Gov. Cooper shows his backbone on Medicaid expansion

If your only source of information about healthcare spending is press releases from Phil Berger, the Republican leader of the North Carolina Senate, you might believe that Vice President-elect Mike Pence, Chris Christie, John Kasich and Jan Brewer were wildly irresponsible liberal politicians eager to waste tax money on bloated social programs.

All four Republican governors signed legislation — in Indiana, New Jersey, Ohio and Arizona, respectively — to approve what Berger called “a massive, budget-busting Obamacare expansion” of Medicaid. If Medicaid expansion has triggered financial crises in these Republican-controlled states, it seems to have escaped public notice.

While the legality of Democratic Gov. Roy Cooper’s efforts to expand Medicaid in North Carolina will have to be determined by the federal Centers for Medicare & Medicaid Services or the courts, the financial sense of his plan is not in doubt.

North Carolinians’ federal tax contributions are currently paying to subsidize Medicaid expansion in 31 states and the District of Columbia because the federal government covers 95 percent of the cost of the program, although the state match will balloon to 10 percent after 2020. Without Medicaid coverage for some of the state’s poorest residents, the NC Hospital Association says its members are chipping in $1 billion to care for residents who can’t afford it. Cooper, a Democrat, says expansion would allow the state to access between $3 billion and $4 billion in federal funds.

“We need healthcare that’s affordable and available,” Cooper said in his inaugural address on Jan. 7. “It’s long past time to expand Medicaid, so more working North Carolinians can get the healthcare they need. It just makes common sense. It’ll create tens of thousands of jobs, hundreds of thousands of North Carolinians will finally be insured, and rural hospitals will stop being closed down. That’s why Republican governors across this nation have put partisanship aside and done what’s best for their states. It’s time for us to do the same.”   

Cooper is potentially hemmed in by a 2013 state law that stipulates that North Carolina “will not expand the state’s Medicaid eligibility under the Medicaid expansion provided in the Affordable Care Act.” It also states, “No department, agency or institution of this state shall attempt to expand the Medicaid eligibility standards provided… unless directed to do so by the General Assembly.”

Former Republican Gov. Pat McCrory signed the bill, although he himself apparently doubted whether it constrained him from taking executive action, judging by reports that he continued to negotiate with Washington for a possible expansion of Medicaid.

While the feasibility of Cooper’s proposal is far from certain, it’s good politics. In contrast to McCrory’s maddening foot-dragging and equivocation about whether he might pursue expansion in the future, it’s refreshing to have a governor who’s not afraid to stand up to the ultra-conservative legislature and who sets out clear political goals. Yes, opposition from the Republican leadership at the General Assembly, not to mention pledges from the Trump administration and the Republican Congress to dismantle the Affordable Care Act, creates significant uncertainty, but Cooper and his fellow Democrats are wise to present voters with a clearly drawn alternative vision.

Considering that the legislature holds the power of the purse, one option floated by the new governor to cover the state match is for the hospitals — which would significantly benefit from Medicaid expansion — to kick in through fees.

Resistance from the Republican leadership in the General Assembly was entirely predictable.

“Cooper is three strikes and out on his attempt to break state law: He does not have the authority to unilaterally expand Obamacare; his administration cannot take steps to increase Medicaid eligibility; and our constitution does not allow him to spend billions of state tax dollars we don’t have to expand Obamacare without legislative approval,” Berger said.

Of course, Republican lawmakers could remedy that immediately by coming to their senses and passing a resolution in support of expansion.

Speaking of breaking the law, there’s more than a little bit of the pot calling the kettle black here, with the federal courts ruling that the General Assembly’s 2011 state redistricting law is an unconstitutional racial gerrymander. The districting plan, which virtually guarantees a Republican supermajority in both chambers of the state legislature, is precisely why most citizens do not have a voice in state government anymore and why Republicans can refuse to expand Medicaid while passing unpopular laws like HB 2 without fearing repercussions at the ballot box.

Even if Cooper’s plan doesn’t get traction, it’s important for him to propose good policies to force Republican lawmakers to defend their bad ones. Unlike his Republican opponents, the new governor had to face all of the state’s voters to get elected. He’s not going to win any points letting the legislature set the agenda — the people sent Roy Cooper to Raleigh to be a strong leader. Good for him for leading.