Medicaid and Moore v. Harper: two issues that dominated North Carolina politics in 2022

This year in North Carolina was notable for something that didn’t happen – Medicaid expansion.  

Republican legislative leaders had largely dismissed the idea of expanding Medicaid until this year. Then in May, Senate Leader Phil Berger, once a staunch and vocal opponent, said he had changed his mind.  

After that blockbuster announcement, a Medicaid expansion bill passed the Senate, but soon thereafter, momentum slowed and the measure stalled.  

Gov. Roy Cooper, a Democrat, and Democrats in the legislature have been advocating for Medicaid expansion for years.  

Nearly 600,000 adults would be newly eligible for the government-sponsored health insurance if Medicaid is expanded, according to the Center on Budget and Policy Priorities.  

The federal government pays 90% of the cost of people who become insured under Medicaid expansion. North Carolina proposals would have hospitals picking up the other 10%. 

Advocates for Medicaid expansion said in late December that they will keep working on the issue and are looking forward to the state passing it in 2023.  

“I do believe 2023 will be the year that we get it done,” said Abby Emanuelson, executive director of Care4Carolina, a constellation of groups that has been working for years for Medicaid expansion.  

The focus on Medicaid expansion started in early 2022 with a series of meetings of a special legislative committee. One meeting featured John Kasich, the Republican former governor of Ohio, who told legislators that handing a lifeline to people in desperate need of health care would become their legacy. “You’ll have people thanking you forever,” Kasich told them.  

Patrick Woodie, president of the NC Rural Center, told the committee that 20 of 22 counties with the highest percentages of uninsured residents are rural. 

Most low-income adults without dependent children don’t qualify for Medicaid in North Carolina. Many hold jobs that don’t offer health care benefits. They fall into what’s called the coverage gap – they make too much money for Medicaid but not enough to qualify for subsidies in the health insurance marketplace set up under the Affordable Care Act.  

After Berger announced his support, the state Senate overwhelmingly approved an expansion bill that included several other elements, such as provisions loosening the state’s Certificate of Need laws and allowing nurses with advanced degrees to treat patients without doctors’ supervision.

The North Carolina Healthcare Association, the state’s hospital group, has long advocated for expansion, but balked at Certificate of Need changes. Under Certificate of Need, healthcare providers must receive state approval before adding certain facilities or services. 

The Senate bill died in the House. The House passed its own bill calling for NC Department of Health and Human Services Secretary Kody Kinsley to come up with an expansion plan. The House bill died in the Senate.  

While the issue lay dormant in North Carolina, another state decided to expand.  

South Dakota voters approved Medicaid expansion in November through a ballot initiative. That leaves North Carolina as one of just 11 states that has not approved it.  

During the federal health emergency brought on by the pandemic, states have been prohibited from ending Medicaid beneficiaries’ health coverage. People who typically would have lost their coverage because they no longer met income limits have been able to keep their insurance. States received extra federal money to cover the cost.  

At meetings this year, state health officials told legislators that a good number of people who have Medicaid because of the health emergency are those who would qualify for the insurance under expansion.  

Included in the $1.7 trillion funding package Congress debated at year’s end is a provision that would allow states on April 1 to start removing people from Medicaid who are still using it because of the emergency declaration.  

“Having Medicaid expansion so folks won’t fall in the coverage gap will be extremely important for the state of North Carolina,” said Lucy Dagneau. She works on Medicaid for the American Cancer Society’s Cancer Action Network as director of the state and local campaigns team. “For me, the deadline is now April 1.” 

People who often fall in the coverage gap — home health care workers, baristas, barbers and landscapers — would benefit from Medicaid expansion, Dagneau said.  

“North Carolina has the fourth highest number of people in the coverage gap remaining,” she said. “It’s a big deal. This is something that can be done in a bipartisan way.” 

Moore v. Harper

A U.S. Supreme Court case originating in North Carolina that has the potential to give more power to state legislatures brought national attention to the state’s latest redistricting battle.  

North Carolina’s Republican legislative leaders brought the case, arguing that state courts should not have the power to review laws for federal elections, including congressional redistricting plans, passed by state legislatures.  

The lawmakers’ argument is premised on the “independent state legislature theory,” which is based on the U.S. Constitution’s Elections Clause. GOP leaders appealed to the US Supreme Court after the North Carolina Supreme Court threw out plans for new election districts, calling them unlawful partisan gerrymanders.  

The U.S. Supreme Court heard the case on Dec. 7. Three of the conservative justices, Samuel Alito, Clarence Thomas and Neil Gorsuch, seemed sympathetic t the Republicans’ argument, while Justices Elena Kagan, Ketanji Brown Jackson and Sonia Sotomayor weren’t buying it.  

Chief Justice John Roberts and Justices Brett Kavanaugh and Amy Coney Barrett asked questions that appeared to test some middle ground.  

“I think what those questions were really getting at was the radical reshaping that the petitioners’ theory would have wrought on our entire way of running elections,” said Josh Rosenthal, legal director for the Public Rights Project. Rosenthal filed a friend of the court brief on behalf of local government law professors that warned of chaotic elections with two sets of rules — one for federal offices and another set for state offices – if the court endorsed the independent state legislature theory.  

It’s dangerous to try to predict based on oral argument what an opinion will look like, he said, but “there was a definite interest in avoiding the extreme version that the petitioners were putting forward of deep federal court intervention to protect state legislatures and to hold state legislatures up on this pedestal where they get to make all the rules and ignore state constitutions.”