North Carolina’s failure under Republican leadership to improve low-income residents’ access to health care via the Medicaid program has been like a persistent, throbbing pain in the state’s civic and economic life.
The pain can be literal, when people must do without the kinds of care and treatment that everyone recognizes as meeting basic standards of quality and cost-efficiency.
It is figurative but no less real when those same people, because of unresolved medical issues, fall into underemployment or outright joblessness, or when their relatives are forced to become caregivers, or when hospitals – especially smaller, rural ones – are swamped with the red ink that flows from their obligation to treat everyone who shows up at their emergency rooms.
Now, finally, after four years of rock-hard resistance by the General Assembly’s Republican majority, a few of their number are proposing that Medicaid in North Carolina be broadened to serve more of the state’s adults who typically can’t afford health insurance on their own or who don’t have access to it through work.
The plan, dubbed “Carolina Cares,” is not perfect. There’s no telling how its requirement for premium payments would limit the number of people who actually signed up. There’s no telling whether the state’s hospitals, which would face additional fees, would be wholeheartedly on board.
There’s no sign as yet that legislative chiefs who decide which bills will be allowed to advance are ready to soften their opposition to what they decry as Medicaid expansion.
Yet House Bill 662 signals what hopefully will become a deeper look at the many factors that have made expansion a top priority of health care and anti-poverty advocates, the Council of Churches included. For starters, the bill’s four primary sponsors bring credibility to their cause.
Rep. Donny Lambeth of Winston-Salem, for example, is a former hospital administrator. He says the plan will save the state money and help keep small hospitals open on the strength of an influx of federal funds. Rep. Greg Murphy of Greenville is a surgeon. Rep. Josh Dobson of McDowell County, a budget analyst, sees the bill as a viable way to improve health care in the state’s rural corners. Rep. Donna White of Clayton has been a public health nurse.
An Obama legacy
An expanded role for Medicaid was an integral part of President Obama’s health care reform, the Affordable Care Act. The Supreme Court, while letting the ACA go forward, allowed states to opt out of the expansion.
So even though the federal government (i.e., the broad base of federal taxpayers) would have absorbed most of the cost, several Republican-controlled states, including North Carolina, balked because of a professed concern about state expenses down the road. Of course, that was in the context of Republican opposition to the ACA in general. If Obama was for it, they were against it.
Left in the lurch have been people who earn too much to qualify for unexpanded Medicaid but too little to qualify for subsidies under the ACA – subsidies enabling them to afford health insurance through the program. For most, health coverage from any source has been out of the question, so treatable conditions often go untreated and preventative care doesn’t happen.
Such folks typically have to rely on emergency rooms when aches and pains no longer can be ignored. Hospitals have to swallow the costs or pass them along to insured patients through higher charges. It’s a situation that flunks every test of humaneness and financial prudence.
H.B. 662 would give people earning up to 133 percent of the federal poverty level a chance to enroll in Medicaid. By that standard, a single person would be eligible if his or her annual income were less than $15,800. These are the working poor, almost by definition.
Coverage conditions
Yet that points to a couple of the bill’s key trade-offs – unfortunate trade-offs, frankly. The sponsors must have reckoned that if the bill were to have a chance in this legislature, they’d have to include some features that would appeal to those self-righteous pillars of the community who tend to regard the poor as lazy free-loaders. So, new Medicaid beneficiaries would have to work, or at least be looking for work or preparing for it. And they’d have to pay.
The bill says that “Carolina Cares” participants would have to “be employed or engaged in activities to promote employment.” There would be some exceptions, such as when a person had caregiver responsibilities for someone who was disabled.
Of course having a job is a good thing, and jobs usually go to people who look for them. Yet such a requirement is insulting, in that it presumes folks would rather sit around on their couches rather than work to better themselves. It also ignores all the reasons why many North Carolinians, especially in declining rural areas, remain jobless. Those reasons usually boil down to lack of opportunity, not lack of effort. They might even include health problems lingering because of the lack of convenient, affordable care.
In exchange for their Medicaid coverage, folks enrolled in “Carolina Cares” would face annual premiums amounting to 2 percent of household income. So, the single person with earnings of $15,800 would have to pay $316 a year.
While that sounds like a health insurance bargain, it also might be a disincentive that would deter some people from enrolling. Considering the overall public savings from broader access to good-quality health care – the kind of care that helps prevent minor illnesses or conditions from escalating – such a premium requirement could be both unnecessary and counterproductive.
Out of the turmoil
It’s been estimated that between 300,000 and 500,000 North Carolinians would be served by an expanded Medicaid program offered without conditions such as those proposed in H.B. 662. The goal ought to be to reach as many among that group as possible – not to tailor the expansion so that some people, their barely-scraping-by incomes notwithstanding, still are left out.
Even though some Republican governors have led the way to broadened Medicaid programs in their states, North Carolina’s Pat McCrory never got out front on the issue. He may have seen it as a lost cause, given that his fellow Republicans in the legislature went out of their way to enact a law taking expansion off the table.
Democratic Gov. Roy Cooper put Medicaid expansion high on his agenda after taking office at the start of this year. He was stymied by legislative opposition and by the advent of a president who had made repeal of the Affordable Care Act a signature campaign promise.
Yet it turned out that Obamacare would survive, at least for the time being, when those repeal efforts collapsed amid Republican turmoil on Capitol Hill and President Trump’s inability to broker a deal. It’s hardly a coincidence that H.B. 662 has emerged in the aftermath.
The “Carolina Cares” approach, despite its flaws, deserves a thorough and open-minded review. Jobs are at stake. People’s health is at stake. The survival of hospitals – key institutions in many smaller communities – is at stake. And the state, by most reckonings, has nothing to lose.
To avoid additional state expense, should hospitals be expected to help pay for poor people’s broader Medicaid access since it will mean less of a burden on their emergency rooms? That might be an acceptable bargain, as H.B. 662 envisions.
In any case, what’s now clearer than ever is that we look to North Carolina’s political leaders, Republicans and Democrats alike, for sincere efforts to bring health insurance and thus better health care to many of our fellow citizens on whom good fortune has rarely smiled.
