Oct. 2--RALEIGH -- These days, support for Medicaid expansion in North Carolina varies from Republican to Republican.
Republicans in the state House are working on a proposal to expand the federal coverage program for the poor. Republicans in the Senate say they're not interested in Medicaid expansion. Meanwhile, some Republicans in rural North Carolina feel neglected as they await solutions.
"We don't have the luxury of doing things based on some national political party's stance on some issue," Dale Wiggins, chairman of the Graham County commissioners, told Republican Senate leader Phil Berger in a recent letter.
Democratic Gov. Roy Cooper vetoed the GOP's proposed state budget largely because he wanted to negotiate Medicaid expansion. The Obama-era Affordable Care Act allows for expansion, and 36 states, including some under Republican control, have decided to go along. The proposition is dividing North Carolina Republicans.
The House compromise, House Bill 655 -- NC Health Care for Working Families -- includes a work requirement and a premium of 2% of the person's income. Both are additions to Medicaid expansion that Democrats do not want. And some Republicans don't want any kind of Medicaid expansion at all.
Berger said Tuesday that the work requirements are just "window dressing" and had been shot down by the courts in other states.
The House hasn't so far approved the GOP compromise. Rep. Donny Lambeth, a Forsyth County Republican, told reporters when the bill was in committee a few weeks ago that he wanted to work out questions raised before getting it ready for a floor vote.
Republicans say expansion adds to the federal deficit and raises the possibility that the federal government won't always pay the bulk of the costs as it does now.
Lambeth said he's talked about the issue to civic groups and others, trying to explain it, and that some conservatives have told him they don't like it because they think it's Medicaid expansion. When he tells them about the work requirement, that there's no state funding and that it includes preventative care they are more supportive.
Lambeth is sticking to the work requirement, which can also be volunteer work, and the premiums.
Berger stopped short of saying Senate Republicans would automatically reject the bill.
"We'll have to look and see what comes over" [from the House] and then discuss it among Republicans, he said.
Berger said, however, that they are looking at ways to cover the working poor who are not eligible for Medicaid and can't afford private insurance. He said Senate Republicans do not think Medicaid expansion is the answer to that, citing fiscal uncertainties with future budgets.
"Make no mistake, the House bill is Medicaid expansion," Berger said. "I do not support it."
In a September health committee meeting, Rep. Becky Carney, a Mecklenburg County Democrat, said the work requirement would add bureaucratic red tape and administrative costs.
On Tuesday, Democratic lawmakers held a hearing on Medicaid expansion at the Legislative Building.
Waiting for solutions
Amid the standoff, Berger exchanged letters with commissioners in Graham County, located west of Asheville.
The board, which has four Republicans and a Democrat, released a statement on Aug. 26 supporting House Bill 655 and saying commissioners "understand that the majority of uninsured individuals in North Carolina are employed but do not make enough money to afford health insurance coverage."
On Sept. 10, Berger sent a letter to Graham commissioners hoping to clarify the situation. He suggested commissioners had been misled by a letter from Cooper "that doesn't provide all of the facts."
Berger encouraged the board to "contact Governor Cooper and tell him to drop his single-issue ultimatum and support the budget passed by the General Assembly."
The board apparently didn't appreciate Berger's letter. Wiggins, the board's chairman, responded to Berger in a Sept. 16 letter.
"Here in Graham County Senator, we are accustomed to being ignored by not only the governor but by our legislature as well," Wiggins wrote.
"We supported Medicaid expansion because our citizens need it. Did you know Senator that our poverty level is near 30%?" he continued. "Did you know that we have several hundred working adults with no means to have health care?"
The decline of manufacturing left Graham County without a large private employer, Wiggins said. Given the dire circumstances, he said commissioners have to consider solutions that aren't necessarily Republican ideas.
"While some politicians like to operate as 'one size fits all,' that approach doesn't fit rural NC," he told Berger.
"The reality is in places like Graham County," Wiggins said, "a mom or dad working at McDonald's or Wendy's for just over minimum wage cannot afford $1,500 a month for insurance."
Wiggins concluded his letter by suggesting legislators don't understand his county's hardship.
"You know Senator Berger," he said. "for some people who have good paying jobs and good health insurance it is easy to say that those without health insurance just need to go to work, isn't it?"
Asked for comment on Wiggins' letter Tuesday, Berger spokesman Pat Ryan said the Senate leader appreciated the commissioner's feedback.
"While Senator Berger disagrees that Medicaid expansion is good policy, the health care access issues raised by the Graham County Commissioners are real," Ryan said. He again called on Cooper to drop "his Medicaid-or-nothing ultimatum" and to negotiate health policy apart from the budget.
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