NORTH CAROLINA (WECT) - As lawmakers battle over the state budget in Raleigh, arguably the biggest sticking point between the two political parties is Medicaid expansion.
One side wants to open up the program to an additional half a million North Carolinians, but those on the other side claim it will cost taxpayers millions in expensive — and unnecessary — emergency room bills.
North Carolina is one of 13 states that has not expanded Medicaid since the Supreme Court decision over the Affordable Care Act made it possible, but not required, in 2012.
Governor Roy Cooper included expanding Medicaid to between 450,000 and 670,000 additional North Carolinians in his proposal for the state budget. However, the Republican-held General Assembly is poised to pass the 2019-20 budget without it, but they may not be able to override Cooper’s veto this go-around.
One of the major arguments over Medicaid expansion is whether or not expanding the program would cause an influx of patients to emergency rooms for non-emergency medical needs.
Proponents of expansion say expanding Medicaid would allow low-income patients the option of visiting a primary care physician, where having no coverage may have prevented them before. Opponents say increasing the number of Medicaid patients, combined with their assertion of a low inventory of primary care physicians who accept Medicaid, will overrun emergency rooms.
Research on the issue in expansion states has been mixed. Some have seen an increase of emergency room patients, but the percentage of patients visiting without any form of health insurance has decreased dramatically.
The Centers for Disease Control’s most recent report shows nationwide, 37.7% of emergency room patients in 2016 were on Medicaid, the Children’s Health Insurance Program (CHIP) or a state equivalent.
That CDC report indicates 5.3% of emergency room patients on Medicaid were treated for “non-urgent” conditions and 28.3% for “semi-urgent” conditions, compared to 3.5% and 23.6%, respectively, for privately-insured patients.
Locally, medical professionals estimate the percentages of non-urgent patient visits are similar.
“Those are a very small number of our patients,” said New Hanover Regional Medical Center Administrator of Emergency Services James Bryant.
Bryant estimated somewhere around 10% of NHRMC emergency department patients fall into the non-urgent category, or around 25-30 every day at the 17th Street location.
Statewide, that expense of non-urgent visits by Medicaid patients is in the tens of millions each year.
WECT was able to access North Carolina’s 2018 Medicaid expenditures, and compare the amounts spent on different emergency department diagnosis codes, from fussy infants and coughs to chest pain and severe trauma.
Conditions such as coughs, sore throats, colds, mild flues and headaches were all conditions Bryant said are commonly seen in emergency departments, but that could more effectively be treated by a primary care physician or in an urgent care facility.
In 2018, North Carolina’s Medicaid program paid out $9.48 million for acute upper respiratory infections — otherwise known as the common cold. In the same time-frame, the program paid out $12.38 million for all patients who presented with chest pain, a condition typically prioritized by emergency departments.
Those visits cost much more than if patients had visited a primary care or urgent care facility.
“The emergency department is one of the most expensive places to be seen, and it’s because we have to have equipment to take care of so many different illnesses and injuries,” Bryant said. “So, we are very, very expensive.”
Patients utilizing an emergency department for non-urgent conditions can also add to wait times, and lead to crowded waiting rooms.
Bryant said emergency departments generally operate on a “sickest person first” scale, meaning someone having a heart attack or who has been in a major automobile accident will be seen before anyone else.
“If you come in with a sore throat and your vital signs are stable, you may have to wait much longer,” he said, “because we will see everyone, but you may have to wait, you know, from a few minutes to several hours to be seen for that care.”
Bryant said in his opinion, most people who use the emergency room for non-urgent conditions are doing so because they feel they have nowhere else to go.
Primary care shortages have long been an argument used by opponents of Medicaid expansion, such as the John Locke Foundation, as a rebuttal to the claim that expansion opens doors for patients to seek treatment outside of emergency rooms.
As of Dec. 2018, North Carolina has 186 federally-identified Health Professional Shortage Areas (HPSA), including more than a dozen primary care HPSAs in Southeastern North Carolina alone.
As with private insurance companies, not all primary care physicians accept Medicaid, and Bryant said he thinks that’s one of the leading reasons those patients would come to an emergency room for something non-urgent.
“If you don’t have access to it, and you’re having what you believe is an emergency, you will come to the emergency department,” he said. “And so, there is higher utilization oftentimes associated with that population just because of access — not because they don’t want to be seen other places, it’s just getting an appointment.”
Bryant said education on the benefits of having an established primary care physician, and the resources available to those on Medicaid, is the best way to reduce non-urgent emergency room visits.
“We are not a substitute for a physician’s office, because when you go to a physician, and you’ve got that ongoing relationship — they’re not just taking care of you while you’re sick, they’re also keeping you well,” he said.
On May 31, the Republican-led state senate passed a 2019-2020 budget without Medicaid expansion that will be sent back to the state house of representatives.
However, because Republicans no longer have a veto-proof supermajority, Governor Cooper would be able to push back, and has indicated his displeasure with what the senate has proposed, Medicaid-related and otherwise.
“With their budget, Senate Republicans once again prioritize more corporate tax cuts at the expense of public education, clean water and providing affordable health care for hard working North Carolinians,” a release from Cooper’s office reads. “These are unacceptable priorities and Governor Cooper will continue pushing for a budget that represents middle class families instead of special interests and corporate shareholders.”
A veto from the governor could mean a months-long stalemate in Raleigh.
State Senate leader Phil Berger pushed back with a press release of his own.
“As a result of their singular focus on expanding socialized health care for able bodied adults, most Democrats just voted against a budget that increases access to health care for disabled individuals, lowers taxes for families and employers, provides the largest pay increase for state employees in more than a decade and provides the sixth and seventh consecutive teacher pay raises.” Berger’s release said. “It’s unfortunate that we can’t find common ground on issues that would benefit all North Carolinians. I am pleased that Republicans were able to once again pass a budget that delivers on these important priorities and ensures the success story we have seen in our state over the past eight years will continue.”
Unlike the federal budget, North Carolina’s state government will not shut down if lawmakers cannot agree by the time the fiscal year ends on June 30.