The future of the Affordable Care Act dominated the news Wednesday. While Democrats and Republicans huddled on Capitol Hill to discuss the future of the law, here in North Carolina Governor Roy Cooper announced his plan to expand Medicaid in the state.
But the future of that move is as murky as the fate of Obamacare itself.
Governor Roy Cooper backed into the announcement with a hypothetical. "What if I were to tell you," he began, "that we have the opportunity to bring in $2 to $4 billion a year in investment to North Carolina?"
He focused on points sure to intrigue the business leaders seated in the hall. The investment, federal tax dollars. The headline was this, "We have to accept Medicaid expansion that is being offered to our state."
Medicaid expansion is a key component of Obamacare. It increases the number of low income adults eligible for the government insurance offered to the poor and disabled.
But there are three major hurdles Cooper faces.
The first is the future of Obamacare itself.
Republicans have said repealing and replacing the law is a top priority. But Cooper told the crowd that "one of the things I’ve read a lot about and talked to a lot of people is yes, you do expect changes in the affordable care act that’s coming. But Medicaid is one of the programs that is most likely to be preserved."
Julie Rovner disagrees. "I think it's one of the things most likely to be changed. They really want to get rid of the Medicaid expansion." Rovner is a reporter with Kaiser Health News and she’s been covering the Affordable Care Act since its inception.
But she adds, "if Cooper can get in before the Obama Administration leaves I suspect the state could be grandfathered in at least for a while." Meaning Medicaid expansion would possibly stand for some time before being struck down or changed by lawmakers on Capitol Hill.
The second major hurdle has to do with paying for the expansion.
The federal government currently pays 95 percent of the cost of Medicaid expansion. That will drop to 90 percent by 2020. The North Carolina Constitution gives taxing and budgeting authority to the General Assembly – not the governor. So the Republican controlled state legislature could simply not fund the expansion.
On this point Cooper said he would look to others to pick up the state’s share of the tab. Specifically North Carolina’s Hospitals. "I would ask them to step up and be willing to place upon themselves mandatory assessment in order to provide the 5 percent so that we are there."
The theory is financially hospitals would be better off. After all 95 percent of something is better than 100 percent of nothing. It’s a model already in place in some states. And Julie Henry, vice president of Communications for the North Carolina Hospital Association says her group is open to the idea. "That is certainly something that we have not closed the door on but we want to have more conversations with all parties involved, meaning the General Assembly and the governor and see that this is something that is agreed upon by everybody and then we can talk more specifically about how we make that happen."
And having everybody agree is the final stumbling block.
Republican lawmakers have long worried about the long term costs of Medicaid expansion.
In 2013 the General Assembly passed a law specifically banning the governor from taking part in Medicaid expansion without their permission.
Republican leaders in the North Carolina House and Senate have each sent out press releases stressing this proposed expansion is against that law. And showing they haven’t changed their minds.
In response to that Cooper told reporters the law impinges on the core executive functions of the governor to look out for the public health of the people.
All this seems to point to yet another dispute between the governor and the state legislature headed to court.