The Republican version of Medicaid expansion will move to the House floor.
NC Healthcare for Working Families passed the House Health Committee on Wednesday, Sept. 18.
For more than an hour, the debate revolved around the two pillars of the GOP version of Medicaid expansion — work requirements and premium co-pays.
Predictably, Democrats tried to weaken the work requirements and the premiums, while some Republicans questioned whether they’d survive legal or bureaucratic challenges, fearing the bill would back them into traditional Medicaid expansion.
The bill would expand Medicaid to cover those earning up to 138% of the federal poverty line, about $17,000 a year for individuals. Like Gov. Roy Cooper’s proposal, it would enroll at least 500,000 adults, and spend $6 billion over the next decade, 90% of which would be paid for by federal taxes. But unlike traditional Medicaid expansion, the GOP-alternative would require participants to complete a work requirement and pay a premium of 2% of their income.
Other red states have tried to temper Medicaid expansion into something more palatable to Republicans. Usually, this involves slapping work requirements and premiums onto expansion, but several states have run into trouble over these mandates.
Kentucky, Arkansas, and New Hampshire floated work requirements, and federal courts sunk them all. After repeatedly calling the approval of work requirements “arbitrary and capricious,” U.S. District Judge James Boasberg ruled that they violated the core purpose of Medicaid.
“It did not address … how the project would implicate the ‘core’ objective of Medicaid: the provision of medical coverage to the needy,” Boasberg said. “[It] never adequately considered whether Kentucky HEALTH [the state’s Medicaid expansion program] would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid.”
The Trump administration has shrugged off such rulings. It approved work requirements for six states, while they’re pending in seven, and the three mentioned earlier have been set aside by the courts.
“[The administration wants] to give states greater flexibility to help low-income Americans rise out of poverty,” said Seema Verma, the head of the Centers for Medicare and Medicaid Services. “[It will] vigorously support their innovative, state-driven efforts to develop and test reforms that will advance the objectives of the Medicaid program.”
Rep. Donny Lambeth, R-Forsyth, said he modeled his bill off of Indiana’s expansion, but several lawmakers remained skeptical of the cost of collecting the premiums and data for the work requirement.
“There are several unanswered questions about why we need to add work requirements. Is this a good use of our taxpayer money? Do we know the cost? We’re not sure,” Rep. Carla Cunningham, D-Mecklenburg, said. “It seems to increase the bureaucratic red tape and the cost of administering it.”
The state would have to create a reporting system for the work requirement, as well as a way of calculating the dollar amount of 2% of each enrollees’ income.
“That’s certainly a big lift for the department,” said Dave Richard, N.C. Medicaid deputy secretary. “We would model what other states have done. But we know there would be a technology requirement for us to make that happen. Certainly it’s one of the more complicated pieces of legislation that we would need to make work.”
Democrats also objected to the work requirements on principle.
“Most people that are eligible for expansion are already working,” Cunningham said. “This adds another level of hardship for them to try to put [reporting] into their crammed work schedules.”
Bill sponsor Lambeth didn’t budge, and various amendments to shoot down both requirements failed.
“The premium is at the heart of the bill,” Lambeth said. “As I was talking to people, one theme was that they were very proud and they don’t mind paying something.”
Democrats pleaded to extend the deadline before enrollees were dropped if they failed to fulfill the work requirement. This amendment passed with Republican support.
They also tried to create a safety mechanism to shut off the work requirement if the economy dives into a recession.
At the close, the debate moved to consider those suffering from substance abuse, who usually don’t qualify for Medicaid under the current narrow eligibility categories.
“There’s a good number of people who are not covered at all. Those people only get services if there are available funds,” Kenny House, a licensed clinical addiction specialist, said. “We’re putting ourselves in a dangerous, precarious situation by not finding a way to cover these individuals. … When they don’t get treatment, people are more likely to wind up overdosing, in the emergency room, in jail, or worse, dead.”
Advocates for those suffering from substance abuse have long campaigned for expansion, and the committee hearing was no exception.
“Next month, I’ll celebrate 15 years of sustained recovery. … I lost two sisters to this illness, to mental and substance use disorders. We have strikingly similar risk factors and protective factors. The one fundamental difference between us was that I had access,” Donald McDonald, a veteran and addiction specialist, said.
The bill has been referred to the House Rules Committee, where it will sit until it is put on the House calendar. That’s unlikely to occur until October. House Speaker Tim Moore, R-Cleveland, announced at Wednesday’s House session the chamber plans no floor votes before Sept. 30.