The soaring cost of health care, which leaves too many families without health insurance coverage or forces households to choose costly medical coverage over other necessities, is one of the biggest challenges facing the state, according to a survey of some of the state’s thought leaders.

Among the 48 leaders who answered this week’s North Carolina Influencers survey, a consensus emerged that the inability of residents to afford health care is an economic impediment to local businesses and national prosperity, and a moral indictment of an affluent society.

And a number of the influencers from a wide range of backgrounds — political, business, academic and faith communities — believe that health care is so important to the state and to the nation that it should be treated as a moral obligation for society to provide to its citizens. Some even went so far as to say that health care is a basic human right, implied in the U.S. Declaration of Independence affirmation that all people are endowed with the right to “life, liberty and the pursuit of happiness.”

“As the country with the most advanced economy in the world, I believe it is our national responsibility to make quality, affordable healthcare a reality for every citizen,” wrote survey respondent Carol Folt, chancellor of UNC Chapel Hill. “No one should get sick and suffer or die just because they are poor or old or cannot get access to the healthcare services they need. No greater service can be rendered by a nation to its citizens.”

The survey respondents who rejected the concept of universal health care said it’s not a practical solution because of the considerable cost involved and of the inefficiencies it would bring about. Some, however, acknowledged a humanitarian motive for making health care available to all even as they disavowed the legal obligation to do so.

“Citizens are not entitled to ‘universal’ or ‘free’ health care, which means health care provided by a government monopoly and paid for by others,” wrote survey respondent Art Pope, the former budget director under Republican Gov. Pat McCrory. “Just as importantly, even good faith attempts to provide ‘universal health care,’ result in government run health care that is rationed, of poorer quality and more costly.

“The universal right of every person is for the person to decide how much health care or health coverage to buy, in what form, and from whom,” said Pope, who is CEO of Variety Wholesalers and chairman of the John William Pope Foundation. “While I do not believe that universal health care is a right, I do believe that voluntary charitable care should be given to those in need who cannot provide for themselves.”

Ranking priorities

Our 60 influencers — a group that includes former governors, university and nonprofit leaders, philanthropists, executives and authors — were asked what health care challenges face the state, and to rank their national health care priorities.

Requiring insurers to cover pre-existing conditions ranked first among the national priorities, while repealing the Affordable Care Act, which established a federal health care marketplace, came in last.

The coverage of pre-existing conditions is stipulated by the Affordable Care Act, and bars health insurers from turning down ill applicants or charging them exorbitant prices. Pre-existing conditions can include cancer and heart disease, and requiring insurers to pay for the medical care of sicker citizens is one the factors that has been attributed to the rising cost of health insurance since the 2010 enactment of the ACA, also known as Obamacare. (Next year is the first year in North Carolina that health insurance rates under the ACA are seeing a decrease on average rather than an increase.)

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Concern about lack of affordable health insurance was consistently the No. 1 statewide challenge in the survey, regardless of ethnicity, gender, occupation or political party.

Half of the female respondents and a third of the males ranked lack of affordable health insurance as the state’s biggest challenge. Two-thirds of black respondents and half the white respondents ranked that as the biggest challenge. Likewise, half the respondents employed in business, and three-fourths of those in advocacy picked affordable health insurance as the No. 1 challenge.

The differences became more pronounced by political affiliation. The most pressing national priority for Democrats is turning Medicare into a national health plan for all citizens, not just for those aged 65 and older. That priority ranked low for Republicans, who said the most pressing priority is to allow insurers to provide low-cost, stripped-down coverage (like health plans commonly sold before the ACA outlawed them for the most part).

Expand Medicaid

Three-fourths of North Carolina’s influencers said state legislators should expand Medicaid — the federal health insurance program for low-income people and their children and some disabled people — to cover several hundred thousand low-income adults in the state who are currently without health insurance and often rely on charity care in hospital emergency rooms.

Among those who reject the call for government to take a greater role in providing health care to citizens, some allowed for the feasibility of doing so, but only under carefully controlled conditions.

“Proposals related to Medicaid expansion can play a role in increasing access to insurance coverage, but it shouldn’t come without asking for responsibility from recipients,” GOP fundraiser Madison Shook wrote in her survey response. “North Carolina can take steps to reduce long-term risks to taxpayers by ensuring that able recipients are complying with work requirements and have ‘skin in the game’ by meeting modest premium and co-pay targets.”

Underlying the responses on government health care expansion are two irreconcilable economic assumptions: Those in favor of expansion said it would buoy rural hospitals, create a healthier workforce and bring down social costs; while those opposed to expansion said it would saddle society with a huge economic burden.

In its decision not to support the Affordable Care Act and not to expand Medicaid, North Carolina’s Republican-led legislature expressed concerns about the potential costs and consequences of expanding a major program that already costs $14.6 billion a year. To date, 34 states have accepted federal financial support and expanded their Medicaid programs, according to the Kaiser Family Foundation.

The influencers also said that 2018 state and federal candidates from North Carolina are not doing a great job focusing on health care solutions. Indeed, no respondent said a candidate is doing “very well,” and most ranked candidates as “somewhat” or “slightly” successful. For 20 percent of respondents, it is too soon to tell how the candidates are addressing health care challenges.

In previous surveys, the state’s influencers tackled such issues as education, political polarization and the economy, and were divided by political affiliation and ethnic background. While the health care survey showed divisions, it also showed general agreement on broad issues.

Many survey respondents offered their own solutions. Among them:

Pearl Burris-Floyd, secretary of the UNC Board of Governors, said the state should, “continue to support the Rural Center, tuition forgiveness for family physicians/nurse practitioners with the desire to practice in rural communities, expansion of tele-medicine and train more general/family and psychiatrists to address the growing physical and mental health needs.”

Bob Morgan, president and CEO of the Charlotte Chamber of Commerce, called for promoting association health insurance plans for small businesses to allow more competitive pricing. He added that “preventive medicine and behavior should be incented and rewarded.”

And Bob Page, CEO of Replacements, Ltd., in Greensboro, said the state should limit hospital consolidations. “These consolidations are in effect creating a small number of ‘mega” systems’ and eliminating provider options,” he said. “The General Assembly needs to limit these regional monopolies to create competition and lower health care costs.”

Nancy Webb and News & Observer news researcher David Raynor contributed.

Murawski: 919-829-8932; @johnmurawski

About this series

This is the fifth in a series of surveys The News & Observer, The Charlotte Observer and The Durham Herald-Sun will conduct with the Influencers through the November elections to help focus media and candidate discussion around the policy issues of most importance to North Carolinians. Look for the next report in two weeks.

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Calling health care a right, most NC influencers say expand Medicaid, keep Obamacare