Medicaid reform in North Carolina

My granddaddy would say the N.C. General Assembly is “on a twisty path” so far as their Medicaid reform goes. 3.5 years after they took over the General Assembly, and 2.5 years after the Republican Party gained total control of the state’s policy apparatus, the details of what they have termed to be absolutely crucial to the future of the state (Medicaid reform) are clear as mud. It has gone something like this.

  • The Governor initially wanted to bid out the entirety of the Medicaid program to managed care companies. The provider community was skeptical.
  • Later, the Governor changed his mind and was in favor of a regionalized, Medicaid ACO system that maintained the role of Community Care North Carolina (CCNC). The provider community seemed ready to get behind this and a way forward was glimpsed.
  • The Senate budget a few weeks ago produced a vague paragraph in their budget that put us back to bidding Medicaid to private managed care companies with a couple of specifics: CCNC was going to be eradicated, and we were going to reduce Medicaid eligibility for the aged, blind and disabled to the lowest level allowed by law.
  • The House decided to move a separate (outside of the budget) Medicaid bill. It went from a 10 page bill in May with CCNC intact and and something similar to the Governor’s preferred regionalized Medicaid ACO approach, to a vague 3 pager.

I have no idea what will happen. I hate to invest lots of blogging on this because it keeps changing and getting less specific over time. If you like conspiracies (and I always suspect incompetence/confusion over a plot–especially when a legislative body or a university is involved) then here is one for you. This vague bill is set up to let the Governor call for Medicaid expansion as key part of reform the week after the 2014 election.

Stick with me.

Sections 1 and 2 are aspirational and outline goals for Medicaid (e.g budget predictability, slow rate of cost growth), and Section 3 states that the Executive Branch (Governor) in the form of the Department of HHS is to lead the movement toward such a system. Sections 8 and 9:

ScreenHunter_01 Jun. 21 12.31

Last year’s budget explicitly banned DHHS from seeking any Medicaid waiver without express permission of the General Assembly. This bill provides an outline and says DHHS work out the details after consulting with stakeholders

ScreenHunter_02 Jun. 21 12.36

Let me promise that all the stakeholders that are involved in health care delivery know that expanding insurance coverage is a part of developing an improved Medicaid program. We could even develop a privatized option, and I have even written a policy outline suggesting how we could do this in a way that increases competition in North Carolina’s exchange. Plenty of other Republican led states have figured out how to move ahead.

Far fetched? Maybe. But, two years from this November, Governor McCrory is going to have to run for re-election in a non-gerrymandered district, unlike the members of the General Assembly. For context, he won by ~500,000 votes, and President Obama lost N.C. by ~100,000 in 2012. I think it is safe to assume that the 400,000 persons who split Obama/McCrory are not so thrilled with the direction of the state. Further, you will never undertake a huge reform without the existing health care system being involved. I have heard several Republicans say that the large systems (like Duke, UNC, etc.) are going to have to step up and do some things they don’t like for the good of the State. I agree.

The same thing could be said to those in charge of our State today. They may be setting up a way to make it happen.

About Don Taylor
Professor of Public Policy (with appointments in Business, Nursing, Community and Family Medicine, and the Duke Clinical Research Institute), and Chair of the Academic Council at Duke University . I am one of the founding faculty of the Margolis Center for Health Policy. My research focuses on improving care for persons who are dying, and I am co-PI of a CMMI award in Community Based Palliative Care. I teach both undergrads and grad students at Duke. On twitter @donaldhtaylorjr

4 Responses to Medicaid reform in North Carolina

  1. Pingback: Duke and WakeMed Explore “Collaborating” | freeforall

  2. Pingback: Others move ahead on Medicaid while N.C. stands still | freeforall

  3. Pingback: Decreasing Medicaid eligibility: reducing or shifting costs? | freeforall

  4. Pingback: End of the session Medicaid stuff | freeforall

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