• Care Ring

The Paramount Public Policy Decision



The way we finance, access, and provide health care in North Carolina is going to change when the Affordable Care Act comes into full bloom in the coming months and years. Of all the topics facing our leadership in Raleigh, implementation of the Affordable Care Act (ACA) and the option to expand Medicaid in North Carolina I believe is the paramount public policy issue facing our state.

Whether one likes it or not, the ACA is here and is highly unlikely to go away. The ACA directly impacts every single North Carolinian and every single North Carolina public, private, and nonprofit enterprise. The rich and the poor, senior citizens and our youngest babies, citizens and undocumented folks – everyone is going to be impacted by this legislation.

Over the next few months our newly-elected state leadership will need a crash course in the ACA and its many nuances and impacts. Legislators will have to go beyond scoring political points on the merits or failures of Obamacare. The ACA is an extraordinarily complex and multifaceted piece of legislation. If the devil is in the details, then the ACA and its thousands of pages of rules and regulations is the Great Satan.

But with President Obama’s re-election secured, implementation of the Affordable Care Act continues. And America’s statehouses will be overheating with activity as they set up new systems, policies and programs to implement the ACA.

This summer the Supreme Court upheld the constitutionality of the Patient Protection and Affordable Care Act (ACA) that was signed into law back in 2010.

Many of the major changes from the ACA were not designed to hit until many months or years after passage. Starting January 2014:

  • For most individuals, if they can afford it then they will be required to obtain basic health insurance or pay a fee to offset the costs of caring for the uninsured

  • New competitive marketplaces for insurance – Affordable Insurance Exchanges – will be operational in all states, including North Carolina. If an employer doesn’t offer insurance, the worker will be able to buy it directly in an exchange.

  • Americans who earn less than 133% of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid, assuming states agree to expand their Medicaid programs.

  • Tax credits to help the middle class afford insurance will become available for those with income between 100% and 400% of the poverty line who are not eligible for other coverage

While the Supreme Court validated most of the ACA, in their decision the Court provided states the option to expand Medicaid coverage to non-elderly people with low incomes.

North Carolina’s Division of Medical Assistance has previously estimated the total cost of covering newly eligible and existing Medicaid eligible in North Carolina would be approximately $16.3 billion from 2014 – 2019. The federal government would pick up the vast majority of these costs – approximately $15.4 billion.

However, many Governors and state legislatures are predicting financial devastation if Medicaid eligibility grows in states across America. So they vow to stand in the doorway and block any state legislative efforts to reach out to cover more of the uninsured.

If North Carolina elects to not expand Medicaid, then many of the promised benefits of the ACA – especially the goal of reducing the number of uninsured across our state – will not reach nearly as many individuals as envisioned. While the ACA provision providing a subsidy to individuals with incomes between 100 – 400% of the Federal Poverty Level to purchase health insurance goes into effect, those with the greatest need – people at or below 100% of the FPL will be left out of the mix.

The safety net provider community across our region will be one of the few resources remaining for these very poor individuals who will be left out of the ACA if Medicaid does not expand. And undocumented individuals in our region were left entirely out of the ACA –this legislation ignored our neighbors who have been working, living, learning, and contributing to our community for years.

There will be many critical public policies clawing for the attention of our leaders in Raleigh in the coming months. Tax policy, economic development strategies, and proper investment in public education are but a few of the major issues facing our leaders.

But health care policy – and implementation of the ACA – is perhaps the most important public policy decision awaiting our new leadership in Raleigh.

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