Two weeks ago, I wrote a column in which I considered the future of the Affordable Care Act in the hands of a Trump presidency. I acknowledged then that I was no expert on the politics or policy of the American health care system and I’ll do so again now. This week I’m writing about Medicaid expansion—the most thrilling political conversation-starter out there (a guy can dream, right).
In January—shortly after returning to campus for my first spring at Duke—I woke up early to do some reporting. That Sunday, I walked to the edge of East Campus among sporadic flurries of snow and made my way to Watts Street Baptist Church. I was there for a guest sermon by Duke alumnus, Rev. Rodney Sadler, who received his Ph.D. in Hebrew Bible and Biblical Archaeology from the Divinity School in 2001. Martin Luther King Jr. Day was the following Monday and Sadler’s sermon was a celebration of the legendary civil rights leader’s life and legacy in an America still learning to recognize and mend racial divisions.
After the service, Sadler—who has been deeply involved in the North Carolina NAACP’s health care advocacy and activism—briefly spoke with me about the Affordable Care Act’s implementation in North Carolina and the obstruction of Medicaid expansion by a Republican state legislature.
“Not only is it wrong politically, it’s wrong morally; what we’re doing is hurting people and we want to find a way to lift people up,” said Sadler.
Lifting people up certainly seemed to be the law’s initial intention.
Originally, the Affordable Care Act expanded Medicaid eligibility in all 50 states, extending the program to individuals with incomes up to 138 percent of the federal poverty level—meant to begin in 2014. But in 2012, the Supreme Court simultaneously upheld the Affordable Care Act and gave states the option to opt out of expanded Medicaid, thus placing the decision of whether to participate within the purview of the country’s state legislatures and governors.
31 states have taken up the federal government on its offer to support expanded Medicaid, while the remaining 19 states have blocked the measure. The decision on whether or not to implement has been largely divided along party lines. Only ten Republican governors—including Vice President-elect Mike Pence—elected to expand Medicaid under “Obamacare.” And, unfortunately, none of the ten was named Pat McCrory.
Only a couple weeks into 2016—months before the passage of House Bill 2 and almost a full year before the Tar Heel State cast the majority of its ballots for Donald J. Trump—Sadler told me, “North Carolina has a history of progressive politics that have helped people and made us a light in the South, but what has happened under this new administration is we’ve gone backwards.”
From Reconstruction up until 2011, Democrats maintained control over at least one chamber of the General Assembly, but for the past five years, Republicans have enjoyed the elusive majority. Similarly, the North Carolina Governor’s Mansion was occupied by Democrats from 1993 to 2013, when McCrory got the keys.
Since then, Republicans—armed with supermajorities and the governor’s office—have effectively thwarted any forward movement on Medicaid expansion, citing fiscal concerns as the hold-up despite the federal government’s promise to shoulder a majority of expansion costs. Conservative state leaders have called for the reform of the existing state Medicaid system, which has “consistently overspent its budget by billions of dollars,” before any sort of expansion takes place.
Cutting out overspending is an important goal, but not at the cost of human life. It’s estimated that 300,000 North Carolinians go uninsured because they fall into the “Medicaid gap.” Without access to regular preventative care, people with life-threatening medical conditions are forced to rely on the last-resort of the emergency room. As Douglas McCarthy—senior researcher at the Commonwealth Fund—notes, there is a clear and significant relationship between “access to care and quality of care.”
“Many of these people have chronic illnesses like diabetes and heart disease…so [Medicaid expansion] is an opportunity for them to get help, but [the Republicans] refused it,” said Sadler.
And if the preservation of human life isn’t worth the extra dollars, doubtful Republicans should look at the economic upside of Medicaid expansion. A 2014 study by the Cone Health Foundation found it would generate over 40,000 jobs and allow the state to collect more than 21 billion dollars in federal funds between 2016 and 2020. North Carolina would have to cover around 1.7 billion dollars in new Medicaid costs, though these would be offset by increased state tax revenue. What’s more, according to a study from the University of North Carolina Chapel Hill, rural hospitals located in states with expanded Medicaid had improved chances of turning a profit.
Despite all that, it’s hard to be optimistic about Medicaid expansion’s prospects in North Carolina. Even if Roy Cooper wins the protracted gubernatorial race, he’ll face a General Assembly with Republican majorities in both chambers—35 seats to the Democrats’ 15 in the State Senate and 74 to the Democrats’ 46 in the North Carolina House. And if the state legislature and governor were somehow able to get together on expanded Medicaid, the whole thing might be torn to bits by the Trump administration’s switch to block grants for Medicaid—a measure which could very well entail problematic cuts in federal funding.
Whatever becomes of Medicaid expansion under the impending Trump presidency, I hope we might learn from the lack of compromise by our state legislature and governor’s office over the past few years. Citing fiscal concerns and reform as justification for rejecting federal aid—aid desperately needed by a sizeable population of North Carolinians—is a little like turning the fire truck away from your burning house because you haven’t yet been able to patch the hole in your leaking garden hose.
Like a lot of things, the best way to start making Medicaid expansion work is to actually put some effort toward it. And if these people are unwilling to make that endeavor, maybe they should stop running for office.
Jake Parker is a Trinity sophomore. His column, "thinking too much, feeling too little," runs on alternate Wednesdays.
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