Thirteen years after the passage of the Affordable Care Act, North Carolina is poised to become the 40th state to expand Medicaid under the law, thanks to the persistence of Democratic Gov. Roy Cooper and a growing recognition by Republican legislative leaders that their rural base has the most to gain. A breakthrough agreement will expand health-care coverage to an estimated 600,000 residents who make too much to qualify for the traditional Medicaid program, which predated the ACA expansion, but too little to qualify for subsidized private plans on the Obamacare marketplaces.
North Carolina offers a blueprint for breaking the logjam in the 10 remaining holdouts of Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin and Wyoming. Rural hospitals in each of these places have struggled because so many of their patients lack health insurance, which means they don’t get reimbursed unless the state picks up the tab. But GOP lawmakers in these states have held out in a dogged, partisan protest of the ACA, for which their constituents pay.
In places such as the western mountains or the southeastern Sandhills region of the Tar Heel State, as many as 1 in 5 adults are uninsured. A December poll showed 78 percent of North Carolinians in favor of Medicaid expansion, including 64 percent of Republicans. The business community has been strongly supportive.
Nevertheless, this hard-won compromise took years to hash out. Senate leader Phil Berger (R), who was long one of the most outspoken critics of expansion, first expressed openness to a deal in the fall of 2021. Both the state House and Senate passed bills last year to expand Medicaid, but negotiations fell apart. After 10 months of mostly behind-the-scenes talks, and a marathon session one night last week, Mr. Berger and House Speaker Tim Moore (R) agreed to reform state laws that closely regulate North Carolina’s medical industry, loosening rules to ensure the supply of providers will keep up with demand as coverage increases.
The federal government pays 90 percent of the cost of Medicaid expansion, leaving the state responsible for just 10 percent. Under the deal, hospitals will cover that share through assessments levied by the state. The lobbying group for the hospitals, the North Carolina Healthcare Association, endorsed the final deal because of sweeteners, including the Healthcare Access and Stabilization Program, that will offset new costs. “When you put a pen to the back of a napkin, it’s a net break even at worst,” said Mr. Moore, the House speaker. “A net positive, frankly, if you do the math.”
Follow Editorial Board's opinionsFollow
Unfortunately, the final deal does not include a scope of practice provision that would have let nurse practitioners, instead of doctors, treat patients with certain ailments. That would have lowered costs and expanded competition among qualified medical professionals. But the lobbyists for the physicians kept it out. It can still be adopted in a stand-alone bill next year.
In an interview, Mr. Cooper credited support from law enforcement officers, namely the North Carolina Sheriff’s Association, for creating momentum to get a deal done. “Their deputies are dealing with mental health patients, having to spend time with them and taking them to emergency rooms when they need to be doing their jobs,” he said. “They recognize that they shouldn’t be doing this, and they connected the dots that Medicaid expansion can help alleviate that.”
Press Enter to skip to end of carousel
End of carouselAlso on the Editorial Board’s agenda
- The misery of Belarus’s political prisoners should not be ignored.
- Biden has a new border plan.
- The United States should keep the pressure on Nicaragua.
- America’s fight against inflation isn’t over.
- The Taliban has doubled down on the repression of women.
- The world’s ice is melting quickly.
Ihar Losik, one of hundreds of young people unjustly jailed in Belarus for opposing Alexander Lukashenko’s dictatorship, attempted suicide but was saved and sent to a prison medical unit, according to the human rights group Viasna. Losik, 30, a blogger who led a popular Telegram channel, was arrested in 2020 and is serving a 15-year prison term on charges of “organizing riots” and “incitement to hatred.” His wife is also a political prisoner. Read more about their struggle — and those of other political prisoners — in a recent editorial.
The Department of Homeland Security has provided details of a plan to prevent a migrant surge along the southern border. The administration would presumptively deny asylum to migrants who failed to seek it in a third country en route — unless they face “an extreme and imminent threat” of rape, kidnapping, torture or murder. Critics allege that this is akin to an illegal Trump-era policy. In fact, President Biden is acting lawfully in response to what was fast becoming an unmanageable flow at the border. Read our most recent editorial on the U.S. asylum system.
Some 222 Nicaraguan political prisoners left that Central American country for the United States in February. President Daniel Ortega released and sent them into exile in a single motion. Nevertheless, it appears that Mr. Ortega let them go under pressure from economic sanctions the United States imposed on his regime when he launched a wave of repression in 2018. The Biden administration should keep the pressure on. Read recent editorials about the situation in Nicaragua.
Inflation remains stubbornly high at 6.4 percent in January. The Federal Reserve’s job is not done in this fight. More interest rate hikes are needed. Read a recent editorial about inflation and the Fed.
Afghanistan’s rulers had promised that barring women from universities was only temporary. But private universities got a letter on Jan. 28 warning them that women are prohibited from taking university entrance examinations. Afghanistan has 140 private universities across 24 provinces, with around 200,000 students. Out of those, some 60,000 to 70,000 are women, the AP reports. Read a recent editorial on women’s rights in Afghanistan.
A new study finds that half the world’s mountain glaciers and ice caps will melt even if global warming is restrained to 1.5 degrees Celsius — which it won’t be. This would feed sea-level rise and imperil water sources for hundreds of millions. Read a recent editorial on how to cope with rising seas, and another on the policies needed to fight climate change.
1/7
The biggest hitch at this point is that Republicans in the legislature plan to include Medicaid expansion as part of a broader budget package at the end of the session. That might not pass until the summer, which could delay the effective date. More concerning is that it increases the odds of a poison pill getting added to the budget, perhaps an abortion ban or permanent limits on the governor’s powers — that Mr. Cooper would feel compelled to veto.
In addition to $8 billion in federal money that will flow annually to North Carolina, federal incentives included in pandemic relief legislation mean that the state can still collect an additional $1.8 billion if a deal gets through this year. Mr. Cooper used his State of the State address, delivered Monday night, to urge immediate passage. He emphasized that the state forgoes $521 million a month in federal funds while waiting for final passage. “No business would make that kind of financial decision,” he said.
Mr. Cooper is right. It’s time to get this done — and not just in North Carolina, but in every other GOP-run state that has refused, for no good reason, to deny Medicaid coverage to its working poor.