Cooper and Trump together on Medicaid? Not so fast

North Carolina's request applies only if Medicaid expansion, long a political pipe dream for Gov. Roy Cooper and other Democrats, comes to fruition here.

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Travis Fain
RALEIGH, N.C. — In announcing Thursday that states can add work requirements to their Medicaid programs, the Trump Administration held North Carolina out as one of 10 states seeking such a change.

But North Carolina's request applies only if Medicaid expansion, long a political pipe dream for Gov. Roy Cooper and other Democrats, comes to fruition here. Cooper's administration hasn't asked for permission to add work requirements to the state's existing Medicaid health insurance program, which covers more than 2 million people.

The Governor's Office billed its willingness Thursday on expansion work requirements, a policy many other Democrats reject, as a pragmatic bid toward compromise. Outsiders looking in had a similar read of the situation.

"The governor strongly supports Medicaid expansion and has been fighting for it since the day he took office, and he realizes that most people who would qualify already are working," Cooper spokeswoman Sadie Weiner said Thursday via email. "Some state House Republicans support increased access to Medicaid with a work requirement, and although the Governor has serious concerns about that, he's pleased that there is some movement on this.”

Some Republicans pointed Thursday to the suddenly aligned policies of Cooper and President Donald Trump, congratulating him on joining their side of the issue, but foregoing any promise to actually back his Medicaid expansion pitch.

Even with the policy just limited to expansion, Cooper's support does put him out of step with traditional allies. Democratic 4th District Congressman David Price's Twitter account had blasted the Trump Administration shortly after Thursday's announcement: "If @realDonaldTrump succeeds in his assault on low-income Americans, we will be undoing the damage for generations."

Asked whether that criticism extended to Cooper's proposal, a Price spokesman said simply that the congressman believes health care is a basic human right.

"He wants Medicaid recipients to be healthy and to be able to work, but he does not believe that working should be a condition for receiving federal assistance," spokesman Sawyer Hackett said in an email.

North Carolina's request was part of a broader waiver application sent to Washington in November. It laid out the basics for work requirements that would be attached to a proposal called "Carolina Cares," a bill with some Republican backing that contemplates a modified version of Medicaid expansion.

"Carolina Cares enrollees would be required to be employed or engaged in activities to promote employment," the state's waiver request states.

Like the policy the Trump Administration announced Thursday, the proposal has exceptions for pregnant women, elderly beneficiaries, children and people unable to work because of a disability.

The state's request is still pending with federal Medicaid regulators, but the Trump Administration's announcement indicates such a request would be approved. There was no indication that the open path toward work requirements makes Medicaid expansion any more palatable in a Republican-controlled General Assembly that has repeatedly rejected it, though.

"I don't know that that one change would make any sort of fundamental change," House Appropriations Chairman Nelson Dollar, R-Wake, said.

Medicaid now generally covers pregnant women, children, the elderly and the disabled in North Carolina. Expansion was a key part of the Affordable Care Act, the idea being it would extend the federal- and state-financed program to the working poor – people who make too much money to qualify for Medicaid but don't get insurance through work or make enough money to qualify for federally subsidized insurance plans through the online exchanges set up under the ACA, often called "Obamacare."

When the U.S. Supreme Court declared Obamacare constitutional, though, it also made expansion optional for state governments, and not all of them expanded the program. In North Carolina, that left hundreds of thousands of people in a coverage gap.

"I think the Cooper Administration recognized the reality that, to have any viability, their expansion proposal had to have work requirements," Curtis Venable, an attorney who specializes in Medicaid at Ott Cone & Redpath, said Thursday.

Most of the population that would qualify for Medicaid expansion already works, Venable said. If the price of expansion is backing a requirement most people already meet, "Oh, please don't throw me in that briar patch," Venable said.


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