North Carolina: Bravo! Medicaid expansion finally passes NC state senate nearly unanimously...now that "Obama" is no longer attached to the "Care"

Almost exactly ten years ago, in the federal National Federation of Independent Business v. Sebelius case which was the first of several high-profile federal lawsuits which attempted to eliminate or cripple the Patient Protection & Affordable Care Act, the U.S. Supreme Court spared the ACA...mostly:

The Supreme Court, in an opinion written by the Chief Justice, John Roberts, upheld by a vote of 5–4 the individual mandate to buy health insurance as a constitutional exercise of Congress's Taxing and Spending Clause (taxing power). A majority of the justices, including Roberts, agreed that the individual mandate was not a proper use of Congress's Commerce Clause or Necessary and Proper Clause powers, although they did not join in a single opinion. A majority of the justices also agreed that another challenged provision of the Act, a significant expansion of Medicaid, was not a valid exercise of Congress's spending power, as it would coerce states to either accept the expansion or risk losing existing Medicaid funding.

In other words, most of the ACA was deemed Constitutional, including the now-defunct "individual mandate penalty," but one big provision was struck down: The SCOTUS ruled that the federal government couldn't force states to expand Medicaid under the ACA; each state had to agree to do so on its own.

Fortunately, around half the states jumped on right out of the gate--with very good reason: The federal government would pay for at least 90% of the cost, and their wealthier residents would be paying the taxes for Medicaid expansion to the IRS whether their state expanded the program or not. Unfortunately, the other half of the states didn't.

At least at first.

Over the decade which has followed, another dozen or so states have gradually done so as well. In some cases a new governor did so via executive order. In others, the state legislatures grudgingly came around. In several deep red states such as Oklahoma, Utah, Idaho and Missouri, both the Republican governor and/or the Republican state legislatures continued to refuse, so the voters of the state took it upon themselves to force the program though via statewide ballot initiatives. South Dakota is the latest holdout in which a statewide ballot proposal may force the issue this November.

Besides South Dakota, there are eleven other states which are still refusing to expand Medicaid to low-income adults...including some of the biggest in the country like Texas, Florida, Georgia...and North Carolina.

Well, lo and behold:

In a key step toward half a million uninsured people around the state receiving health care coverage, the North Carolina Senate approved Medicaid expansion in two votes on Wednesday and Thursday with overwhelming support.

“It protects patient choice and access to affordable health care,” said Republican Sen. Ralph Hise of Spruce Pine, a former opponent of Medicaid expansion who has since reversed course and helped write the expansion bill, House Bill 149 or “Expanding Access to Healthcare.”

Despite the lopsided votes, 44-2 on Wednesday and 44-1 on Thursday, the fate of Medicaid expansion is less certain in the House of Representatives, where it heads next.

But supporters on Wednesday were not focused as much on the future challenges as they were on the historic vote in the Senate — which signaled a change in opinion from GOP leaders that Democrats have been pushing for for a decade.

The actual number of North Carolinans who will become eligible if the bill passes the state House as well (NC has a Democratic Governor, Roy Cooper, who has long supported expanding Medicaid) is a bit vague--the Kaiser Family Foundation pegged it at 404,000 last year, while some local NC papers put it as high as 600,000. Whatever the exact number, it would reduce the total number of Americans caught in the so-called "Medicaid Gap" by around 10%.

So, what's changed? Well, way back in 2015 I authored a post over at healthinsurance.org titled "Hating 'Obama' but loving the 'Care':

Here’s what’s interesting: Since the beginning of the debate about exchange implementation, Republican governors and state legislators have fought like hell to have nothing to do with Obamacare. They refused to set up their own exchanges, they refused to expand Medicaid, they threw absurdly restrictive regulations in the way of navigators trying to help their own citizens acquire decent healthcare coverage.

But in the end, not only has Medicaid expansion started to spread across the GOP landscape, as it turns out, red state numbers are actually outpacing Democratic state private enrollments by a wide margin!

Democratic NC State Senator Jeff Jackson summed it up best earlier today via Facebook:

I'm getting a lot of questions about why Senate Republican leadership reversed on Medicaid expansion after a decade of strong opposition.

I think they’ve wanted to pass this for years. I think the policy arguments they made last night have been true for a long time, and they've known that.

So what changed? In short, the political liability of Obamacare (of which Medicaid expansion was a crucial piece) among Republican *primary voters.*

I think this year, some (but not all) Republican leaders here decided that we’ve finally reached enough distance from Obamacare’s passage that they feel comfortable supporting it without it becoming a lethal issue in their primaries.

This isn’t about them looking for a win in the upcoming general - it’s about their level of comfort with their own primaries.

I'm not saying they're justified in having waited this long, but I think that's the basic reason.

I also think that the Republican leaders who continue to oppose this in the state House are doing so partly because they've got more members who would be vulnerable in a primary than the state Senate. Remember, state House districts are much smaller than state Senate districts. It's easier to get tanked in a primary because the number of people voting is so small.

I think that understanding should inform our advocacy here. The vast majority of state House Republicans *want to pass this.* This is as much about speaking to their constituents - i.e., our friends and neighbors in rural counties - as it as about speaking to them.

We need to use the next month to make sure everyone understands how strong the benefits would be for those counties - saving their hospitals, insuring their families.

And when this passes, it needs to be marked as a major milestone for our state - not an occasion for recrimination, but a celebration of what we finally accomplished by coming together and doing the right thing.

-Sen. Jeff Jackson

(Yes, I agree with Sen. Jackson that what's most important is getting the bill passed and implemented, but I couldn't help but throw some shade in the headline.)

Stay tuned for the House vote...