NC Senate votes for Medicaid expansion, uphill battle looms in the House

The North Carolina Senate voted Wednesday to expand Medicaid in the state, pairing new government health insurance for the state’s working poor with a sweeping rewrite of health industry regulations.

If finalized, the bill would mean a colossal shift for one of the last dozen states that has not expanded Medicaid.

A largely perfunctory follow-up vote is expected in the Senate Thursday to move the bill to the House, where it faces major opposition. Despite newly found support for the idea among Senate Republicans, House Republicans have repeatedly said the bill is a nonstarter, and Speaker of the House Tim Moore’s office reiterated that Wednesday.

Now a waiting game begins as House Bill 149 becomes one more bargaining chip in the annual high-stakes, back-and-forth negotiations between the House and Senate as they work through a number of legislative issues, including the state’s nearly $30 billion annual budget.

“Quite frankly our work has just begun,” Senate President Pro Tempore Phil Berger, the top Republican in the Senate, said from the chamber floor Wednesday evening. “There are 120 people on the other side of this building that we’ve got to start working on. I’m going to do my part.”

The bill promises a multibillion-dollar infusion of federal cash to pay 90% of the cost of health insurance for several hundred thousand people in North Carolina, many of them among the working poor. These are largely adults who make too much money to qualify for Medicaid under regular state rules, but not enough to afford health insurance on their own or to qualify for federal subsidies through the health care exchanges which, like Medicaid expansion, were created by the Affordable Care Act more than a decade ago.

Sen. Kevin Corbin, one of the few legislative Republicans who has supported expansion for years, told other lawmakers to think about a single mother of two working a retail job. Her children qualify for Medicaid, but she does not. She faces a choice, Corbin said, between buying insurance for herself and putting food on the table.

To make expansion more palatable to conservatives, Senate Republicans packaged it with a long-desired rollback of the state’s certificate-of-need rules, which require hospitals and other medical groups to seek state approval before expanding a long list of services.

The process is complex and time consuming, and it allows other providers to object to expansions. Hospitals have argued for years that they need this system to avoid over-saturating the market with profitable services, like elective surgeries, which would leave hospitals without profit centers to help pay for emergency rooms and other money-losers.

Republicans also pasted in the SAVE Act, which would roll back state requirements and allow advanced practice registered nurses—who have at least a master's degree—more freedom to treat patients without direct supervision from a doctor. This proposal has been around for years, and doctors groups have worked against it, saying it would erode the quality of care, particularly for people in poorer or rural communities.

Nursing groups say that hasn’t borne out in states that implemented similar policies. Sen. Ralph Hise, R-Mitchell, said North Carolina now requires “supervision in name only,” and that this portion of the bill would let advanced practice nurses do “what they are educated, and trained to do, and what they are already doing.”

The SAVE Act, on its own, has enough legislative sponsors to become law, but leadership has not brought it to the floor for a vote in either chamber.

The bill also includes new notice requirements to cut down on surprisingly large medical bills for out-of-network services, as well as a telehealth provisions that would require insurers to cover online doctor’s visits, though not necessarily at the same price as in-person visits.

Senate Republicans pitched both the SAVE Act and the certificate-of-need reforms as a way to increase the supply of health care services, particularly in rural North Carolina—a necessary change, they argued, if more people are about to have health insurance.

“We’d be exacerbating the problem if we only expand access to coverage,” Hise said.

Just how many people that would be is a moving target. For years state officials have said expansion would help 500,000 to 600,000 people, but the state’s regular Medicaid rolls swelled during the pandemic, and a federal rule—which will eventually expire—forbids the state from removing people from those rolls.

Sen. Joyce Krawiec, a key Republican on health care issues, said this month that it’s likely 300,000 of the people who would benefit from expansion are already on Medicaid, which in normal times serves mostly children, senior citizens and disabled adults.

“The numbers may work out really well for us,” Sen. Jim Burgin, R-Harnett, said during Wednesday’s Senate debate. “A lot of [people who will benefit from expansion] I think are already on Medicaid right now.”

Wednesday’s Senate vote was 44-2, an unusually lopsided and bipartisan count for major legislation that has divided Republicans and Democrats at the statehouse for a decade.

“It does my heart good that, even though it took 10 years,” Sen. Gladys Robinson, D-Guilford, told her Republican colleagues. “...Praise the Lord.”

Berger, R-Rockingham, acknowledged during the debate that he has probably spoken against Medicaid expansion over the years more than anyone else in the state. He said his long-standing fiscal concerns have been alleviated, though, in part because the Affordable Care Act survived so many Republican efforts to kill. It is clearly here to stay, he said.

Republican lawmakers also built off-ramps into the bill in case the federal government’s promise to cover 90% of expansion costs goes away, something Berger said is very unlikely.

The expansion bill also calls for work requirements for new Medicaid expansion recipients, but those are unenforceable unless the federal government, and federal courts, reverse course on the issue and allows these requirements. Berger said some people who benefit from expansion “aren’t going to do anything and are going to get coverage” anyway.

But most, he said, are “trying to do the best they can.”