Opinion: The Woodshed

NC Medicaid expansion: A political loser then and now

The television ad run against State Sen. Bob Steinburg was brutal.

The ad accused Steinburg, R-Chowan, of being responsible for the closure of a rural hospital, leading to a woman’s death due to heart issues.  Visuals in the ad include the woman’s husband visiting her gravesite.

The message was clear: Steinburg was killing people by refusing to expand Medicaid.

As GOP lawmakers begin final state budget negotiations with Democratic Gov. Roy Cooper, they must make clear that broad expansion of Medicaid under the Affordable Care Act, or Obamacare, is not up for negotiation. In most legislative elections in 2020, Medicaid expansion was a critical issue, and virtually every time it lost.

Agreeing to expansion now, even to secure the governor’s signature on a budget that provides significant tax cuts and meets North Carolina’s most pressing needs in a responsible way, would be to ignore the messages voters sent in 2020.

It would be a blow to conservative voters who have been told by their legislative leaders that stopping the unaffordable expansion of government health care, in most cases to able-bodied men of working age, was a line in the sand worth fighting for.

Will the budget deal include Medicaid expansion?

A poll this spring obtained by Carolina Journal showed 64% of N.C. Republican primary voters opposed Medicaid expansion while only 28% supported expansion.

Republicans in the State House and Senate have agreed in principle to a budget deal. While we don’t know the details yet, House Speaker Tim Moore and Senate President Pro Tem Phil Berger have led their chambers to find GOP common ground on overall spending, state worker pay increases, the scope and structure of tax cuts, as well as many other issues that make up the state’s more than $20 billion budget.

“Now heavy lifting begins to see if acceptable changes for all can be made so Democratic Gov. Roy Cooper will sign a final proposal,” Berger spokesperson Pat Ryan wrote in an email to the Associated Press. “Final budget negotiations with Gov. Cooper will now begin in earnest.”

The battle over Medicaid expansion has consumed the state capital for several years. Cooper refused to sign a budget in 2019-2020 in large part because Republicans refused to expand Medicaid. While some budget adjustments were made, North Carolina has been without a fully updated comprehensive budget since July 2019.

Both sides decided to take the issue to voters in 2020, and Cooper and Democrats lost in state House and state Senate races where Medicaid was a key factor.

The front on Medicaid expansion runs through N.C. main streets, and voters are not buying it

Back in Chowan County, in rural northeastern North Carolina, Steinburg’s Democratic opponent Tess Judge appeared on camera in two television ads directly attacking Steinburg over Medicaid expansion.

Besides the seven-figure ad purchases, mailboxes were stuffed with mailers attacking Steinburg over Medicaid.

Steinberg defeated Judge 55% to 44% in 2020. His winning percentage increased a couple of points over his 2018 victory over a different Democratic opponent.

Joining Steinberg in victory was Winston-Salem-area Sen. Joyce Krawiec, R-Forsyth, who defeated Terri Elizabeth LeGrand 53% to 47%, even though similar mail and TV ads attacked Krawiec on Medicaid.

“Access to health care is a huge issue,” LeGrand told the Winston-Salem Journal. “Even before the pandemic, there were so many people in North Carolina who had no access to health care because of the political decision not to expand Medicaid.”

Medicaid expansion was also a key topic in Senate District 24, an open seat to replace retiring Sen. Rick Gunn. In that race, the winner between Democrat JD Wooten and Republican Amy Galey was touted by WXII television as one that “could determine which party controls the Senate next year.”

Wooten said the Republican majority’s refusal to “fully fund” education and expand Medicaid were major reasons he decided to make a second run for the seat.

Galey joined fellow Republicans in opposing Medicaid expansion in North Carolina, defeating Wooten 52-47%.

“I’m not sure that buying into Obamacare and latching on to the federal government’s plan is the best way to serve the people of North Carolina,” Galey said.

As reported by the Wilmington Star News, the rematch between Democrat incumbent Sen. Harper Peterson and former Republican Sen. Michael Lee also featured Medicaid expansion as an issue. Lee’s narrow victory ended any hopes that Democrats would flip the state Senate to Democratic control.

House campaigns in swing districts were similar. In Greensboro’s House District 59, Democratic challenger Nicole Quick used a compelling personal ad to attack Jon Hardister. Hardister won, 52-47%.

It’s about politics and price tags, and the stakes are high for both

Highlighting just how high the stakes are in North Carolina’s legislative races, a headline in the New York Times from Oct. 27, 2020, just one week before the election, was “A Chance to Expand Medicaid Rallies Democrats in Crucial North Carolina.”

North Carolina, a crucial battleground for the presidential race and control of the United States Senate, has another coveted prize at stake in this election, one that is drawing serious out-of-state money, dominating television ads, and driving get-out-the-vote efforts. 

Democrats believe they have a chance of gaining control of the State Legislature for the first time in a decade, which would make it possible to expand Medicaid to cover half-a-million more low-income adults here after years of Republican resistance.

The health care issue is paramount up and down the ticket in North Carolina, with left-leaning national and in-state groups using it to motivate Democratic voters — especially those who stayed home in 2016. Many of them belong to the demographic who would become eligible for Medicaid, the free government health insurance program, if the legislature voted to expand it as the Affordable Care Act allows.

When Cooper released his budget this spring, it again focused billions on Medicaid expansion.

“The biggest item in Cooper’s proposed budget has no price tag,” John Locke Foundation researchers wrote when the governor released his plan. “The [Cooper] budget document has no spending requirement for Medicaid expansion, though every indication is that it would cost ‘over $5 billion’ more than the current system, with state costs for ‘up to six years’ covered by $1.3 billion from a $1.7 billion increase in federal reimbursement for the nonexpansion population.

“Cooper’s 2019 budget proposal estimated Medicaid expansion would cost the state $474 million per year. Based on experience in other states, a more realistic state share would be between $568 million and $632 million per year, meaning the entire $1.7 billion would last no more than three years. Once that money is spent, Cooper continues to assume that hospitals would agree to a new provider tax paid directly to DHHS. Regardless, hospitals were not so eager to pay such a tax when it was offered before.”

Even with those sky-high price tags,  research on other states that expanded government-funded health care demonstrates that they notoriously underestimated expansion costs. Rather than across-the-board expansion, Republicans are expected to target extensions of Medicaid coverage to new mothers this year, but that effort is much smaller in scale and not connected to the larger Medicaid expansion under Obamacare.

The costs of Medicaid expansion, and an understanding of the scope of new beneficiaries, were not lost on voters.

By our count, Democrats running for the state legislature failed to win a single seat where Medicaid was a driving factor. In the end the General Assembly retained Republican majorities, with Democrats gaining one Senate seat and Republicans obtaining a net gain of four seats in the House. That final result:  Republican majorities of 28-22 in the Senate and 69-51 in the House.

Almost all winning Republicans expressed opposition to Medicaid expansion under Obamacare. While a few Democrats expressing support for expansion did defeat Republican incumbents, all those Democratic candidates were running in recently altered election districts that were more favorable to Democrats than before. That was the driving factor, not Medicaid expansion.

The political left and right do not agree on the policy wisdom of Medicaid expansion.

That is why we have elections. GOP leaders need to remind Cooper how Medicaid expansion lost at the ballot box in 2020.

The Woodshed, by investigative political analyst Dallas Woodhouse, is a unique blend of news and opinion based on his expertise and years of experience in North Carolina’s political trenches. For more follow him on Twitter at @DallasWoodhouse