January 30, 2023
Legislators returned to Raleigh last week to begin the business of legislating for the 2023 long session.
The length of session is almost entirely dependent upon how long it takes to enact a new state budget. The goal is to adopt a consensus budget bill by the end of the fiscal year on June 30th, but in previous years the legislature has stayed in session for additional months due to disagreements between chambers, and with the Governor, over budget priorities. In 2021, it took until November for the legislature and Governor to reach an agreement on a budget and an additional 5 months of session to reach agreements on other matters.
Chances are good that the experience from 2021 will not be repeated due, in large part, to gains Republicans achieved in the 2022 election. In the Senate, Republicans picked up two seats to gain a supermajority (30R-20D). Although Republicans fell one seat short of gaining a supermajority in the House (71R-49D), which means they will have to attract at least one Democrat to cross party lines to override a veto or to enact legislation over the objections Governor Cooper (D).
There are a number of major legislative issues on the horizon that the North Carolina General Assembly will address during the long session. Several of the top issues, many of which are priorities for Duke, are highlighted below.
Medicaid Expansion: North Carolina is one of 12 states in the country that has yet to expand Medicaid. Over 600,000 North Carolinians would be eligible for Medicaid benefits if the state were to expand the program. In 2021, the federal government issued incentives for non-expansion states by offering a two-year, 5% increase in the federal match rate, meaning North Carolina could receive an additional $1.5B from the federal government if the state were to adopt expansion. Historically, legislators expected hospitals and health systems to cover the state’s share of the expansion population (10% of the overall costs) through an increased hospital assessment tax but that is something hospitals oppose.
During the 2022 short session, legislative leaders attempted to reach an agreement on a healthcare omnibus bill that included Medicaid expansion, optimized Medicaid reimbursements for hospitals through the Healthcare Access and Stabilization Program (HASP), and other major healthcare policy reform. The legislation failed, however, due to continued opposition to Medicaid expansion from certain legislators, the hospital community’s opposition to the Certificate of Need (CON) reforms offered and because of the NC Medical Society’s opposition to full-practice authority for APRNs which was also included in the omnibus bill. Medicaid expansion will be at the top of the healthcare agenda for the legislature in 2023 and will likely be tied to HASP and CON reforms again.
Healthcare Access and Stabilization Program (HASP): HASP is a directed payment program that would provide hospitals in North Carolina with enhanced Medicaid reimbursements. The current Medicaid Program, with a state share primarily funded by assessments on hospitals, reimburses hospitals at Medicare equivalent rates i.e., at cost for services to Medicaid patients. HASP will pay hospitals the difference between their current Medicare equivalent rates and the average commercial rate they would receive for those services. HASP would help hospitals overcome financial liabilities, unreimbursed costs for uninsured patients, and the significant reimbursement gap for providing safety-net services. The program would be implemented at no cost to the State and would put hospitals in the right financial condition to consider using the hospital assessment tax to pay for the entire State share of Medicaid expansion.
Certificate of Need (CON): North Carolina’s CON law allows for the coordinated planning of new services as current provider volumes reach capacity, and permits planning of construction projects to specifically meet the needs of communities across our state. The ultimate goal is to use data-driven need methodologies to equitably distribute healthcare services across the state while ensuring quality services. The law ensures access to care for medically underserved populations and prevents oversupply that can lead to higher healthcare costs for patients. Hospitals across North Carolina have historically been opposed to significant CON changes, but have indicated a willingness to consider thoughtful reform to the law if the changes are coupled with Medicaid expansion and HASP.
Medicaid Managed Care: Following NC Medicaid’s transition to managed care in 2021, providers have expressed frustrations with the prepaid health plans (PHPs) on a number of critical issues that have caused negative impacts to beneficiary care, unpaid provider claims, and additional administrative burdens. Hospitals are seeking legislative oversight of PHP performance to ensure that Medicaid beneficiaries receive adequate access to care and that providers are paid for the services provided.
Behavioral Health: Hospitals will be focused on proposing solutions to the state’s growing behavioral health crisis, including increasing access to community-based behavioral health services, expanding inpatient capacity for behavioral health patients, and increasing the number of psychologists and guidance counselors in public schools. There is also likely going to be legislation aimed at improving the state’s foster care system and how adolescents with mental health issues are treated.
Abortion: Republican leaders have stated that imposing further restrictions on abortion will be considered in 2023. House and Senate leadership will convene working groups to further discuss the issue and plan to introduce legislation in the coming months.
Independent Practice Authority for APRNs: A bill that would provide independent practice authority for advanced registered nurse practitioners (APRNs) has been filed the last several legislative sessions and is expected to be reintroduced in 2023. Previous versions of the bill would have allowed nurse practitioners, nurse midwives, clinical nurse specialists and certified nurse anesthetists in North Carolina to practice without a supervising physician. The bill has repeatedly failed due to opposition from the NC Medical Society.
Redistricting and Voter ID: State legislators are required to draw new district maps this year for the N.C. Senate and U.S. Congress due to the N.C. Supreme Court’s recent decision to strike down the maps over partisan gerrymandering. The N.C. Supreme Court also recently struck down the state’s voter ID law that passed in 2018 but was never implemented due to ongoing legal challenges, and it’s likely that legislators will look to implement new voter ID requirements during the long session.
Medical Marijuana: The Senate passed a bill last year that would have legalized the use of medical marijuana in North Carolina for patients with certain chronic conditions, but the House never considered the bill over concerns about legalizing any form of cannabis. This bill was already re-introduced in the Senate last week but it’s unknown whether or not opposition has softened in the House.
There are several other issues, such as medical debt collection practices, hospital consolidation, regulation of charity care by nonprofit hospitals, and LQBTQIA+ rights, that will be introduced in the form of legislation this session. These bills, along with dozens of others, will be reviewed and tracked by the staff in Duke State Relations. In response, DSR will engage in support of and in opposition to many bills, in addition to working with bill sponsors and legislative staff to amend legislation when appropriate. DSR will continue to provide updates each week on legislation that affects Duke University, Duke Health, and Duke LifePoint Healthcare. In addition to our newsletter, our website contains resources to stay up-to-date about what’s happening in Raleigh including a bill tracking chart, position statements and additional resources on issues, blog posts, and more. Please contact our office if there is an issue you are interested in learning more about.