Doctors and hospitals have spent years pushing for Medicaid expansion in North Carolina. But now that Republican leaders have proposed a bill that would do just that, some are now either lukewarm on the bill or even actively opposed.
In large part, that’s because the bill also contains a number of other health care policy changes that threaten to upend other parts of the medical industry.
Chip Baggett is CEO of the North Carolina Medical Society, an influential lobbying group for doctors. He said they still support Medicaid expansion, but they oppose the way the legislature is currently proposing that it happen — namely, with so many unrelated policy changes tacked on.
“It’s all muddied up,” he said.
The opposition from some outside groups to parts of the bill hasn’t stopped the bill from quickly moving forward at the legislature, at least for now. The Senate backed the measure nearly unanimously Wednesday in the first of two votes.
If approved, the federal government might pay North Carolina $1.5 billion, similar to a signing bonus — plus 90% of the costs of covering uninsured North Carolinians, an estimated $8 billion per year.
Gov. Roy Cooper and other Democrats have long clamored for Medicaid expansion. Republicans in North Carolina have remained largely opposed to it even as GOP-led states elsewhere approved it in recent years. But that has now changed, at least in the N.C. Senate. And while powerful Republicans like Senate leader Phil Berger have changed their position to support Medicaid expansion, it’s also clear that they intend to use the bill to chip away at other rules and regulations in the health care industry.
What’s in the bill?
Industry groups including Baggett’s say some of the various rules and regulations that the bill targets are useful to improve safety in health care settings, or reduce costs.
But critics of those rules — who include, importantly, powerful Republicans who are now supporting Medicaid expansion tied to the other changes — dismiss those claims. They say the industry complaints are really just about special interests looking out for themselves.
“Nobody likes to be knocked off the top and not be in charge anymore,” Sen. Ralph Hise, a top GOP lawmaker who co-chairs the Senate’s committee on health care, said during a recent meeting of his committee where the bill passed easily.
The bill, formally called “Expanding Access to Healthcare” contains a number of health care policy changes:
▪ Medicaid expansion, which would give coverage to roughly 500,000 North Carolinians. Most of them make too much money to qualify for Medicaid currently, but also work in jobs that don’t offer benefits.
▪ The SAVE Act, which would allow certain nurses to perform higher-level duties, like administering anesthetics, without a doctor’s supervision.
▪ A partial repeal of “certificate of need” regulations that limit health care companies from buying new machines or building new hospitals without government approval. Supporters, like the hospital industry, say it keeps costs down by discouraging needless spending. Critics say it actually raises costs by killing free-market competition.
▪ A “surprise billing” ban that would require patients to be given at least 72 hours advance notice if one of their providers for a medical procedure is out-of-network for their insurance.
▪ Telehealth expansion, to make it easier for people and their doctors to schedule visits remotely by phone or video rather than in-person visits.
With so much in the bill — and each piece representing millions or even billions of dollars at stake — the jockeying behind the scenes has begun in earnest.
“We are still conferring with our members and legislators and have not yet taken a position on it,” said Cynthia Charles, a spokeswoman for the hospital lobbying group N.C. Healthcare Association. “It’s a 33 page bill with a lot of moving parts and a sophisticated financing structure that we need to thoroughly review and discuss with our members before taking a position.”
While the group supports expanded health care access in general, she said, “The details of how the state can best accomplish that goal matter.”
The bill is rushing through the Senate at lightning pace. But it seems less guaranteed to sail through the House of Representatives — where House Speaker Tim Moore has deflated the hopes of supporters somewhat, saying he doesn’t currently expect to vote on it this year.
Lobbying groups at odds
Medicaid expansion may be more likely to get GOP support if it’s also tied to other policy changes that key lawmakers have tried to pass but failed due to intense lobbying efforts. The question could become how much those same lobbying groups are willing to push now to change the bill, if it might kill the effort altogether.
Complicating matters is the fact that influential groups disagree with one another on what parts of the bill are good or bad — something that supporters of the bill, like Hise, say is natural when dealing with a complicated topic like health care.
For instance, both the Medical Society that represents doctors and the Healthcare Association that represents hospitals support Medicaid expansion. The hospitals oppose the “certificate of need” overhaul while not having much to say about the SAVE Act changes. The doctors oppose the SAVE Act piece but remain agnostic on certificate of need. And on the opposite side is the John Locke Foundation, an influential conservative think tank in Raleigh that supports the non-Medicaid pieces of the bill but opposes Medicaid expansion.
And then there are the scores of other political groups representing more targeted parts of the health care industry — all with money to throw around, and many with competing interests.
State campaign finance records show, for example, show nine political groups active in North Carolina for radiologists alone. There are even more for anesthesiologists, plus there’s yet another for nurse anesthetists — which is not to be confused with yet different groups for nurse practitioners, or for nurse midwives, or for nurses in general. There are also separate groups for surgeons, veterinarians, eye doctors, pharmacists and more.
Their level of spending varies widely. Many of the smaller groups spend a few thousand dollars per election. The bigger groups are a different story.
The Medical Society gave more than $160,000 to politicians in 2020 and so far in 2022, on both sides of the aisle. One of its main goals in the Medicaid bill is to get the SAVE Act piece removed. But on the other side, nurse anesthetists would benefit from those changes. And in the same period, their PAC has outspent the doctors’ PAC by roughly $100,000.
The SAVE Act would allow advanced practice registered nurses, who have advanced degrees, to perform higher-level duties without being supervised by a doctor. Currently doctors are allowed to charge nurses they supervise, and some charge thousands of dollars a year. Nicole Livanos, who represents the National Council of State Boards of Nursing, said nearly every county in North Carolina has a shortage of doctors — and that nationwide, other states that have passed SAVE Act rules have seen large improvements in health care access once nurses are allowed to do more, particularly in rural areas where there are few doctors.
“When barriers are removed (advanced practice registered nurses) are more likely to relocate in rural and underserved areas,” she said.
Baggett recently told lawmakers that doctors oppose the SAVE Act in part because nurses don’t have as much training as doctors. Livanos dismissed those concerns, saying other states have already proven there’s no harm in making the change.
“North Carolina is not the first state to take this on,” she said. “It’d be the 27th state, if it passes. And what we have not seen is the sky falling.”
In addition to the SAVE Act debate, big money can also be found swirling around the certificate of need issue.
The Healthcare Association has spent more than $350,000 on outside ads and direct political contributions in 2020 and so far in 2022. They oppose changing certificate of need laws.
But Hise is in favor of changes, and when he faced a tough primary election earlier this month against a fellow Republican incumbent, more than $60,000 worth of mailers went out to voters in his new Western North Carolina district supporting his campaign. That’s 12 times more money than any person or group is allowed to give directly to a politician, but outside spending is not subject to the same rules.
The money came from a coalition of business leaders who want certificate of need changes, plus other health care policies. In a recent blog post the group, which includes current and former Blue Cross Blue Shield of North Carolina officials, wrote that they support most but not all of what’s in the bill.
Focus on rural health
GOP leaders hope that, overall, the bill attracts enough support to pass. If so, they say, it will be a huge help not just to the hundreds of thousands of people who have gone without health insurance for years, but also to the economy in general.
Many point to the likely benefits of Medicaid expansion in rural areas, which have been hard-hit by hospital closures in recent years — affecting an area’s health and also its economy, since a hospital is often one of the largest employers in any given area.
In North Carolina since 2005, 11 hospitals in rural areas have closed down, according to a report presented to the legislature in February — which said that nationwide, most rural hospital closures have occurred in states that did not expand Medicaid.
Some supporters frame it explicitly as a pro-jobs bills. Without expansion in place, people can be punished for working by getting kicked off Medicaid if they make too much money — for example, a single mom with two kids making $25,000 a year would be considered too wealthy for Medicaid currently, Berger said.
Having health coverage can also help keep people healthy and working, said Sen. Danny Britt, a Republican from Robeson County.
“Whenever people suffer, whether it’s from a physical issue or a mental health issue, that takes them out of the job force,” he said. “And that hurts us even more.”
After years of GOP opposition to Medicaid expansion, Republican voters are now hearing support for it from some leaders of their party. Just before the bill was announced last week the Republican sheriff of Macon County, Robbie Holland, wrote a newspaper editorial calling for Medicaid expansion.
Macon County, a rural part of Western North Carolina that borders Georgia and South Carolina, is hardly a bastion of liberalism. Donald Trump got more than twice as many votes there as Joe Biden in 2020.
So for a highly politicized topic like Medicaid to gain the backing of the county’s Republican sheriff — who’s often the single most influential leader in smaller counties — was notable. Holland framed it as a public safety issue.
“When inmates are in our custody they have access to mental health treatment and substance abuse classes,” he wrote. “In fact, many become sober for the first time in their adult lives. … More times than not, these inmates walk out of the doors of our facility and right back into society with nowhere to turn and with very few resources available to continue those services. Which, of course, too often leads to more trouble.”
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This story was originally published June 1, 2022 9:58 AM.