The Path to Insuring All North Carolinians: An Interview with Senator Joyce Krawiec

Introduction

North Carolina’s uninsurance rate as of the 2020 Census was 11.3%, above the national rate of 9.2% [1]. North Carolina is 1 of 12 states that have not expanded Medicaid, an option under the Affordable Care Act to cover most adults with incomes up to 138% of the federal poverty level with an enhanced federal matching rate. In this interview, Adam Zolotor, MD, DrPH, speaks with Senator Joyce Krawiec (R–31) about the recent passage of a bill extending postpartum Medicaid benefits from 60 days to 12 months [2] and her ideas for further improving North Carolinians’ access to insurance.

Adam Zolotor (NCMJ): What do you see as the most important benefits of having health insurance?

Senator Joyce Krawiec: We all know health care costs have just skyrocketed over the last number of years. And without health insurance, it can bankrupt a family. So, it’s really important to make certain that we’re able to get the care that we need, and most people can’t actually afford to pay for it at the moment that we need it. Having a health insurance policy, we can spread out our costs over a long period of time.

AZ: What are the driving reasons that the North Carolina General Assembly voted to extend postpartum Medicaid benefits to 12 months in the last session?

J.K. I’m a big proponent of improvements in our foster care system, and we’ve seen that when mothers give birth, if they have drug problems, their children are taken away. They can’t afford treatment. They lose their health insurance when the baby is six or eight weeks old. And so, we originally thought, “We’ve got to help those new moms be able to get the treatment that they need.” But we couldn’t extend it just for that population of moms, so we thought, “Okay, let’s see what it will cost to do it for all moms.” We thought that was something we could do and see some immediate benefits in those moms who need treatment, so that they can take care of their families.

AZ: What do you see as the direct and indirect benefits to women and families of extending Medicaid benefits to 12 months postpartum?

JK: As we know, a lot of women have postpartum depression, and were not able to get treatment for that, if they have Medicaid, when they lost their coverage [after six weeks]. I think it’s just very important that those new moms, in order to have healthy babies, [are] able to stay healthy as well.

AZ: Do you see a realistic path forward for Medicaid expansion in North Carolina, or another version of a state-sponsored plan to help provide insurance options for people earning less than 100% percent of the federal poverty level? And if you do see a realistic path forward, what’s changed over the last year?

JK: Part of the negotiation with the governor on the budget was to create the Access to Healthcare and Medicaid Expansion Committee to look at all things that will improve access to health care in North Carolina. Representative [Donny] Lambeth and I, who are co-chairing that committee, have already met several times with staff, and we’re going to look at everything, including Medicaid expansion. We have some presenters coming in from the National Council of State Legislators, and they are giving us an update on Medicaid expansion throughout the country. We’re going to look at what worked [in other states]. We’ll be looking at something that we can craft that will be North Carolina-specific that will improve access to health care.

We know that there is a real problem with health care access in North Carolina. We know we have provider shortages everywhere, and we know Medicaid expansion will probably create more, so we have to find a way to increase providers in order to meet that demand.

All along I’ve said, “We can’t really talk about Medicaid expansion until we get through transformation.” Now we’re through [Medicaid] transformation, and it has gone remarkably well. So, it appears that now’s the time to look at other ways to expand access to care for our citizens, including expansion, if we can do that.

AZ: We’ve made it through Medicaid transformation, as you pointed out, and there’s been a change in the federal financial incentives for Medicaid expansion. Are there other things that you’re seeing, either in the political or health care or business climate, that have made conditions more favorable for Medicaid expansion?

JK: I think many of my colleagues never really objected to expansion, per se. What many of us are concerned about is that there are only 200,000 to 250,000 in that so-called gap, yet the governor’s proposal that we have been talking about for several years is expanding to 600,000 people. That’s going to include some people that are now on the [Health Insurance Marketplace] exchanges who pay very little, and those are the kinds of things that we really don’t want to disrupt. That would also include some people who have employee-provided coverage and don’t make a lot of money, and some of those will be pushed into Medicaid. Most people who didn’t want to move forward at the time, those were the concerns that they had, and we’re going to try to answer all of those concerns.

AZ: Do you think that our relatively high rates of uninsurance in North Carolina have impacts on the state beyond the health of individuals?

JK: I don’t know to what degree, but it definitely has an effect on people’s outcomes. The hospitals can’t turn anybody away, so people who don’t have insurance traditionally use the emergency room as their primary care physician, and that’s the most costly place you can go for any kind of treatment. So, we’re trying to look at all of that to see how much that is costing the state now, how much we will save by folks not using the emergency room, and I think [the transition to] managed care is already doing that. I think they’re already making some great inroads there, in that they are making certain that their clients are not using the emergency room: they’re calling them, they’re checking on them, they’re asking what they need. They’re reminding them of their medication. They’re taking them to appointments at their doctors, if they need it.

Even in the outcomes for Medicaid, a lot of folks also use the emergency room as their primary care physician. We’re hoping that all of these changes we’re making are going to alleviate a lot of that pressure, and going to stop a lot of those emergency room visits for things that truly are not emergencies.

AZ: Aside from changes to North Carolina Medicaid policy, do you see other realistic paths forward for improving North Carolinians’ access to health insurance?

JK: Yes. We are looking at states that have provided a different type of insurance coverage, as opposed to Medicaid. We’re talking about everything. Nothing is off the table if it’s going to improve access to health care in North Carolina.