Will North Carolina implement Obamacare?

I am going to do a series of posts looking at the implementation of the Affordable Care Act, aka Obamacare in North Carolina. Surely one of the key goals of the Obama administration’s second term is to see through the implementation of the law in states who have heretofore been opposed. A key question is whether they will be successful in convincing such states to move ahead?

Similarly, a key question for Republican politicians who have been opposed to the law until now is whether they will continue to be opposed, or move ahead with implementation? If they remain opposed, can they provide a better alternative?

Republicans in North Carolina beginning in the Summer of 2010 consistently said they believed Obamacare to be unconstitutional and I take them at their word that they believed this to be true. However, the Supreme Court of the United States disagreed in June, 2012. After that, to the extent that health policy was discussed at all in the recent elections in our state, Republicans said that President Romney would repeal Obamacare on day one, so why move ahead with implementation plans, or even contemplate them? Now that will not occur.

So, what will the new Republican Governor and Republican-controlled General Assembly actually do as they move to govern our state? First, we have some extra time in deciding about whether to set up a state-based insurance exchange in which North Carolinians can purchase private insurance with income based federal subsidies. And even if the federal government initially sets up an exchange which seems likely (that would be similar to the way state based Medicare Advantage plans are offered for sale in N.C.) there will be time to shift to a state based exchange later.

Regarding the potential to expand Medicaid under financially advantageous terms to our state, Republican leaders wisely kept their options open during the campaign and said little about this choice.

As the new Republican majorities in the state move toward governing, it is important to keep in mind the most important question in evaluating any given public policy: what is the counter-factual? Put another way, as compared to what? It is easy to say we don’t want to expand Medicaid, but very hard to figure out a way to provide health insurance to 500,000 North Carolinians in financially advantageous terms.

The process of governing a state tends to be quite practical. The question that should be on the tip of your tongue in considering whether our state will implement Obamacare should be ‘what is the alternative plan to provide health insurance to the 1.3 Million uninsured North Carolinians?’

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Coming posts below (if there is a topic you want to see covered, email me and I will try)

Introduction-what is the counter-factual? (this post)

What is a health insurance exchange? (Nov. 15, 2012)

What are the advantages and disadvantages of a state-based exchange?

How many North Carolinians are likely to be covered by a health insurance exchange?

Should N.C. create a state-based exchange or allow the federal government to set up an exchange in our state?

How many persons would be covered by the Obamacare Medicaid expansion?

Are there non-health reasons to expand Medicaid?

How is insurance coverage expansion linked to cost control?

A few GOTV thoughts

A few odds and ends on the election and GOTV that I wanted to write down.

  • I was heavily involved in “get out the vote” (GOTV) efforts in Durham N.C. for the Obama campaign, as I was in 2008.
  • We were thinking we needed a +85,000-90,000 vote margin for the President in Durham county for him to have a chance to win the state. He ended up with ~76,000 margin before provisionals, up from ~71,000 in 2008, but a bit short of our goal. He lost N.C. by ~100,000 votes.
  • Turnout was lower in Durham County this time (~68% v. ~75% in 2008).
  • Turnout was disappointingly low in some key precincts for the President to have had a chance at +85,000-90,000. In particular, precincts 05, 13-15, and 18 were disappointing (05 less than 50% and the others lower than 60%).
  • We tried to have consistency in canvassing (door to door turnout appeals). I walked and knocked on doors of the same turf in the same precinct the last 4 Friday late afternoons/evenings of the campaign, in each case seeking to talk to ~50 voters in that turf who had been identified by a statistical model as the ~50 people least likely to vote in that turf, who had expressed preference for President Obama in some way. The first Friday was the week prior to early voting, and the last 3 were during early voting when I had a driver to call to provide a ride immediately if someone was willing to go and vote. Once someone voted, they dropped off the knock list (electronically updated within about 24 hours using online election board data). So, all the people weren’t always the same, but in some cases I personally talked to the same person 3 or 4 times before they actually voted. Some essentially voted out of self preservation (Oh, you again).
  • During the last week of early voting, my colleague Gunter Peck developed a brilliant idea for a canvassing/drive operation–the Durham bus terminal. We asked people if they wanted a ride to the early vote stop that was near the bus terminal, and drove people to vote and back to the bus stop, typically before their connecting bus left. On election day, we canvassed and drove people from the bus terminal to vote and then their job in the morning, and in the afternoon/evening typically to vote and then to their home. We knew where to drive them by simply checking the online voter registration database (took about 30 seconds per voter). We had ~10 and 25 canvassers/drivers at the bus terminal on election day depending upon the time, and drove several hundred people, most of whom had no plan to vote, but who were registered supporters of the President.
  • A canvass/drive operation like this will work best where you have an aggregation of voters with almost unanimous support for your candidate. I would guess about 95% of the folks riding the bus in Durham were Obama supporters, and our goal was to increase the likelihood they voted.
  • The bottom line of GOTV is to be willing to engage individuals and to ask them for their vote. In this way, I understand GOTV to be a sign of respect–that a person is worthy of being asked for their support. Asking actual people to vote and making it as easy as possible is the key to GOTV.

It was a disappointing loss, but we new it would be hard to repeat the narrow win of 2008 (President Obama won by ~14,000 votes out of 4.3 Million cast). N.C. was the closest win for President Obama in 2008 as well as the closest win for Gov. Romney in 2012. All in all, working on the campaign was important and fun.

update: edited for clarity.

Why I take the N.C. election personally

This is a personal story.

I am a strong supporter of President Obama primarily because I agree with his policy views, and I think his re-election provides the best chance for the best policy going forward. However, my support of him does not explain why I have worked so hard on the grassroots “get out the vote” aspects of his campaigns in 2008 and again this year (I didn’t go door-to-door for President Clinton, or for VP Gore or Sen Kerry).

The reason is encapsulated in this television commercial, the so-called “Hands” ad that appeared in the 1990 North Carolina Senate race between Senator Jesse Helms and Harvey Gantt.

Like most kids, I voted like my parents, who are fairly conservative (but I should note not the least bit racist; in fact, the opposite) and so-voted for the re-election of President George HW Bush in 1988, the first time I was old enough to vote. However, I didn’t have a particularly strong party identification, in part because of the influence of my granddaddy who was a blue-dog, Eastern North Carolina Democrat with whom I spent much time growing up and who also had a great influence on me. But, I come from fairly conservative stock.

As the 1990 campaign approached, I recall mostly feeling like Senator Helms represented the “rear view mirror” of North Carolina and that it was time for a change. However, I was a person without a strong party identification and still thrashing about for my political identity. I volunteered a bit that year for Mayor Gantt’s campaign and it seemed like he had a reasonable chance of winning, at least until the “hands” ad appeared and Senator Helms was re-elected (I also lived in Chapel Hill then, so I may have been overly optimistic).

That fall, the Republican Party lost me forever, because of that despicable ad. That ad encapsulates what I have mostly HEARD* from most Republican candidates since then: appeals to my fears. And I am a hopeful person.

On election night 2008, even after President Obama was declared the victor, I was desperately nervous to see if he had won the state of North Carolina, which he did by 14,000 votes (out of over 4.3 Million cast). I wept that night when it became clear that he had won North Carolina, because it put the politics that made Senator Helms’ hands ad so potent a bit further in the rear view mirror of my great state.

As a 44 year old man who grew up in the rural South, I am still sometimes struck when I see President Obama and re-remember that we have a black President. However, my children who are 12, 15 and 17 think nothing of it, and for that I am glad. That is what progress looks like, and the election of President Obama greatly advanced our country in this intangible way.

*it may not be what they meant to say, but it is what I have heard.

If you want a sustainable budget, stay the course with Pres. Obama

I have an op-ed in today’s Durham Herald-Sun newspaper arguing that the re-election of President Obama increases the chances of a deal that will put us on the path to a sustainable budget. It is reproduced below. This will be a familiar argument if you have read my book Balancing the Budget is a Progressive Priority.

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By Donald H. Taylor Jr., Herald-Sun guest columnist

The fate of Obamacare and the direction of the next step in health reform is the clearest choice in the presidential election.

Obamacare has already expanded insurance coverage to young adults by allowing them to remain on their parents’ insurance, and it will begin the setup of state-based markets (think Orbitz.com) in which the uninsured and those working for small businesses can purchase private insurance coverage with income-based subsidies. North Carolina will have the choice of expanding Medicaid in financially advantageous terms if we wish to do so (the Supreme Court said states could not be forced).

Obamacare contains many efforts that begin changing the way we pay for care — policies that if tried, evaluated and implemented, could help us address cost inflation while improving quality.

However, the hardest steps on cost containment will never be taken so long as health reform remains the policy of only one political party. Eventually, there has got to be a deal that makes both political parties responsible for taking the hardest steps.

Re-electing President Obama and moving forward with Obamacare will provide the conditions under which such a political deal is most likely to occur, yielding the best chance for the best health policy.

Gov. Romney is in many ways a hero of health policy, having achieved near universal coverage in Massachusetts; his plan is the pattern for Obamacare. He now says that he will repeal and replace it on day one of his presidency, and that is the clear sentiment of the Republican Party.

When viewed purely in policy terms, Obamacare represents a moderate track, and not the single-payer system that many liberals want. The part of Obamacare that is most offensive to Republicans is the Obama part.

If Republicans record a clean sweep in this election (presidency and both houses of Congress), they will be able to repeal the vast majority of Obamacare. However, there is no reason to believe they will get around to the replace part. It is not that they don’t have ideas on health reform. They do. What they lack is the political will (it takes 218 votes in the House, 60 in the Senate, months of discussion) to push a reform through from scratch.

When was the last time the Republican Party invested political capital to push a health reform effort that would expand insurance coverage while addressing costs and quality? There is no example.

There is a tremendous amount of policy work that must be done in Washington in the coming weeks and months on taxes and spending, and the scope of the tax and spending changes that happen by default mean that the time will be ripe for a large-scale deal, one whose inevitability has been delayed only by the election. If we can identify some modifications of Obamacare that are to the liking of Republicans in the midst of these broad negotiations, and while doing so make the hardest work of health reform the responsibility of both parties, then we have a reasonable chance of moving toward a sustainable budget over the next decade.

If the first step on health reform is back to nothing via repeal, then I fear that will be the last step for some time. And we have no hope of a sustainable budget without consequential health reform because health care costs are our biggest long-run spending problem.

If you want a sustainable budget, the best course of action is to stay the course and re-elect President Obama, in large part because he already has a health reform vehicle that provides many great steps and is flexible enough to accommodate the inevitable next ones.

Donald H. Taylor Jr. is an associate professor of public policy at Duke University and author of “Balancing the Budget is a Progressive Priority.” He blogs at http://www.donaldhtaylorjr.com. Taylor has contributed financially to the Obama campaign and has canvassed, but this column was not seen by anyone else and he is not a policy adviser to the campaign.

Quick debate thoughts

The second North Carolina Gubernatorial debate between Mayor McCrory and Lt. Gov Dalton featured no discussion of Medicaid (potential expansion under Obamacare, issues related to mental health, etc.) or health reform. Keep in mind that about 1 in 4 dollars of the state budget goes to Health and Human Services, with Medicaid being by far the largest portion. Further, Gov. Romney says that he plans to repeal Obamacare and provide states with more flexibility (and less money) to develop their own health reform plans. Wonder what Mayor McCrory plans to do if elected (he is far ahead in the polls)? I have never heard him mention one word about health reform. If anyone has, please point me to it.

The Presidential debate didn’t have much on health policy either. My registered Republican wife who is mostly disinterested but who did watch had two thoughts: she thought Gov. Romney was disrespectful to both the moderator and the President, and she thought the Libya exchange made Gov. Romney look petty. Me, I am pretty much exhausted by it all, and as I was drifting off to sleep, was reminded of a story about my granddaddy.

There was a revival meeting of sorts at his church in rural, Eastern North Carolina, and a visiting evangelist had come to give a series of messages, and I went with my granddaddy one evening. After the sermon, the Preacher was asking various congregants and Deacons if they wanted to add or amplify on what had been said. When he was asked “Brother P.L. do you have a word?” my grandaddy who was a bit of a stoic and not much of a talker said with a quick glint in his eye “Preacher, I believe that enough has been said tonight already, and it is time to go home.”

In much the same way, it is time to vote. It starts tomorrow in North Carolina.

Is North Carolina really a swing state?

I attended a presentation yesterday in Raleigh given by David Simas, Director of opinion research for the Obama campaign, at which David laid out the Obama campaign’s understanding of the electorate 45 days from election day (in North Carolina and otherwise). The detailed presentation was fascinating, especially the way in which the Obama campaign integrates qualitative focus groups/interviews with more traditional polling information to target advertising and other resources.

Simas claimed that the Obama campaign’s internal polling in North Carolina over 20-odd polls has always shown the President and Gov. Romney to be within 1 or 2 points of one another, with the lead shifting back and forth. He predicted North Carolina would be very close again (~14,000 vote margin out of 4.2 Million cast in 2008).  Simas said the Obama campaign is committed to North Carolina until the end of the campaign (they now have 54 field offices in the state) and concurred with the general sentiment that without North Carolina, Gov. Romney has no plausible path to victory, but that the President has many electoral college paths to victory at this point.

The most telling bit of data that suggests North Carolina is truly a swing state in 2012? David Simas could only be one place on Saturday morning, and he was in North Carolina.

Impact of Medicare Sequester v. Medicaid expansion on providers

The Advisory Board has a new analysis of the impact on hospitals of the looming Medicare cuts that are a part of the Sequester. (h/t @ddiamond)

Although most of the sequestration cuts target defense and domestic discretionary spending, the deal includes a 2% cut to Medicare payments. The OMB’s analysis suggests that number is equivalent to about $5.8 billion in hospital payment reductions in FY 2013.

Most interestingly to me, they note a smaller average negative impact on hospital margins (1.6% reduction in 2021 margins) of the Sequester than a potential decision by a State to not undertake the now-optional Medicaid expansion (projected 2.5% reduction in 2021 margin). They note large cross-state differences in the potential impact of the Medicaid expansion (or not).

We estimate that failure to expand Medicaid coverage would result in an additional 2.5% reduction in Pleasantville’s 2021 margins. Note that this estimate will vary significantly from state to state, depending on current Medicaid payment rates and eligibility rules, and whether expansion occurs.

As previously noted here, the decision to expand Medicaid under the ACA or not will have a huge impact on North Carolina. The highlights of North Carolina’s Medicaid choice:

  • 488,867 more persons will be covered by Medicaid in 2014, 95% of whom would otherwise be uninsured
  • The state will have to pay $830 Million for these newly insured persons (the federal government will pay ~ $15 Billion) over the 6 year period in question
  • The costs of uncompensated medical care that are now borne by North Carolina will decrease by $1-$2 Billion over this same period, more than offsetting the additional State outlays for the Medicaid expansion

Interestingly, the impact of the Sequester on health care providers is beginning to get some news coverage in North Carolina, but there has been very little discussion of the Medicaid expansion choice along the same lines, in the media or in the campaigns for Governor and General Assembly.