9K across WNC and state to lose health insurance each month until Medicaid expansion

ASHEVILLE – Amanda Branks loves to spend time with her two children, but she purposely hides a lot from them. Her husband is a sanitation worker, bringing in about $31,200 per year. Branks, who is 29-year-old and lives in Hendersonville, does her best to conceal her family’s tight budget from her kids.

Summer camps are not feasible for her family. She and her husband took their kids camping in Pisgah National Forest. Her husband teaches the children about the dangers of poison oak and ivy. Brans teaches them about flowers. They make s’mores at night and tell ghost stories.

“I was raised in a poor family. Even though we are financially tight, we are nowhere near as bad as it was with my family,” Branks told the Citizen Times July 11. “My parents did not hide it. They kind of involved me in it and it made my childhood very hard. I don’t want my kids to ever have to worry about that. They’re too young to worry about that. That’s mom and dad’s problems, not theirs.

Brans also does her best to keep her mental health episodes from her kids. Among her afflictions are bipolar disorder and manic depression. These health issues have made it challenging for her to hold a job and accordingly maintain health insurance. She has slid on and off Medicaid as she has gained and lost employment, falling into and out of the coverage gap that has plagued North Carolina because the state has opted not to expand Medicaid.

The state legislature passed Medicaid expansion earlier this year. A March 27 news release from Gov. Roy Cooper’s office noted that this policy will provide insurance to more than 600,000 people. However, the expansion will not go into effect until elected officials in Raleigh pass the budget for the 2024 fiscal year and the state’s plan is approved by the federal government. This will send thousands of North Carolinaans back into the coverage gap.

What is Medicaid? What is the coverage gap?

Medicaid is the state-run insurance program for people with low incomes. In North Carolina, for a family of four, people need to make less than $744 per month to qualify for Medicaid; that’s $8,928 for the year and just below 30% of the federal poverty level.

As part of the Affordable Care Act, which became law in March 2010 under President Barack Obama, adults making between 100% and 400% of the poverty level could qualify for health insurance assistance. States were also mandated to expand their Medicaid coverage to people with incomes below the 138% poverty level. A 2012 Supreme Court ruling upheld the Affordable Care Act but made Medicaid expansion optional. People living in states that do not expand Medicaid who have incomes below the federal poverty level and above the state Medicaid barrier don’t have access to government provided insurance. This is what is known as the “coverage gap.”

In North Carolina, adults who financially qualify for original Medicaid also need to have a disability to get coverage, which can be difficult to prove without an extensive medical history.

North Carolina Governor Roy Cooper, pictured here, is pushing to separate Medicaid expansion from the state's budget.

North Carolina Governor Roy Cooper, pictured here, is pushing to separate Medicaid expansion from the state’s budget.

Branks became a Medicaid member again early in the pandemic. As part of the federal public health emergency, states were prohibited from terminating Medicaid enrollees, meaning that no matter Branks’ income level, she was going to have insurance. Recently she has made progress on her health struggles. She once had episodes two or three times each day. Now they are less frequent.

Congress detached this “continuous coverage” requirement from the public health emergency as part of the omnibus spending bill it passed in December, meaning that states would soon need to begin recertifying Medicaid eligibility.

For states that did not implement expanded Medicaid like North Carolina, this means that people who lost their jobs during the pandemic and qualified for Medicaid could lose insurance if their current income placed them in the coverage gap, according to the Buncombe County Department of Health and Human Services Economic Services Director Phillip Hardin.

Legislators in Raleigh addressed that concern when Cooper signed expanded Medicaid into law March 27. When expanded Medicaid goes into effect, the disability requirement will be removed. North Carolina will be the 40thth state to expand Medicaid, however, a provision in the bill timed Medicaid expansion implementation to the legislature approving the 2024 fiscal year budget. Cooper opposed this stipulation at the time and continued to. Despite the 2023 fiscal year ending June 30, legislators in Raleigh have not agreed to a budget, delaying Medicaid expansion.

In a July 3 statement, Cooper urged the General Assembly to separate Medicaid expansion from the budget. State Department of Health Human Services Secretary Kody Kinsley agreed in a July 10 conversation with the Citizen Times.

“There is no reason why Medicaid expansion should be tied to the budget,” Kinsley said. “Having it tied to the budget significantly ties our hands and makes implementation incredibly complex.”

Republicans, who control the state senate and house, would lose leverage over Cooper in budget negotiations if they separate expansion. Cooper holds veto power over the budget.

“Medicaid is a substantial portion of the annual state budget and shouldn’t be separated for the Governor’s political expediency,” spokesperson for Senate President Pro Tempore, Phil Berger, Lauren Horsch said in a July 11 statement to the Citizen Times. Berger represents Guilford and Rockingham counties. “Legislative leaders are making good progress on budget negotiations, and we look forward to Gov. Cooper swiftly signed the budget.”

As budget negotiations drag on, counties are moving forward with recertifying Medicaid eligibility, placing some North Carolinaans back in a momentary coverage gap. Kinsley estimated 9,000 people per month will lose insurance and not qualify for ACA subsidies until expansion is implemented.

Based on state direction, county health departments began opening cases for recertification on April 1. This process took 90 days, so recertifications started going into effect June 30.

Branks said she would soon lose her Medicaid coverage. She would qualify for Medicaid expansion if she was in operation and her family’s income was just high enough for her to receive an ACA subsidy.

The federal government has created a special enrollment period for people who lose Medicaid coverage, allowing people to sign up for coverage through the open marketplace outside of the open enrollment period that begins Nov. 1. According to Thomas Lodwick, Public Benefits Program Director at Pisgah Legal Services, a legal aid organization based in Asheville, changing insurance providers can cause difficulties for enrollees, who may need to find new in-network doctors, which can cause delays in care . This change can also cause an increase in the cost of care and benefits. Lodwick noted that if the Medicaid expansion was already online, people would be able to seamlessly move from one Medicaid category to another without experiencing a gap in coverage.

Thomas Lodwick, Public Benefits Program Director at Pisgah Legal Services.

Thomas Lodwick, Public Benefits Program Director at Pisgah Legal Services.

Branks is also applying for federal disability. It is difficult for people to prove disability without building their medical records, according to Lodwick.

Income changes are not the only reason people lose their Medicaid coverage. According to Hardin, many do not turn in the necessary information for the county to certify their eligibility. When people apply for Medicaid a few months down the road, the process takes more time.

more: Opinion: Strong bipartisan majority of North Carolinans want to expand Medicaid

more: NC approved Medicaid expansion, could help 600,000 adults

“If I could keep up the percentage of people who return their recertification paperwork to 80%, it would be like gaining staff for me,” Hardin said to the Citizen Times June 27. “It may take me an hour to do a recertification. It may take me two and a half hours to do an application.”

Expansion approval with budget is just the beginning

Once the state approves the budget, North Carolina’s Medicaid expansion plan is reviewed by the federal Center for Medicare and Medicaid Services. According to Kinsley, this process can take time depending on when the budget passes.

“The process with CMS for getting their approval and getting our go-live date for expansion is not a single factorial,” said Kinsley “It is not solely based off time. It is based off time and exactly when that time begins.”

He went on to explain that it could take weeks or months to implement Medicaid expansion. CMS may be dealing with hospital assessments, or end or quarter reports, for example.

Lodwick says not having health insurance can put people in dangerous situations.

“Lives are hanging in the balance. It’s just catastrophic to not have health insurance coverage,” Lodwick said. “I’m just hoping they move as expeditiously as possible. Remember that these are real lives of people facing terrible choices. Potentially having to choose between the cost of food and the cost of medicine.”

For Branks, there is no choice. Paying out of pocket for the care she needs to handle her mental health challenges means taking money away from her kids. She won’t entertain that.

“My kids have to come first, so if it was too expensive, I would probably have to skip a month or two,” she said “That’s one of the things that scares me with this whole Medicaid ordeal. I’ve been working on getting to a spot in my health where I feel somewhat normal. I’ll never feel completely normal with my health issues.”

“I don’t want to lose all the progress I have made just because I don’t have insurance,” she added.

Need assistance?

Call Pisgah Legal at 828-253-0406 or visit pisgahlegal.org.

Mitchell Black covers Buncombe County and health care for the Citizen Times. Email him at [email protected] or follow him on Twitter @MitchABlack. Please help support local journalism with a subscription to the Citizen Times.

This article originally appeared on Asheville Citizen Times: Waiting for Medicaid expansion keeps families waiting health insurance