Medicaid expansion bill clears final NC Senate step Medicaid expansion bill clears final NC Senate step

A multilayered health care reform bill that would expand the state's Medicaid program cleared the final Senate committee step Tuesday.

Senate Republican leaders continue to make good on their pledge to fast-track House Bill 149.

The Senate Rules and Operations recommended the legislation, and it was placed on the Senate floor agenda for Wednesday.

The Health Care and Finance committees unanimously recommended the bill Thursday - little more than a day after the amended bill was unveiled May 25 by Senate leader Phil Berger, R-Rockingham, and Sen. Joyce Krawiec, R-Forsyth.

If the full Senate approves, it would put pressure on House Republican leadership to act on HB149 before the projected end of the 2022 short session in early July.

House GOP leaders have been lukewarm about Medicaid expansion, so much so that speaker Tim Moore, R-Cleveland, has indicated there is little expectation the House will take up HB149 in the next four to five weeks.

Medicaid currently covers 2.71 million North Carolinians, which increased by nearly 27% or 588,611 people since the pandemic surfaced, according to the N.C. Department of Health and Human Services.

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

GOP bill priorities

Senate GOP leaders have changed their stance on Medicaid expansion thanks in part to several Republican priorities included in the Senate's version of HB149.

Berger emphasized that Senate GOP leaders believe Medicaid expansion "needs to happen with additional reforms, including the very real supply-side issues that prevent North Carolinians from accessing care."

Krawiec and Sen. Ralph Hise, R-McDowell, said Medicaid expansion, as proposed in this bill, is preferable to a feared scenario in which the Biden administration, or future administrations, would force expansion onto states that haven't already offered Medicaid to more residents.

Among the GOP priorities HB149 includes: easing restrictions on certificates of need, which health care providers must obtain from the state before building new health care centers or adding certain equipment.

Easing that restriction could allow for more competition, including from for-profit groups, for medical procedures.

The state's not-for-profit health care systems have opposed weakening certificate-of-need laws out of concern that large for-profit groups would enter North Carolina and cherry-pick the more lucrative services, leaving the not-for-profits treating the sickest patients, likely without health insurance, who come into emergency departments.

Other key elements of the proposed Medicaid expansion: permitting nurse practitioners, certified nurse midwives and nurses with other advanced specialties to practice without a physician's formal supervision; requiring health insurers in the state to cover telehealth services; and requiring in-network health facilities to alert consumers when out-of-network providers are scheduled to provide care.

Krawiec said the proposed bill "pairs with many other policy changes that will improve access to care" and emphasized that it would reform certificate-of-need laws "that I have been working on since I got here."

Berger said the state "must do something to improve health care, especially expand access and control costs. We need coverage in North Carolina for the working poor."

Work requirement provision

The few Finance committee questions centered on whether a controversial work requirement in the bill could disqualify the state from receiving federal COVID-19 relief money.

The proposed work requirement for new Medicaid recipients has received grudging support from some Democratic legislators.

The federal relief law would provide North Carolina $1.5 billion over two years to treat traditional Medicaid patients if it accepts expansion and, most important, agrees to not put stipulations on enrollees.

Legislative fiscal research analysis staff told Finance members they did not believe North Carolina would be eligible for the relief money if HB149 contains the work requirement provision.

"In order to qualify ... you can't exclude anybody who would be part of the expansion population," legislative research analysis staff member Mark Collins told the committee.

"With work requirements, there's of course the possibility that somebody could be excluded."

Krawiec said Thursday that, in her discussions with state Health Secretary Kody Kinsley, "he did not mention that we may not be qualified. So, that's an interesting note."

Sen. Paul Newton, R-Cabarrus and Finance co-chairman, responded to questions about the federal relief funding by saying that "there's gray area there as to whether we would be eligible or not. It's TBD (to be determined), but it's a fair current reading of the (federal relief act)."

A Medicaid work requirement passed by the Arkansas and New Hampshire legislatures has been struck down by federal courts. In March 2021, the U.S. Supreme Court said it would not hear additional arguments on the appeals made by the two states.

Berger said May 25 the plan is to pass the bill 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."

Berger said that, while the work requirement is being litigated, unemployed enrollees would remain eligible and not be denied.

New reality

Berger and Krawiec said May 25 that most GOP Senate leaders have embraced "a new reality" about Medicaid expansion.

"Medicaid expansion has now evolved to the point that it is good state fiscal policy and helps us address the mental health crisis we're facing," Berger said.

Cooper's office said the progress on Medicaid expansion is encouraging and that the governor "will carefully review this legislation."

Berger said recent Medicaid reform legislation, highlighted by the managed care transition that began in July, has made the state's system "capable of handling the additional (450,000 to 650,000) people who will be covered without creating problems for the state budget."

"It was a broken program that was mismanaged and burdened taxpayers with billion-dollar shortfalls on a regular basis," Berger said.

"Fortunately, over the past decade, Republican leadership in the General Assembly has turned Medicaid around in N.C. with eight straight years of solid Medicaid budgets without cost overruns."

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