Medicaid myths debunked at first study panel meeting

Emily Blanford is an expert on state health policy with the National Conference of State Legislatures, a nonpartisan nonprofit research group that studies policy and outcomes across all 50 states. She and a colleague, Kate Blackman, gave the committee an overview of how other states have handled Medicaid expansion.

"If we're going down this path, we want to create a North Carolina plan or North Carolina solution," committee co-chairman Rep. Donny Lambeth told the committee. "And because we are not an expansion state, the value of having this workgroup is to look at what's worked well in other states and maybe pull from those positive things, and then what's not worked so well, avoid that pitfall."

Lambeth, R-Forsyth, asked Blanford how expansion has affected state budgets.

"One of the hallway conversations always comes around to, 'Well, you know, so-and-so state is having all kind of financial problems because they expanded Medicaid. They're way over budget, this, that and the other,'" he said.

Blanford said Medicaid in general puts pressure on state budgets, even in non-expansion states. But Medicaid expansion in itself does not seem to have added to the problem.

"As I’ve seen, the state level of spending has not gone up much. It really hasn't. It's been so much of a large influx of federal dollars that state funding has stayed relatively stable," she said.

Other committee members asked about a 2009 Oregon study that seemed to show that Medicaid expansion did not led to better health outcomes for people who gain coverage.

Blanford said newer studies seem to show that it does.

"In the Oregon study, they only looked at one to two years' worth of the data," Blanford explained. "They've done studies now where they looked at five years after someone got coverage, and they did see some movement on the health outcomes when you're looking at it in a longer-term range."

"What the newer studies might show," she added, "is that it just takes a lot longer to develop your relationship with your providers, to do that behavior modification that might actually lead to those differences in your health outcomes."

Lambeth said one concern he’s frequently heard is that the federal government could just decide to reduce its share of the cost of expansion. It currently covers 90% of the bill, he said.

"What prevents them from going down to 70 or 60 or 50, and pull the rug out from under us, put more pressure on our state budget?" Lambeth asked. "Now we've done it, it's hard to take away a benefit, and we're just gonna have to pay more."

Blanford explained that's not a change that could be made by federal regulators.

"The 90% is written into the Social Security Act," she said. "It's not a regulation, it is in law, so it would take a federal piece of legislation to undo it."

With 38 states having expanded Medicaid in some form or other, such a bill would likely face substantial opposition.

Blanford also fielded questions about whether Medicaid expansion increases access to care and whether it lowers the uninsured rate in a state.

"Expanding Medicaid reduced the uninsured rate in states that expanded, and there are also studies indicating that expansion helps narrow the coverage gap particularly between urban and rural residents. And many studies do demonstrate that expanding Medicaid did increase access to care," she said

However, she said, although expansion has helped rural hospitals in other states, it has not always been enough to keep their doors open.

"Even though uncompensated care was reduced, there's still a gap between the cost to provide services and the Medicaid reimbursement rate," Blanford said.

But after a federal judge threw out work requirements in other states' programs, House leaders said the GOP caucus would not support expansion.

Several lawmakers asked the presenters from the National Conference of State Legislatures about that ruling.

"I take it it's your opinion," said Rep. Larry Potts, R-Davidson, "that any premium for access or work requirements for a program, a new program being submitted for Medicaid expansion, would not be approved."

Blanford responded: "Right now, the Biden administration is not approving it, and in fact, they've rescinded previous approvals. So they aren't approving it right now."

Blanford said at one point, 10 states had work requirements for Medicaid expansion, and many others had requested to add them. But the judge's ruling threw out many of them, and two that remained, Arkansas and Montana, have agreed to phase out their requirements over a year.

She said Georgia, on the other hand, has sued over the change, "So we will be seeing this issue play out in the courts again."

Some committee members suggested adding workforce development programs instead of a work requirement.

"Are you aware of any states that have tried to bring in training or education requirements to try to move Medicaid population folks in the coverage gap into better employment situations?' asked Sen. Mike Woodard, D-Durham. "It's okay to try to require folks to work, but if we're not getting them on a solid career path, they may lose that job or not be able to maintain that job or the career might change."

Lambeth said: "I think in North Carolina in our environment, we do need to look at something like a work training program to incentivize and move these people into a better paying position, so they can get off of Medicaid."

Blanford said she did not know of any states that require job training, though at least one, Indiana, offers a voluntary training program for expansion enrollees.

The committee meets again in two weeks, and again in mid-March.