Healthcare seemed to be a big campaign issue way back in 2016 — both nationally and in North Carolina.

President Trump promised a “beautiful” healthcare plan. Gov. Roy Cooper put Medicaid expansion in his first budget proposal. Neither has happened.

Could that soon change? There appears to be renewed interest in expanding health care coverage to more low-income North Carolinians.

We’re talking about subsidized insurance for the roughly 500,000 people who would qualify under federal Medicaid expansion as part of the Affordable Care Act, if North Carolina had chosen to go that route1.

This chart from the N.C. Justice Center shows the current Medicaid eligibility thresholds in North Carolina as a percentage of the federal poverty level. The Affordable Care Act expansion would make everyone up to 133% of the federal poverty level eligible.

Of course, politics make all of this complicated.

Expansion under the Affordable Care Act is unpopular among Republicans. In fact, a state law passed in 2013 prevents the governor from expanding Medicaid2.

But there is a Republican-led effort called “Carolina Cares” that would do almost exactly the same thing that could get moving soon.

Here’s the lay of the land.

Medicaid waiver

The main thing to know is that North Carolina is continuing to move toward a program that pays doctors based on outcomes instead of procedures3. This is expected to happen after July 2019. The Medicaid waiver stuff does not include expanding healthcare to anyone new.

If you don’t care about political infighting or nitty-gritty details, you can skip this part and head right to the “Carolina Cares” section below.

If you’re still here, here’s the full story:

Though former Gov. Pat McCrory did not choose to expand Medicaid under the Affordable Care Act4, his administration did craft a detailed proposal that would change how it was administered in North Carolina.

His plan would not really expand access to insurance to anybody, but would have created new incentives for doctors to focus on long-term health and paid hospitals based on outcomes rather than individual tests procedures.

McCrory also pushed for requirements that new Medicaid recipients be working as part of the waiver, but then-President Obama had said that was a non-starter.

This 216-page plan was submitted to the federal government in June 2016. At the time, it was expected to take 18 months to review.

Photo by Pat McCrory via Facebook

Of course, everything changed a few months after that. Both the White House and the Executive Mansion flip-flopped parties.

Cooper, a Democrat, had long said North Carolina should expand Medicaid. And as governor, his administration had the right to amend that plan his predecessor had submitted to the feds.

Fearing that Cooper wanted to sneak in expansion, Republicans immediately sued to try to keep Cooper from doing this. They got some temporary delays, but the new plan was ultimately submitted in November 2017.

It keeps most everything the same, including a pay-for-outcomes approach. It doesn’t expand insurance to anybody new, either. Cooper’s plan does try to provide more incentives for doctors to participate in Medicaid through loan repayments, and more specifically addresses opioid abuse.

N.C. Department of Health and Human Services Secretary Mandy Cohen says the state expects to hear soon from the Trump administration on whether their request is approved.

N.C. Department of Health and Human Services Secretary Mandy Cohen

Carolina Cares

This one has the potential to actually be impactful.

House Bill 662, which has four Republicans as primary sponsors, sets up a program to offer health insurance to people making less than 133% of the federal poverty line5.

People would pay 2% of their annual income as a premium, billed monthly. Copayments would be similar to those paid by Medicaid participants.

And people would be required to work to be eligible, unless they’re caring for children/dependent adults, in substance abuse treatment or “medically frail.”

The state Department of Health and Human Services would be required to come up with a plan to secure the most federal funding possible6.

So basically, it’s Medicaid expansion without technically being Affordable Care Act expansion, plus a work requirement7.

The 3-page bill is currently sitting in House committees, but in recent weeks the bill has received some renewed attention and interest — though General Assembly leaders have largely been silent on the issue.

The N.C. legislative building. Photo by Gerry Dincher via Flickr (Creative Commons)

What about work requirements?

Here’s why you’re hearing about this lately.

The deal here is that the Trump administration said a few weeks ago that it is cool with work requirements being a part of Medicaid in general, a reversal from the Obama administration.

In his Medicaid waiver plan back in November, Cooper signaled that he is OK with work requirements being part of the Carolina Cares program only.

We’ll update this story if anything moves.

Cover photo of UNC Hospitals by William Yeung via Flickr (Creative Commons)

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