Medicaid expansion offers relief, but when?

On March 27, 2023, Gov. Roy Cooper signed House Bill 76, Access to Health Care into law. He called it a historic moment for North Carolina.

“Medicaid expansion is a once-in-a-generation investment that will strengthen our mental health system, boost our rural hospitals, support working families and so much more,” Cooper said. The new law received an enthusiastic welcoming for the 600,000 North Carolinians who will benefit by gaining access to health care.

Local effects of expansion

Dr. Sue Lynn Ledford, executive director of Four Square Community Action, has served on the front lines in health care and home care for many years.

“Many of our working families have no health coverage now, and Medicaid will help provide a healthier workforce in our community,” said Ledford, a former health director in Wake County. “The ability to have preventive care, needed medications and seek attention for medical necessities earlier can alleviate many of the poor life outcomes, advancing diseases and health conditions.”

Amanda McGee, director of the Cherokee County Department of Social Services, expressed her support of Medicaid expansion. She agrees with Ledford that preventive care is crucial to the community.

“A larger number of citizens in Cherokee County will now have access to all medical health care. There is data that a number of people have died because of no insurance,” McGee said.

Ledford expanded on McGee’s projection.

“Without medical services,” she said, “many in our rural communities endure declining quality of life, disabilities and often death at an earlier age from treatable conditions.”

Ledford and McGee have worked toward this end by helping form the Cherokee County Interagency Coalition, which meets every other month to work on solutions to these problems.

Today, North Carolina has about 178,000 uninsured adults in the Medicaid coverage gap. The new bill will give them access to medical coverage.

According to the N.C. Department of Human Health & Services, “About 2 million of North Carolina’s more than 10 million residents will experience a mental illness and substance use disorder, but in 2019 more than 55 percent of people who needed it did not receive treatment because of cost.”

Yet, despite the rural communities’ need for medical care, the bill nearly didn’t pass the N.C. General Assembly this year after legislators rejected Medicaid expansion for a decade.

Bill suffered setbacks

Cooper’s attempts to sign Medicaid expansion into law were thwarted in January 2017, when Senate President Pro Tem Phil Berger and House Speaker Tim Moore filed suit to stop it. In a joint release, the legislative leaders said, “Cooper’s brazen decision to press on with his unconstitutional Obamacare expansion scheme and ignore the General Assembly’s constitutional role to make laws requires swift legal action.”

However, the expansion experienced a rough and tumble life long before the Berger/Moore lawsuit. The bill itself originated out of President Barack Obama’s Federal Affordable Health Care Act in 2010. Three years later, North Carolina’s GOP legislators passed a law requiring the governor’s expansion to be passed by the General Assembly, but as state after state adopted the expansion, political objections weakened.

As an incentive, COVID-19 recovery law allowed the state to receive $1.75 billion over two years if it expanded Medicaid coverage, which further softened some of the harsher rhetoric. While the opposition remained both vocal and fierce, Senate leader Berger reversed his position, saying, “We need coverage in North Carolina for the working poor.”

Obstacles cause delay

Now that the expansion has become law, making North Carolina the 40th state to adopt the measure, there remain still more hurdles before those working poor can start receiving benefits. McGee explains.

“There is no launch date,” she said. “The Legislature still has work to do.”

This work may prove more difficult to achieve than seeing cooperation between the state legislators and the governor’s office. First of all, the law cannot come into effect until the state budget is finalized. This is expected to happen early in the summer.

And then there is issue of the rates.

“Medicaid needs to pay providers a rate they will agree to accept clients,” McGee said. “Shortage of providers is a very definite concern. You can expand the population [receiving benefits], but with no providers, you have to solve this problem.”

DHHS says on its website, “The shortage of primary health-care providers (including advanced practice providers) in North Carolina is significant, particularly in the state’s rural areas. There is also a severe shortage of behavioral health providers and dental professionals who serve Medicaid, uninsured and low-income patients.”

So it remains unclear how this historic problem will be solved in a way that allows the newly insured to find a provider for services. Ledford remains optimistic that the shortage can be leveraged.

“I expect that the added Medicaid revenues could promote a better compensation medical service,” she said. “By recouping the uncompensated indigent care costs to medical providers, this can enable a better opportunity for reimbursements.”

In addition, Ledford considered the state programs dedicated to medical worker recruitment.

“The DHHS Office of Rural Health works with federal, state and local entities to identify shortage areas and offer practice incentives, technical support and placement services,” she said. “A few of our state universities are actively seeking North Carolina’s rural students that have interest in medical programs with the hope that those students will return to their home communities to practice, hopefully we are encouraging our local students to seek these opportunities.”

Cooper said he expects that Medicaid expansion will create 40,000 jobs statewide.

Preparing for launch

For now, the enrollment of 2.9 million in the North Carolina Medicaid program will remain steady until these obstacles are overcome. Once the expansion becomes available, which is expected in January, McGee encourages people to sign up.

“They can come to the local DSS office, call us or apply online,” she said. “They can come here, and we will help them.”

Cooper encourages the Legislature to move with haste.

“Since we all agree this is the right thing to do, we should make it effective now to make sure we leverage the money that will save our rural hospitals and invest in mental health,” he said int a release.

McGee feels that bill, which will not raise taxes, will help the state’s budget because of the lower cost of preventative care when compared to crisis care.

“More people will get preventive care,” she said. “This is a good thing. More people who really need health coverage will get preventive or mental health care.”

McGee said the coverage will diminish crisis situations, which will in turn cost the state less in emergency care.

Ledford understands the bureaucracy that may entangle those seeking relief once the rollout commences.

“Hosea 4:6 says that people perish for lack of knowledge,” she said. “Four Square and many others will be assisting in the communication outreach.”