For many of us, these are troubling times as Donald Trump ascends to the nation’s highest office. We can hope for the best but it’s hard not to anticipate the worst: valuable alliances trashed, environmental protections ravaged, civil rights eroded, neighbors pitted against neighbors as Trump’s own crude selfishness like a virus afflicts our civic character.
Then there’s the prospect of a seismic shock to our health care system as the new president and congressional Republicans pursue what’s become for them a white whale – repeal and, supposedly, replacement of President Obama’s signature Affordable Care Act. How or whether they’ll manage that feat without triggering an explosion in the ranks of the uninsured and thus in human misery is anyone’s guess.
In North Carolina, it’s also anyone’s guess how a subplot of that health care drama will turn out. The story has twisted and turned by the day.
But this we know. The effort by North Carolina’s new governor to expand the state’s Medicaid program – an effort bitterly opposed by leaders of the General Assembly – is a long-awaited and significant attempt to better the lives of some of our least fortunate fellow Tar Heels.
If Roy Cooper’s effort succeeds despite the odds, the Medicaid umbrella will be enlarged to cover as many as half a million additional people. Most of them would have income so low as to have made them previously ineligible for Medicaid coverage. But they also would have struggled to afford ordinary medical care — the kind most of us take for granted — at doctors’ offices. They would have had to rely mostly on hospital emergency rooms.
ERs of course serve a vital need in treating all manner of acute problems – in other words, emergencies. But they’re not well-suited to help patients manage their health over the long term in the ways that personal physicians can do. People who have to forgo that kind of care pay a steep price not only in lingering conditions and illnesses but also in their ability to work and to carry on as productive citizens.
What’s more, when people who can’t afford expensive emergency room bills show up there anyway, often out of desperation, hospitals are obliged to treat them. Costs typically are passed along to other, paying patients, resulting in higher bills for them and higher insurance premiums. But the strain on hospital budgets can be severe.
A dual win
So the expansion of Medicaid to cover more low-income adults makes sense both in humanitarian and economic terms – doubly so, considering that when states do expand their Medicaid programs as encouraged under the Affordable Care Act, most of the cost is picked up by the federal government. In other words, it’s spread across the base of federal taxpayers, cushioning the impact on state budgets.
That North Carolina’s legislature, controlled by conservative Republicans, in 2013 enacted a law meant to block Medicaid expansion remains a singularly dark blot on a record spattered with narrow-minded callousness and over-the-top partisanship.
Republican Gov. Pat McCrory, whose criticism of a “broken” Medicaid system was as unremitting as it was unfounded, went along with the expansion ban despite the urgings of health care specialists and anti-poverty advocates, including the Council of Churches.
Although McCrory signaled from time to time that he was inclined to follow several other Republican governors down the expansion path, top legislators such as Senate President Pro Tem Phil Berger and House Speaker Tim Moore maintained a position that boiled down to “Not gonna happen!”
Medicaid thus became yet another policy area where McCrory ended up toeing the legislature’s hard conservative line – and no doubt bearing the consequences in the November election as Cooper, the state’s veteran Democratic attorney general, denied him a second term.
When Cooper took over the governor’s office on Jan. 1, the long-smoldering Medicaid issue suddenly flared. One could say that it went from chronic to acute – and from the new governor’s perspective became even more urgent with Trump set to succeed Obama in the White House.
Cooper declared his intent to move ahead with Medicaid expansion as a first big policy initiative. Federal health officials promised to give the state’s expansion request a speedy review – mindful that Trump and the Republican-controlled Congress wanted to pull the plug on Obama’s entire approach to health care reform in which a larger role for Medicaid has been a key component.
That’s when Berger and Moore – fresh from their December flurry of moves to curb Cooper’s executive powers – went to federal court to try to derail the governor’s Medicaid plans.
Their Jan. 13 suit accused Cooper of violating the law requiring any Medicaid expansion to proceed only with legislative approval. And because the state would have to cover part of the expansion cost, if no more than 10 percent, they ripped the governor for unilaterally committing the state to a tax increase. Which of course he couldn’t actually do, but it sounded good – at least to the conservatives for whom holding down taxes seems to be their chief goal, despite the damage to state programs and harm to the people those programs serve.
Federal District Judge Louise Flanagan on Jan. 14 granted Berger and Moore’s request for a temporary restraining order that would keep both Cooper and federal officials from moving ahead with Medicaid expansion for two weeks. That would mean the Trump administration, not officials reporting to Obama, would have the final call – a discouraging prospect for those seeking better health care access for the poor.
Neither Cooper nor his federal allies were ready to surrender. They filed their own documents (here and here) urging Flanagan to lift the restraining order because, they argued, Berger and Moore didn’t have a legal leg to stand on.
The dispute didn’t belong in federal court, they said, because no federal laws were properly at issue.
They asserted that regardless of the legislature’s expansion ban, Cooper was entitled to propose revisions to the state Medicaid program and the federal Department of Health and Human Services was entitled to review them.
And they noted that even if federal approval were obtained, the expansion wouldn’t take place until the beginning of 2018 – and then, only if state matching money were provided and the state’s Medicaid eligibility rules were broadened.
It’s fair to say those are some big “ifs” – especially with the presidential turnover and pending policy changes in Washington. But if the state’s proposal somehow gets in under the federal wire, at least that would put Cooper in a better spot to bargain with the legislative leadership – potentially with $2 billion-plus in federal Medicaid funds on the table.
Those leaders don’t want to commit to more Medicaid spending because they think the program is too expensive. But the social costs of forcing some of our hardest working but lowest paid neighbors to get along without health insurance or subsidized care are enormous in their own right.
Gov. Cooper now has pointed the way toward a more sensible, humane approach. It will be to North Carolina’s credit and advantage if that approach finally wins out.