Phil Berger, who spent years as one of North Carolina’s most ardent opponents of Medicaid expansion, is now one of the program’s most powerful advocates on the right.
The change of heart from Berger, the leader of the state’s Republican-controlled Senate, is driving North Carolina to join the 39 states and Washington, D.C., that take federal money – made available during the Obama administration – to extend health insurance benefits under the state program to more people with low incomes.
“If there’s somebody who’s spoken against expansion more than I, more publicly than I, I just don’t know who that would be,” Berger, the Senate president pro tempore, said in an interview.
Opposition to the program was for years a hallmark of the conservative movement. But more than 10 years after the passage of the Affordable Care Act, red states are increasingly warming to Medicaid expansion, thanks to its popularity with voters and successes in the states that have done it.
South Dakota was the most recent state to make the shift after voters approved expansion through a ballot measure in November.
The federal government helped drive the recent momentum through an emergency measure during the COVID pandemic that temporarily added millions of people to Medicaid rolls and new incentives for states to extend postpartum Medicaid enrollment to 12 months from the standard two.
That emergency measure is set to expire in April. Increasing the stakes is the wave of rural hospital bankruptcies, an issue that is expected to worsen this year, particularly in the 11 states that have not expanded Medicaid.
Among the holdout states, Alabama, Kansas and Wyoming are likely to renew debates this year, but North Carolina is the closest to adopting expansion. Berger and House Speaker Tim Moore (R) have said they believe Medicaid expansion will pass this year, with the support of Gov. Roy Cooper (D).
Here is an interview with Berger about his support for Medicaid expansion, edited for length and clarity.
Pluribus News: What changed your mind?
Phil Berger: It’s pretty clear that the law – the Affordable Care Act and the Medicaid expansion portion – are not going to be struck down by the courts as being in violation of some constitutional provision. And so that was one thing that ameliorated my concerns about our state budget, and about the potential for the federal government changing the payment mix.
Additionally, we spent several years here in North Carolina reforming our Medicaid system. We took it from the fee-for-service model that was, in many respects, creating the budget uncertainty that we had. We now have a managed care Medicaid system. We are seeing good results from that, which was something I was concerned about. We’re seeing some budget predictability. The risk of people on Medicaid utilizing more than projected ends up being on those managed care companies as opposed to the state.
My final concern was about who was covered, whether or not we were basically providing a benefit to folks who are able-bodied and not working. In looking into it more carefully, the design of the Affordable Care Act is such that you really have a lot of people who are working full time that don’t qualify for additional Medicaid, but because of the amount of money they make, and how the qualification of subsidies on the exchange works, they don’t qualify for a subsidy on the exchange.
Those folks, I believe there’s a way to help them. We want to help.
PN: What is your advice to lawmakers in the 10 other states who haven’t expanded Medicaid?
Berger: In some places, the philosophical opposition to expansion of a social program is likely to be such an impediment that they won’t expand. Certainly, continuing opposition here in North Carolina is one of the things that is talked about.
I certainly understand that argument. And in many respects, I don’t disagree with the argument. But I think, on balance, expanding Medicaid will be the right thing for North Carolina. Other folks have come to a different conclusion and I respect that.
PN: Debate about relaxing the state’s Certificate of Need Law, which requires hospitals to get state approval before adding new services, and a provision that would give more independence to advanced practice nurses held up negotiations last session. How do you plan to get to a resolution on those issues?
Berger: If we’re going to give another half-a-million-people-plus an insurance card, I think it’s time for us to do something on the supply side other than talk about how we need to train doctors. Because you’re just not going to get the numbers fast enough to avoid the difficulty of people, even people with insurance, or who currently are on Medicaid to see physicians when you add in another half a million plus people to the rolls.
PN: Advocates say there could be big repercussions for the state and for the health of potential enrollees if the state can’t get expansion passed before April, when states will start removing people from Medicaid rolls who were automatically re-enrolled during the COVID pandemic, or before the state budget is passed. How do you see those deadlines informing the debate?
Berger: My view is that advocates for expansion are trying to generate a sense of urgency. I just don’t feel that sense of urgency. We’ve been talking about expansion for over a decade. If it takes us another year or even two years, if we can get to the finish line I think that’s the important thing.
PN: How do you think expanding Medicaid could affect North Carolina’s reputation as a business-friendly state?
Berger: We acquired the title of most business-friendly without expanding Medicaid. If we actually expand Medicaid, I don’t think it hurts. But I don’t know that it has any real impact.
PN: How do you respond to fears that federal funding could disappear and other questions about potential drains on the state budget?
Berger: The history of what we’ve seen over the past decade plus leads me to believe that that’s not going to happen. I equate it to some of the historical arguments that took place around Social Security. For years after the adoption of Social Security, there were folks out there talking about how the federal government was going to stop it.
In fact, Democrats regularly now use as a political point the fear that Social Security is going to be cut or curtailed, and it’s just not going to happen. The only budget issues that I would highlight in the context of expansion are all positive for the state budget.
PN: What are your thoughts on how expansion could help rural hospitals?
Berger: I don’t know that expansion by itself is a solution to many problems that we’ve got as far as rural health care is concerned. I don’t think it hurts. I think it probably does have some benefit. But I don’t think it will save rural health care.
It’s sort of like, we had a debate for years here in North Carolina about a lottery. And the proponents of the lottery had gotten to the point where they were puffing the lottery so much that a lot of folks came to the belief that, if we pass the lottery, it’ll solve all the problems we have in education as far as funding is concerned. So we passed the lottery and, lo and behold, we still have folks claiming we don’t have enough money for education. I’m a little concerned that an expectation may be created that, you expand Medicaid then all of a sudden any rural hospitals out there aren’t going to have a problem. That’s a false expectation.
PN: Do you want Medicaid expansion to be part of your legacy?
Berger: I don’t know if that’s up to me.
PN: If it were, what would you want people to remember about your role?
Berger: Since it’s not, I’m not going to answer that.