The House budget  includes a requirement that the position of Medicaid Director be subject to confirmation by the North Carolina General Assembly. Here’s some of the language:
4 APPOINTMENT AND CONFIRMATION OF MEDICAID DIRECTOR
5 SECTION 12H.36.(a) Effective July 1, 2014, and applying to Directors of the
6 Division of Medical Services appointed on or after that date, G.S. 108A-54 is amended by
7 adding a new subsection to read:
8 “§ 108A-54. Authorization of Medical Assistance Program; administration.
10 (e) The Medicaid Program shall be managed by the Director of the Division of Medical
11 Assistance (Medicaid Director), who shall be recommended by the Secretary of Health and
12 Human Services and appointed by the Governor, subject to confirmation by the General
13 Assembly by joint resolution. […] 
This provision should raise many questions and concerns. The legislature does not have appointment authority over any other position that is so central to carrying out the policy agenda of the Governor. If, for example, the legislature is bent on limiting access to Medicaid while the Governor wants to streamline enrollment, then the conflict will likely shut down any ability to get a Medicaid Director in place.
And while there is a clear process to appoint a Director if the Governor does not forward a nomination, the budget does not spell out what happens if the legislature refuses every nominee from the Governor. What would most likely occur is that the Governor would have to wait until the legislature is out of session and then appoint a temporary Medicaid Director.
If all of this sounds familiar it’s because this is how the process works in Washington, DC, where politics clouds every decision and ties up the basic functions of government. Instead of fostering bi-partisanship and stability, Congress has caused major disruptions in the running of Medicare and Medicaid by refusing to approve presidential nominees.
The same is likely to happen in Raleigh.
The Governor, who is elected statewide, should be able to appoint his or her preferred Medicaid Director to carry out the policies that he or she was elected to enact. If this confirmation requirement survives negotiations between the House and the Senate then leadership elected in select pockets of the state will have veto power over how the Governor runs one of the most important agencies of the executive branch.