The concept of providing basic healthcare services individuals in need has undergone an agonizing transition, from a luxury once only afforded by the affluent to a basic human right granted to citizens of every economic station, and the recently enacted Affordable Care Act (ACA) was designed to finalize this ethical evolution. Reflecting perhaps the bitter political enmity currently consuming the nation's once cherished democratic process, Republican legislatures in states throughout the union have bristled at the ACA's primary provisions, threatening all manner of procedural protestation as they attempt to delay and derail the bill's eventual implementation. One of the most intriguing aspects of the sprawling, thousand page law, however, has been the stipulation that individual states will be given a choice to either accept federal funding to expand their statewide Medicaid roster, or to forfeit all federal funding for that program in perpetuity. This Faustian bargain of sorts was crafted by federal lawmakers to provide resistant states with an offer that could not be refused, but in the wake of President Obama's reelection to a second term in the land's highest office, the willingness of Republican-ran states to fall on their proverbial sword appears to have been vastly underestimated. Presently, North Carolina has joined a number of neighboring Southern states in rejecting the ACA's offer to provide expanded Medicaid funding, with Governor Pat McCrory concluding on February 12th that it has been made "abundantly clear that North Carolina is not ready to expand the Medicaid system and that we should utilize a federal exchange" (Dalesio, 2013).
After an especially contentious debate, the Republican supermajority which dominates North Carolina's state congressional chamber voted 75-42, largely along party lines, to approve a measure explicitly rejecting any expansion of the state's Medicaid rolls, sending Senate Bill 4 to the state senate for final passage. With over 500,000 low-income residents of North Carolina eligible to receive coverage under the ACA's expansion of Medicaid services, the state legislature's politically motivated decision will immediately cause a half million people to lose their newly granted right to receive subsidized medical insurance. One of the bill's most ardent and enthusiastic sponsors, Rep. Justin Burr (R-Stanly), has publically expressed his opposition to the federal government's perceived interference with his state's healthcare delivery system, repeatedly stating that North Carolina's already reeling economy simply could not bear the additional burden expected in 2017, when the financial responsibility for the federal expansion of Medicaid shifts back to the states. Burr has been partial to reminding concerned members of the media of the old maxim which holds that "when you've got a house in shambles, you don't build onto it" (Dalesio, 2013), but an objective analysis of the state's financial situation suggests that by voting to reject President Obama's ACA, and its associated Medicaid funding assistance, Burr and his allies in the North Carolina legislature may not be acting with their state's best interests at heart. An impartial consultant contracted by the state's Department of Health and Human Services has consistently estimated that "expanding Medicaid would generate 23,000 new jobs in North Carolina through 2021 and increase disposable income by $1 billion a year statewide as doctors and hospitals increased hiring to meet higher demand for compensated treatment" (Dalesio, 2013), but despite the pleas voiced by 500,000 uninsured citizens, and the healthcare centers hoping to provide them with additional access to services, Rep. Burr and his colleagues refuse to budge from their battle hardened positions.
As with any contentious legislative debate, North Carolina's decision to reject federal funding for the expansion of its Medicaid rolls can be viewed from two distinctly perspectives: the pragmatism of drafting and ratifying state law, and the politicized process of social division which poisons sound decision making. In this case, Rep. Burr and his allies in the North Carolina legislature are ostensibly acting to preserve their state's financial solvency, disassociating themselves from a federal mandate that some analysts believe will eventually transfer budgetary burdens to back to individual states. In response to the outcry which was voiced by media members and citizens after the bill's preliminary passage, Governor Pat McCrory (R) released a public statement affirming his office's commitment to objectively analyzing the situation and acting accordingly. Describing the thorough review he commissioned to examine the viability of Medicaid expansion and health insurance exchanges in his state, Gov. McCrory revealed that "this assessment included our existing systems, operations, potential new administrative costs and barriers, and the amount of control and flexibility North Carolina will have to reform the system & #8230; (and) the results of our findings make it abundantly clear that North Carolina is not ready to expand the Medicaid system and that we should utilize a federal exchange" (2013). According to Gov. McCrory's official explanation, the rejection of federal financial assistance to expand Medicaid coverage for North Carolinians living in the low-income bracket is simply an exercise in prudent financial planning, motivated by mathematics more than animosity.
While this appears to be a valid justification for such a bitterly debated decision, a number of statements issued by Gov. McCrory's Republican allies in the legislature suggest that politically charged hostility towards the recently reelected President Obama represents a readymade ulterior motive. When Rep. Bert Jones (R-Rockingham) told members of the local media that the proposed expansion of Medicaid coverage "would simply build more dependency on government among a widely expanded segment of our citizens (because) it's simply another step toward the goal of socialized medicine controlled by the federal government" (Dalesio, 2013), his explicit reference to socialism provides a telling clue. One of the more regrettable complaints to emerge from the tumult of the American political arena, launched most vociferously by ardent opponents of President Obama's progressive domestic agenda, is the dubious charge that he secretly aspires to replace the nation's capitalist system with a European-style socialist structure. Although most reasonable political observers have roundly debunked this claim, it is clear from Rep. Jones' public statement that a misguided fear of the specter of socialism informs his voting record on the subject of Medicaid expansion and medical insurance exchanges. Another member of the Republican supermajority responsible for stripping healthcare coverage from 500,000 of North Carolina's neediest citizens, Rep. Bob Steinburg (R-Chowan), revealed the reasoning behind his vote by stating simply "this is a financial Armageddon" (Dalesio, 2013). This overt appeal to the religious misgivings of his largely Christian constituency, in a region where data from the Public Policy Polling group indicates that a fair percentage of voters believe President Obama is secretly a Muslim (Jackson, 2012), is indicative of the personal and political rivalries which are likely the driving force behind the North Carolina legislature's recent decision.
The Republican-led opposition to the ACA's proposed expansion of Medicaid provisions has remained steadfast, despite numerous appraisals by independent observers who have concluded that North Carolina, and indeed every state in the union, stands to benefit immensely from federal collaboration on healthcare delivery. In response to the Supreme Court decision striking down Constitutional basis for the ACA's originally mandatory expansion of Medicaid coverage, a ruling that paved the way for state legislatures to independently reject federal involvement in their healthcare delivery models, University of Michigan law professor Samuel Bagenstos offers his opinion on the ramifications of this potential landmark case. In an interview with The Atlantic, Bagenstos states that his "initial reaction is it probably isn't going to mean a whole lot for the Medicaid expansion in the Affordable Care Act, because the Medicaid expansion is such a good deal for the states" before offering the following caveat: "the $64,000 question as to Medicaid is how many states are going to decide that they don't want to cover this expanded population, even with the very substantial financial incentive" (Weissmann, 2012). Representative Deborah Ross (D-Wake) also poses an interesting question in response to the bill slated for approval by her Republican colleagues in the state legislature, asking "why are we turning this down?" before offering her own answer; "I think it's fear and loathing" directed at President Obama and the affirmation of his policy agenda after a heated election. The objections raised by Democratic members of the North Carolina legislature are consistently legitimized by countless independent analysts, financial policy think tanks, and medical industry watchdogs, showing that despite their pragmatic message control, Republican representatives have likely hijacked their state's health care delivery apparatus strictly to gain an edge in the increasingly convoluted political calculus of the day.
Political machinations aside, the expected passage of an official Republican rejection of the ACA's offer to expand Medicaid rolls is already wreaking havoc on the lives of hundreds of thousands of low-income North Carolinians. When the language of the ACA was originally conceived it was anticipated that those individuals and families earning less than $38,000 annually, a figure which represents 138% of the federal poverty level, would be covered by the proposed expansion of Medicaid eligibility. An estimated 500,000 people in North Carolina fall under this earnings threshold, from the…