EDITOR’S NOTE: Democrats filed bills in the state Senate and State House in January to expand Medicaid coverage in North Carolina. Gov. Roy Cooper advocated for Medicaid expansion in his State of the State address last month. How could that impact local healthcare and what do Randolph County’s state Republican representatives think of the idea?
ASHEBORO – About one in six Randolph County residents under the age of 65 have no health insurance, according to a study from the Robert Wood Johnson Foundation.
The care of those uninsured individuals strains resources.
Randolph Health’s emergency department had just over 40,500 visits in fiscal year 2017. More than 7,400 of those patients did not have insurance.
“Patients use the emergency department because they don’t have access points because they don’t have a payment source,” said Angela Orth, Randolph Health’s chief executive officer.
People without insurance also go to MERCE Family Healthcare in Asheboro. MERCE provides medical and dental services regardless of a patient’s ability to pay. Copays are charged based on income. The medical office is on North Fayetteville Street in Asheboro; the dental office is on Brewer Street.
“For uninsured patients in Randolph County, there are very few resources,” MERCE CEO Teresa Shackleford said. “We serve the working poor of Randolph County. There’s a misperception out there.”
The majority of MERCE’s uninsured patients, Shackleford said, would qualify for government insurance if Medicaid, which covers many low-income residents, was expanded in North Carolina.
Many Randolph residents find themselves in what is sometimes referred to as a “doughnut hole.” They earn too much money to qualify for Medicaid, but they do not earn enough money to qualify for subsidies and tax credits designed to make buying insurance affordable under the Affordable Care Act.
Right door, right time
In fiscal 2018, Randolph County received some $200 million in Medicaid dollars. The money goes directly to health-care providers, not to Medicaid recipients.
Based on income levels in census data, said Richard Park, business officer for the Randolph County Department of Social Services, an estimated 8,000-10,000 people in Randolph might be eligible for Medicaid under expansion proposals.
“We certainly think it would be beneficial to our community,” said Randolph County DSS Director Tracie Murphy. “When they’re healthier or they get preventive care versus going to the emergency room and getting charity care, that kind of benefits the whole community.”
Orth agrees.
Residents who qualified for Medicaid would be able to see their own doctor for regular checkups, not just when they were sick.
“It would improve the overall health status of our community,” Orth said.
Of course, it’s much more expensive to go to the emergency department when you have a sore throat — or any other common ailment — than to go to doctor’s office.
“Having that expanded access would have people come to the right door at the right time,” Orth said, “instead of the more expensive door late.”
Medicaid expansion would help promote Randolph Health’s mission to provide quality health care and foster health and wellness in local communities, Orth said.
It also would provide additional revenue for uncompensated care. From October 2016-Sept. 30. 2017, Randolph Health had $13 million in uncollected revenue or bad debt — the patient’s portion of the bill after insurance is deemed uncollectable — and provided $3 million in charity care.
About 65 percent of hospital’s business is covered by Medicare and Medicaid and about one quarter have private insurance. The rest, nearly 11 percent, have no insurance. A small percentage of those with no insurance pay out of pocket.
Orth noted that Medicaid expansion would not cure Randolph Health’s financial challenges, but it would help. “What we’re hoping is that a good portion of that 11 percent could be reduced,” Orth said. “That would certainly help our situation right now. We are struggling to make ends meet.”
Net revenue from to Randolph Health from all payers in fiscal year 2017 was $85.8 million; Medicaid accounted for $8.8 million of that total. Hospital officials estimate net Medicaid revenue would increase by about $1 million annually under expansion proposals.
Do much with little
MERCE Family Healthcare’s four doctors, two dentists, nurse practitioner and dental hygienist serve those who have insurance — Medicare, Medicaid, private payer and self-insured — but last year 1,545 patients who saw a doctor or dentist did not have insurance.
The nonprofit, a federally qualified health center, receives a portion of its funding from the federal government to provide primary medical and dental services to underserved residents of the county and the surrounding area.
Uninsured patients can qualify, based on income, for copays for medical office visits and discounts for dental work. Twenty-three percent of patients are on a sliding fee scale, from $20-$50; most fall on the lower end of the scale. MERCE offers payment plans for patients who struggle to meet copays.
The United Way of Randolph County provides a grant which is used primarily to provide prenatal care for uninsured women in the first trimester. The Randolph County Health Department reimburses MERCE for prenatal visits for patients at or below poverty level.
The United Way also provides funding that pays for a simple test for uninsured diabetic patients that monitors how well they are managing their diabetes. Many used to turn down the test because it cost an extra $10.
“The purpose is for health centers to be in the community,” MERCE CEO Teresa Shackleford said, “and be the safety net for the community, and do as much as you can with as little as you can.”
What is Medicaid?
Medicaid is a government insurance program funded with federal and state dollars. It varies from state to state, depending on how lawmakers want to structure it.
Eligibility for the medical assistance portion of the program is based on income and assets. It covers only part of the population. Eligibility depends on age, health needs, income and resources, but those who may qualify include:
* Adults 65 and older.
* Individuals who are blind or disabled.
* Infants and children under 21.
* Low-income individuals and families.
* Pregnant women.
Recipients are eligible for up to a year and must be re-certified when their eligibility expires.
The Affordable Care Act of 2010 required states to expand to include people earning less than 133 percent of the federal poverty level with a pledge to cover 100 percent of the expansion for the first three years and 90 percent of costs to 2020.
The expansion mandate was challenged in court. A 2012 Supreme Court ruling said the federal government could not require Medicaid expansion and left it up to each state to decide what to do. Since then, 36 states and the District of Columbia have expanded benefits. North Carolina is not one of them.
A Republican-sponsored bill to expand Medicaid was introduced during the 2017 session on the N.C. General Assembly. Entitled “Carolina Cares”; it never advanced through committee. In January, Tar Heel Democrats filed bills in both the state Senate and House to expand Medicaid.
Last month, Gov. Roy Cooper advocated for Medicaid expansion in his State of the State address. The program now serves 2.1 million residents. The estimated number of people who might qualify under Medicaid expansion ranges from 450,000-650,000.
Statewide, about 13 percent of the residents have no health insurance. Randolph’s uninsured rate (about 16 percent) is lower than neighboring Montgomery County (17 percent) but higher than neighbors Chatham (15 percent) and Moore (12 percent).
Headline
ASHEBORO — In his State of the State address last month, Gov. Roy Cooper advocated for Medicaid expansion that would allow more North Carolinians to qualify for the government insurance program. The program now serves 2.1 million residents.
Medicaid expansion would extend benefits to people earning less than 133 percent of the federal poverty level, which is $12,140 per year. Estimates of the number of people in the state who might qualify range from 450,000-650,000.
Randolph County’s representatives in the N.C. General Assembly, all Republicans, say they do not see a way to expand Medicaid rolls without raising taxes or cutting services somewhere else.
Under the Affordable Care Act of 2010, the federal government is paying, at least through 2020, 90 percent of the cost in states that expand their Medicaid programs. A Republican proposal called “Carolina Cares” and bills filed by Democratic lawmakers this year include hospital assessments designed to offset the state’s 10 percent share of the cost.
“What they’re saying is that this wouldn’t cost the taxpayer any money,” said Rep. Allen McNeill, R-Moore, Randolph. “How’s the federal government paying their 90 percent? Taxpayer money. To use the argument that it’s not going to cost the taxpayer any money is crazy.”
McNeill contends that the federal government is not actually picking up the tab anyway, but simply adding to the nation’s debt.
“The federal government is almost $22 trillion in debt,” he said. “At some point, this is all going to collapse. To me, I just think it’s irresponsible if you don’t have a reasonable expectation of how you’re going to pay for it.”
Both McNeill and Sen. Jerry Tillman, R-Guilford/Randolph, point to another potential problem. Congress might decide to reduce its 90 percent share, leaving the state with a larger portion to cover.
“Whatever we do, we’re still at the federal government’s mercy as to what they’re going to do with it,” McNeill said.
To that point, President Donald Trump this week called for the elimination of federal funding for Medicaid expansion in his 2020 budget proposal.
In a press release, N.C. Senate Leader Phil Berger, R-Rockingham, who has not supported proposals to expand Medicaid in the state, addressed the federal government’s role in Medicaid expansion.
“Obviously pulling all federal funding for Medicaid expansion would be a worst-case scenario, but any reduction in federal funding or added restrictions on the taxes that Democrats propose using to fund expansion would be a budgetary nightmare for North Carolina,” Berger said. “Other important priorities like education and infrastructure would be crowded out by the cost of expansion. This happened for years with the traditional Medicaid program before Republicans fixed it.”
McNeill said to earn his support any expansion of Medicaid would have to go beyond “traditional” Medicaid — that is, simply paying for healthcare services that are billed to the government.
He likes some of the provisions of the “Carolina Cares” bill, which was filed in the General Assembly in 2017, but died for lack of action.
The bill would have required recipients to pay an annual premium (2 percent of household income), to take part in preventive care and wellness activities, including routine physicals, and to have a job or be “engaged in activities to promote employment.”
Someone who qualified for coverage under such parameters, McNeill said, would be paying more than the traditional Medicaid copay of $3 and would be taking some personal responsibility for his health with “skin in the game.”
Expanding Medicaid also does not address a shortage of doctors and nurses, McNeill said. But the bottom line, to him, is funding. Legislators must consider a wide range of funding needs besides healthcare, from education to public safety.
“I’m not going to vote for anything if you can’t tell me how we’re going to pay for it,” he said. “I’m open to listen to anything, but I’m not going to vote for traditional Medicaid expansion.”
McNeill said he probably would not vote for any proposal to expand Medicaid expansion that depends on the federal government covering 90 percent of the cost.
“They can call me cruel and heartless, but I’ll just take my lumps. Show me how we’re going to pay for it, and I’ll be glad to support it.”
Other options
“It’s a complicated issue,” Tillman said. “It seems like a simple matter — we’ll expand Medicaid and cover everybody. There are good points you can make for expanding Medicaid: It will cover a whole bunch of people. It will put people to work. There’s still a whole bunch of money that has to come from somewhere.”
He said he did not think many of the state’s hospitals, which are struggling financially, could afford assessments that are part of current expansion proposals.
Tillman recalls the days when the state of North Carolina found itself in a hole to the tune of billions of dollars following several years of deficits in its Medicaid program. Republicans worked to bring program costs under control. Expansion runs the risk of a return to deficits in the program, he said.
“You’re either going to have to raise taxes or cut something in the budget,” he said. “We’re going to try and work out some options. The House has got some ideas. The Senate has got some ideas. To see an out-and-out pickup (of Medicaid expansion), I don’t think it will come in that form.”
A step in the right direction, he said, is something like Senate Bill 86, the Senate Bill Small Business Healthcare Act, which was approved in the state senate this week. Tillman explained that the legislation, which now goes to the House, would make it easier for small businesses to offer insurance to employees.
“We’ve got to do some small steps to get back to covering these people,” he said.
Personal responsibility
“I don’t think there’s any appetite for the Medicaid expansion,” said Rep. Pat Hurley, R-Randolph. “The federal government is $22 trillion in debt. They don’t have any money to give to the state and that becomes our taxpayer responsibility … I don’t see how we can add more to our taxpayer responsibility at this particular time without knowing the future.”
Hurley said she believes individuals need to take personal responsibility for lifestyle choices that affect their health and for finding jobs that offer benefits such as health insurance.
“I don’t have the answers, but taxpayers cannot afford to pay for every need that everybody has,” she said. “You can’t cover everybody for every need.”
Hurley also that even without expanding who is eligible for Medicaid, the program will grow in North Carolina as the population increases.
“Why would we try to get in debt more? We have to balance our budget,” she said. “It’s not like the federal government. You’ve got different people coming at you for this dollar and that dollar. I just don’t see it happening.”