- The Washington Times - Monday, March 27, 2023

North Carolina has ended years of opposition and opted to expand its Medicaid program in 2024, meaning four-fifth of states have embraced a key plank of Obamacare as opponents find it harder to resist federal funding and voters force a series of Republican-led states to extend coverage.

State Senate President Pro Tempore Phil Berger, a Republican, marked a turning point with his decision to support expansion and set the stage for legislative approval in Raleigh on the 13th anniversary of the Affordable Care Act’s passage last week.

“Medicaid Expansion is a once in a generation investment that will make all North Carolina families healthier while strengthening our economy, and I look forward to signing this legislation soon,” North Carolina Gov. Roy Cooper, a Democrat, said in a post on Twitter.

For a decade, many Republican leaders have resisted Obamacare’s expansion of Medicaid, the federal-state insurance program for the poor. Extending coverage above the poverty level would put able-bodied people on the government dole and strain state budgets, they said, even if the federal government picks up 90% of the tab for the expansion population.

Only 10 states are holding out at this point, compared with 19 that refused expansion at the end of the Obama administration.

States are finding it harder to resist the federal dollars that underpin Medicaid expansion, which the Supreme Court made optional for states in 2012 before it was implemented the following year.

For one thing, Obamacare appears to be here to stay. A 2017 repeal-and-replace effort failed, and the law has survived multiple legal challenges. Studies find that expansion states have slashed their uninsured rates while driving revenue to rural hospitals that need support.

“Unlike previous years, there’s not the same debate on the table of broader ‘repeal and replace.’ There’s continuing evidence of positive outcomes relative to expansion,” said Robin Rudowitz, a vice president at the Kaiser Family Foundation and director of its program on Medicaid and the uninsured.

Virginia decided to expand Medicaid five years ago, and voters in Republican-led states have forced expansion through ballot measures.

South Dakota Gov. Kristi Noem, a Republican, has opposed Medicaid expansion but is implementing a voter-approved plan this year.

“In all seven states where voters have had the opportunity to vote on a ballot measure to expand Medicaid — Idaho, Maine, Missouri, Nebraska, Oklahoma, South Dakota and Utah — they have passed it,” said Kelly Hall, executive director of the Fairness Project, a leading champion of the ballot measures.

Obamacare allows states to expand eligibility for Medicaid coverage to those making up to 138% of the federal poverty level.

Mr. Berger, a former opponent of expansion, told “PBS NewsHour” that the federal government has upheld its pledge to fund 90% of the expanded population through multiple iterations of party control in Washington. He also said expansion seems to have popular support and he believes many of the people who benefit from expansion are working full time.

North Carolina legislators were drawn to the benefits for rural hospitals, which will receive revenue from newly insured patients. As COVID-19 recedes, states are combing through their rolls and kicking off people who are no longer eligible for Medicaid, increasing pressure on lawmakers to figure out who should be covered.

Further, President Biden used an early pandemic relief package to sweeten the deal for states considering expansion.

The American Rescue Plan Act of 2021 incentivized states to expand Medicaid by offering a two-year, 5-percentage-point boost in the federal matching rate for the state’s traditional Medicaid population.

The share of the population regularly covered under Medicaid is far larger than the population added by Obamacare, so the enticement is significant.

“There are already a lot of fiscal incentives, and then ARPA added an additional fiscal incentive,” Ms. Rudowitz said.

Roughly 600,000 North Carolina residents are expected to become eligible for Medicaid when the expansion goes into effect in 2024. Implementation of the North Carolina plan is contingent on the approval of a state budget, which typically happens during the summer.

Once finalized, North Carolina’s decision will leave Alabama, Georgia, Mississippi, Florida, Kansas, South Carolina, Texas, Tennessee, Wisconsin and Wyoming as the states that have refused to expand Medicaid.

Wisconsin extended coverage to people making the federal poverty level but hasn’t embraced the full Obamacare expansion.

An expansion bill in Wyoming advanced out of a committee this year but didn’t get a vote on the state House floor.

In Kansas, Gov. Laura Kelly, a Democrat, has pressed for an expansion bill but the Republican-controlled Legislature is resisting.

“If Medicaid is expanded, Kansas would see 328,000 able-bodied adults enrolled at a state-only cost of $13 billion over the next 10 years,” Kansas House Speaker Dan Hawkins, a Republican opponent of expansion, tweeted in January.

The Obama and Biden administrations have put particular pressure on Florida and Texas. Those states are so large that Medicaid expansion would slash the national uninsured rate.

That’s unlikely to happen anytime soon. Republicans control all levels of government in both states, and Florida Gov. Ron DeSantis is expected to jump into a bruising Republican primary for president.

Fairness Project spokeswoman Georgia Parke said that of the remaining non-expansion states, only Wyoming and Florida have legal processes in place for citizen-driven ballot measures. Mississippi used to have a process, but the state Supreme Court overturned it in 2021 and the Legislature has not reinstated the process.

Florida and Wyoming have requirements that make ballot measures “uniquely challenging,” Ms. Parke said.

Notably, Florida requires a 60% supermajority to approve ballot measures, and its sizable population means about 900,000 signatures would be needed to qualify for the ballot.

Florida Decides Healthcare, a leading champion of a ballot initiative on Medicaid expansion, is eyeing the 2026 cycle for putting the question to voters.

“We are thrilled to see the bipartisan support for Medicaid expansion in North Carolina, which demonstrates that healthcare access is not a partisan issue, but a human one,” said Jake Flaherty, campaign manager for Florida Decides Healthcare. “We believe this momentum will carry over to Florida, where our residents are eager to see a similar expansion and reap the benefits of a healthier, more productive population.”

• Tom Howell Jr. can be reached at thowell@washingtontimes.com.

Copyright © 2023 The Washington Times, LLC. Click here for reprint permission.

Please read our comment policy before commenting.

Click to Read More and View Comments

Click to Hide