Constituents never cease to amaze. Last weekend, a constituent thanked me for the newsletter, but asked why it seemed that I never addressed health care issues, including Medicaid. Of course, he was right. I’d just hoped that no one was noticing.
Well, what follows is my take on the debate over how to provide health care. This week, I’ll explain why I’ve avoided the issue and some of the politics involved. Next week, after the one-week “summer break,” I’ll try to explain some of the substantive issues.
Health care issues are potentially politically toxic because of my district and the wildly conflicting views between the House and the Senate. Additionally, the issues have been highly politicized as reflected in the debate over the Affordable Care Act (ACA) or “Obamacare.”
Part of my reason for avoiding healthcare issues is a deep aversion to the subject. I am the son of two doctors, and my way of rebelling was to become a lawyer. I avoided medical malpractice cases in my law practice, and rocked along avoiding the subject until I was elected a county commissioner.
Having never talked about health care before my election, I was almost immediately confronted by financial issues at the county-owned hospital, Pardee Hospital, followed by the almost complete collapse of the mental health system. Luckily, I had other colleagues who were willing to take on those issues, and I was able to largely follow their lead.
Upon arriving in Raleigh, I also intended to avoid the debate over health care. I quickly determined who among my colleagues seemed to know what they were talking about, and I followed their lead.
Henderson County is the only county in the state (to my knowledge) that has two community hospitals, Pardee Hospital and Park Ridge Health. Moreover, a large number of the Mission Health’s employees and patients live in my district. Because of the demographics of the district, there are numerous nursing homes and other facilities also offering various medical services.
Until recently, Pardee Hospital and Park Ridge Health viewed each other as competitors and often disagreed on policy issues. More recently, they recognize that they have more in common than not. Park Ridge Health and Mission Health certainly have different opinions on the Certificate of Public Advantage (COPA) law, which is sort of an antitrust law protecting Park Ridge Health from its northern competitor, but all the hospitals oppose tax reform proposals put forward by the Senate to limit charitable deductions or sales tax rebates to large nonprofits (typically hospitals). The hospitals also would like to see North Carolina expand eligibility for Medicaid, but they more recently rarely voice that opinion to legislators since they’ve got enough other issues being debated right now.
For example, proposed changes to the Certificate of Need (CON) process have divided health care providers. Some range of health care providers have to get a certificate of need before they can start offering some range of services or buy new expensive medical equipment or expand the number of beds. In recent days, I’ve heard from several doctors wanting to do away with the CON process so that they could provide some types of medical service more cheaply than hospitals. However, the hospitals say they can’t provide all of the free medical services they provide without being able to make some money on other types of services — precisely the services that the doctors say they can provide cheaper. Four Seasons, Henderson County’s nationally recognized hospice and palliative care organization, also opposes CON repeal.
Even doctors don’t agree on these health care issues. Doctors who work directly for hospitals, like radiologists, mostly support CON, probably because their employers support CON. But doctors who have their own practices, ophthalmologists and orthopedists, for example, generally oppose CON. They say they can provide the services more cheaply but aren’t as quick to point out the profits to be made by providing some range of services now only provided by hospitals.
If the constituent disputes weren’t bad enough, the politics are awful. The lead sponsor of the legislation to repeal CON and COPA is Senator Tom Apodaca. His bill is Senate Bill 702 [Repeal CON and COPA Laws]. While that bill hasn’t had a hearing, the Senate put all or most of the bill in its budget. The House is divided on the CON issue and hasn’t weighed in on the COPA issue, since the COPA issue only applies to one hospital, Mission. A House bill somewhat similar to Senator Apodaca’s bill is House Bill 200 [Amend Certificate of Need Laws], but there are many critics of repealing CON in the House.
The Senate is also proposing a significant change to how Medicaid and NC Health Choice programs are managed, moving from a fee-for-service to a full-risk capitated health plans. The Senate proposes allowing large managed care organizations to compete to manage these programs, but the House wants these health plans operated by provider-led entities, in other words by hospitals and doctors and other NC-based health care providers or professionals. So the House and Senate agree on the need to move from a fee-for-service model to one that focuses on health care outcomes, but to the casual observer they don’t agree on much else.
While the House passed a free-standing health care bill, House Bill 372 [2015 Medicaid Modernization], the Senate once again has put its version of health care bill in the budget, House Bill 97 (Seventh Edition). What is politically sticky about that is that two of my fellow co-chairs of the Appropriations Committee, Representative Nelson Dollar (R-Wake) and Representative Donny Lambeth (R-Forsyth), are the primary sponsors of the House bill. So, my senator is firmly behind the Senate approach, and my Appropriations co-chairs are leading the House on the issue.
As already noted, tax policy is also in play. Again, the Senate has put in the budget some significant tax reform changes that impact large nonprofit hospitals. The proposals include limiting sales tax rebates to large nonprofits, typically hospitals, and limiting the size of tax-deductible charitable gifts. These tax reform proposals would severely affect Pardee, Park Ridge, and Mission.
Where all of this puts me is between a rock and a hard place. My constituents disagree, and the legislators most critical to my being effective for my Henderson County constituents also disagree.
And, as already referenced, the issue is made even more complicated by the Senate’s decision not to debate these various issues in free-standing legislation but rather to roll all of the health care-related issues into its budget.
And who will be one of the four senior House negotiators with the Senate on the budget? Yep, that would be me.
For four years, I’ve been able to listen sympathetically to all of my constituents’ conflicting concerns, but could truthfully tell them that I played almost no role in deciding health care policy. I can’t do that anymore. I’m going to be in the thick of it no matter what, so my “summer break” is going to be spent learning as much as I can learn about health care policy and finances and continuing to solicit the opinions of my constituents.