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By Mitch Kokai, Carolina Journal

Fans of Medicaid expansion in North Carolina have been touting a recent change in attitude from the Senate’s top officer. He has dropped his steadfast opposition to expansion.

But now is not the time for Medicaid advocates to pop their champagne corks. They should listen to what Senate leader Phil Berger, R-Rockingham, is saying about expansion. They’ll discover that he hasn’t signed on yet for full-fledged support.

“We’ve spent the last 10+ years with a debate about ‘Should we do it, shouldn’t we do it,’” Berger said during a one-on-one interview with Carolina Journal. The conversation followed his remarks at the John Locke Foundation’s recent Carolina Liberty Conference.

“Up to this point, the decision that’s been made is that we should not in North Carolina expand Medicaid,” Berger said. “But the issue keeps coming back.”

Disagreement over Medicaid expansion helped drive a multiyear state budget stalemate. Democratic Gov. Roy Cooper pushed for expansion. Berger and fellow Republican legislative leaders resisted the idea. With neither side giving in, budget negotiations stalled.

The state budget deal Cooper signed last fall included a provision setting up a new committee. It’s focusing on Medicaid and other health care issues. “I hope what comes out of that process is some form of consensus as to what we need to do,” Berger said.

Facts have changed since the General Assembly first said no to expansion during the Obama administration, Berger said. “Early on, there was a lot of uncertainty about whether the federal government was going to continue to pay 90% of the cost of Medicaid for the expansion population,” he said. “That was a real concern.”

If the feds backed out of the 90% commitment, state leaders would have faced serious questions. “What do we do with the folks who have been promised something? How does that impact our state budget? Can we afford that?” Berger asked.

As political winds have shifted nationally over the past decade, Berger and his colleagues have seen every possible combination of Republican and Democratic leadership in the White House and on Capitol Hill.

“They’ve done nothing to modify that 90/10 split” between federal and state obligations for Medicaid expansion costs, Berger said. “So I believe the fiscal concerns for the state budget are no longer the concerns they were initially.”

So far, so good for Medicaid expansion advocates. But Berger’s questions about expansion extend beyond just fiscal concerns. “Does that change the decision that we make? I think it requires us to take another look at the decisions that we’ve made over the years.”

Expanding Medicaid requires more than just saying yes to the federal government’s offer.

“If we make the positive decision to expand Medicaid, that needs to be done in conjunction with a recognition of the impact of putting 300,000, 400,000 — whatever the number is — of new folks into our health care system, in terms of having access to their bills being paid,” Berger said.

An influx of new Medicaid recipients raises another set of important questions. “Are we going to generate a situation where we have long wait periods for surgical procedures that need to be done? Inability of folks to get to see doctors?”

Answering those questions could lead to proposals that Medicaid expansion advocates might not support.

“I think we need to look at some scope-of-practice issues to expand the availability of medical care,” Berger said. Scope of practice refers to the services a health care professional is qualified and permitted to perform.

State regulations often limit health care workers from practicing to the full extent of their medical training. Some of the same people pushing hard for Medicaid expansion adamantly oppose state government relaxing scope-of-practice restrictions.

Berger mentioned another idea that’s bound to generate heartburn for some of Medicaid expansion’s leading advocates.

“Certificate of need needs to be looked at seriously to — again — expand the availability of the facilities that would be out there that can provide care,” he said.

The certificate of need, or CON, represents a form of government permission slip. Health care providers must secure a CON from state regulators before opening or expanding a hospital, starting certain types of outpatient medical centers or even purchasing major medical equipment.

Hospitals have been among the most vocal proponents of Medicaid expansion. They also lead the campaign to preserve North Carolina’s existing CON regime. It’s unclear how they might react to a proposal that would combine Medicaid expansion with a repeal of CON restrictions.

The Senate leader argues that North Carolina must consider ways to expand access to care. “If we fail to do those things, I think expanding Medicaid is likely not a good decision,” he said. “If we are able to find ways to expand access to care, then — with the fiscal issues not being as paramount as they were at one time — I think it’s a little easier for us to go to a positive decision.”

Medicaid expansion advocates might have to decide what they’re willing to sacrifice to achieve their goal.

Mitch Kokai is senior political analyst for the John Locke Foundation.

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