with no subsidies whatsoever. We get slightly better insurance (due to mandates like dental checkups for kids) for slightly less money. Is it a game-changer? No. Personally, I would rather have a single-payer option, but this works out alright. If the ACA is repealed and replaced with a system that does not include the coverage mandate, our rates will probably rise due to fewer people being insured. This is the "free market solution" Republicans wanted, but now they feel they must run away from it because someone slapped Obama's name on it.

  • jimcricket15 Feb 6, 2015

    I love how folks refer to taxpayer money as "Federal Dollars". Nope it was money that belonged to a person or a company. Then conveniently they leave out the people like me who now has to buy coverage items that are unneeded and unwanted and has caused severe financial strain for my spouse and I. We had good insurance that was affordable. Now we have not so good insurance that we actually can not afford and on top of that our taxes are higher as a result of the Not Affordable Health Care Act. this has pushed us into the paycheck to paycheck syndrome where we have zero buffer to set aside for any unexpected expenses. I would dearly love to see the ACA repealed. Health Care and Health insurance is each person's responsibility. Turning my spouse and I into slaves to pay for others is immoral.

  • sprintpcs Feb 5, 2015

    I meant i make to much for medicaid not medicare, sorry. how about we write about things that pertain to nc us citizens that this helps or hurts not a far away state that does no matter or nor effect us north Carolinian's

  • Amy Whaley Feb 5, 2015
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    Actually The Analyst, Oregon's ER visits increased when they expanded their Medicaid/Obamacare. This has happened in many states, so now we are not only paying for their insurance but also their ER bills cause they haven't met their deductibles.

  • sprintpcs Feb 5, 2015

    I have 2 kids make 15k I could get food stamps do not I have pride, but I make to much did you read that i make to much 15k with 2 kids, for medicare. sorry I not a liar and do things right alot of us do do it right how about a little help to the ones that work give you your food coffee. we pay taxes like you heck we job creators without folks struggling like me you do not go to work. what wrong with some assistance whats wrong with a fair wage.

  • Maurice Pentico Jr. Feb 5, 2015
    user avatar

    The entire way Medicare is administered, from patients, to doctors, to hospitals needs to be overhauled... to reduce waste, fraud and just plain excess. But until we do this... any expansion is simply an expansion of wasted tax dollars.... and with $18 TRILLION in debt... taxpayers can not afford it.