Raleigh, N.C. — Tuesday's election ensured that President Barack Obama's signature health care bill will remain law and that in North Carolina Republicans who opposed the measure will be responsible for carrying out key provisions.
Gov.-elect Pat McCrory, a Republican, was none too complimentary of the health care law on the campaign trail. And now he must work with outgoing Gov. Bev Perdue, a Democrat, as the state gets ready to make key decisions about how to deal with the Affordable Care Act a month before he takes office.
"She (Perdue) is going to have to be making decisions even before I'm sworn into office on policy issues regarding health care, regarding transportation, regarding economic development, the list goes on and on," McCrory said Thursday.
Perdue has been very cooperative with him and his transition team, he said.
McCrory's inauguration date has not officially been set, but it will almost certainly be in the first 12 days of the new year.
In the short term, the state must decide by Nov. 15 whether to apply for federal grant money to plan the law's implementation. More importantly, states were going to have to decide by Nov. 16 how the state will handle the so-called health exchange – a marketplace where those who do not have employer-provided coverage but are too wealthy to be covered by Medicaid can buy coverage.
North Carolina can choose to build its own exchange, participate in a federal exchange or enter into a partnership where the federal government does much of the work but the state has some responsibility.
Late Friday, the U.S. Department of Health and Human Services extended the deadline for designing exchanges by three months. The deadline is now Feb. 15.
However, it appears the Perdue will still have to announce a decision on whether North Carolina wants to pursue its own healthcare change before Nov. 16. The state has longer if it wants to pursue a hybrid plans.
Insurance Commissioner Wayne Goodwin, a Democrat, plans to go ahead with the groundwork toward both the grant and the exchange.
"The Department of Insurance’s plan is to submit a grant application by the Nov. 15 or the February deadline for money for exchange planning related to consumer assistance, plan management and IT infrastructure for a Medicaid system," said Goodwin spokeswoman Kerry Hall.
That either-or uncertainty is typical of those who were interviewed regarding how North Carolina will respond to the health care law this week.
"Most people in the state who have been asked or thought about this have said, ultimately, we probably want to get to a state-based exchange," said Al Delia, secretary of the state Department of Health and Human Services.
However, he said, McCrory and legislative leadership will have to decide whether that is the course the state will go and, if so, how quickly North Carolina can proceed.
Given the complexity of the issue and the looming deadline, a hybrid approach is probably most likely, according to Adam Searing, a public health expert who works for the Health Access Coalition.
Both Searing and Delia said that, if the state started out in a partnership with the federal government, North Carolina could gradually take over responsibility once the state was ready.
"We might want to have a little bit more of a role in figuring out what the rules would be for (health) plans that are offered on the exchange," Searing said.
The exchanges are the next key component of the Affordable Care Act to take effect. Pieces of the federal law, such as requirements that adult children up to 26 years old be able to stay on their parents' health policies, have already taken effect. But the bulk of the law goes into effect over the next two years.
The Affordable Care Act, sometimes called Obamacare, was bitterly opposed by Republicans at the state and national level. When the GOP took control of the General Assembly in 2011, one of their first pieces of legislation involved exempting North Carolina residents from mandates in the bill. Perdue vetoed that measure.
Despite opposing the law overall, state House Republicans passed a bill in 2011 that would have created a state-level exchange in North Carolina.
The state Senate opted not to take up that House bill. Senate leaders wanted to see the outcome of a federal lawsuit that sought to have the Affordable Care Act declared unconstitutional. They also were holding off to see whether Obama would win re-election. His Republican opponent, Mitt Romney, had pledged to repeal large sections of the law.
But the U.S. Supreme Court has ruled the Affordable Care Act constitutional, and Obama has won re-election, moves that virtually ensure the act will go into place.
"Clearly, the best thing for our state is to have a state-directed exchange as opposed to leaving it to the federal government and getting a cookie-cutter, one-size-fits-all program," said Rep. Nelson Dollar, R-Wake, who has been a leader on both budget and health policy issues.
Delia agreed with Dollar that a generic health insurance exchange program would likely encounter bureaucratic hiccups in North Carolina. This state's Medicaid rules don't mesh exactly with federal guidelines, meaning there could be confusion over whether someone should be sent to the exchange or apply for Medicaid. Also, the state has a new benefits application system getting ready to go online that could make applying for health coverage through and exchange easier. That system wouldn't be used if a generic federal approach comes about.
Dollar says lawmakers should push through a bill quickly so that the federal government is not left in control of the state's exchange. Senate leaders were not available to comment Friday but have expressed caution about such a move in the past.
McCrory said he doesn't have enough information to make a decision yet.
"There's total confusion," McCrory said Thursday of the federal health care law. "Nobody understands the bill or its implementation."
A McCrory spokesman said on Friday that the governor-elect had been on a call with other governors about the law and how others were approaching it but that McCrory was still studying the matter.
Perdue said she has not made any final decision.
"We are determining which option would serve in the best interest of North Carolina families and taxpayers," said Perdue spokeswoman Chris Mackey. "With this in mind, we will consult with Gov.-elect McCrory and Commissioner Goodwin before the governor makes her final decision."