The socioeconomic and political tug of war known as North Carolina Medicaid expansion is expected to get more complicated with the expected relaunch of the Carolina Cares legislation.

Medicaid serves 2.14 million North Carolinians, representing about 21 percent of the state population. About 1.6 million will be enrolled in managed care under a federal waiver.

Rep. Donny Lambeth, R-Forsyth, was scheduled to hold a news conference at 11 a.m. today to discuss filing Republican-sponsored legislation projected to contain two controversial elements: a work requirement for some Medicaid recipients between ages 19 and 64; and an assessment to health-care systems and prepaid health plans to pay for the state’s 10 percent share of additional administrative costs.

However, Lambeth said today "we had to push out until next Tuesday (at same time). Bill drafters could not get the bill finished up in time."

The federal government would pick up the remaining 90 percent.

The 2017 version of the bill received bipartisan backing — reluctantly by some Democrats — as a potential moderate initial step toward expanding state Medicaid for between 450,000 and 670,000 North Carolinians.

The bill, however, stalled in committee because of lack of GOP leadership support.

Lambeth has said his Carolina Cares bill would work “more like an insurance product for those working who can pay a portion of the cost, and the benefits and coverage are built around preventive and wellness care.”

For example, participants would have to follow protocols for routine physicals and screenings to improve their health if they have such conditions as diabetes, obesity, etc.

On March 11, Senate leader Phil Berger, R-Rockingham, took aim at provisions in Carolina Cares, saying that a hospital assessment represents a tax that ultimately will be passed on to patients.

The N.C. Healthcare Association and N.C. Medical Society have indicated their support for Carolina Cares.

Proposals

In all the swirling Medicaid proposals and rhetoric, there is one reality.

The Centers for Medicare and Medicaid Services made clear Oct. 25 it would not consider Medicaid expansion proposals — including a requirement that some recipients must work to receive benefits — unless these are first approved by the legislature.

Lambeth’s bill is not alone in proposals for potentially providing more North Carolinians with health-insurance coverage.

Two Democratic-sponsored 2019 expansion bills (House Bill 5 and companion Senate Bill 3) also would require health-care systems and hospitals to pay for the state’s 10 percent share of expanded service and administrative costs.

Senate Republican leadership has cast its lot with Senate Bill 387, which would require a work or community-service requirement for “able-bodied” adult Medicaid recipients without expanding the program.

That bill, co-primary sponsored by Sen. Joyce Krawiec, R-Forsyth, would use the work-requirement guidelines for participating in the federal SNAP (supplemental nutrition assistance program) for non-disabled adults. The goal would be having the requirements in place by July 1, 2020.

“Despite the hundreds of billions of dollars that have been pumped into the Medicaid system at both the state and federal level, there are still numerous studies that show Medicaid does not guarantee improved health outcomes,” the bill co-sponsors said in a joint statement.

“Conversely, there is strong evidence suggesting that productive work and community engagement may improve health outcomes. By encouraging these folks already on Medicaid to work and engage with their community, not only are we increasing their chances of improved health outcomes, we are also increasing their chances of someday moving off government-assistance programs altogether.”

Critics have said SB387 would serve to reduce, rather than add to, the number of Medicaid recipients.

The bill was introduced the same day that a federal judge blocked Kentucky from implementing a similar Medicaid work requirement and keeping Arkansas from continuing its program. More than 18,000 Arkansas enrollees have lost Medicaid coverage since the state began the mandate last summer.

Eliot Fishman, senior director for health policy for left-leaning advocacy group Families USA, said that “while this decision will almost certainly be appealed, it sends a clear and definitive message to the states that work requirements are not permitted under federal law. The decision is based in the plain language of the Medicaid statute and it is likely to stand up on appeal.”

“No state should move forward with these restrictions to health coverage until all appeals have been exhausted. States and federal officials cannot create red tape that makes it harder for people to see their doctor.”

Brendan Riley, policy analyst with left-leaning N.C. Justice Center, called SB387 “a deeply flawed proposal that imposes red tape requirements on people with low incomes, creating administrative hurdles between North Carolinians and their health care.”

“It ignores the fact that most North Carolinians with Medicaid are already in working families, and that so many jobs in today’s economy don’t provide health benefits.”

Budget plan recommendation

Democratic Gov. Roy Cooper highlighted — as expected — expanding Medicaid in his 2019-20 state budget recommendations.

“Gov. Cooper’s budget plan recommends expanding Medicaid to bring $4 billion into North Carolina’s economy, create an estimated 40,000 jobs and provide more affordable health care for 500,000 people,” according to a statement from Cooper’s office.

The competing initiatives could spark a compromise in state budget negotiations or signal another year without expansion.

“While I believe (Berger’s) opposition is earnest, I also think everything we’ve been seeing — the Senate throwing out all sorts of controversial proposals is the Senate trying to prepare for a long and challenging negotiation around all things health care,” Riley said.

Riley includes in the comments the Senate’s attempt to assist small businesses with expanding coverage through association health plans, and another attempt to repeal the state’s certificate of need program that’s designed to limit unnecessary duplication of medical services.

Riley said Senate GOP leaders also are trying a divide-and-conquer tactic by “pitting the Medicaid coverage gap against the innovations waiver,” of which there are at least 12,000 North Carolinians on a wait list for additional services.

The Arc, a national advocacy group for individuals with intellectual/developmental disabilities, said last week that “cutting off Medicaid won’t help anyone work.”

“The policy serves no purpose other than to remove people from the Medicaid roles,” said Peter Berns, the Arc’s chief executive.

“It’s a bad policy idea that just keeps coming back, and we encourage the Trump administration and leaders in the states considering work requirements to abandon it once and for all.”

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rcraver@wsjournal.com 336-727-7376 @rcraverWSJ

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