Those pledges spawned some significant successes, foremost Cooper’s signing of the 2021-23 state budget on Nov. 18.

It represented the fruits from the first earnest negotiations over a Republican-sponsored budget bill involving Cooper and Democratic leadership since Cooper took office in January 2017.

A major part of the state budget compromise was Republican leadership’s agreement to form the Committee on Access to Healthcare and Medicaid Expansion. Although the committee focused on expansion, it discussed many of the health-care reform priorities over the past three months.

Fast-forward to last week, and there was a second remarkable bipartisan development in which Senate Republican leadership — after 10 years of often intense opposition to Democratic legislation — agreed to fast-track Medicaid expansion as part of a multilayered health-care reform bill.

The bill already has advanced to its third and final committee step where it will be heard in Rules and Operations at noon Tuesday.

That sets up a potential Senate floor vote later this week, although House Republican leadership remains lukewarm to addressing Medicaid expansion during the current session.

Cooper’s office said the progress on Medicaid expansion is encouraging and that the governor “will carefully review this legislation.”

Partisan hurdles

Medicaid currently covers 2.71 million North Carolinians, which increased by nearly 27% — 588,611 people — since the pandemic surfaced, according to the N.C. Department of Health and Human Services.

Those who might be eligible under the expanded program are those who earn too much to qualify for Medicaid coverage, but not enough to purchase coverage on the private insurance marketplace.

It is likely, the Associated Press reported, that many of those new enrollees could remain on Medicaid post-pandemic if the proposed expansion bill becomes law.

HB149 may represent the best opportunity toward making North Carolina the 39th expansion state with the projection of assisting between 450,000 and 650,000 potential enrollees.

Yet, even with once-fervent expansion opponent Senate leader Phil Berger, R-Rockingham, now in support, legislative analysts caution against thinking it’s a breakthrough moment amid often-bitter partisan battles over the past 10 years.

“I would be very hesitant to draw any more general conclusions from Senate Republicans’ shift on Medicaid expansion, (in particular) to suggest that this is a sign of a general spirit of compromise or a lowering of the temperature on partisan battles in Raleigh on other issues,” said John Dinan, a political science professor at Wake Forest University who is a national expert on state legislatures.

“On the same day (Wednesday) that this shift in Medicaid expansion was announced, legislators from both parties were engaged in heated exchanges about a new proposed parents’ rights bill.”

That same dynamic likely will hold true during Tuesday’s Rules and Operation meeting since House Bill 755, titled “Parents’ Bill of Rights” is slated to be addressed after the HB149 discussion.

Given Cooper’s initial statement opposing HB755, calling it North Carolina’s version of the “Don’t Say Gay” Florida law, it’s highly likely he will veto the bill if it clears the legislature and Democratic lawmakers will uphold the veto.

HB755 is “among other sharp disputes about other policy differences that will continue to divide the parties even if agreement is reached on the Medicaid expansion issue some time this year or next year,” Dinan said.

Why now? Why this?

Senate GOP leaders say their opposition has thawed in part because of the federal government’s track record — during the Obama, Trump and Biden administrations — on paying 90% of what it costs to expand Medicaid in the 38 states that allowed more people to be covered.

“I had concerns the federal government would break its promise … leaving states, such as North Carolina, holding the bag with bigger and bigger health care expenses and holes in our budget,” Berger said.

“The Affordable Care Act is not going to go away.”

“At this point in time, all legal and legislative attempts to overturn that act have not succeeded, and I do not think they will succeed in the future,” Berger said. “It’s highly unlikely that the 90% cost share will change.”

Although the proposed bill would allow the state’s health secretary to end North Carolina’s expansion efforts if the federal government stops covering 90% of the administrative expansion costs, Sen. Joyce Krawiec, R-Forsyth, said, “We don’t believe that will happen.”

Dinan agreed that “there is no sign of the federal government reducing its current 90% contribution to the costs of covering Medicaid expansion beneficiaries.”

Krawiec said part of what could make HB149 as a compromise health-care reform bill is that “there are aspects of many bills that have some parts that everyone may not agree on.

“In fact, this is not unusual at all.

“We cannot add hundreds of thousands of citizens to the health-care rolls without improving access and increasing providers,” she said.

GOP HB149 priorities

Berger emphasized that Senate GOP leaders believe Medicaid expansion “needs to happen with additional reforms, including the very real supply-side issues that prevent North Carolinians from accessing care.”

Perhaps foremost is easing some restrictions on certificates of need, which health care providers must obtain from the state before building new health care centers or adding certain equipment.

Easing that restriction could allow for more competition, including from for-profit groups, for medical procedures.

The state’s not-for-profit health-care systems have opposed weakening certificate-of-need laws out of concern that large for-profit groups would enter North Carolina and cherry-pick the more lucrative services, leaving the not-for-profits treating the sickest patients, likely without health insurance, who come into emergency departments.

Other key elements of the proposed Medicaid expansion: permitting nurse practitioners, certified nurse midwives and nurses with other advanced specialties to practice without a physician’s formal supervision; requiring health insurers in the state to cover telehealth services; and requiring in-network health facilities to alert consumers when out-of-network providers are scheduled to provide care.

“Senate Republicans see an opportunity to secure passage of a number of longstanding health policy priorities that could not pass on their own, but could pass as part of a Medicaid-expansion package,” Dinan said.

Dinan said there are some electability issues present with HB149 for both parties.

“The issue of Medicaid expansion has been more of a drag than a help to Republican candidates’ prospects in state elections,” Dinan said, especially as more rural Republican elected officials have expressed their support.

“Getting that issue off the table, or at least reducing its salience, is likely a net benefit to Republican candidates heading into the 2022 election.”

Michael Bitzer, a political science professor at Catawba College in Salisbury, said the state budget compromise “certainly opened the door to working toward this potential deal,”

However, Bitzer cautioned that persuading House speaker Tim Moore, R-Cleveland, to support HB149 likely will take into 2023 to accomplish.

“One area that I think is critical to watch is among House Republicans, who have moved toward not going along with expansion when they were open to considering it” in 2020 and 2021, Bitzer said.

Work requirement

Bitzer said that “the big question among that group would be, what kind of work requirements would be instituted, and how can those be approved by the federal government.”

The work requirement for new Medicaid recipients has received grudging support from some Democratic legislators.

However, work requirements in other states have proven problematic.

A work requirement passed by the Arkansas and New Hampshire legislatures has been struck down by federal courts. In March 2021, the U.S. Supreme Court said it would not hear additional arguments on the appeals made by the two states.

Berger said the plan is to pass the bill with the work requirement included, “and then we’ll deal with whether or not we can convince the Biden administration or the courts that this is the right thing to do.”

Berger said that, while the work requirement is being litigated, enrollees would remain eligible and not be denied.

“There’s a lot of moving pieces to work this policy through, though the sweeteners are obviously something that Berger is well aware of,” Bitzer said.

Bitzer said he’s not sure whether voters, particular those in the middle, will pay enough attention to the dynamics of how HB149 came together to reward either party in the November general election. 

“We know that mid-terms are generally hard on the president’s party,” Bitzer said.

“There’s the energy and motivation for both political parties, the economic issues at the forefront, and the potential uncertainty of what these new legislative districts may play out.

“I’d be cautious in trying to read any tea leaves into what one or two factors would influence November’s outcome at this point in the cycle,” Bitzer said.

NCHA opinion

The N.C. Healthcare Association said last week it “is reviewing and digesting the bill and its components to consider how it would potentially impact health systems and hospitals.

The association has been as intense an opponent of reforming the state’s certificate-of-need laws as Berger and Krawiec had been anti-Medicaid expansion.

State health regulators must issue a CON before a health care system or other medical provider can build a facility, buy equipment or offer a surgical procedure. It affects 28 health care sectors. The law took effect in 1978.

The primary goal of the laws is to prevent unnecessary duplication of services within a community or region as a means of controlling costs with service capacity.

CON opponents, which includes Krawiec, claim that adding competition, particularly from for-profit groups, would lead to new services and facilities, including more acute-care hospitals, diagnostic centers and rehabilitation centers.

They say competition would force more providers to lower fees for high-risk procedures.

CON advocates, particularly the NCHA, say ending or significantly diminishing the laws would allow for-profit groups to cherry-pick the most profitable medical procedures.

That, in turn, could leave not-for-profit systems with caring primarily for the sickest patients coming into emergency departments who also may lack health insurance.

“Regarding certificate of need, our position remains that North Carolina’s hospitals and health systems support the current law and urge legislators to not change it, thereby protecting access to care for rural and under-served patients,” NCHA spokeswoman Cynthia Charles said.

“Any changes to the program would put already vulnerable hospitals at much greater risk of having to make difficult decisions, as new entrant health-care providers could pick off commercially insured patients without taking on responsibilities of caring for Medicaid, under-insured or uninsured patients.”

Charles said NCHA views Medicaid expansion as a must since “any North Carolina hospitals are in a perilous place after giving their all to protect our state during the COVID-19 pandemic.”

“They are facing unparalleled financial and operational strain because of inflated costs for labor, drugs and supplies, on top of impacts from the pandemic. For example, labor shortages have forced hospitals to use more contract labor, with costs up 100% over the previous year.

“At a time when hospitals are dipping into their reserves to fund operations, this is not the time to lean on hospitals to fund expansion, or to look at repealing or changing the current certificate-of-need law,” Charles said.

Politically complex

Mark Hall, a public-health and law professor at Wake Forest, said the challenge with a multilayered health-care reform bill is that “tying together a number of somewhat different initiatives is politically complex, making it unlikely that enactment will occur quickly.”

“The tricky part will be what happens if there is significant opposition to one or more of those pieces: will the rest of the bill survive, or will it be politically feasible to spit off individual parts into separate bills?

“The only way to find out is to start the serious legislative deliberations.”

Mitch Kokai, senior policy analyst with Libertarian think tank John Locke Foundation, agreed that the multilayered reform approach could represent a make-or-break scenario.

“Those who have screamed loudest for Medicaid expansion have also raised the strongest opposition to reforms, such as certificate-of-need repeal and expanded scope-of-practice for nurses,” Kokai said.

“If Senate leaders tie those measures, we’ll see just how much expansion advocates are willing to sacrifice for their goal.”