RALEIGH, N.C. – After negotiating feverishly for several weeks, the Republican leaders of the North Carolina General Assembly stood before the cameras Thursday and did something they for years had declined to do: They announced a deal to expand Medicaid coverage in North Carolina.

The state had remained one of 10 that never accepted the billions from the federal government allotted in 2010 under the Affordable Care Act, and here were Senate Leader Phil Berger and House Speaker Tim Moore smiling and announcing a deal to expand coverage for 600,000 or so residents as soon as the 2023 budget is passed.

“We are going to have a policy that is going to expand access to working North Carolinians and ensure a more robust supply to services,” Moore said at a press conference called earlier on Thursday morning. “It is vitally important to protect access to healthcare, particularly in our rural areas.

“We knew where we wanted to be. We reached this deal late last night, put the finishing touches on it this morning. We wanted to go ahead and get it out there. … This is something we can all be very proud of.”

Democrats had for more than a decade pushed for the expansion, and last spring Berger and Senate Health Chair Joyce Krawiec (R-Kernersville) had said their views had changed and Medicaid needed to expand.

They introduced Senate Bill 408, which included various concepts to expand Medicaid under the Affordable Care Act and add programs they believed would provide greater access to healthcare in rural counties. That bill passed the Senate with near-unanimous support but never gained traction in the House.

Then even as Berger and Moore were negotiating behind the scenes – with advocacy from Gov. Roy Cooper – Rep. Donny Lambeth (R-Winston-Salem), a retired hospital administrator, last month pushed through House Bill 76, a stripped-down bill simply about expanding Medicaid, with strong bipartisan support.

The Senate now will take Lambeth’s bill, Berger said, modify it, add details, and move it through for passage. He said he wasn’t sure if that bill would be introduced next week but that “we will move with all due speed.”

Under the agreement, the Medicaid expansion aspect would take place when the budget is passed, primarily because this involves billions of recurring dollars. But local hospitals will be able to seek reimbursement through the federal Healthcare Access and Stabilization Program (or HASP) as soon as the bill becomes law.

The big sticking point in earlier negotiations was not so much the Medicaid dollars as the other aspects that senators thought would enhance access to healthcare in rural areas. This included specifications for the certificate of need that a healthcare company must fulfill before opening a new facility, a touchy issue with hospital companies, and the licensing of nurse practitioners, which riled some physician organizations.

Moore said legislators “consulted with stakeholders … hospitals … healthcare providers … you name it … to get varying points of view. We came up with something that I believe is very carefully crafted and an appropriate balance for where we are in North Carolina.”

The new plan

Berger ticked off the stipulations that would be addressed in the new bill:

• 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 the 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.

“If you take the house bill that came over to us and add these things to it, you’ve got 95% of the bill,” Berger said.

Berger said he, Moore and their staffs had been involved in “processes that were ongoing for the last four weeks or so. I don’t know if there was one thing that broke things loose. It was clear we were going to take some time to get folks comfortable. … Our agreement, we are comfortable with it.”

Said Lambeth in an email to WGHP: “The bill will reflect changes we have discussed and agreed to between House and Senate leadership. … It will include minor modifications to HB 76 as it was originally passed by the House. 

“It is a good compromise and certainly moves NC forward to vastly improve healthcare in NC.”

Reaction to the passage

North Carolina Medical Society CEO Chip Baggett issued a statement of support for the compromises found in the bill.

“The hard work of Senator Phil Berger, Speaker Tim Moore, countless other members of the legislature, and external stakeholders including NCMS, has led to a huge step forward in access to quality healthcare,” the statement said, and Baggett added that it “represents a true commitment to the people of North Carolina and their health. It is legislation the NCMS has long considered of utmost importance, and we thank everyone who has helped move it forward.”

Said Anderson Clayton, the new chair of the North Carolina Democratic Party:

“Expanding Medicaid is the difference between being able to afford to go to the doctor and putting off life-saving care, between throwing our rural hospitals a financial lifeline and throwing away health care access for small towns across North Carolina,” she said. “Thanks to Governor Cooper and Democrats’ relentless fight to make Medicaid expansion a reality, hundreds of thousands of working people across the Tar Heel State will finally be able to access the affordable care they deserve. Let’s get it done.” 

SAVE act is separate

One element that is not included is the so-called SAVE Act, a provision to expand the licensed treatments that can be administered by  Advanced Practice Registered Nurses. Krawiec, Lambeth, state Sen. Ralph Hise (R-Alleghany) and state Rep. Pricey Harrison (D-Greensboro) all have been advocates for that element of the original Senate bill.

Krawiec said in an email that she is “delighted that Medicaid expansion will become a reality in North Carolina. Many of our hard-working families will now be able to receive the health care they need, without any cost to the state.

“I am disappointed that the SAVE Act did not make it into the final negotiated bill. A separate bill was filed yesterday, The Save Act. This will allow the bill to move forward as a ‘stand-alone bill.’”

When it begins

Berger said the new bill represents negotiations between the House and the Senate and that Gov. Cooper was not involved except “being an advocate. … I am confident that the governor will be pleased. I think he would want Medicaid expansion to be immediate.”

Cooper did mention that in a statement he released later, calling this “a monumental step that will save lives and I commend the hard work that got us here. Since we all agree this is the right thing to do, we should make it effective now to make sure we leverage the money that will save our rural hospitals and invest in mental health. I look forward to reviewing the details of the bill.”

Said Harrison in a text message: “I understand it becomes effective when the budget passes, which is at best months way, and in my humble opinion it would be better if it took effect as soon as the bill passed,” she wrote in an email.

Moore has said the House will have its budget to the Senate by Easter (April 9), which Berger said caught him by surprise.

Moore smiled and glanced at Berger: “And the Senate has promised to pass the budget as we give it to them.”