Plenty of uncertainty looms over North Carolina's Medicaid expansion plan

Nearly five months after North Carolina Democratic Gov. Roy Cooper passed legislation allowing the state to expand Medicaid, there is uncertainty surrounding when, or whether, the program will be expanded after all.

Expansion would give about 600,000 North Carolina residents access to healthcare coverage by raising the maximum allowed income to $20,120, but that cannot happen until a state budget is passed, provided the issue is not “decoupled” from the state budget, as Cooper requested. Republican lawmakers are slowing implementation of the bill, unwilling so far to expedite the program.

If decoupling doesn’t occur, the state will lose up to $60 million in federal funding, and its $1.6 billion bonus for implementing expansion is also threatened, according to North Carolina Health News.

“When you look at Medicaid expansion, certainly politics plays a big role,” Gary Jessee, a senior vice president of Sellers Dorsey, a national Medicaid consulting practice, told Fierce Healthcare. Jessee served as the deputy executive commissioner for medical and social services in Texas. “When you look at the number of states that have expanded and you look at the number of states that haven't, you can't help but generalize that part of the hesitance to expand Medicaid certainly is state's desire.”

Jessee noted that Medicaid expansion does play a substantial role in a state’s budget, though the federal government covers 90% of the cost for adults covered through the Affordable Care Act. Medicaid is traditionally a budget driver and has been increasing in cost for decades.

North Carolina’s legislation includes “provisions to increase hospital assessments to fund the state share of expansion, increase hospital imbursement rates, and implement a comprehensive workforce development and referral program,” according to KFF. For expansion to take place Oct. 1, the state’s legislature would need to approve it by Sept. 1. Delays could push implementation as far back as 2024.

Axios reported earlier this month that North Carolina House Speaker Tim Moore believes there is “no chance” the legislature will pass a budget by October.

Among the people that could benefit from Medicaid expansion are mothers who lose coverage post-birth and adults with low income. Jessee also said expansion would reduce uncompensated care—or healthcare services provided by hospitals that don’t get reimbursed due to lack of insurance—and increase preventive care in the state. 

A recent survey from The Harris Poll found that 35% of Medicaid members were not contacted by their health plans to renew coverage, potentially leaving thousands of individuals who qualify for coverage in the dark as to their potential options.

In Georgia, the state chose to launch Georgia Pathways to Coverage, a state health plan for low-income residents that has received just 265 applications by early August, reported ABC. Experts said the program has inherent flaws that make it difficult for “submitting and verifying work hours,” while the state juggles federal redeterminations that are kicking eligible individuals off the program after the government mandated states not to disenroll participants during COVID-19.

Just 10 holdout states remain without having passed expansion, and it seems unlikely there is a political appetite in those states to expand the program.

“It’s not going to happen unless there is clearly a legislative desire, and you’d have to have some bipartisan support,” explained Jessee.