The medical crisis that finally convinced North Carolina Republicans to expand Medicaid

Colby, a 31-year-old woman who lives west of Asheville, could have been one of those moms. When she found out she was pregnant in 2018, her sister helped her enroll her in the CARA project, MAHEC’s perinatal drug addiction treatment center. About 90% of patients at the center are on Medicaid, and the most common addiction they treat is opioid use disorder. Colby, who asked to be identified only by her first name, said the people at the center were warm and compassionate despite the shame she felt about her drug use. “They helped me feel like I needed to improve and do better.”

She remained in treatment after the birth of her son and retained her Medicaid coverage while training to become a phlebotomist. Now her son is 3 years old and Colby works as a certified medical assistant. She continues to take medication to contain her addiction.

Medicaid coverage for buprenorphine, which helps people wean off opioids, is key to saving mothers’ lives, said Melinda Ramage, co-founder of the CARA Project. Before the extension took effect, some women felt discouraged from taking the drug during pregnancy because they knew they would not be able to afford it when their insurance ended. This made them more vulnerable to fatal overdoses. (A Massachusetts study found that the highest rate of opioid overdoses among new moms occurred seven to 12 months after giving birth.) But it would be more helpful if they could start buprenorphine. before they got pregnant, Ramage said. “It’s a big change,” she said of the postpartum stretch. “And we’re not done.”

Most counties in the state that have the highest rates of uninsured residents are rural, according to the North Carolina Rural Center. Over time, Democrats and Republicans in these areas have come to recognize that fully expanding Medicaid would provide insurance for people working in low-paying jobs such as construction and fast food, and help keep open their struggling hospitals. Last year, five rural county commissions and the Eastern Band of Cherokee Indians passed resolutions supporting Medicaid expansion.

Dale Wiggins, a Republican commissioner from Kevin Corbin’s district, helped garner that support. “The fact that one of my neighbors can’t afford to go to the doctor is silly,” Wiggins told me last fall. “If we can spend all this money on foreign aid, we can ensure that we have a healthy population.”

Yet there was still significant resistance to the idea in Raleigh. When Corbin realized that full expansion would not pass the state legislature last year, he and his colleagues proposed adopting postpartum expansion as an interim step. Focusing on mothers, rather than all low-income people, was a much easier sell. “We had no organized opposition,” he said.

Today, Tucker-Wiles, the MAHEC psychologist, sees more patients at five or six months postpartum. She doesn’t have to rush their treatment plans or panic about fitting everything into limited sessions. She can help the whole family by inviting dads on appointments and assessing how a mom is coping several months after the birth of her baby.

And Lillethun, the nurse practitioner, no longer needs to write a prescription for hypertension or diabetes and then say goodbye to her patients six weeks after giving birth. She can help them with everything from quitting smoking to thyroid issues. “Every one of my patients is going to benefit from this extension,” she said.

At the end of May, Less than two months after postpartum expansion took effect, a bill to fully expand Medicaid in North Carolina was leaked to the press. It was passed by the State Senate 44-2, after what Democratic Senator Jeff Jackson called “the most remarkable [debate] I heard about it in eight years.

Berger, the state senator who decried Medicaid as ineffective three years ago, defended the bill. “Medicaid expansion has now evolved to the point where it is good state fiscal policy,” he said in June.

In fact, the Biden administration had significantly sweetened the deal. Under the U.S. bailout, the 12 states that resisted expanding Medicaid can receive an additional 5% in federal funding for the first two years if they expand the program now. For North Carolina, that equates to an estimated infusion of at least $1.5 billion, according to a report by the National Conference of State Legislatures.

In 2020, the Families First Coronavirus Recovery Act provided additional Medicaid funding to states so they could maintain coverage for their poorest citizens for the duration of the pandemic. North Carolina added 559,000 people to its rolls between March 2020 and March 2022; they are not allowed to be removed until the public health emergency is over (Biden extended it until October). State budget policymakers realized they could save money by expanding Medicaid instead of adding people piecemeal, as they have done during the pandemic.

The political justification for resisting expansion has also faded. “I think the most controversial part of Obamacare has always been the Obama part,” said Taylor, a politics professor at Duke. Republicans like Berger have long feared that once Obama leaves office, the cost-sharing deal would go away. Now that the Democratic and Republican administrations have kept the deal in place — with the federal government covering 90% of the expansion costs — they have no reason to protest, Taylor said.

The full expansion would add an estimated 500,000 to 600,000 people to North Carolina’s Medicaid rolls, though it’s unclear how many of those people have already gotten coverage during Covid. Some Republicans think the state budget can handle those numbers better than it did a few years ago. “We are in better financial shape now than five years ago,” Corbin said.

Krawiec said she initially opposed the expansion, but now that North Carolina has moved to a managed care system for Medicaid, she supports it. She is co-chair of a committee studying the issue and trying to learn from the mistakes made by other states. “I think we have a better understanding of how to do it right,” she said.


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