Asheville – “However you wanna celebrate,” said Buncombe County Health and Human Services Director Stony Blevins, “WHOO! That’s how I like to celebrate.” He was delivering a presentation before the Buncombe County Commissioners about North Carolina becoming the 40th state to sign Medicaid Expansion into law, and he just had to “stop a minute and celebrate this.”
Medicaid Expansion, defined by the Affordable Care Act (ACA), would extend Medicaid coverage to all citizens between the ages of 18 and 65 who are living at or below 133% of the federal poverty level. For 2023, that would translate to individuals earning no more than $19,390 and families of four earning no more than $40,000.
The ACA called for Medicaid Expansion to take effect nationwide, but this was challenged in the courts. After the United States Supreme Court ruled that forcing states to expand Medicaid coverage did not constitute a constitutional exercise of Congressional spending powers, adoption became voluntary.
While North Carolina has now signed Medicaid Expansion into law, the county cannot begin enrolling customers yet. One reason is that acceptance and implementation of the measure were made conditional upon adoption of the state budget. In recent years, the legislature has delayed budget adoption until long after dependent organizations, like the school systems, have had to set their budgets. In 2019, the legislature totally failed to pass a budget and had to default to existing funding levels.
Now there is a great incentive to pass a budget, namely the $1.8 billion “bonus” the state would get from the federal government for expanding Medicaid by December 1. “I cannot imagine that our lawmakers would miss out on that, but that’s beyond my influence to say,” said Blevins. Meanwhile, Brad Branham, attorney for the City of Asheville, said he would be monitoring the budget very closely. With such an incentive to pass, a lot of riders that couldn’t pass on their own merits could be tagged onto the budget in last-minute, closed-door meetings with neither public knowledge nor input.
The second reason is that the Center for Medicare and Medicaid Services (CMS) must approve North Carolina’s expansion plan. One obstacle to this could be that North Carolina legislators want to impose a work requirement, which Blevins said could be troublesome depending on how the CMS wants to interpret it. To date, the CMS has rejected proposals from all other states attempting to make Medicaid benefits contingent upon workforce participation. The CMS and the state may, however, come to an agreement to only require beneficiaries to participate in a work referral program.
Blevins said Medicaid Expansion could go live in North Carolina anytime between July 1 and December 1 this year. When this happens, the number of Medicaid beneficiaries in the county is expected to increase from 60,934 to 76,363.
To respond, the county is expected to need 38 more employees and expand its operating budget by $3.4 million. So, the commissioners will have to vote on an authorizing ordinance at a later date. Things could have been worse, as the county currently administers multiple Medicaid programs. Consolidating these into a single program with one set of eligibility requirements will reduce staff time spent on activities like means verification.
On the flip side, all staff members will have to receive training for the new program. In addition, Blevins said the county will need “100% quality control for an extended period.” He explained that if a member of county staff were to make an error that caused somebody to rack up non-reimbursable medical bills and this was discovered in an audit, the county would be responsible for reimbursing Medicaid.
Commissioner Martin Moore said hiring anybody these days is difficult, so he wanted to know how the county hoped to go about hiring 38. Blevins said the county hoped to promote from within, so those who will fill the supervisory, training, and quality-control positions are already on staff. For the other positions, staff is meeting to define job titles, job descriptions, and qualifications. Once that is done, the county will run an expanded advertising campaign, continuously recruiting until all positions are filled. Recruits will be interviewed a priori and hired as the county is able to accommodate successful applicants.
Not counting federal taxes, interest on the national debt, and inflation from printing and minting, Blevins said taxpayers would not pay for operational costs through FY25. Not only is the state expected to pass some of the $1.8 billion through to counties, the federal government already pays 75% of the costs of Medicaid administration. Blevins said the enabling legislation was unclear about what would happen after 2025, but interest groups may attempt to make county taxpayers more directly responsible.
Another question was whether the provider network would be able to take on the needs of 15,429 more clients. Blevins said Dogwood Health Trust was participating in the state’s Healthy Opportunities Pilot program, so Western North Carolina was already “ahead of the curve in doing some of the social determinants work.”
Commissioner Al Whitesides asked how the 15,429 were paying for medical treatment now, and Blevins said treatment comes largely through various Federally Qualified Health Centers (FQHCs), which receive federal funding via an assortment of programs. In addition, “the county very graciously also participates in what I call the assurance model to make sure people do have access to primary care services.” In addition, nonprofits like Asheville Buncombe Community Christian Ministries (ABCCM) provide services like prescription filling. “The free clinic model,” he said, “is all but gone in Western North Carolina.” Blevins argued the expansion would “free up nonpublic dollars to focus on the small population that remains.”