NED BARNETT: N.C. GOP went wrong - and now will stay wrong - on Medicaid expansion

Posted July 24


EDITOR’S NOTE: Ned Barnett is editorial page editor for the News & Observer of Raleigh, where this column originally appeared.

Deciding the worst thing done by the Republican-led General Assembly is a challenge. Was it House Bill 2, voter suppression, gerrymandering, passing tax cuts that favor the rich, underfunding public schools or stripping environmental protections?

But in the end the choice is simple. The worst thing Republican lawmakers have done since taking power in 2011 was what they didn’t do: They refused to expand Medicaid under the Affordable Care Act.

The impact of that refusal is stunning. More than 400,000 low-income adults are blocked from obtaining health care insurance under Medicaid. The state took a pass on three years of the federal government paying 100 percent of the cost of expansion with a promise to pay no less than 90 percent afterward.

The 10-year expense to North Carolina to expand from 2013 to 2022 would have been $3.07 billion, about $300 million a year, according to a 2014 report from the Urban Institute. The gain to North Carolina over that period would have been $39.6 billion in federal Medicaid funding plus $11.3 billion in hospital reimbursement funds. That river of federal funding would have created an estimated 23,000 jobs.

After three years of holding out, the stress is showing, especially in the state’s rural hospitals. On July 10, Morehead Memorial Hospital in Eden, the home of state Senate leader Phil Berger, filed for protection under Chapter 11 of the U.S. Bankruptcy Code. The 108-bed independent hospital with 700 employees will stay open as it seeks a large hospital network that will take it in.

Dana Weston, Morehead Memorial’s president and CEO, said the hospital’s financial troubles had various causes and Medicaid expansion was not a “silver bullet” that would have prevented bankruptcy, but she said expansion would have helped the bottom line. “For any hospital in any community there is a benefit that comes from that,” she said.

North Carolina’s Republican leaders – like those in 18 other Republican-led states – have chosen hardship for hospitals and denial of insurance for the working poor over cooperation with the signature legislation pushed through by Democratic President Barack Obama. They say they’re acting out of fiscal prudence, but it’s clear the real motive is spite – to block or at least diminish Obama’s historic accomplishment.

But now it appears that resistance has backfired badly. Despite a Republican Congress and Republican president, the party’s goal of repealing and replacing “Obamacare” is proving extremely difficult. One major obstacle is Medicaid. The Republican-led states that expanded don’t want to give the benefit back, and enough Republican senators from those states are balking at any proposal that revokes Medicaid’s expansion.

Sen. Dean Heller, a Republican up for re-election in 2018, objected to the original Senate repeal and replace proposal saying, “I’m telling you right now, I cannot support a piece of legislation that takes insurance away from tens of millions of Americans, and hundreds of thousands of Nevadans.”

Given concerns like Heller’s, Medicaid expansion is likely to survive. Even if Republicans do finally agree on changes, those will involve the private insurance side of the ACA.

Lawmakers in states that resisted expansion thought they’d look wise when the ACA was tossed and states that expanded were left in the lurch. But now it appears the holdouts are in the lurch. They said “no” and now a Republican Congress will reward the states that said “yes.”

John Holahan, a fellow in health policy at the Urban Institute in Washington, said, “There was never any economic advantage to states staying out and it’s even more so now that (Medicaid) is not going away.”

Mark Hall, the director of the Health Law and Policy Program at Wake Forest University, said the failure of the ACA repeal effort “reframes” the expansion issue for holdout states.

“Now it looks like the smart move would be to go ahead and expand, not only to help those who need the help, but because when Congress does make changes it’s clear that they will provide more benefits to those that expanded than those that didn’t,” he said. In North Carolina, he said, “There’s sort of a new window of opportunity to get our share of the expansion money before it disappears.”

Are North Carolina’s Republican leaders prepared to make that smart move? Apparently not. On Thursday they welcomed the end of Gov. Roy Cooper’s attempt to expand Medicaid from the executive level. In a joint statement, Berger and House Speaker Tim Moore said: “We are pleased Gov. Cooper abandoned his plan to defy state and federal law and unilaterally expand Obamacare in North Carolina, but remain prepared to take swift legal action if he tries to make this unlawful move again.”

You have to give them credit. They were wrong when the ACA began, and they’re even more wrong now that it lives on, but they’re consistent.


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