Expanding Medicaid focus of new bill US House bill allows cities, counties to bypass legislatures to expand Medicaid coverage

Winston-Salem and Forsyth County would have the ability to directly pursue Medicaid expansion for their communities through a U.S. House Democratic bill submitted last week.

H.R. 31, titled Cover Outstanding Vulnerable Expansion-Eligible Residents Now (COVER Now) Act, was submitted Jan. 9 by U.S. Rep. Lloyd Doggett, D-Texas.

It has 42 co-sponsors, including Rep. Kathy Manning, D-6th, and all seven of North Carolina's U.S. House Democratic representatives.

North Carolina is one of 11 states - along with Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin and Wyoming - that have not expanded their Medicaid program. There are bill co-sponsors from nine of those states.

Several studies have shown that North Carolina could have between 450,000 and 650,000 potential Medicaid beneficiaries upon expansion.

H.R. 31 would allow a federal government bypass of legislative roadblocks in those states.

Unlike some states that expanded through a voter referendum, it is currently not an option in North Carolina.

Expansion must be approved through the Republican-controlled General Assembly that has been cool, if not ice cold, to most Democratic expansion bills.

"This landmark legislation authorizes the (federal) Centers for Medicare and Medicaid Services to work directly with counties, cities and other political subdivisions to expand Medicaid coverage," according to a news release from Manning.

"It would, for the first time, allow local leaders to help their vulnerable residents in states which have declined to accept federal resources for Medicaid expansion."

H.R. 31 goals

Medicaid currently covers 2.71 million North Carolinians, according to the N.C. Department of Health and Human Services.

States can expand Medicaid eligibility to nonelderly people with incomes up to 138% of the federal poverty level under the federal Affordable Care Act.

Those who might be eligible under the expanded program are between the ages of 18 and 64 and earn too much to qualify for Medicaid coverage, but not enough to purchase coverage on the private insurance marketplace.

Among the bill's goals are:

* Authorizing CMS to contract directly with counties and other political subdivisions to establish demonstration projects expanding Medicaid coverage to their residents;

* Allowing participating entities to receive the same deal previously made available to states - 100% federal funding for the first three years and a gradual reduction to 90% federal funding by year seven and thereafter;

* Permitting entities to apply individually or jointly if they wish to establish a regional expansion project;

* Keeping existing Medicaid rules and systems in place and applying them to local expansion programs;

* Requiring states to cooperate and authorize access to state Medicaid systems for participating entities, with additional federal administrative Medicaid funding for cooperation and subject to federal penalties for non-cooperation; and

* Ensuring that should a state expand, eligible beneficiaries enrolled in a local expansion program would be automatically enrolled into the state Medicaid program.

Slim odds

Meanwhile, political analysts said the odds are very low that the Republican U.S. House majority would act on the legislation even though 14 red states have expanded their Medicaid programs.

"During the last two years, Congress enacted measures to give states extra incentives to expand Medicaid," said John Dinan, a political science professor at Wake Forest University who is a national expert on state legislatures.

"Congress also considered, but failed, to enact some measures that would provide direct coverage to persons who would be eligible for Medicaid expansion in states that have declined to take that step."

Those bills were considered by a Congress where Democrats held majorities in the U.S. House and Senate, Dinan said.

"Now that Democrats have lost majority control of the House, further legislation encouraging Medicaid expansion is unlikely to move very far in Congress," Dinan said.

Zagros Madjd-Sadjadi, an economics professor at Winston-Salem State University, that with an all-Democratic sponsorship to date, "I give the chances of this legislation less than a 20% chance of clearing the House and that may be generous."

"If it clears the House, it will likely become law, but I seriously doubt this will go forward in its current form.

"The Republicans in the U.S. House want to cut spending, not increase it."

Stalemate

The General Assembly begins its 2023 session in earnest Wednesday with Senate Republicans holding a 30-20 supermajority and House Republicans with a 71-49 majority that's one member shy of a supermajority.

Senate Republicans can override a Democratic Gov. Roy Cooper veto if all 30 GOP senators vote in favor.

Senate leader Phil Berger, R-Rockingham, and House speaker Tim Moore, R-Cleveland, voiced during the 2022 session their support for separate Medicaid expansion bills.

However, they and other Republican legislative leaders have been unable to reach a compromise on whether to include certificate-of-need reform within expansion legislation.

Manning noted the General Assembly's inaction and/or unwillingness to expand Medicaid. "Blocking health care access disproportionately affects communities of color," Manning said.

"After years of Republican-led obstruction, I'm proud to cosponsor the COVER Now Act to help North Carolinians in need get the health care coverage they deserve."

Rep. Don Davis, D-1st District, and a former six-term state senator, said the General Assembly's failure to expand Medicaid "ultimately prevents more than 95,000 eastern North Carolinians from accessing lifesaving health care and bringing more than 3,000 jobs."

"I am proud to join my colleagues from the non-expansion states to ensure all citizens across eastern North Carolina have the resources they need to access health care."

Turning point?

A pivotal turning point in Berger and Moore agreeing to consider Medicaid expansion was the potential for the federal pandemic relief law to provide North Carolina with $1.5 billion over two years to treat traditional Medicaid patients.

That funding is contingent on the Republican-controlled legislature agreeing to not put stipulations on Medicaid enrollees.

The CDC under the Biden administration has denied Medicaid expansion waivers from several states, such as Arkansas, Georgia, Michigan, New Hampshire and Texas, that would have required new enrollee to pay a monthly premium and/or meet a work requirement.

Legislative fiscal research analysis staff have told legislators they did not believe North Carolina would be eligible for the relief money if House Bill 149 contains the work requirement provision and certificate-of-need reform.

Even with the urging of Cooper, state Health Secretary Kody Kinsley and the N.C. Healthcare Association, loggerheads remain on whether to include Senate requested certificate-of-need reform into any expansion legislation.

Berger said the plan is to pass HB149 with the work requirement included, "and then we'll deal with whether or not we can convince the Biden administration or the courts that this is the right thing to do."

Moore supports a clear Medicaid expansion bill in the revamped Senate Bill 408.

"We believe this bill will help address some really critical needs while being fiscally responsible to taxpayers and without incentivizing a person not to get a job," Moore said.

Those federal funds would free up DHHS to re-direct General Fund dollars to other priorities; $1 billion would be used to address substance abuse and mental health.

Local beneficiaries

The Urban Institute estimated in a November report at least 346,000 potential beneficiaries in North Carolina if it occurred in 2023.

That includes at least 28,000 residents in the five-county Winston-Salem metro area - 16,000 whites, 8,000 Blacks, 3,000 Hispanics and 1,000 listed in the other category.

By comparison, there would be at least 30,000 beneficiaries in the Greensboro-High Point metro area - 15,000 whites, 11,000 Blacks, 2,000 Hispanics and 2,000 listed as other.

The institute's report was commissioned by the Robert Wood Johnson Foundation.

"This single policy change would have a profound effect on hundreds of thousands of people in these two states," said Katherine Hempstead, the foundation's senior policy adviser.

"Previous research has shown health coverage saves lives, improves individuals' financial security, and improves hospital finances."

According to the report, "without Medicaid expansion, the Winston-Salem area's uninsurance rate of 11.6% is somewhat below the state average, and it would remain below the state average with expansion at 7.6%."

For Greensboro-High Point, its uninsurance rate with expansion would be the lowest in North Carolina at 7.4%.

"Increasing coverage through Medicaid expansion would have significant benefits for North Carolina, moving the state with the ninth highest uninsurance rate in the nation to the 24th highest," said Michael Simpson, principal research associate at the Urban Institute.

"In Winston-Salem, Greensboro and three rural areas of North Carolina, around one-third of people without health insurance would gain coverage."

The report does not factor in about 589,000 North Carolinians who have gained Medicaid coverage during the COVID-19 pandemic through federal public-health relief legislation.

According to the Kaiser Family Foundation, a national nonprofit health-care advocacy group, Congress enacted the Families First Coronavirus Response Act soon after the pandemic erupted in the U.S. in mid-March 2020.

Part of the act is a requirement that Medicaid programs keep people continuously enrolled through the end of the month in which the COVID-19 public health emergency ends, in exchange for enhanced federal funding.

That has been the pathway where many of the additional Medicaid beneficiaries in N.C. gained coverage during the pandemic

The latest expectation is that the Biden administration will set an April end date after several extensions.

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