Not to belabor the obvious, but when North Carolina’s elected leaders craft a spending plan for state government, they take positions on many issues that have a moral dimension. And among the budget issues resonating on the level of morality, few if any resonate more loudly than those involving access to decent health care.
Life itself, after all, is at stake. Freedom from needless suffering. The ability to work, to support a family, to function as a productive citizen taking reasonable advantage of one’s potential.
So yes, it ought to be obvious why Gov. Roy Cooper has pushed so vigorously for a new state budget that would finally address what can only be described as an abject moral failure – the refusal by leaders of the General Assembly to extend health care coverage under Medicaid to many of their poorest fellow residents.
Those leaders have made no secret of their disdain for the Medicaid expansion that remains a key component of the Affordable Care Act, President Obama’s signature health care initiative. If Obama was for it, many Republicans from President Trump on down have been dead-set against it. So it came as no surprise when the legislature’s Republican chiefs on June 25 released a final budget plan for the year beginning July 1 that ignored Cooper’s Medicaid entreaties and more or less told the governor to buzz off.
Last year, before Democratic gains in the November elections, there was little Cooper would have been able to do in response to that kind of treatment other than to keep making his case as the state’s chief executive, elected to represent the interests of all North Carolinians.
But now he holds a stronger hand, as Democratic ranks in both the House and Senate have grown to the point where it’s no longer a cinch for Republicans to override the governor’s veto. A veto of the budget would be strong medicine indeed – an escalation of the conflict between Cooper and legislative leaders that could have consequences hard to predict and unpleasant to contemplate. Yet for the governor to surrender without firing a shot, figuratively speaking, would make little sense either politically or in terms of advancing his priorities, among which Medicaid expansion understandably is atop the current list.
A wider umbrella
The N.C. Council of Churches, whose own priorities also center on fair treatment for people struggling with the disadvantages of poverty and lack of opportunity, long has favored a broadening of Medicaid so that it provides health coverage to more of the state’s poorest. As far back as 1997, in a policy statement calling for a range of improvements to the state’s health care system, the Council’s Governing Board advocated a larger role for Medicaid, “especially by increasing eligibility, improving outreach efforts to those who qualify, and making services easier to access.”
So from the Council’s standpoint, it makes perfect sense that when and if the current budget plan arrives on Cooper’s desk, he should veto it and call on his Democratic legislative allies to back him up when Republican majorities try for overrides.
Medicaid needs to be broadened so that everybody who earns too little to qualify for subsidized health insurance through Obamacare still has coverage that enables them to receive care without going to an expensive hospital emergency room – expensive for others picking up the tab. That’s what the Affordable Care Act originally envisioned. But the Supreme Court, following Republican challenges to the act, allowed states to opt out of Medicaid expansion – and several Republican-led states, North Carolina included, have done just that. (Some others have seen the light.)
The number of people affected by the opt-outs can be sliced and diced, but a conservative reckoning by the Kaiser Family Foundation says that as of last November, 208,000 North Carolinians fell into the so-called coverage gap. Most of them are adults without dependent children who earn less than the federal poverty level (for 2019, $12,140 a year).
The Republicans’ critique of expansion – summarized by Sen. Phil Berger, leader of the Senate, in this op-ed piece — is anchored in the expense. Although the federal government, meaning the broad base of federal taxpayers, would pay for 90 percent of expansion’s cost, a state now must absorb the remaining 10 percent, pegged by Berger at an annual $173 million. That money would be raised via charges to hospitals and insurance companies which presumably would benefit from the expansion. But Berger and his allies say they worry that the federal share could be cut back, putting a heavier burden on the state. They seem to dismiss the economic benefits of expansion, which could bring several thousand new jobs.
While fiscal prudence always is in order, the Republicans’ objection smacks of straining to come up with a dire scenario to justify opposition that’s ultimately rooted in politics, ideology and yes, some barely suppressed contempt for poor people, many of whom happen to be people forced by circumstances mostly outside their control to swim against the economic tide.
Off the couch?
That contempt seeps through in complaints that expanded Medicaid coverage would become available to “able-bodied” folks without dependent kids. Of course, these would be people with pitifully low earnings. There’s an unavoidable implication that if they just got their “able” bodies in gear, they could climb out of the poverty ditch and maybe even reach the threshold for subsidized health insurance through Obamacare (although someone making barely more than the federal poverty level still would have a hard time affording coverage). And never mind that these Republicans, or many of them, say they want to repeal Obamacare from the ground up!
The Kaiser Family Foundation, in this March, 2019 issue brief, takes a more humane view of the health care challenges faced by our non-disabled, non-child-rearing neighbors who happen to be clustered at the bottom of the economic ladder:
By definition, people in the coverage gap have limited family income and live below the poverty level. They are likely in families employed in very low wage jobs, employed part-time, or with a fragile or unpredictable connection to the workforce. Given limited offer rates of employer-based coverage for employees with these work characteristics, it is likely that they will continue to fall between the cracks in the employer-based system. …
If they remain uninsured, adults in the coverage gap are likely to face barriers to needed health services or, if they do require medical care, potentially serious financial consequences. Many are in fair or poor health or are in the age range when health problems start to arise but lack of coverage may lead them to postpone needed care due to the cost. While the safety net of clinics and hospitals that has traditionally served the uninsured population will continue to be an important source of care for the remaining uninsured under the ACA, this system has been stretched in recent years due to increasing demand and limited resources.
Most people in the coverage gap live in the South, leading state decisions about Medicaid expansion to exacerbate geographic disparities in health coverage. In addition, because several states that have not expanded Medicaid have large populations of people of color, state decisions not to expand their programs disproportionately affect people of color, particularly Black Americans.15 As a result, state decisions about whether to expand Medicaid have implications for efforts to address disparities in health coverage, access, and outcomes among people of color.
What a lovely picture.
The proposed state budget represents a compromise between House and Senate versions that differ in some details but are in broad agreement over the amount of money to be spent and how to raise it – or not raise it, as the case may be, since the Republican push to cut taxes, particularly on businesses, continues. The tax-cutting emphasis makes GOP arguments about all the things North Carolina can’t afford, including more investment in health care for the poor and significantly more spending for the public schools, ring hollow.
And even though Cooper was invited to take part in budget negotiations and has had various discussions with legislative chiefs, his key priorities seem to have been snubbed. So any compromise aspect of the budget that likely will be sent to him was compromise between legislators, not among him and them.
Legislators have the prerogative of enacting a budget, no question there. But the governor has been vested with veto power, and he now has enough legislative muscle so that vetoes aren’t doomed from the get-go to be blown off.
A budget veto might set the stage for a showdown extending well into the new fiscal year, but given the many ways this budget fails to meet Cooper’s well-considered concept of the public interest, he shouldn’t hesitate to use one of the most important tools in his toolkit.
Some hard bargaining no doubt would remain, but at least the governor would come to the bargaining table with the moral force that comes with standing up for people who for too long have lacked a powerful advocate.