Nearly three dozen physicians, clinicians, university academics, parents, and assorted health association representatives attended a March 30 public hearing on Medicaid reform — the state’s first — and predictably, the most common topic of testimony was a plea to expand Medicaid under President Obama’s Affordable Care Act.
Sandy Irving, representing the North Carolina Council of Churches, was among those receiving polite, supportive applause in beseeching government officials to enlarge the Medicaid program.
“Providing health insurance for everyone and closing the gap for a half million people … is a moral issue,” Irving said. “I would appeal to your conscience to please include everyone and close the gap … for all of God’s children.”
Jonathan Kotch, representing Health Care for All NC, said expanding Medicaid would be a welcome change to federal reviewers at the Centers for Medicare and Medicaid Services, and could fast-track approval of reforms. Medicaid expansion could extend mental health and behavioral health services at no initial cost to the states, he said, because the federal government has promised to pick up all additional costs.
Despite Kotch’s claim, many health policy analysts have warned against buying into federal promises of funding that may not be honored as costs continue escalating. Sen. Louis Pate, R-Wayne, agrees with them.
“I think the whole plan of the Affordable Care Act is under a lot of scrutiny, and whether that all stands or not remains to be seen” after the presidential election, said Pate, chairman of the Joint Legislative Oversight Committee on Health and Human Services, and a member of other health care and Medicaid-related committees.
“But even it it all stood, can we believe the feds? Can we believe they are going to cover all the costs of expansion for two years, and still continue to cover it at a very high rate for the foreseeable future?” Pate asked.
“I don’t think so. Who would be left holding the bag? The taxpayers of North Carolina,” he said.
The Republican legislative majority has “finally begun to learn how to manage Medicaid so we don’t have these huge cost overruns that we inherited” in 2011 when the GOP took control of the General Assembly, Pate said.
“I don’t think there’s much appetite in the leadership of the Senate … to expand Medicaid in North Carolina,” Pate said. “I think the caucus would not want to go forward with that.”
Sen. Ralph Hise, R-Mitchell, chairman of the Joint Legislative Oversight Committee on Medicaid and N.C. Health Choice, said “Democratic groups” are ginning up emotions through a Twitter campaign to use the public hearing process to clamor for Medicaid expansion.
“I don’t know how the legislature could have been more clear on what our stance of the expansion of Obamacare is in this state, and how it applies to Medicaid,” Hise said. Senate Republicans oppose it, and he has not seen any House committees or leadership members “in any way advocating for the expansion of Medicaid services.”
Hise said pleas for expansion are not relevant to the public hearing process being conducted by the state Department of Health and Human Services. The General Assembly has been clear n laws passed during the administrations of both Gov. Beverly Perdue and Gov. Pat McCrory that only the legislature, not the executive branch or DHHS, can change Medicaid eligibility criteria.
“I do think you are seeing the proponents of the Affordable Care Act get desperate,” Hise said.
The push to expand Medicaid follows repeated problems with the federal health care exchange, escalating premium rates under exchange plans, failure to hit targets for reducing the number of Americans without insurance, and little improvement in medical outcomes under Obamacare.
Hise called the expansion drive a last-ditch effort “to get so many people dependent on the programs under the law that they can resist [repealing] it.”
Roughly one in five North Carolina residents, or 1.9 million people, already receive Medicaid. The state allocates $3.7 billion to Medicaid, or 17 percent of the General Fund budget.
At the hearing, DHHS Secretary Rick Brajer said the state hopes to file a waiver with the federal government by June 1 to alter the Medicaid program. He told the roughly 200 attendees at the McKimmon Center on the N.C. State University campus that approval and implementation of Medicaid reform could take up to four years.
More predictable costs, and moving toward a plan providing set monthly fees for patients (giving higher amounts for those with greater medical problems) under a private, for-profit administrator of the Medicaid system are key components of the change.
“This is about improving health outcomes, and ensuring our incentives drive that in a sustainable way,” Brajer said.
“We’re going to build a community of health care” through a community-centered, people-based system, Brajer said. “Medicaid reform really is going to be a North Carolina solution built on a foundation of innovation.”
He said a broad spectrum of health care interests, including beneficiaries, advocacy groups, hospices, medical providers, and government agencies, are participating in drafting the waiver.
But Christine Kim of the Duke University School of Law, representing the North Carolina AIDS Action Network, said nobody from the HIV-AIDS provider community was invited to participate. She and several HIV-AIDS providers requested Medicaid expansion to allow those infected with the disease but uninsured to obtain treatment as a public health benefit.
Brajer said beneficiaries “will have even more choice” under the revised plan. “They will be choosing their doctors. They will be having a choice of plans as well,” with five or more options in some counties. Providers would be rewarded for better health outcomes under new quality measure metrics.
The plan would have a strong emphasis on inequities in medical care, especially in the areas of rural health and child mortality, Brajer said.