RALEIGH, N.C. (WGHP) – Sometime in the next few days, North Carolina Gov. Roy Cooper is going to find a document on his desk he had longed to see there: a bill to expand Medicaid coverage for hundreds of thousands of residents.

Cooper’s signature is all that remains to be done after the House on Thursday morning in an atypical third reading approved, 87-24, their concurrence with the Senate’s compromise version of House Bill 76, the announced plan to expand the program that Cooper – and most Democrats – have encouraged for the past decade.

State Rep. Donny Lambeth (R-Winston-Salem) during one of his pitches of Medicaid expansion. (WGHP)

For almost that long, state Sen. Donny Lambeth (R-Winston-Salem), a retired hospital executive, has inched this concept along in various fits and starts, and he was there on Wednesday to cover that final mile.

“Today marks an important day for so many North Carolina citizens,” Lambeth said in nominating the bill on Wednesday. “The General Assembly has received lots of media coverage as we considered this these past 10 years.”

“This has been a long, bumpy journey, but we are here to make history and move North Carolina forward.”

On Thursday morning, he said he had been “pondering how much I wanted to go through with this, particularly the last eight years … only thing I’m going to say to you is, ‘“thank you, thank you, thank you. Vote!”

Said Rep. Carla D. Cunningham (D-Mecklenburg) on Wednesday: “I’ve been waiting a good, long time to get to a bittersweet end of this journey. I want to thank Rep. Lambeth for staying the course. … We didn’t give in and finally finished the journey.”

When he gaveled the final vote and announced the measure had been passed, Speaker Tim Moore (R-Cleveland) said that had occurred “no matter how much we might like it or not.”

In a statement released by his office, Cooper said, “Medicaid Expansion is a once-in-a-generation investment that will make all North Carolina families healthier while strengthening our economy, and I look forward to signing this legislation soon.”

When he signs the bill – and a ceremonial but unusual voice vote on a third reading must occur on Thursday before he can – HB 76 would become law immediately in some cases, but the full expansion of Medicaid will occur with the passage of a biennial budget.

Still, this bill removes North Carolina from the list of 11 states that had not expanded Medicaid following the adoption 13 years ago today of the Affordable Care Act. HB 76 will provide coverage to about 600,000 and bring in billions in revenue to the state.

There will be immediate help for local hospitals that will be able to seek reimbursement through the federal Healthcare Access and Stabilization Program (or HASP).  The bill has several aspects that are designed to improve healthcare access in rural areas.

The delay for full rollout until after the budget passes, though, means that Employees of the North Carolina Department of Health and Human Services will begin on April 1 a recertification of benefits that could lead – and emphasis on “could” – to 300,000 people being removed from medical coverage because a national law covering them expires.

These are people who were receiving coverage through the first Coronavirus Response Act under a stipulation that states keep all Medicaid-eligible residents covered, regardless of whether that state had expanded Medicaid under provisions of the Affordable Care Act.

As Lambeth explained on the House floor, the state will realize $1.7 billion annually from the federal subsidies and another $14 billion in the next five years for HASP. Lambeth said that the economic impact was about $6 billion per year and that the state’s operating fund will realize $107 million to $125 million annually.

How the votes broke down

The third reading was unusual. “Concurrence votes are rarely more than one vote, but staff ie legal team advised the bill coming back from Senate was material in terms of the changes from the original bill,” Lambeth told WGHP. 

In the second reading on Wednesday afternoon, the vote was 95-21. All no votes on both ballots were Republicans, including five members representing the Triad: District 64 Rep. Dennis Riddell (R-Snow Camp), District 70 Rep. Brian Biggs (R-Trinity), District 78 Rep. Neal Jackson (R-Robbins), District 74 Rep. Jeff Zenger (R-Lewisville) and District 77 Rep. Julia C. Howard (R-Mocksville).

The three additional “no” votes on the third reading came from two people who didn’t vote on the second reading and Rep. Jeffrey McNeely (R-Iredell), who switched from “aye” to “nay.” The change in yes votes was because of absences.

“As a small government, fiscal, conservative, who was sent to Raleigh by constituents who believe in reducing the size and scope of government,” Jackson wrote in an emailed response to a question from WGHP. “I could not in good conscience vote for a bill that violates the core principles of what I was sent here to do.”

How the bill came to be

Senate Leader Berger (left) and House Speaker Tim Moore announce a deal on Medicaid expansion. Rep. Donny Lambeth is behind them. (WGHP)

State Sen. Joyce Krawiec (R-Kernersville), a co-chair of the Senate Health Committee and a new advocate for the expansion as an opportunity to help rural hospitals, had presented the bill for final approval in the Senate, which came on a vote of 44-2.

“We have been talking about this for a long time,” Krawiec said debate last week. “Actually we have been talking about this long before many of us arrived here in Senate.

“Many of us were opposed for a very long time. I was one of those. We were dealing with a broken Medicaid cycle in North Carolina. Every cycle we were plugging holes. We had to fix that before going into expanding Medicaid.”

She cited nine years of balanced budgets, underscored the negotiated aspects of the bill, called it a “lifeline for rural hospitals” and the inclusion of a work requirement that could become a federally accepted pilot program.

But Cooper decried that entanglement with the budget process even as he praised the next step. Some legislators also said they wished the expansion was immediate, because delays cost the state revenue payments from the federal government.

The budget process often becomes long, arduous and entangled in political gamesmanship. Senate Leader Phil Berger (R-Eden) and Moore said when they announced a compromise that they felt strongly that this was a “budgetary” matter.

They also have said they have agreed on the first aspects of their 2-year budget: a 6.5% increase for 2023 and 3.75% for 2024. Cooper had submitted a budget proposal to them that Berger immediately said was too extreme in spending.

Moore has promised to deliver his spending plan to the Senate by Easter, which is April 9.

The Medicaid expansion plan

The compromise that Berger and Moore announced two weeks ago included these stipulations:

  • The new version of the bill will eliminate certificate of need for:
    • Behavioral health beds
    • Chemical dependence beds
    • Raise replacement equipment threshold to $3 million and index to inflation.
    • Increase threshold for diagnostic centers to $3 million and index to inflation.
    • MRI machines in counties with a population above 125,000 effective three years from first HASP payment.
    • Ambulatory surgery centers in counties with a population above 125,000, effective two years from first HASP payment for multispecialty and single specialty.
      • 4% charity care requirement for ambulatory surgery centers (in counties with population above 125,000).
      • Annual reporting requirement regarding charity care.
  • HASP would become effective immediately.
  • Medicaid expansion would be effective only upon passage of the 2023 budget.

Immediate response

The bill’s passage drew immediate praise from organizations that had been involved in the long discussions about the concept.

“This is the kind of day we work for!” Chip Baggett, CEO of the hospital-affiliated North Carolina Medical Society, said in a release. “Our team, our members, our partners, and people from across the state have long hoped for this bill to be signed. The bipartisan support it received is a clear sign that lawmakers in North Carolina see access to healthcare as part of a strong citizenry.  We thank the many legislators who joined us as we moved toward this day.  We also thank the NCMS members who have been helping and our partner organizations. It is because all these dedicated individuals and groups came together to champion this bill that the future of North Carolina is a bit brighter today.”

NC Democratic Chair Anderson Clayton: “On the 13th anniversary of the Affordable Care Act, the General Assembly has finally voted to expand Medicaid and get health care to more than 600,000 North Carolinians who fall in the coverage gap. This is a huge step forward in ensuring everyone in the Tar Heel state has the access to the quality, affordable care they deserve, while strengthening our economy and creating jobs in every corner of our state.”