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The defining policy question of 2015

medicaid-2015 [1]

In North Carolina, one policy and political issue stands above the others

The 2015-16 session of the North Carolina General Assembly convenes tomorrow and a lot of what will take place is very predictable. Just as it always does, the session will commence with a measure of pomp and circumstance, several self-congratulatory speeches and some grand promises about all the things that will be accomplished over the next six months or so.

What happens after that, however, is a little tougher to predict this year. Some political observers are forecasting a period of calmer seas, with legislative leaders focusing more on “governing” and less on enacting additional dramatic rollbacks of 20th Century progress. Others foresee a period in which the radical policy changes and accompanying political turmoil of the past four years continue unabated. 

The explanation for these divergent views is easy enough to understand: Signals emanating from the powers that be in state government of late have been mixed. One minute, even ultra-conservative lawmakers are talking about the urgent need to spend more public funds on meaningful pay raises for veteran teachers. The next, others are promoting the idea of enacting still more radical policy changes like eliminating the corporate income tax – or even the income tax itself. Add to all this, the uncertain political dynamic created by the presence of a new and untested House Speaker, a veteran, seemingly all-powerful Senate leader and a Governor still trying to find his sea legs after two years and it’s no wonder things are a tad murky.  

Happily, as muddled as all these pre-session signals are, it is not at all difficult to forecast either the key issue or the central political figure of the drama that is to come. The issue is Medicaid expansion and the politician is Governor Pat McCrory.

The Medicaid imperative

To say that the decision on whether to expand Medicaid under the Affordable Care Act is the issue of 2015 is not to say that it is the only important issue of 2015. There are obviously dozens: taxes, teacher pay, university funding, unemployment insurance, marriage equality, redistricting reform, consumer lending, renewable energy, coal ash, reproductive freedom, mental health just to name a few.

One completely unique factor, however, explains why no other single issue is ultimately as important to determining the near term future of North Carolina – namely, the lives at-stake. The simple and most powerful truth about expanding Medicaid is that it will save human lives – lots and lots of them. As health policy expert Adam Linker reported last fall [2], numerous reputable and in-depth studies confirm this fact:

“The North Carolina Institute of Medicine’s 2009 Access to Care study begins with this statement: ‘The lack of health insurance coverage is the foremost barrier to accessing health care services…In fact, adults who lack insurance coverage are 25% more likely to die prematurely than adults with insurance coverage.’…

A Families USA report in 2010 estimated that before the Affordable Care Act passed nearly 1,000 North Carolinians died each year between 2005 and 2010 due to lack of health insurance….

In 2012 researchers from the Harvard School of Public Health published a study [3] in the New England Journal of Medicine that examined the health impacts on states that expanded Medicaid coverage to childless adults between 2000 and 2005. They found reduced mortality rates in states that expanded coverage amounting to 2,840 deaths prevented per year for each 500,000 adults gaining Medicaid coverage. Mortality reductions were greatest for racial and ethnic minorities and residents of the poorest counties.

In 2014 researchers from Harvard and the City University of New York combined data from the Oregon Health Insurance Study and two larger examinations of mortality and lack of health insurance to project that between [4] 455 and 1,145 North Carolinians will die every year without expansion.

All of these estimates are the direct health impacts on adults. They do not take into account the reduction in infant mortality rates that stem from increases in insurance coverage. And these studies do not include indirect impacts, such as hospital closures, that kill people who lack access to nearby emergency services.”

Think about that for a second: the political leaders of our state literally hold the very lives of thousands of their fellow citizens in their hands.

If they do one thing, these people will live longer, healthier lives. If they do the other, they will get sick and suffer and die. Indeed, by failing to act for the last couple of years our leaders have already assured the premature deaths of thousands. It is a stunning and sobering fact. This is what led the conservative Republican Governor of Ohio, John Kasich, to say the following in explaining his decision to expand Medicaid to cover the uninsured people of his state [5]:

“When you die and get to the meeting with St. Peter, he’s probably not going to ask you much about what you did about keeping government small, but he’s going to ask you what you did for the poor. You’d better have a good answer,”

There are many other critical facts that militate in favor of Medicaid expansion – most notably the billions of dollars and thousands of jobs that would flow to the state [6] and the simple dignity and reduction in stress and fear that would flow to hundreds of thousands of good human beings – but all of these ultimately pale in comparison to the death toll that could be dramatically reduced right away.

Even if it were somehow true that the state would face significant new expenses to effect such a reality (and as is explained here [7], it will most certainly not), it would still be the single best and most important thing that elected officials could do for their state and their fellow citizens in 2015 (or just about any other year).

McCrory’s defining moment

And so it is that 2015 will serve as the defining moment in the gubernatorial term (and probably in the political career and life) of Pat McCrory. The Governor says he wants to expand Medicaid and though he’s late to the party and muddled (sometimes absurdly so [8]) in his explanations, he deserves credit for taking such a position.

That said, he has given little indication of any real capacity to deliver the goods on the issue –even with the Obama administration’s willingness to agree to almost any conditions. As with so many other positions espoused by the Governor over the last two years, McCrory seems to be flummoxed about how to take charge and make it the law of the land. After having spent the better part of six years campaigning to be Governor, he seems surprisingly incapable of seizing the bully pulpit and appealing directly to the public for something in which he believes.   

Indeed, it’s a pretty remarkable state of affairs that 24 months into the McCrory administration, the Governor lacks any signature issue – any single, definable accomplishment (or even a visible, well known goal) with which he is associated. Maybe one can get elected and re-elected Governor of the state by doing little more than riding the coattails of the national economic recovery and claiming to regularly “step on toes,” but these seem like thin reeds on which to hang one’s hat. (It also begs the question: Why in the world does he even really want to be Governor?)

All of which in combination serves to make 2015 a defining year for the McCrory governorship. Will the man finally unearth his inner Jim Hunt and lead the state on the most important of issues or will he continue to meander along as a glorified caretaker and junior partner to the leaders of the General Assembly?

The bottom line: It’s hard to say exactly what will happen this year in Raleigh, but come July, the presence of this most critical of issues assures that it won’t be hard to assess the results. Stay tuned.