The N.C. House passed a bill Tuesday evening 101-6 that would direct the state’s health agency to come up with a Medicaid Modernization Plan. The bill lays out the fiscal requirements that members would require in order to vote to expand Medicaid to an estimated 600,000 new enrollees.
Those policies outlined in the Rural Healthcare Access and Savings Plan Act (Senate Bill 408) include work requirements for enrollees, $1 billion earmarked for behavioral health and substance abuse, expansion of health care to rural areas, and a requirement that the state withdraw from Medicaid expansion if the federal government reverses its promise of covering 90% of the costs.
“I feel confident that this plan has been set up in a way, with fiscal accountability and responsibility in place, if the secretary can meet that,” said Speaker Tim Moore, R-Cleveland, on the House floor Tuesday evening. “I’m certainly going to support it and encourage my colleagues to support it, because it’s the right path forward, with these guardrails in place.”
Six months to strike a deal
The bill authorizes Department of Health and Human Services Secretary Kody Kinsley to work with the federal Centers for Medicare and Medicaid Services (CMS) to come up with a plan specific to North Carolina and gives him until Dec. 15 to present it to lawmakers. A vote would then be held on that plan.
Democrats in the chamber Tuesday expressed concern that the bill’s plan requirements would be difficult to meet, asking the speaker if House leaders have designed to set it up for failure.
“Are these criteria such that they are almost impossible to meet?” asked Rep. William Richardson, D-Cumberland.
Moore assured him that Kinsley has agreed to the terms of the bill and believes they can be met.
“If I wanted this bill to fail, the easiest thing to do is to say we aren’t going to take it up, but that’s a lot of trouble to go through and a lot of hours spent for this to ultimately fail,” said Moore. “The beauty of this, though, is that instead of us giving that blank check out, we actually have the final say once the product comes back here. I believe these benchmarks will be met.”
House Minority Leader Rep Robert Reives, D-Chatham, encouraged Democrats to vote for the bill.
“I’m going to support this because I’d like to keep the conversation moving forward,” said Reives.
“The people who are being left out right now are people who are working. They are working, they are trying, and they are in a terrible gap,” he added. “If there is a human being out there who will say, ‘Hey, I got Medicaid insurance, now I’m going to quit my job,’ I’d like that person to come by my office because that would mean you would be homeless, you wouldn’t have any food. If you are homeless and you go without eating or drinking, the health insurance can’t save you.”
During the break between official legislative sessions, a study committee of members, chaired by Rep, Donny Lambeth, R-Forsyth, examined Medicaid expansion, talking to health care groups and officials from other states that have expanded the federal entitlement program. However, the committee’s report was never completed before the state Senate passed an outright Medicaid expansion bill in May.
Senate members have been pressing the House to take their bill up, but House leadership said they wanted a clearer view of the costs and to have their requirements met before they would agree. The House bill gives N.C. DHHS six months to hammer out the details to get a vote.
“If the secretary did bring back something that did not meet the criteria, there would probably be a lot of folks on this side who would vote no, and I don’t know if it would pass,” said Moore.
Some House Democrats wanted the body to take up the Senate’s bill, too, before adjourning. Gov. Roy Cooper has also called for Medicaid expansion since taking office in 2017.
“It’s no secret that the governor didn’t like the fact that there would be votes in December,” said Moore. “I made it very clear to the governor that if there was not a second vote in December on this bill, it would go nowhere in the House. So it was either this way or no way, just to be candid.”
In other states that have expanded Medicaid under the Affordable Care Act, experts generally underestimated the size of Medicaid expansion enrollments, underestimated its cost, and overestimated its health benefits.
What is in the bill
The bill lays out some additional requirements of NCDHHS’ proposed expansion plan including that, “Individuals who are not United States citizens shall not be covered except to the extent required by federal law.” DHHS is also required to establish a system of reporting back on enrollment numbers, whether enrollees are using preventive care, and how it is impacting health outcomes.
Work requirement waivers to allow states to put work/volunteer requirements or a small co-pay into expansion plans were offered by the Obama administration to encourage states to expand the program back when the Affordable Care Act passed. Under the Trump administration, states that expanded Medicaid had their work waivers approved, but the Biden administration has put a stop to them. Kinsley will now be required to negotiate with CMS to pass them.
The House bill also requires that $1 billion be spent on opioid, substance abuse, and mental health crisis in North Carolina, “using savings from the additional federal Medicaid match available under the American Rescue Plan Act.” ARPA is the $1.9 trillion plan passed by Congress in 2021 that economists are blaming for the nation’s historic inflation rate.
Under the House legislation, a DHHS-created task force of leaders in the faith community, law enforcement professionals, mental health experts, and addiction specialists would be required to guide the $1 billion in spending on drug and mental health issues.
The plan also has specific proposals to increase access to health care and preserve hospitals in rural areas of the state. Lambeth said North Carolina ranks 43rd out of 50 states for access to health care and that 11 rural hospitals have closed since 2005, with 19 currently at risk of shutting down.
“Members, we have universal care in this state and in this country. It’s called the emergency room,” said RIchardson Tuesday evening on the floor.
“The is a great step forward,” he added. “I urge you to vote for it, and in December I urge you to vote to put North Carolina as part of this plan so that our people can get adequate health care, so they can work and not live in the emergency room.”
What is NOT in the bill
The directives for DHHS in the House bill do not include some of the industry reform measures that the Senate offered in its bill, including the SAVE Act, which would address needs in rural areas and giving nurses more independence, and partial repeal of some certificate-of-need requirements.
Rep. Gale Adcock, D-Wake, a registered nurse, stood on the floor to object to the omission of the SAVE Act (House Bill 277) in the House Medicaid bill. It would allow nurses to work up to the level of their training, even if a doctor was not immediately available. It is intended to address labor shortages in rural hospitals.
“I know that at least half the members of this chamber signed on as co-sponsors of the SAVE Act,” she said. “The SAVE Act does really important things for this state economically.”
Adcock announced on the House floor that she wanted to file a discharge petition to get the SAVE Act heard before lawmakers leave Raleigh.
Ultimately only six members of the House voted against the bill, with 101 voting in favor. It now goes to the Senate for approval.
“I believe that this will be successful, that we will have a product back that we can all be very proud of when we vote on this in December,” stressed Moore.
The legislature is driving to wrap up business and adjourn the short session by Saturday afternoon, July 2.