NC Budget and Tax Center

N.C.’s public health investments lag behind population growth

This past Saturday concluded National Public Health Week 2019, which makes this a good time to revisit the level of investments that North Carolina leaders have made in public health and other areas that are known to affect health.

Last September, we highlighted the ways that public investments are tied to improved health outcomes. A growing body of research shows that funding for local health departments, in particular, is tied to fewer adverse outcomes and improved health, even when controlling for community differences in demographics, socioeconomic characteristics, and medical resources.

And yet, North Carolina lawmakers have agreed to spend fewer dollars on public health efforts in the state, even as the population has increased. Instead, investments should be made in strategies that are proven to help communities thrive, including in public health, in addition to other areas such as education and housing. Together, these cross-sector approaches help to build a culture of health that works to ensure that everyone can live in a healthy, thriving community.

Suzy Khachaturyan is a Policy Analyst with the Budget and Tax Center, a project of the North Carolina Justice Center.

Commentary, News

Amid N.C. Medicaid debate, Utah foregoes federal dollars in partial Medicaid expansion

Amid a roiling debate in North Carolina over Medicaid expansion, one U.S. state has opted for a partial expansion.

Last week, the Centers for Medicare and Medicaid Services (CMS) approved Utah’s 1115 Medicaid demonstration waiver, which would introduce partial Medicaid expansion and, with it, no enhanced federal match funds.

While the Affordable Care Act (ACA) provides an enhanced federal match rate of 90 percent beginning in year 2020 and each year thereafter for states that choose to expand, states must expand coverage to individuals up to 138 percent of the federal poverty level (FPL) in order to receive the higher match.

As a result of its limited expansion, Utah’s Medicaid match will remain at its existing federal rate of 68 percent, foregoing nearly $1.5 billion in federal funds during the first two fiscal years alone. It is likely to result in overall budget losses for the state.

In November, Utah voters approved full Medicaid expansion, up to 138 percent FPL, via a ballot measure that would provide coverage to approximately 150,000 newly eligible individuals in the first year. However, the following month, the Utah legislature ignored the will of voters by passing a bill which would only extend coverage up to 100 percent FPL.

The bill was signed into law in February 2019, and it includes plans to submit additional waivers in phases that will implement additional barriers to coverage – including work reporting requirements, per capita enrollment caps, and lock-out periods – in addition to requesting higher federal match rates.

Utah’s partial Medicaid expansion will leave more than 40,000 adults – those between 101 and 138 percent FPL – without Medicaid. While these individuals are eligible for coverage and subsidies in the ACA Marketplace, deductibles and out-of-pocket costs would prove a significant financial barrier to coverage and may result in those individuals foregoing insurance altogether.

Utah’s partial expansion not only leaves a coverage gap, but it fails to take advantage of the federal dollars available to increase affordable coverage for individuals with low incomes. Instead the state could fully close its coverage gap, reap the state budget benefits of full expansion, reinvest in its communities, and boost the well-being of families.

Suzy Khachaturyan is a Policy Analyst with the Budget & Tax Center, a project of the North Carolina Justice Center.

NC Budget and Tax Center

With the influx of federal dollars, Medicaid expansion would pay for itself

Recent estimates of the costs and savings of Medicaid expansion from Governor Cooper’s recommended budget show that closing the coverage gap is a great deal for North Carolina. Given our state’s more than one million uninsured individuals and approximately 626,000 additional Medicaid enrollees expected to be newly eligible, the decision on whether or not to expand coverage is clear.

Each year since 2014, North Carolina has foregone billions of federal dollars as a result of not expanding Medicaid. Beginning in 2020 the federal government will pay for 90 percent of the cost of expansion, and the state’s 10 percent share will be covered through a combination of budget savings and fees collected.

With billions in federal dollars coming into the state, Medicaid expansion would generate significant savings for the state budget – an estimated $30.7 million and $69.3 million, respectively, in the first and second fiscal years. Increased federal Medicaid funding would reduce the need for existing state spending on health care services by state agencies like the Division of Mental Health, the Division of Health Benefits, the Department of Corrections, and other state agencies.

The remaining portion of the state’s share will come from assessing fees on hospital revenues and capitation payments made to Medicaid health insurance plans, common revenue-generating strategies used by states. Because these health care organizations will experience significant patient revenue growth with more insured patients under Medicaid expansion, they stand to benefit on net even after paying the fees.

In addition to the zero net cost of expanding Medicaid, it will allow hundreds of thousands of individuals to become newly eligible for affordable health coverage and achieve the benefits that come with it, including improved health and financial security. In addition, when our neighbors are healthy, we all benefit; it allows people to fully participate in their communities and lowers health care costs for all of us.

While the national conversation centers on health care as a right, North Carolina lawmakers in the General Assembly have the opportunity to cover the uninsured and to do it in a fiscally responsible way. With these data, lawmakers will have a tougher time making the case for why the time isn’t right for Medicaid expansion.

Commentary, immigration, News, Trump Administration

After Trump administration rule change, immigration visa denials soar

New data released by the U.S. Department of State show a significant uptick in the number of visa denials on grounds of public charge compared to data from prior years.

These data, in addition to the public charge rule change proposed late last year, demonstrate the Trump administration’s commitment to restricting immigration, particularly for families accessing critical resources.

While the public charge rule has existed in some form for more than 100 years, its current definition took effect in 1999 and is based on the likelihood that someone will become a “public charge” by using certain public benefits for which they are eligible.

Experts agree that the departure from previous data on visa denials is likely due to a revision made in early 2018 to the State Department’s Foreign Affairs Manual (FAM), which instructs U.S. consular officials on granting visas to immigrants and non-immigrants who are abroad and seeking to enter the U.S.

The new manual language imposes stricter rules about use of public benefits, income levels, and proof of financial support from family. This change came as part of a response to a 2017 White House Memorandum prompting increased vetting of visa applicants and others seeking entry into the United States.  While the FAM governs persons who are abroad and seeking to enter the U.S., the proposed public charge rule that is currently being reviewed at the federal level impacts those who are already inside the U.S. and are seeking to obtain a visa or green card.  The increase in denials based on public charge for visa applicants outside the U.S. could be a bellwether of what would happen if the proposed public charge regulation were to go into effect for applicants inside the U.S.

News about this dramatic increase in visa denials, along with confusion and fear about the current proposed rule,  could have a chilling effect on families accessing the programs they need to make ends meet.  It can also thwart our country’s vision of ensuring people in need can live in a country that respects and supports their well-being.

Suzy Khachaturyan is a Policy Analyst with the Budget & Tax Center, a project of the North Carolina Justice Center.

NC Budget and Tax Center

North Carolina’s budget and policy choices can improve health

Deeper and smarter investments in education, infrastructure, economic security, housing, and other areas can eliminate barriers to good health for low-income residents and communities of color, according to a new report from the Center on Budget and Policy Priorities (CBPP).

In addition to these and other public investments, North Carolina can remove obstacles to better health by:

  • Improving access to affordable health care, including by expanding Medicaid under the Affordable Care Act (ACA);
  • Leveraging Medicaid to improve access to other economic and social programs known to improve health, like case management and supportive housing;
  • Enacting social and economic policies known to improve health, like creating and expanding paid leave programs and raising minimum wages; and
  • Improving state and local tax systems by basing them on a taxpayer’s ability to pay and ensuring they raise enough revenue to maintain the quality of the places in which residents live, work, learn, and play.

Social, economic, environmental, and behavioral factors account for 80 percent of an individual’s health; health care access and quality are responsible for just 20 percent.

Opportunities to be healthy are not available to all North Carolinians. Where there is greater income and wealth inequality, there are also greater disparities in health. Income and wealth inequality and a history of structural racism have erected barriers to health for low-income residents as well as communities of color:

  • Black North Carolinians die more than three years earlier than white residents, on average.
  • Black babies born in North Carolina are nearly twice as likely as white babies to be born with low birthweight.
  • Black babies are also more than twice as likely as white babies to die before their first birthdays.

Generating revenue that will allow for investments in programs that help to ameliorate these deep disparities has been more difficult in North Carolina, due to changes to the state’s tax code starting in 2013. Findings from the CBPP report support the need for increased investments, including those strategies described above, in order to equip all North Carolinians with opportunities to be healthy.

Suzy Khachaturyan is a Fiscal Analyst with the Budget & Tax Center.