You should read our earlier post about Rep. Nelson Dollar’s excellent objections to Medicaid reform. Dollar deserves kudos for pointing out that our system is not broken.

Despite these objections the legislature is charging ahead. If we want reform, however, the state needs to expand Medicaid at the same time. Why? Because to reform Medicaid we need permission from the federal government. According to the bill passed by the General Assembly we will officially seek this permission from the federal government by June of 2016. The Obama Administration is unlikely to make privatizing our Medicaid program a major priority in its last few months of office. That is not the sort of legacy he is interested in leaving.

If we do not get approval from the current leadership at Health & Human Services then North Carolina will need to wait until a new President takes office. Then the new President will have to nominate an HHS Secretary and we will have to wait for the Secretary to be confirmed. At some point after that HHS will begin to review our reform proposal.

Alternatively, North Carolina could include expansion in the reform plan. Then the Obama Administration would act quickly to approve our waiver. Certainly HHS is not excited about dismantling our model Medicaid system, but they could live with legislative changes if it meant covering 500,000 more people in our state.

With expansion reform will move quickly and our proposed changes will be accepted by HHS. Without expansion reform will be a long, long road to an uncertain destination.


North Carolina’s uninsured rate fell in 2014 thanks to the implementation of federal health reform but data released today show our state is leaving many citizens behind by refusing to expand Medicaid.

The Census Bureau today released the country’s official data on health insurance rates, which shows that 1.27 million North Carolinians lacked health insurance in 2014 compared to 1.5 million uninsured North Carolinians in 2013. Expanding Medicaid would have resulted in a more dramatic drop in the uninsured rate.

We see that many of the states that expanded Medicaid such as West Virginia and Kentucky now have single-digit uninsured rates whereas North Carolina’s uninsured rate was 13 percent in 2014 compared to 15.6 percent in 2013. The Affordable Care Act is working, but it would work better if policymakers stopped blocking coverage for the working poor families who don’t earn enough to buy private insurance and don’t currently qualify for Medicaid.

A study by George Washington University released last year shows that expanding Medicaid in North Carolina would extend coverage to 500,000 more people while creating 43,000 jobs and attracting $21 billion in federal funding over five years.

Nationally, the Census data show that the uninsured rate dropped to 10.4 percent last year, down from 13.3 percent in 2013. These numbers reflect individuals who were uninsured throughout the year. The Affordable Care Act helped more than 8.8 million people gain health insurance coverage.

It’s not too late for North Carolina to catch up with the rest of the nation. The Governor could propose, and the legislature could adopt, a state-specific plan to close the coverage gap at any time.

Commentary, Uncategorized

The North Carolina Justice Center launched radio and digital ads this week urging people to ask Gov. Pat McCrory to release a plan that expands affordable health insurance in our state.

We have the opportunity to tap federal funds to extend affordable insurance coverage to more than 500,000 people struggling to pay for care. Our tax dollars are sitting in Washington waiting to be used to boost rural health care in our state and save more than 1,000 lives every year.

We can expand Medicaid with this money or we can develop a state-specific plan to experiment with new coverage ideas. Conservative Governors in Arkansas, Iowa, Indiana, Montana, Utah, Tennessee and elsewhere have proposed specific policies. Gov. McCrory told news outlets at the beginning of the year that he was considering doing the same. The hold up, he claimed at the time, was the latest Affordable Care Act challenge at the U.S. Supreme Court. He would announce his support, or opposition, to expanding coverage after the high court ruled in King v. Burwell.

King v. Burwell came and went and still no word from the Governor.

The Governor and legislators all have access to taxpayer funded healthcare so they can afford to delay a decision. Many others in our state aren’t so lucky.

These 500,000 North Carolinians are mostly the working poor with jobs in construction and food service that do not provide health insurance benefits. They don’t currently qualify for Medicaid because eligibility is restrictive in our state. They can’t afford to buy private insurance. Now they are stuck and just need action from their elected representatives.

It starts with the Governor. He can change the dynamic by showing leadership and proposing a plan. Go to NC Left Me Out and share your story if you or a loved one are in the coverage gap. And then use the phone number listed to contact Gov. McCrory and ask him, “Where’s the plan to expand coverage?” We can’t wait any longer.


Last week the Senate released its latest version of Medicaid reform calling it a compromise measure with the House. There are some changes to the Senate’s original proposal.

Under the amended plan a new Department of Medicaid is created but it remains within the Governor’s purview. It also allows for regional provider led entities to compete for Medicaid contracts with statewide managed care companies. For the most part, however, the bill is a radical revamping of Medicaid. It is difficult to see how adding all of this complexity will increase predictability. Instead, this restructuring creates a system with many moving parts that will require a new oversight regime. In the end patients are likely to get pinched between gaps in this structure and the state will spend time and money tracking problems and pursuing legal claims against private insurance companies.

Due to consolidations in the industry there are not many insurance companies that will bid to control Medicaid delivery in the state. Companies like Amerigroup and Centene and United HealthCare will likely get contracts under the Senate plan. North Carolina will get glittery promises and great deals in the first year. Then the problems will start.

Whether it’s discriminating against pregnant women, or improperly denying speech-therapy services for children, or denying patients timely access to critical medical services,  or delaying payments to doctors and hospitals, or pulling out of a state before completion of a contract, private managed care companies introduce a  great deal of uncertainty.

Although the Senate allows regional provider led entities to form, these organizations have major disadvantages when trying to compete with large corporations. The provider groups, for example, must meet the solvency requirements of a private insurance company. They must also move within a year to take on full risk. That means if they give too much care at too much cost the providers are stuck. They only get the amount of money they originally budgeted. This is not a huge problem for an insurance company with billions in revenue. It is more difficult for a small collection of rural clinics and hospitals. Also, if a big insurer is losing money it can pull out of the state never to return. Not so with a doctor’s office.

The Senate persists in wanting to end contracts with Community Care of North Carolina, our state’s Medicaid medical home model that has won national recognition.

It is difficult to see what problem the Senate hopes to solve by injecting so much complexity and uncertainty into the system. Trying to negotiate with large insurance companies and regional provider entities will introduce opportunities for fraud, waste, and abuse. It will also mean a major loss of state control over our Medicaid program.

The biggest beef legislators have had with Medicaid is the agency’s difficulty in projecting costs. Now that private insurance companies are having to deal with constant policy change, and now that they can’t cherry pick customers, we are seeing that they also have trouble predicting costs. Tearing down our entire Medicaid structure to get more reliable budget numbers seems like a bit much. We could, after all, move to a full-risk capitation model using provider agreements and CCNC.

Ultimately, the most short-sighted part of both the House and Senate proposals is that neither includes expanding Medicaid eligibility. Most states across the country are now expanding and reforming Medicaid at the same time. This allows governors to negotiate more conservative reform deals with the federal government. If we are going to ask patients and providers to undergo a painful reform process we could at least cover more people.


Fifty years ago today President Lyndon B. Johnson created two of our most important safety net programs, Medicare and Medicaid. Medicare gave many seniors the health care access and financial security they lacked, and Medicaid gave many children a stable start in life. To help celebrate the occasion we decided to share several historical and policy-minded blog posts about these critical programs from some of our favorite national partners.

Community Catalyst says that we should celebrate the achievements of Medicare and Medicaid but notes that now is no time to rest:

At the time of enactment, roughly half of all older adults in the United States had no health insurance. Today, Medicare and Medicaid cover nearly 1 out of every 3 Americans – more than 100 million people. But there are still millions more without coverage of any kind, or with coverage, but inadequate access to care and services they vitally need.

While a pause for celebration is in order today, complacency is not.

The United States continues to spend almost twice as much per capita on health care as any other western democracy, with far less “bang for our buck,” in terms of health status and outcomes to show for it. Significant health disparities and unequal access to quality care continue to be hallmarks of our health system. These issues pose a threat to the sustainability of Medicare and Medicaid, as well as new programs established under the Affordable Care Act.

The Georgetown Center for Children and Families is celebrating because Medicaid has made a critical difference in the lives of so many kids (They even have a bonus video!):

With 50 years of experience serving growing numbers of America’s children, a new body of research is able to take a look at the long-term effects of childhood Medicaid coverage. Medicaid expansions in the 1980s and 1990s provided a natural experiment for researchers to evaluate how Medicaid eligibility affects children later in life. This longitudinal research tells us that children eligible for Medicaid grow up to be healthier, more academically successful, and financially secure adults than their non-Medicaid-eligible peers. We released a report that summarizes these findings earlier this week.

The Center on Budget and Policy Priorities has a post with 10 facts about Medicaid and Medicare. You should read them all but for our purposes number 9 is especially important:

9. Health reform’s Medicaid expansion is saving states money. The federal government will pay the entire cost of health care for newly eligible beneficiaries through 2016, and many states that have expanded Medicaid have found that it has produced net savings for their budgets. States will spend just 1.6 percent more on Medicaid and CHIP with the expansion than they would have without health reform, CBO estimates. Hospitals in expansion states are treating fewer uninsured patients, and the amount of uncompensated care they are providing is declining steeply. Meanwhile, hospitals in the states that have not expanded Medicaid continue to provide large amounts of uncompensated care, and the states are missing the opportunity to leverage billions of dollars in new federal funding through the expansion.

And, to commemorate the occasion, FamiliesUSA posted its many resources on Medicaid expansion with a reminder that Medicaid protects people from every walk of life.

Medicare and Medicaid were signature health care and anti-poverty achievements that we must work everyday to protect and strengthen. In our state that means pushing to expand the benefits of health care access to 500,000 more of our neighbors to give them a fair shot at living full, productive lives. Fifty years of experience tells us that’s the right thing to do.