Republican state lawmakers filed a bill Tuesday to expand health care coverage to low income North Carolinians, closing the health care coverage gap.
Sponsors of the House Bill 655, titled “NC Health Care for Working Families ,” took pains to say it is not technically expanding Medicaid – a perception that helped sink the “Carolina Cares” proposal in 2017. That bill failed to get enough GOP support.
“If you look at our track record, we have been opposed to Medicaid expansion in the traditional sense and we continue to be opposed to it,” said Rep. Donny Lambeth (R-Forsyth), a primary sponsor of the bill. “We think this is an alternative to close the coverage gap – an innovative way to be able to do that.”
Whether the bill is technically a Medicaid expansion, it could mean health care coverage for about 543,000 low-income North Carolinians.
Right now Medicaid covers about 2.14 million people in the state – about 21 percent of the total population.
There are an estimated 1,083,000 North Carolinians with no health insurance at all. That’s incredibly dangerous and can lead to poor health outcomes over generations for some of the state’s most vulnerable populations, lawmakers said.
The new program proposed by the bill would be open to North Carolinians between the ages of 19 and 64 who meet all federal Medicaid citizenship and immigration requirements but do not otherwise meet the North Carolina Medicaid program eligibility criteria. Their income would need to be less than 133 percent of the federal poverty level  and they cannot be entitled to enroll in Medicare Part A or Part B benefits.
Covering that population could save a lot of lives, lawmakers said.
“I’m not only a legislator but I still practice medicine,” said Rep. Greg Murphy (R-Pitt). “So I see on a daily basis individuals who are caught in that coverage gap – people who put off coming to see physicians, people who put off coming to our emergency department, with life-threatening conditions, often-times with cancer.”
“Cancer doesn’t care if you have an insurance card or not,” Murphy said.
Health coverage is also critical in combating the opioid epidemic, Murphy said. Only one in six people who are treated for an overdose in hospitals actually has health insurance or access to primary care, the lawmaker noted. Those who can’t get treatment are likely to continue a cycle of addiction and criminal behavior that could otherwise be broken, he said.
While expanding coverage through the creation of a new NC Health Care for Working Families Program could be a game-changer, the bill contains a number of provisions that are likely to be partisan tension points.
Both North Carolina House Speaker Tim Moore (R-Cleveland) and Senate President Pro Tempore Phil Berger (R-Rockingham) have said they don’t believe there is support in the General Assembly for any kind of Medicaid expansion.
To try to garner enough GOP support, a work requirement for most recipients was included – something that’s not a part of traditional Medicaid coverage and a non-starter for many Democrats.
Under the bill, the requirements would follow those of the Able-Bodied Adults Without Dependents policy under the Supplemental Nutrition Assistance Program (SNAP) as closely as possible.
There’s a possibility the same thing could happen to a North Carolina program with work requirements, Lambeth said. Still, he said, they’re a political necessity.
“You have to be realistic here,” Lambeth said of the work requirement. “There are things we as legislators have to do in order to get things done. This started a couple of years ago and as I talked to a number of colleagues, that seemed to be a predominant area that they felt strongly about; if we were going to pass any legislation to close the coverage gap, we had to have some kind of work requirement.”
How such a requirement would be enforced and what the cost would be for administration isn’t clear yet, Lambeth said – it’s one of many things that would need to be ironed out over the course of this legislative session if the bill is to succeed.
Those participating in the program would also have to contribute up to 20 percent of their household income toward premiums.
The North Carolina Justice Center, the parent organization of N.C. Policy Watch, has prepared estimates of the potential costs of a 2 percent premium for a number of typical families. A single parent with two children making $29,400 would pay $589 annually. A married couple making a combined $15,220 would pay $768.
“We are pleased to see our lawmakers recognize that far too many of their constituents cannot access treatment without fear of medical debt and even bankruptcy,” the Justice Center said in a statement on the bill. “However, NC Health Care for Working Families would create financial and administrative obstacles for people who stand to gain coverage, blocking many North Carolinians from the health care they need.”
“It would charge costly premiums to low-wage workers who are already living paycheck-to-paycheck and struggling to make ends meet,” the statement said. “It would also take health care away from working families unless they report their work activities, despite the fact that only recently a federal judge ruled against similar requirements that left nearly 18,000 Arkansans uninsured.”
The bill also includes an assessment to health care systems and pre-paid health plans in order to pay the 10 percent of additional administrative costs that would fall to the state. That would come to about $758 million annually with the federal government covering the other 90 percent of the cost. If that cost formula were to change, Lambeth said, the program would be terminated.
Some of that assessment money – about 1.9 percent – would go toward a “Rural Access to Healthcare Grant Program” that Lambeth said would help struggling rural hospitals continue to serve their communities.
That provision is likely to be popular with some rural Republican lawmakers for whom failing rural hospitals are a priority.
Still, Lambeth said, he recognizes that the bill faces some significant political challenges to passage. If passed, he said, it could be implemented by July of 2020.
“Can I stand here and say it’s going to go through with flying colors in the next few weeks?” Lambeth said. “No, I can’t do that. We have a lot of work to do.”
Rep. Darren Jackson (D-Wake), the House Minority Leader, said his party still favors an actual Medicaid expansion as proposed by Democratic Gov. Roy Cooper.
“I am pleased to see that some of my Republican colleagues recognize the need to provide more North Carolinians access to affordable health insurance,” Jackson said. “ I have concerns about work requirements and premium co-pays that make it harder for people to use their insurance.”
A competing bill – House Bill 5  – was filed more than two months ago with 55 sponsors, Jackson said. It would pass were it allowed a floor vote, he said.
“The quickest and simplest way to close the health care coverage gap for 500,000 North Carolinians is through Medicaid expansion,” Jackson said in a statement Tuesday. “We have delayed for years now. These delays have cost North Carolina countless lives and billions of dollars.”