Several Republicans in our state still have a lot to learn from conservatives. Moderating your principles is something entirely different from compromising on policy solutions. That seems to be a lesson that some Republicans and allegedly “conservative” politicians in Raleigh have not yet grasped.

In a short-sighted op-ed on April 19 in the Raleigh News & Observer, former state Representative Chris Malone attempts to make a case for a “conservative” expansion of Medicaid under Obamacare in North Carolina – the latest proposal being House Bill 655 – NC Health Care for Working Families.

Let me be clear, Medicaid expansion, in any form, is bad policy and a political trap for conservative politicians. Furthermore, it is intrinsically not a conservative policy.

I will be asking a few rhetorical questions throughout this article. The first is:

• How will conservative lawmakers not be hypocrites if they vote to expand Obamacare in North Carolina?

Let’s look at former Rep. Malone’s claims on “conservative” Medicaid expansion.

The Coverage Gap

In his piece, Malone immediately talks about the health insurance coverage gap in North Carolina. The coverage gap does exist and came to exist after the Supreme Court of the United States ruled that the federal government could not compel states to expand Medicaid under Obamacare. Malone fails to note that of the 500,000 people that would be part of Medicaid expansion, 297,000 are eligible for a free bronze plan – private insurance – on the Obamacare exchange in North Carolina, according to the Kaiser Family Foundation. If North Carolina expands Medicaid, these 297,000 people will be legally forced from their exchange plans, and onto the state Medicaid rolls.

Malone also fails to mention that of those who would be newly eligible for Medicaid under expansion, 78 percent would be working-age, able-bodied, childless adults.

Two more questions:

• How does it align with conservative principles to force citizens from private health insurance to government health insurance?
• How does it align with conservative principles to expand a government welfare program to working-age, able-bodied, childless adults?

Here you can read some of the Civitas Institute’s conservative policy solutions for closing the coverage gap.

The Mythical Pot of Gold

Malone then makes what we at Civitas refer to as the “pot of gold” argument. He writes, “Every year, our state sends over $800 million to Washington to fund Medicaid expansion in other states. Lambeth’s proposed legislation would redirect some of that money back to North Carolina to allow our hard-earned tax dollars to benefit our own residents.”

However, that is simply not true. There is no pot of federal money uniquely allocated to fund Medicaid expansion in state budgets.

Several healthcare experts have covered this topic. Former John Locke Foundation health care policy analyst, Katherine Restrepo put it succinctly:

Despite what expansion proponents say, North Carolina is NOT leaving $5 million a day on the table by opting out of expanding. According to the Congressional Research Service (CRS), when Congress drafted Obamacare, a pot of money was not allocated for Medicaid expansion. Instead, the reality is that an influx of federal funding would merely be adding to the deficit.

In other words, expanding Medicaid only adds to the federal debt. By not expanding Medicaid, North Carolina has prevented billions of dollars from accruing onto the deficit. It’s terrifying that someone who is careful to note that he is “a former state representative who served as chairman of the House Appropriations Health and Human Services Committee” is not aware of how Medicaid expansion would be funded.

Now I have another question:

• Does adding to the national debt through increased government spending align with conservative principles?
• Is adding to the national debt an electoral strategy that conservative politicians can use to win?

“No New Taxes”

Regarding the financing of House Bill 655, Malone writes, “This bill would close the health insurance gap without adding any new taxes on our state’s hardworking citizens.”

However, that is simply not true. The text of the bill says:

The State and county share of costs that are not covered by federal funds or participant contributions will be funded through intergovernmental transfers and health care–related assessments, including, but not limited to, hospital assessments. It is the intent of the General Assembly that all State funds needed for the program shall be generated through increased revenue from current assessments and intergovernmental transfers, as well as new revenue from additional assessments enacted to meet the requirements of this act. (page 4, lines 3-10; emphasis added)

A quick look at the dictionary will tell Rep. Malone that an assessment is, “an amount that a person is officially required to pay especially as a tax.”

House Bill 655 proposes to fund Medicaid expansion through federal funds (adding to the national debt), current assessments (or taxes) on North Carolina hospitals, and a new hospital assessment (that will undoubtedly be passed on to other patients).

Here are my three final questions:

• Are there any assurances from North Carolina hospitals that the cost of the new tax will not be passed on to patients?
• Was Rep. Malone unaware of the new tax when he wrote his article?
• Does it align with conservative principles to levy new taxes to pay for government health insurance?

Medicaid Expansion is a political loser for conservatives

For a moment, let’s set aside the fact that passing House Bill 655 would mean that the two Republican majorities in the North Carolina General Assembly joined with a Democrat governor to expand a federal program passed by a Democrat-dominated Congress and a Democrat president. Let’s also set aside the fact that Republicans have tried for a few decades to position themselves as the party of conservatives and ran in elections for eight years on the principle of repealing Obamacare.

Aside, from this political about-face, most North Carolina voters simply are not interested in Medicaid expansion, once they have some facts about the policy.

A November Civitas Poll asked 500 likely North Carolina voters about Medicaid expansion, the expansion population and cost.

In one question, voters were told “Medicaid expansion would mainly cover healthy, working-age adults with no children. Many of these people already have private health insurance.” Overall, this question found that the majority of voters (52 percent) are less likely to back Medicaid expansion after hearing this information. This message is particularly impactful for Republicans and Conservatives, but even makes pluralities of Democrats and moderates less likely to support Medicaid expansion.

In a second question, voters were told, “Expanding Medicaid in North Carolina would likely add five hundred thousand new individuals to the program and would cost state taxpayers more than $340 million per year.” Overall, this question found that a majority of voters (50 percent) also are less likely to support the expansion after hearing about the cost to taxpayers. The cost is a strong negative message for Republicans and conservatives. Unaffiliated voters and moderates are also less likely to support expansion based on cost concerns.

Medicaid expansion sounds fine to voters on its face. However, when voters see details about a potential expansion, they begin to sour on it.

Conclusion

The inclination for North Carolina Republicans for the past few years has been to claim conservatism as a mantle but to moderate their principles. While not a verbal mantra, the idea that “we need to spend more to prove we care more,” has been the drumbeat of an allegedly-conservative majority in the General Assembly. Unfortunately, the result is that conservatives look more like progressives and less like conservatives. “I am the same as the other guy” is not a compelling political message.

We have seen this play out in policy issues on energy (tax credits and mandates) and education (increased funding and public employee pay) in particular. And have conservatives been able to claim electoral credit for stances on green energy mandates and successive years of teacher pay increases? No.

Rep. Malone’s 2018 election result teaches us that political lesson.

Politics is about competing interpretations for the future. Some ideas are good, and some are bad. However, saying that you’re just like the other guy makes voters want to vote for the other guy.

Conservatives in the North Carolina General Assembly need to provide alternatives to Medicaid expansion, and these alternatives should focus on passing policies to provide low-cost private insurance, as well as increased access to health care providers. That’s where good policy will meet good politics.