The Medical Crisis that Finally Convinced Republicans in North Carolina to Expand Medicaid

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Colby, a 31-year-old who lives west of Asheville, could have been one of those moms. When she discovered she was pregnant in 2018, her sister helped enroll her in Project CARA, MAHEC’s perinatal substance use treatment center. About 90 percent of the center’s patients are on Medicaid, and the most common addiction they treat is opioid use disorder. Colby, who asked to be identified by her first name only, said the people at the center were warm and compassionate despite the shame she felt about her drug use. “They helped me feel worth getting better and doing better.”

She remained in treatment after her son was born and kept her Medicaid coverage while she trained to become a phlebotomist. Now her son is 3 and Colby works as a certified medical assistant. She continues to take medication to keep her addiction at bay.

Medicaid coverage for buprenorphine, which helps people wean off opioids, is key to saving mothers’ lives, said Project CARA co-founder Melinda Ramage. Before the extension went into effect, some women felt discouraged from taking the drug while they were pregnant because they knew they couldn’t afford it when their insurance ended. This made them more vulnerable to fatal overdoses. (A Massachusetts study found the highest rate of opioid overdoses among new moms occurred seven to 12 months postpartum.) But it would be more helpful if they could start buprenorphine before they became pregnant, Ramage said. “This is a big game changer,” she said of the postpartum extension. “And we’re not done.”

Most of the counties in the state that has the highest rates of uninsured residents are rural ones, according to the North Carolina Rural Center. Over time, Democrats and Republicans in those regions have come to recognize that full Medicaid expansion would provide insurance to people working in low-paying jobs such as construction and fast food, and help keep their struggling hospitals open. Last year, five rural county commissions and the Eastern Band of Cherokee Indians passed resolutions supporting Medicaid expansion.

Dale Wiggins, a Republican commissioner in Kevin Corbin’s district, helped garner that support. “The fact that one of my neighbors can’t afford to go to the doctor, that is asinine,” Wiggins told me last fall. “If we can spend all this money on foreign aid, we can ensure that we have a healthy population.”

Nestled in the Appalachian mountains, Western North Carolina is mostly rural. About 90 percent of patients enrolled in MAHEC’s perinatal substance use treatment program are on Medicaid, and the most common addiction they treat is opioid use disorder. Before the extension went into effect, some women felt discouraged from taking the drug while they were pregnant because they knew they couldn’t afford it. This made them more vulnerable to fatal overdoses.

Yet there was still significant resistance to the idea in Raleigh. When Corbin realized the full expansion would not pass the state legislature last year, he and his colleagues proposed adopting the postpartum extension as an interim step. Focusing on mothers, rather than all low-income people, was a much easier sell. “We had no organized opposition to it,” he said.

Now Tucker-Wiles, the MAHEC psychologist, sees more patients who are five or six months postpartum. She doesn’t have to rush their treatment plans or panic about fitting everything into limited sessions. She can help their whole family by inviting dads to appointments and assessing how a mom is adjusting several months after her baby is born.

And Lillethun, the nurse practitioner, no longer has to write a prescription for high blood pressure or diabetes and then say goodbye to her patients six weeks after they give birth. She can help them with everything from quitting smoking to thyroid conditions. “Every single one of my patients is going to benefit from this extension,” she said.

In late May, less than two months after the postpartum extension went into effect, a draft bill to fully expand Medicaid in North Carolina was leaked to the press. It passed the state Senate 44-2, after what Democratic senator Jeff Jackson called “the most remarkable [debate] I’ve heard in eight years.”

Berger, the state senator who had decried Medicaid as inefficient three years ago, championed the bill. “Medicaid expansion has now evolved to the point where it is good state fiscal policy,” he said in June.

In fact, the Biden administration had significantly sweetened the deal. Under the American Rescue Plan, the 12 states that have resisted Medicaid expansion can receive an additional 5 percent in federal funding for the first two years if they expand the program now. For North Carolina, this amounts to an estimated infusion of at least $1.5 billion, according to a report by the National Conference of State Legislatures.

In 2020, the Families First Coronavirus Recovery Act gave extra Medicaid funding to the states so they could maintain coverage for their poorest citizens throughout the duration of the pandemic. North Carolina added 559,000 people to its rolls between March 2020 and March 2022; it is not permitted to remove them until the public health emergency ends (Biden extended it to October). The state’s budget crunchers realized they could save money by expanding Medicaid instead of adding people piecemeal, as they did during the pandemic.

The political rationale for resisting expansion has also waned. “I think the most controversial part of Obamacare was always the Obama part,” Taylor, the Duke policy professor, said. Republicans such as Berger have long voiced concern that once Obama left office, the cost-sharing agreement would disappear. Now that both Democratic and Republican administrations have kept the agreement in place — with the federal government covering 90 percent of expansion costs — they have little reason to protest, Taylor said.

The full expansion would add roughly 500,000 to 600,000 people to North Carolina’s Medicaid rolls, although it’s unclear how many of those people already gained coverage during Covid. Some Republicans think the state budget can handle those numbers better now than it could a few years ago. “We’re in better shape financially now than we were five years ago,” Corbin said.

Krawiec said she initially opposed expansion, but now that North Carolina has switched to a managed care system for Medicaid, she’s in favor of it. She’s co-chair of a committee that has been studying the issue and trying to learn from the mistakes other states have made. “I think we have a better understanding of how to do it right,” she said.

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