By Jaymie Baxley
After being held up for months by the General Assembly’s protracted dispute over a state budget, Medicaid expansion is set to finally take effect in North Carolina on Dec. 1.
The launch date was announced Monday by Gov. Roy Cooper, who called expansion a “monumental achievement” that will eventually provide health insurance to more than 600,000 low-income residents. He also noted that the measure, which was signed into law nearly seven months ago, could have been implemented sooner if not for a provision that required lawmakers to first enact a budget, which they delayed by almost three months.
The N.C. Department of Health and Human Services had hoped to begin moving expansion-eligible people onto Medicaid in October, but the agency was forced to adjust its timeline after overall budget negotiations broke down between the state Senate and House of Representatives. The impasse ended last week, with both chambers of the Republican-controlled legislature agreeing to move forward with an almost $30 billion spending plan.
Despite being strongly opposed to several aspects of the budget, the Democratic governor said he does not plan to veto it. Instead, Cooper will allow the budget to become law without his signature to clear the way for expansion.
Ten days must pass before the budget can become law. After that happens, DHHS will spend the next two months readying its local and county partners for the anticipated influx of newly eligible Medicaid enrollees. The department must also release legally required policies for public comment and secure final approval from the federal Centers for Medicare & Medicaid Services, among other tasks.
In an email to NC Health News on Tuesday, DHHS wrote that it normally takes 90 to 120 days to implement expansion after a state receives authority to move forward. The department was able to shorten that to 60 days by doing some of the work in advance.
“To be ready once the budget was passed, the team at the North Carolina Department of Health and Human Services has been working closely with implementation partners since the initial passage of Medicaid expansion in March,” DHHS wrote. “In addition, we negotiated a significant compromise from CMS to pre-submit policy documents to reduce the time to go live once given final authority which enabled North Carolina to be able to go live on Dec. 1 instead of into 2024.”
During a news conference in Raleigh on Monday, Cooper said the wait for expansion has been “an unnecessarily long and agonizing journey for many North Carolinians.”
“Since my very first day as governor, getting help to people who need it by expanding Medicaid has been a top priority,” he said. “To many of these families I say, ‘Now, finally, help is on the way.’”
Federal incentives sealed the deal
Medicaid expansion has been a decade in the making. Advocates began pushing lawmakers to widen access to the government-funded program after the 2012 implementation of the Affordable Care Act, but their efforts were repeatedly thwarted by Republicans in the General Assembly.
The promise this year of more than $1.4 billion in federal financial incentives prompted the state’s G.O.P. leadership to reconsider, and legislation making North Carolina the 40th state to expand Medicaid passed in March with bipartisan support.
In a news release, Kody Kinsley, head of DHHS, said expansion is the “most significant investment in the health of North Carolina in decades.” The measure, he said, will bring in “billions of dollars” each year, helping to “keep clinics, providers and hospital doors open.”
Once implemented, expansion will loosen some of the state’s long-standing eligibility requirements for Medicaid. Among other things, it will raise the existing income limit to 138 percent of the federal poverty level. That means single adults, a population that is effectively ineligible for coverage under the current criteria, will qualify if they make less than $20,000 a year.
Parents and caregivers will have higher thresholds based on their household size. A single mother with three children could qualify if her annual income does not exceed $34,000, for example.
The first residents expected to benefit from expansion are those currently enrolled in so-called Medicaid family plans, which offer fewer benefits than traditional Medicaid. DHHS estimates that 300,000 family plan enrollees will be automatically upgraded to full coverage.
Usually, the federal government picks up about two-thirds of the cost for North Carolina Medicaid patients. But under expansion, federal coffers will finance 90 percent of the cost for beneficiaries who fall into the expansion category. The other 10 percent will be paid for in the form of hospital assessments, much of which were offset by a new federal financing reimbursement strategy for hospitals in the state.
Advocates rejoice
Susan Shumaker, president of the Cone Health Foundation, a Greensboro nonprofit that works to address health care inequities, said Monday’s announcement signals the beginning of “a really exciting moment in time for our history in our state.”
“I’m so excited that we’re here because it means so many people who are primarily working in jobs that don’t offer health insurance can have access to care,” Shumaker, who once served as the administrator of a rural hospital, said in a phone interview. “And many of these folks, as we know, are working in multiple jobs. They’re working on jobs that we all depend on.”
She added that expansion will give hundreds of thousands of residents access to treatment for mental health and substance use disorder. Shumaker said the COVID-19 pandemic created an urgent need for such care.
“The pandemic has had a tremendous negative impact on mental health,” she said. “We’ve had a mental health crisis in this country for a long time, and it’s been heightened by COVID, so I think this is timely.”
Cone Health, the Kate B. Reynolds Charitable Trust and other organizations have pledged more than $3 million to support outreach efforts aimed at people who may soon qualify for Medicaid and not know it. In a joint statement released Monday, the nonprofits wrote that their goal is to “ensure that everyone is aware of the opportunity to get health coverage, and no one is left behind.”
“It has taken a diverse group of stakeholders to speak to the breadth of those living in the Medicaid gap,” they wrote. “Black, white, rural, urban, veterans, moms, health professionals, those impacted by opioid use and many others, all had a place at the coalition tables that pushed Medicaid expansion across the finish line in North Carolina. Their work is the reason we can all mark this momentous policy win.”
Other organizations issued similar statements after Cooper’s announcement. Writing in an email, the North Carolina Justice Center said it was “thrilled” that expansion will soon be implemented.
“After 10 long years, over 600,000 North Carolinians are now finally guaranteed a path to health coverage and will no longer have to live in fear of getting sick and facing medical bills they can’t afford,” the center wrote. “We thank Governor Cooper and lawmakers at the N.C. General Assembly for their bipartisan efforts to expand Medicaid. Together, they demonstrated that healthcare is a priority that crosses party lines.”
‘On a lifeline’
Dec. 1 can’t come soon enough for DeAnna Brandon, a Rowan County resident diagnosed last year with a rare blood cancer.
Brandon, 45, will qualify for Medicaid under expansion, allowing her to begin the process of scheduling a stem cell transplant that could extend her life by at least 10 years. Without the transplant, her doctors predict she’ll die in less than three.
“Knowing that I can now plan to have this and hopefully it’ll give me more time, I feel I can actually make some plans and look forward to a future,” Brandon said in a phone interview on Monday. “I’m more hopeful.”
But the clock is ticking, she said. The chemotherapy Brandon receives to manage her cancer symptoms may eventually cause irreversible damage to her cells, undermining the effectiveness of the stem cell procedure.
Anthony Brooks, a Beaufort County man in need of a surgically implanted defibrillator, is also desperately waiting for expansion to take effect. The 58-year-old is about to be kicked off Medicaid because his monthly disability check — his main source of income after a heart attack forced him to quit his job as a nursing assistant — is $7 over the state’s current income limit.
“I’m having to ask my doctors to compile all my prescriptions so I can keep getting medicine for the next three months,” said Brooks, who will qualify for coverage again under expansion. “I’m on a lifeline.”
Lisa Franklin, a soon-to-be-eligible Rutherford County resident suffering from cirrhosis of the liver, doesn’t know if she can wait until December for expansion to launch.
“It greatly affects me that they’re going to delay it that long,” said Franklin, who needs a liver transplant. “Because of that, what may end up happening is I have a decision that I have to make about possibly leaving North Carolina and going to another state that has enacted it.”
That’s not what Franklin wants to do. She loves North Carolina. Her family lives here. This is where she “decided to plant my roots and settle down,” she said, after moving from Illinois three years ago.
“We need this now,” she said of expansion. “We needed it back in March when it passed to begin with.”
Editor’s note: The Cone Health Foundation and the Kate B. Reynolds Charitable Trust provide funding to NC Health News.
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