The early days of the General Assembly long session have included about a half-dozen Republican proposals to improve health care in North Carolina. Put together, they represent one of the biggest potential shifts in the state’s health care policy in years.

Here, we’ll examine 5 proposals introduced by N.C. Senate GOP leaders in the state House or Senate. Keep in mind that they do not have a guarantee of passing. This year, there’s been significant differences of opinion between House Speaker Tim Moore and Senate President Pro Tem Phil Berger — and both need to be on board for legislation to pass.

For our purposes, we’ll set aside the one big Democrat proposal: Medicaid expansion. This effort to cover able-bodied, low-income single adults with government insurance is a non-starter in the current legislative session.

We’ll also defer on examining the one big N.C. House proposal: Forming a study committee on how to govern the State Health Plan. This is the result of a philosophical difference between State Treasurer Dale Folwell and rural legislators. Folwell wants to save state taxpayers $300 million, primarily but cutting the amount the state reimburses health care providers for care. Some lawmakers are concerned about the impact this would have on rural hospitals, which are already on thin financial ice.

Here are the proposals you need to know and what they mean. We’ve also decided to rank them in order of how transformative they would be, from most to least.

1) Allow small businesses to band together for health insurance

This complicated and little understood proposal could potentially have a major impact on millions of North Carolinians.

Here’s how it works: Large employers are able to get good deals on health insurance plans by virtue of their thousands of employees. A proposal from the N.C. Senate would help small businesses do the same.

It would legalize something called “Association Health Plans,” or nonprofits formed by groups of affiliated small employers to offer health insurance to all of their members. This opens the door for businesses to offer health insurance that never could afford it before.

For example, all of the mom-and-pop retailers in a city with only a handful of employees could come together to offer health insurance, something that would have been cost-prohibitive for any one of them to do by themselves.

Sole proprietors would also be able to come together. This would open the door for, say, chambers of commerce to sponsor health insurance plans for solopreneurs.

This proposal is part of Senate Bill 36, called the Small Business Healthcare Act.

2) Eliminate North Carolina’s “Certificate of Need” laws

North Carolina is currently one of 35 states that use central planning strategies for healthcare facilities, known as “Certificate of Need” laws. These require any health care provider that wants to buy medical equipment, or build or expand their facilities, to get approval from the Department of Health and Human Services in a stringent process.

The trend nationwide is for states to repeal these laws, and that’s the biggest component of Senate Bill 361, called the Health Care Expansion Act of 2019.

The idea behind eliminating CON laws is to increase the supply of healthcare services, thereby reducing prices.

3) Add a work requirement to receive Medicaid

Under the Trump administration, state’s are now allowed to require able-bodied Medicaid recipients to show they are working or looking for work to receive government insurance. And that’s what North Carolina is proposing in Senate Bill 387.

The work requirement would only apply to adults who are not elderly, pregnant, disabled or medically needy. This is currently a relatively small percentage of people receiving Medicaid in North Carolina.

4) Ban surprise “out of network” hospital service bills

Patients don’t always realize it, but health care providers you see at a hospital don’t always actually work for the hospital. So when you go in for a procedure, the hospital itself might be in your insurance network — but one of the doctors who treats you might be out of network.

Senate Bill 386 would keep patients from receiving surprise bills from providers who are out of their insurance network, which generally cost a whole lot more than in-network providers. Instead, the hospital would have to disclose if a patient may be seen by an out-of-network provider and inform them that they’re not legally obligated to pay the additional fees.

The bill also tightens rules that prevent hospitals from charging “out of network” rates on emergency services or services the patient is unable to get from in-network providers.

5) Expand funding for in-home care to 2,000 more people

This proposal would add $41 million in funding to a program that provides money to Medicaid recipients with intellectual or developmental disabilities for in-home care or medical devices that help them live independently.

Currently, about 12,000 people receive this money, called North Carolina’s Innovations Waiver. The wait list is about 7 years. The new proposal would add 2,000 people to the program.

This proposal is also part of the Health Care Expansion Act of 2019.

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


  1. “Medicaid expansion. This effort to cover able-bodied, low-income single adults with government insurance is a non-starter…”
    Really? That’s how you describe Medicaid? Coverage for “…able-bodied, low-income single adults”?

    Medicaid in North Carolina covers:
    * 2 in 5 children
    * 5 in 8 nursing home residents
    * 3 in 8 individuals with disabilities
    * 1 in 6 Medicare beneficiaries
    * 57% of adult Medicaid enrollees are working
    * 49% of children with special health care needs

    Enrollees & Expenditures:
    * 1 in 4 (28%) enrollees are elderly/children
    * 2 in 3 (64%) expenditures go to elderly/children

    Share of those with favorable view of Medicaid:
    Nationally: 74%
    Democrats: 82%
    Republicans: 65%

    Source: Henry Kaiser Family Foundation, 11/2018

    I know Longleaf Partners is just a right-wing blog that, as you can see from so few comments on the “articles,” not many people read. But really, Andy. Has your partisanship completely dwarfed any journalistic standards that might still be “yearning to breathe free”?

  2. “The work requirement would only apply to adults who are not elderly, pregnant, disabled or medically needy. This is currently a RELATIVELY SMALL percentage of people receiving Medicaid in North Carolina.”

    So, if you acknowledge that here, why diss (rhymes with p…) Medicaid earlier? (See comment above)

  3. The obvious problem with expanding Medicaid to more people is that it might not expand health care to the same, since growing numbers of doctors will not accept Medicaid patients — the paperwork is excessive and the remuneration is insufficient. In the meantime, another block of people become dependent upon government for their care. If the Obamacare formula were followed in the expansion plan, it was to be financed by a tax on hospitals, a tax that would increase their expenses and put the weaker institutions out of business. How does that improve health care for anybody?

  4. You realize that all Medicare, Medicaid recipients are subsidized by current working people who pay health insurance premiums, right? This bill would not raise your taxes. If you pay for health insurance, it WILL raise your premiums. That is how healthcare businesses will respond.

    Rural hospitals that are struggling are in favor of expansion. Why? most have an overwhelming number of Medicaid, Medicare patients. One hospital in my area has Medicare/Medicaid patients accounting for over 70% of their services provided. These federal payments do not come close to covering the cost of services provided. Hospitals in rural areas generally do not have enough businesses that offer decent health benefits to offset the huge amount of uncompensated and undercompensated care. The NC Healthcare Association has been in favor of Medicaid expansion ever since it came out. Why? because it cuts down on the amount of uncompensated care they have to provide. Getting something is better than getting nothing.

    In short, not expanding Medicare will lead to MORE weaker institutions closing and make healthcare scarce in rural communities. Healthcare premiums will also continue to rise.

    Expanding Medicare will lead to better access and greater viability for rural health facilities but, healthcare premiums will rise even more. The issue is complex and being against it just because Obamacare is evil doesn’t solve the problem. I would seem that “Obamacare is evil” is the entire federal level Republican platform on healthcare. That is why we haven’t ever seen a Republican healthcare plan submitted in Congress. Truth is, they don’t have a plan. If they ever do come out with an economically feasible plan, they will have to go back on too many promises they have made over the past decade. In a sense, they have painted themselves into a political corner. At some point you have to be for a solution instead of always criticizing the solutions of the other party.


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