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We have written before about King v. Burwell, the case that will be heard before the US Supreme Court to determine whether or not health insurance subsidies can flow to states that refused to establish state-based marketplaces under the Affordable Care Act. As John Stewart has noted, justices would have to be more literal than Amelia Bedelia to find for the plaintiffs, but we live in strange times where anything seems possible.

The next question then is if the Supreme Court strikes down subsidies how many people would it impact? Now Kaiser Family Foundation has a helpful interactive map to estimate an answer. KFF researchers think more than 13 million people nationally, and about 1 million people in North Carolina, would lose tax credits if the Supreme Court denies subsidies to federal marketplace states. For most of these folks insurance would immediately become unaffordable. This is especially true because prices would most likely spiral upward as younger, healthier enrollees lose coverage.

That is a stunning figure. It would be like the Supreme Court cutting the number of North Carolinians receiving Medicare in half.

The cruel truth is that Congress could easily fix this problem by adding a few words to the Affordable Care Act, but they are so obsessed with repealing the legislation that they are unlikely to repair it. The state legislature could also provide a patch by at least establishing a governance structure for a state-based marketplace, but they are also unlikely to move. After all, the federal government stands ready to pay the state to expand insurance to 500,000 more state residents and that hasn’t gained any legislative traction.

So, we wait, while medical care for 1 million North Carolinians hangs in the balance.

Commentary

Notwithstanding the unceasing efforts to undermine and obstruct the Affordable Care Act, America’s health care law continues to pile up an impressive list of accomplishments. The latest was detailed this morning in this post by Tara Culp-Ressler at Think Progress:

“For the first time in a decade, the number of people struggling to pay their medical bills has started to decline, according to a new survey released on Thursday by the Commonwealth Fund. The researchers attributed the historic drop to the number of people gaining insurance under the health care reform law.

Between 2012 and 2014 — as Obamacare’s main coverage expansion took effect — the Commonwealth researchers found that the number of people who had issues paying for health treatment dropped from 41 percent to 35 percent. Over the same time period, the people who skipped out on health services because they couldn’t afford them declined from 43 percent to 36 percent:

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CREDIT: Commonwealth Fund

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CREDIT: Commonwealth Fund”

Commentary

As noted below, Gov. McCrory met with President Obama to discuss flexibility in using Medicaid expansion money to implement a North Carolina specific program that will extend health insurance to more low-income residents. As we have also said, the federal government has shown a tremendous willingness to accommodate governors who request authority to design new and innovative programs. This is all encouraging and kudos to the Governor for sticking his toe in the water.

What is not encouraging is McCrory floating the idea of work requirements as a condition to receive health insurance. As McCrory notes in the article, Utah’s Governor has pushed this idea unsuccessfully. Our Governor feels that President Obama may reconsider his opposition to this idea. That will not happen.

As background, an 1115 waiver allows states to waive some traditional protections in Medicaid to experiment with new ideas that can improve this important health insurance program. Specifically, waivers are meant to promote the ultimate objectives of Medicaid. Several states, for example, now have waivers to purchase private insurance plans for low-income people who would be eligible for Medicaid under expansion. This is an interesting and worthwhile experiment and we will collect important information on outcomes and costs from these state innovations.

Some Governors are abusing this process by applying for 1115 waivers that do nothing but erect barriers for people who need health insurance. A prime example is requesting a waiver that requires people to report to work search programs as a condition of receiving health insurance benefits. This is not innovative. It is not new. We know what happens when you include work requirements as a condition for receiving public benefits. It means many people will not be able to access insurance.

The waiver approved in Pennsylvania includes a provision that automatically refers unemployed people to job programs when they enroll in insurance. That’s fine as long as insurance is not contingent on participation in the work program.

We know, for these reasons, that a work requirement will not be approved by the federal government. There is some concern that Gov. McCrory may use this as a poison pill to sink a Medicaid expansion proposal and then blame the Obama Administration for not showing enough flexibility. Let’s hope that’s not the case.

Gov. McCrory has plenty of room to create a North Carolina specific plan to cover low-income people in the state. He should drop this one idea that everyone knows will never get approved and move forward with an evidence-based, innovative policy.

Commentary

mc-1Governor Pat McCrory emerged from his much-publicized meeting with a handful of other governors and President Obama at the White House  Tuesday breathlessly declaring that Obama is open to considering waivers to allow North Carolina to crafts its own version of Medicaid expansion under the Affordable Care Act.

But that shouldn’t be news to McCrory or anybody else.  Nine states, most of them with Republican governors, have already expanded Medicaid with waivers from the feds or have been in discussions with the Obama Administration about waivers for their own versions of the program.

Neighboring Tennessee is the latest state with Republican leadership to move forward, with Governor Bill Haslam unveiling a proposal for Medicaid expansion last month. 

Apparently McCrory had to fly to Washington to figure out that the Obama Administration was willing to work with state officials who are developing their own Medicaid plan.  Or maybe he just wanted us to know he was talking tough with Obama.

I presented a very strong argument for more flexibility if we even consider Medicaid expansion, so we can have a North Carolina plan instead of a Washington plan, and especially a plan that would encourage more people to get a job or get training before we expand another government program,” McCrory said after the meeting.

While it’s too bad it took McCrory much longer than many Republican governors to realize the Obama Administration was willing to work with the states to provide health care for people who need it, at least he seems to finally understand it.

There’s also the head-scratching logic that more people will have to get a job before Medicaid is expanded, as if only people who are working need to be able to see a doctor, not to mention the people with chronic illnesses whose lack of access to treatment prevents them from working in the first place.

But maybe now McCrory can get on with what he should have done already, following the lead of his Republican colleagues across the country by expanding Medicaid in North Carolina and providing health care coverage for several hundred thousand low-income people and creating thousands of jobs in the process. It is past time.

Commentary

A new report from Cone Health Foundation and Kate B. Reynolds Charitable Trust finds that North Carolina lost out on billions of dollars and thousands of jobs by refusing to close the Medicaid coverage gap in 2014 and 2015. If the state acts in 2016, however, we can recoup some lost ground by covering 500,000 more people. Such a move would create 43,000 new jobs by 2020 and reap $1 billion in tax revenue for the state and counties. Closing the coverage gap would save the state budget more than $300 million by 2020.

As followers of this blog know the state had a chance, starting in 2014, to expand Medicaid eligibility to all individuals and families earning less than 138 percent of the federal poverty level. More than half the states have now opted into this deal and they are attracting a huge return on investment. This new report is the first of its kind in the nation that takes a detailed look at every county in the state and uses a nationally respected model to estimate the impact of Medicaid expansion on tax revenue, job creation, business activity, and coverage.

The results are startling. In Robeson County expanding Medicaid would generate more than 700 jobs. In Moore County it would create nearly 500 jobs. In Nash County it would create more than 300 jobs. This is the equivalent of a fleet of new large employers locating in dozens of communities across the state. The increased economic activity will produce more county tax revenue at a time when many local governments are sputtering by on fumes. For Wake County, Medicaid expansion would net more than $25 million in tax revenue. It would earn Guilford County more than $11 million.

New data confirms in finer detail what we have always known, expanding Medicaid eligibility is a no-brainer. Thankfully, Gov. McCrory seems to be moving to the right (or should I say correct) side of this issue. Now that the federal government is allowing governors and legislators the flexibility to design state-specific expansions Wyoming, Indiana, Utah, and Tennessee — hardly redoubts of liberalism — are starting to embrace expansion. We should follow suit.

This is a rich report that deserves a close reading. You can find some reporting on it here, here, here, and here.