NC Medicaid Reform Advisory Team (2016-2017)

What is the best path forward for Medicaid in North Carolina? The question of how our society can provide quality health care at a sustainable cost is one of the most important policy issues of the 21st century and touches all Americans across the education, income and demographic spectrum.

Medicaid covers more than two million North Carolina residents with diverse health needs. It accounts for roughly 30% of total state spending. At the same time, 13% of North Carolinians remain uninsured, and even among the insured, significant health disparities persist across income, geography, education and race. The Affordable Care Act offers states additional federal dollars if states agree to expand their Medicaid programs to all nonelderly adults with income below 133% of the federal poverty level. North Carolina opted against Medicaid expansion. Advocates for expansion argue that an additional 300,000–500,000 low-income adults would gain access to health insurance, with the federal government picking up most of the tab for three years. Opponents cite the growing state financial obligations after those three years, plus the burden of federal mandates that must be followed when accepting federal Medicaid expansion funds.

This Bass Connections project team drew on Duke’s expertise in public policy, law, medicine and business under the umbrella of the Duke-Margolis Center for Health Policy to craft a Medicaid reform proposal to fit the constraints and demands of North Carolina politics, especially in light of the revised political landscape resulting from the 2016 elections. Team members analyzed Medicaid reform proposals from the McCrory Administration (Section 1115 Waiver), Cooper Administration (Berger vs. Burwell) and the General Assembly (House Bill 662). A Section 1115 Waiver allows a state to use federal Medicaid funds in ways that are not otherwise allowed under federal rules, as long as the waiver meets the objectives of the Medicaid program. Previous waivers have expanded Medicaid to those who were otherwise not covered by the program, provided services typically not covered by Medicaid or piloted innovative service delivery systems. The McCrory Administration submitted an NC 1115 Waiver in June 2016, which proposed to shift from the fee-for-service model of primary care management to a managed care system financed on a capitated basis.

On April 25, 2017, the team submitted its report to North Carolina’s policymakers and citizens and hosted a presentation and discussion in Raleigh. The report assesses the Medicaid landscape in and offers recommendations to policymakers concerning the potential impact of federal block grants on North Carolina Medicaid; the construction of Medicaid Managed Care markets; opportunities and risks associated with instituting consumer-driven financial incentives in Medicaid; targeted “hotspotting” strategies to address the needs and escalating costs of Medicaid’s high-utilizers and dual-eligibles; and benefits of pursuing telemedicine and related reforms to reimbursement, regulation and Graduate Medical Education programs that could fuel telemedicine solutions to improve access and delivery.

Also on April 25, the North Carolina Department of Health and Human Services requested public comments regarding a Section 1115 waiver and statewide Medicaid reform. The team submitted a public comment synthesizing recommendations contained in its report.

Four undergraduate team members received a grant to take this work further through a project called Reforming North Carolina Medicaid. They took a “hot-spotter approach” to health policy, identifying the counties with the highest health expenditures and greatest Medicaid burden as well as conducting interviews with officials, providers and patients to understand the challenges of current payment and delivery structures.

Timing

Fall 2016 – Spring 2017

Team Outputs

Hot-Spotting North Carolina’s Medicaid Transformation (by Kushal Kadakia, Shivani Shah, Barak Richman), Health Affairs

Reforming North Carolina Medicaid: A County Level Analysis of Challenges and Opportunities (poster by Kushal Kadakia, Shivani Shah, Jackie Lin, Aakash Jain), presented at Bass Connections Showcase, April 18, 2018

Public comment regarding the North Carolina Department of Health and Human Services (DHHS) Proposed Program Design for Medicaid Managed Care, September 9, 2017

North Carolina Medicaid Reform Advisory Team (poster by Brandon Yan, Brooke Bekoff, Graeme Peterson, Haley Hedrick, Jackie Lin, Kushal Kadakia, Leah Yao, Riley Herrmann, Shivani Shah, Sonia Hernandez, Deanna Befus, Madhulika Vulimiri, Patrick O’Shea, Shanna Rifkin, Trey Sinyard)

NC Medicaid Reform: A Bipartisan Path Forward (Report)

North Carolina Medicaid Reform: A Bipartisan Path Forward (Event, April 25, 2017)

Public comment submitted to North Carolina Department of Health and Human Services on Medicaid and NC Health Choice Request (Deanna Befus, Patrick O’Shea, Shanna Rifkin, Trey Sinyard, Madhulika Vulimiri, Brooke Bekoff, Haley Hedrick, Sonia Hernandez, Riley Herrmann, Kushal Kadakia, Jackie Lin, Graeme Peterson, Shivani Shah, Brandon Yan, Leah Yao, Barak D. Richman, Allison Rice, Donald Taylor, Susan Kline, Leigh Ann Simmons, Hilary Campbell, Amanda McMillan)

Bass Connections Follow-on Student Research Grant (Aakash Jain, Kushal Kadakia, Jackie Lin, Shivani Shah)