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Proposals to close the health insurance coverage gap should follow the data on what actually works

[1]North Carolina’s dubious ranking of having the 10th highest rate of uninsured people in the nation continues to play out across the state in ways that challenge our collective well-being and community stability, even as it leads to worse health outcomes and diminished livelihoods for hundreds of thousands of our neighbors.

It is thus a welcome relief that there is momentum growing in state law and policy making circles to close the coverage gap.

The reality is that the coverage gap affects us all. When large segments of the population are unable to get the care they need and institutions are left without a sound financing model for delivering health care, we are all worse off.

But just as we need to be clear about the problem and its extent, we should also be clear that not all solutions to the problem are equal.

Just last week, Republican leaders introduced their approach to closing the coverage gap [2], calling it a “uniquely North Carolina approach.” Unfortunately, whatever the motivations of its proponents, the substance of the proposal flies in the face of what North Carolinians support and need. It does not recognize our shared fate, nor does it commit to strengthening the connections to opportunity provided through affordable, quality health care. Instead, it proposes to block access for many and fails to recognize the fundamental and systemic challenges facing those without health insurance in 21st Century North Carolina.

Research both nationally and from my colleagues at the North Carolina Justice Center highlight some serious problems with this proposal — problems that will cause it to fall short of closing the coverage gap and, worse, likely to lead to even more harmful conditions for North Carolinians.

Any proposal that our state legislators consider to support the health and well-being of all North Carolinians should follow the evidence as to what really works and, therefore, align with the following goals:

  1. Maximize the number of people in North Carolina with health insurance coverage. Medicaid matters for health outcomes and the well-being of families, neighborhoods, [3] employment, and economic outcomes [4]. North Carolina has too many people without health insurance [5], and many of those without insurance have very low incomes, live in more rural parts of the state, and don’t have the kinds of jobs that provide them with health care benefits.
  2. Finance health care coverage in a fiscally responsible way. North Carolina has missed out on federal dollars since 2013, but the state can still draw down federal funding to cover 90 percent of the cost of providing health care services to those in the coverage gap. This federal funding commitment is stable and durable. [6] The ability of the state to raise the required match through provider assessments and taxes on prepaid health plans further ensures that North Carolina taxpayers aren’t left with a higher tax load and that providers are contributing to a system that will result in net benefits to their bottom lines. Our researchers have also found that expanding Medicaid can save the state lots of money [7] by paying for existing health care services that are already delivered across an array of state agencies.
  3. Don’t erect costly barriers like work and premium requirements that will result in coverage losses and greater hardship. The main barriers to health care access are no mystery: across the state, hundreds of thousands of workers bring home too little income, mostly because there too few jobs and, especially, too few good jobs that provide health care. Our research demonstrates that proposals that create additional barriers to access simply don’t get the job done. Indeed, they make things worse.Recent research and news reports on the experience in Arkansas make clear the danger of work reporting requirements — not only do they result in coverage losses, such requirements can actually lead to employment losses and greater hardship as well. Indeed, recent federal court decisions make clear the illegality of requiring work reporting to access care. [8] Similarly, analysis of the financial hardship that already makes it difficult for North Carolinians in the coverage gap to make ends meet shows that any requirement to pay premiums will further disrupt already precarious household budgets and force families, quite literally, to make the impossible choice of deciding between putting food on the table and purchasing health care [9]. Such choices, if forced to be made, will result in poor outcomes and economic harm.

The bottom line: the current proposal on the table from House lawmakers, while welcome in its recognition of the need to make health insurance coverage available to more North Carolinians, falls short of being the kind of approach that North Carolinians should support or be proud of.

Alexandra Sirota is the Director of the North Carolina Budget and Tax Center [10].