The other day I was putting the finishing touches on a health reform update for the North Carolina HIV/AIDS community. It began “Medicaid Expansion – no decision, few hints.” It’s a good thing I didn’t get the email out, as we now have some big hints about what legislative leaders think about implementation of the Affordable Care Act in North Carolina. In short, not good.
The Legislature gets to work: Bills were introduced yesterday in the North Carolina Senate and House rejecting the two key coverage expansions of the Affordable Care Act: the Medicaid Expansion and the Health Insurance Exchange. If enacted, these bills would pull the rug out from under uninsured people living with HIV/AIDS who are now unable to access insurance coverage. The identical bills (Senate Bill 4, House Bill 16) do several things, the first of which is grab control over health reform implementation. They would reserve to the General Assembly the authority to make decisions on state involvement with the Health Insurance Exchange and on whether to expand Medicaid. The bills also would repeal General Statutes 58-2-40(10), which gave the Insurance Commissioner authority to implement the Affordable Care Act.
The bills direct the State to stop working on a planned state-federal partnership exchange and return the $74 million awarded by the feds earlier this month to fund that work. Although the title describes the legislation as intended to “Reject the Affordable Care Act’s Optional Medicaid Expansion,” the text of the proposed law simply states that the state can’t expand without authority from the legislature. That’s actually nothing new. There was never any question that Medicaid could be expanded without the legislature getting on board.
Insurance Marketplace: In spite of the short title, “No N.C. Exchange/No Medicaid Expansion,” the proposed law would NOT keep a health insurance exchange (or “marketplace”) out of North Carolina. It just leaves operation of the online marketplace entirely to the federal government, rather than a federal-state partnership. Starting 2014, people living with HIV/AIDS will be able to purchase insurance in this marketplace even with a pre-existing condition. People with incomes from 100% to 400% of the federal poverty level will be able to get subsidies to make the insurance affordable. People with incomes at or below 250% of the federal poverty level ($27,975 for a single person) will still get subsidies not only for premiums, but also for cost sharing.
So we WILL have a new Insurance Exchange in 2014, and open enrollment starts this October. This law would do nothing more than cede all control to the federal government, which is a shame. Under Governor Perdue, the state proposed to participate in a “partnership exchange,” in which the state would handle plan management and consumer assistance. North Carolina was awarded a $74 million grant earlier this month to continue planning for this arrangement. Under the proposed legislation, North Carolina would have to send the money back. This is particularly ironic because North Carolina’s SHIIP program, which helps seniors navigate health insurance and Medicare, is a model being used by the federal government in designing its own consumer assistance program.
Although rejecting the federal-state partnership exchange elevates politics over policy, this is something the HIV/AIDS community can live with. The Insurance Exchange/Marketplace experience is expected to resemble online travel services like Expedia, or the Medicare Part D plan selection website. And there will be federal grants to interested North Carolina organizations to help consumers figure out the new insurance exchange. (More on that in a future post – Ryan White grantees can go after these grants!)
Medicaid Expansion: This is the part that really hurts. For the majority of uninsured people living with HIV, the Medicaid expansion is critical. The expansion, which was made optional by the Supreme Court, would cover all citizens with incomes up to 138% of the federal poverty level ($11,170 for a single person; $23,050 for a family of 4). Rejecting it out of hand means about 5000 people living with HIV/AIDS, and over half a million other uninsured people in North Carolina will be deprived of access to insurance coverage. The arguments against expansion, that it will break the bank, attract folks from neighboring states that don’t expand, and that it’s a “failed” program, are based on misinformation. In fact, the cost to the state would be small, and it would bring an estimated $15 billion into the state over the next decade. If North Carolina doesn’t expand, our tax dollars will go to other states that do. Interestingly, that includes four states with Republican governors who have taken a pragmatic rather than political approach to the issue. (Arizona, New Mexico, Nevada, and North Dakota).
What next? A number of health advocacy organizations are speaking out against these two bills. The North Carolina AIDS Action Network (NCAAN) has done an action alert. Health Advocate Adam Searing at the NC Justice Center has an on-point post, Three Dumb Things that Happen if NC Rejects Obamacare’s Medicaid and Health Exchange
What we really need to know is where Governor McCrory comes down on this. Pragmatist like Arizona Governor Jan Brewer, or tea party puppet.