Bill would boost penalties for drug dealers when someone overdoses.
Archives for April 2019
The campaign spending reports of U.S. Rep. Mark Walker show a $50,000 payment to a Washington, D.C., law firm that specializes in white-collar defense and congressional investigations. The payment came … Click to Continue »
A biennial effort among some North Carolina House members to make motorcycle helmets optional for people 21 and over has been stopped. The House Transportation Committee failed on Tuesday to … Click to Continue »
Here’s what’s going on in the General Assembly on Tuesday, April 9.
- National polls find plurality support for getting rid of the Electoral College, but not enough to force a change in the Constitution. A Civitas poll of North Carolinians finds similar results.
- North Carolinians oppose joining the national popular vote interstate compact.
State senators Wiley Nickel (D-Wake), Jay J. Chaudhuri (D-Wake), and Joyce Waddell (D-Mecklenburg) have sponsored S104, a bill that would require North Carolina to join the “National Popular Vote” interstate compact.
What is the Electoral College?
Like so much of the U.S. Constitution, the Electoral College is a product of compromise, this time between those who wanted a national popular vote for president and those who wanted to have the president chosen by Congress. The compromise ultimately provided a body of electors, selected by the states, who vote for president. While the specific method of choosing electors is left to the states, all states choose their electors based on that state’s popular vote for president with all but two (Maine and Nebraska) award all their electoral votes to that state’s popular vote winner.
Each state is given electoral votes equal to its total number of representatives and senators in Congress. While that arrangement is roughly proportional, it gives smaller states some overrepresentation. The District of Columbia also gets three electoral votes, courtesy of the 23rd Amendment. By tying the outcome of the presidential vote to state-by-state outcomes, the Electoral College injects an element of federalism into an otherwise unitary national election.
What makes the Electoral College controversial is that several times the winner of the popular vote lost the Electoral College vote. That happened most recently in 2016 when Donald Trump won the Electoral College vote based in part on unexpected wins in Pennsylvania, Michigan, and Wisconsin despite losing the popular vote nationwide.
How do people feel about the Electoral College?
Most national polls on the electoral college tend to show a plurality support its replacement with a national popular vote, with some polls showing majority support for abolishing the electoral college and others showing that less than half believe so. Support for the Electoral College has increased some over the past decade and there has also been increased partisan polarization over the issue, with more Republicans supporting the Electoral College and more Democrats wanting to end it.
The results of a Civitas Institute poll of 500 likely voters, conducted by Harper Polling March 14-17, found similar results among North Carolinians:
Support for the Electoral College tends to fall along expected lines. Republican voters, conservatives, and people who voted for Trump in 2016 (categories that overlap a great deal) tend to be more supportive than Democratic voters, liberals, and people who voted for Clinton in 2016. While those who are the most actively politically– as measured by how many times they voted in the last two general elections and the last two primaries — are more likely to support keeping the electoral college, there is otherwise no strong pattern between being politically active and support for the electoral college.
Pushing a bad solution: the national popular vote interstate compact
While polls tend to show pluralities favoring a national popular vote over the Electoral College, there is nowhere near the groundswell of support needed to push an amendment to the Constitution. The need to gain approval by two-thirds of both houses of Congress and three-quarters of the states, makes passing such an amendment unlikely. Even Sen. Brian Schatz (D-HI), who was among the senators who introduced an amendment to abolish the Electoral College on April 3, admitted that abolishing the Electoral College is “not going to become law anytime soon.”
To get around that, fifteen states and the District of Columbia have signed on to the national popular vote interstate compact to make an end-run around the intent of the electoral college by having member states base their electoral votes on the nationwide vote for president rather than the vote in their respective states. The compact goes into effect when enough states that have joined the compact represent a majority of the Electoral College.
While most states that have joined are deeply Democratic, somewhat moderate Colorado recently joined, which is part of a bigger push to get more moderate states to join the compact. That push came to North Carolina in the form of S104 which would join North Carolina to the compact. The legislation was sponsored by Wiley Nickel (D-Wake), Jay J. Chaudhuri (D-Wake), and Joyce Waddell (D-Mecklenburg). I have previously explained why S104 is an awful piece of legislation:
[S]enators Nickel, Chaudhuri, and Waddell are pushing legislation that would make North Carolina politically subservient to states with larger media markets and make the wishes of North Carolina voters subservient to those of voters from other states. Our votes are ours and those senators are wrong to try to make our votes irrelevant.
The March 14-17 poll found that North Carolinians agree that S104 is a bad bill:
The poll found that, not only do a majority of North Carolinians oppose the national popular vote compact, the number of people who strongly oppose it (45 percent) dwarfs the total number of supporters (29 percent). The opposition crosses party ID (most Republicans and unaffiliated voters and a plurality of Democrats oppose it) and ideology. It also crosses demographic divides such as race, sex, and age.
S104 is a bad bill on its merits and most North Carolinians oppose it. It deserves to die ignominiously in committee.
Robin Hayes, chairman of the NC GOP and a former congressman, has been indicted in federal court on conspiracy and bribery charges related to purported attempts to bribe NC Insurance Commissioner Mike Causey. What does this mean for the Republican party in the state?
And why does the NCAE, an affiliate of the national teachers’ union group, NEA, insist on students missing another day of school to accommodate their political activities?
Lastly, what’s wrong with price transparency in healthcare? Well, according to some lawmakers, plenty. Recently HB 184 passed in the House, barring Treasurer Folwell from addressing the ballooning healthcare costs entrenched in the State Health Plan.
Watch a live recording of this episode here.
This second round of Civitalk-CPAC Interviews includes the Nikki Neily, president of Speech First. Neily delves into the problem of censorship on college campuses. The final interviews include Congressional candidate Lee Murphy of Delaware and economist Sherry Jarrell, a professor at Temple University. I discuss the federal debt with both of them and what that means for our nation.
Charges against actor Jussie Smollett have been dropped. But what sort of damage do hate crime hoaxes, such as the one Smollett initiated, do to our social fabric?
And, when it comes to abortion, where do North Carolinians really stand? Our latest poll had some interesting findings.
Finally, it seems that many men and women across the state are divided on their feelings regarding the Electoral College. Could part of that be due to our nation’s decline in civic education?
You can watch a live recording of this episode here.
- Medicaid expansion advocates claim the state’s healthcare industry will expand in response to greater demand from expansion
- Evidence from other states tells us otherwise
- State restrictions like CON laws and scope of practice regulations also legally limit the industry’s ability to expand supply to meet demand
In a February Winston-Salem Journal article, Wake Forest University law and public policy professor Mark Hall was asked to evaluate some claims about Medicaid expansion released by Sen. Phil Berger’s office.
For one claim in particular, Hall’s response seems a bit suspect, and warrants further investigation. Specifically, Berger claimed that Medicaid coverage “doesn’t necessarily mean access to health care,” and that expanding the already crowded program by 25 percent would place access for traditional enrollees at risk.
Hall responded to this claim by saying “This assumes that medical resources are fixed. However, new funding would be used to create new jobs, and thus expanded capacity, in healthcare delivery.”
Basic economics tells us indeed that in a freely adjusting market, an increase in demand for a good or service would be met (over time) with an increase in supply in response.
But Medicaid, and our health care system more generally, is far from a freely adjusting market. Medicaid is a third-party payer system in which the government sets and caps reimbursement rates for providers. Prices aren’t allowed to freely adjust to the spike in demand, which eliminates the incentive for additional providers to increase supply.
More specifically, is there any evidence to back up Hall’s claims that the “new funding” from Medicaid expansion would lead to an increase in the supply of healthcare services?
Evidence from Expansion States
Because of low reimbursement rates, a limited number of doctors are willing to treat Medicaid patients.
According to a 2012 survey conducted and reported by the Commonwealth Foundation and Kaiser Family Foundation, only 52 percent of physicians nationwide were accepting new Medicaid patients.[i]
Medicaid expansion as provided for in Obamacare added millions to the Medicaid rolls. With a very limited number of doctors opening their doors to Medicaid patients however, there was a high risk of doctor shortages for enrollees.
In recognition of these conditions, the Affordable Care Act allowed for a two-year increase in the Medicaid reimbursement rate, which expired at the end of 2014. The increased rates however, were not enough to entice more doctors to become Medicaid providers.
According to a 2018 JAMA study, “the payment increase had no association with PCP (primary care physician) participation in Medicaid or Medicaid service volume.”[ii] This, despite a 25 percent increase in the Medicaid share of patients from 2012 to 2015.
The Commonwealth/Kaiser study further found “The share of providers accepting new Medicaid patients does not differ among physicians working in states that expanded their Medicaid program versus those that did not.”
Moreover, a Health Affairs study found “no association” between the “Medicaid ‘fee bump’ and physician-reported measures of participation in Medicaid.”[iii]
Finally, a study co-authored by Stanford and Harvard professors found that “the Medicaid expansion has little impact on physician supply on the extensive margin,” meaning there was no detectable increase in doctors accepting new Medicaid patients after expansion.[iv]
The bottom line: research has shown that Medicaid expansion did not spur an increase in physicians treating Medicaid patients.
Further Evidence: Wait Times
A failure for supply to keep pace with demand can be reflected in a number of ways, most notably increased wait times.
A 2017 study published in the New England Journal of Medicine found that Medicaid expansion was “also associated with longer wait times for appointments, which suggests that challenges in access to care persist.”[v]
A 2014 USA Today article looked at the impact in Reno from Nevada’s Medicaid expansion.
The article notes that “many new enrollees have been frustrated by the lack of providers willing to see them,” and that “(p)hysicians and clinics that treat the poor say they’ve been overwhelmed by new patients.”
Chuck Duarte, the state’s former Medicaid chief and director of the region’s largest community health center, noted, “We are struggling to keep up with demand for care.”
A Kauffman Foundation study found longer wait times for community health centers in expansion states, concluding that expansion states were “more likely to report increased wait times for appointments.”[vi]
Anecdotal evidence for longer wait times exists as well. In California, according to this NPR report, “patient advocates say the Medicaid expansion has exacerbated longstanding shortages in specialty care.”
Government Restrictions Limit Supply Capacity
Further restricting the ability of North Carolina’s healthcare industry to expand in response to Medicaid expansion’s increase in demand for services are our state’s scope of practice restrictions and Certificate of Need laws.
With a shortage of doctors available to treat the sizeable number of new Medicaid enrollees, some of the services could be administered by registered nurses and physician assistants.
Unfortunately, however, North Carolina scope of practice laws prevent that from happening.
Current North Carolina law restricts the scope of care that registered nurse practitioners, advanced practice registered nurses, and physician assistants can provide, while also requiring a certain level of supervision by a licensed physician.
With a shortage of licensed physicians treating Medicaid patients – especially in rural areas – laws restricting the ability of highly-trained medical care providers to provide much-needed care would only exacerbate Medicaid enrollees’ access to care.
Also adding to this problem are North Carolina’s antiquated Certificate of Need (CON) laws. These laws require medical providers to first get permission from the state government to open new facilities, expand current facilities or add medical devices.
Some medical providers desiring to expand capacity, therefore, can be denied by the state’s CON laws. Still others will be discouraged to even attempt to engage in the very costly process of acquiring state permission.
These restrictions serve as yet another reminder of the inability for North Carolina’s healthcare industry to expand to meet rising demand from the swelling ranks of Medicaid patients.
Existing doctor shortages – exacerbated by a growing number of doctors choosing early retirement – and state government restrictions on medical facilities and scope of care point to a potentially hazardous lack of access to care for Medicaid enrollees in the event North Carolina chooses to expand its program.
Evidence from other states that chose to expand Medicaid also suggests that supply growth has been virtually nonexistent, which has contributed to growing concerns about longer wait times and lack of access to care for Medicaid patients.
It is mere wishful thinking for Hall and other Medicaid expansion advocates to believe North Carolina’s healthcare industry can just expand its capacity in order to meet the significant spike in demand that would occur as a result of Medicaid expansion.
There is simply no way to avoid the reality that Medicaid coverage will not mean access to care.
[i] The Commonwealth Fund and Kaiser Family Foundation. “Experiences and Attitudes Among Primary Care Providers Under the First Year of ACA Coverage Expansion.” Issue Brief, June 2015. Accessed online March 26, 2019 at: https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_issue_brief_2015_jun_1823_kaiser_commonwealth_primary_care_survey_ib.pdf
[ii] Andrew W. Mulcahy, PhD, MPP; Tadeja Gracner, PhD; Kenneth Finegold, PhD. “Associations Between the Patient Protection and Affordable Care Act Medicaid Primary Care Payment Increase and Physician Participation in Medicaid.” JAMA Internal Medicine. August 2018. Accessed online March 26, 2019 at: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2687526
[iii] Sandra Decker, “No Association Found Between the Medicaid Primary Care Fee Bump and Physician-Reported Participation in Medicaid.” Health Affairs, Volume 37, Issue 7. Accessed online March 26, 2019 at: https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2018.0078?journalCode=hlthaff
[iv] Monice Bhole and Vilsa Curto, “Early ACA Medicaid Expansions: Impacts on Enrollment and Access.” December 2017. Accessed online March 26, 2019 at: file:///C:/Users/bbalfour/Downloads/EarlyACAMedicaidExpansionsImpactsO_preview.pdf
[v] Sarah Miller, PhD; and Laura Wherry, PhD. “Health and Access to Care During the First 2 Years of the ACA Medicaid Expansions.” The New England Journal of Medicine. March 9, 2017. Accessed online March 5, 2019 at: https://www.nejm.org/do.i/full/10.1056/NEJMsa1612890
[vi] Peter Shin, Jessica Sharac, Julia Zur, Sara Rosenbaum, and Julia Paradise. “Health Center Patient Trends, Enrollment Activities, and Service Capacity: Recent Experience in Medicaid Expansion and Non-Expansion States.” Kaiser Family Foundation. Accessed online March 26 at: https://www.kff.org/medicaid/issue-brief/health-center-patient-trends-enrollment-activities-and-service-capacity-recent-experience-in-medicaid-expansion-and-non-expansion-states/
- The March 2019 Civitas Poll found that half of North Carolinians identify as pro-life, while 40 percent identify as pro-choice
- A closer look at the details, however, reveals the divide is not so clear-cut
- Only 26 percent who identify as pro-choice support abortion at any time during pregnancy
Half of North Carolinians consider themselves to be pro-life, while only 40 percent of respondents identify as pro-choice, according to the March 2019 Civitas Poll. Recent national events have again catapulted abortion regulations to the forefront of state policy debates across the country. North Carolina is no exception. Civitas Communications Director Brooke Medina said it well:
“In the wake of horrific anti-life legislation pushed in the New York and Virginia legislatures in recent months, it is reassuring to see a significant number of North Carolinians identify as pro-life. It should serve as a clear message to politicians that radical abortion legislation is out of step with half of their electorate.”
Just this week, North Carolina’s ban on abortions after 20 weeks was overturned by a federal judge. Despite the outcome, , several states have passed or are considering heartbeat legislation that bans abortions once a baby’s heartbeat can be detected in the womb.
As the policy debates rage on across the country, North Carolinians seem to largely be divided on the issue as well. When asked to identify as pro-life or pro-choice, ten percent of North Carolinians were undecided.
The topline results alone fail to tell the full story. Digging into the survey responses reveals some interesting trends.
Men tend to be slightly more pro-life than women, although the two-point difference is well within the poll’s 4.38-point margin of error.
Perhaps unsurprisingly, Republicans overwhelmingly identify as pro-life, with a margin of 81 to 15. Democrats tend to be pro-choice, although by a slightly smaller margin of 67 to 24. Unaffiliated voters, who make up the state’s second largest voting bloc (behind Democrats), are net pro-life by a 14-point margin of 48 to 34.
All media markets within the state were more pro-life than pro-choice. However, two in particular had huge pro-life advantages: Wilmington and the Triad (Greensboro-High Point-Winston Salem).
Although the terms “pro-life” and “pro-choice” are relatively common in the discussion of abortion policy, they can mean different things to different people. As a follow up to that question, the Civitas Poll also asked people their opinion on when abortions should be allowed.
These responses reveal a new meaning when you look at how people’s answer to the first question influences their answer to the second.
Overall, only 11 percent of respondents said that abortion should be allowed without any restrictions. Even among those that identify as pro-choice, only 26 percent believe that abortion should be available to a woman at any time during her pregnancy. Conversely, 23 percent of pro-life identifiers believe abortion should never be allowed under any circumstance.
On the other hand, nearly 9 percent of pro-lifers polled believe abortion should be allowed during the first three months of pregnancy, while 0.5 percent agree abortion should be allowed at any time. Sixteen percent of those that identify as pro-choice say that abortion should only be allowed in cases of rape, incest, or where the health of the mother is at risk.
Clearly, pro-life and pro-choice are not universally defined concepts. However, abortion continues to be an issue for which people tend to have strong – if nuanced – opinions. This ambiguity can make it difficult to discern people’s abortion policy preferences. Everyone may draw their version of the “line in the sand” slightly differently.
The March Civitas Poll also asked respondents their opinion about House Bill 28. Recently filed in the North Carolina legislature, HB28 would limit abortions performed after 13 weeks to only cases of a medical emergency.
The response to this question seems to have a similar breakdown of the pro-life/choice question. However, a look at the crosstabs reveals that support or opposition did not fall neatly along those lines.
Twenty-seven percent of those who identify as pro-life say that they do not support the ban after 13 weeks. However, if you recall, less than 10 percent of that same group thought abortion should be allowed without an extenuating circumstance. So, why would 27 percent oppose the bill? It could be that they do not think it goes far enough to protect unborn children. We cannot definitively know the motivations of the respondents. However, the data suggests that most North Carolinians would probably disagree with the recent federal court ruling that overturned the state’s ban on abortions after 20 weeks.
As North Carolina grapples with the ramifications of the ruling, the future of abortion policy in the state is uncertain. “Pro-life” and “pro-choice” remain hazy concepts, and elected officials may face difficulty gauging or aligning with the will of their constituents. Abortion is setting up as a defining topic of the upcoming 2020 election. As Civitas President Donald Bryson pointed out, “The issue of abortion is alive and well in North Carolina politics.”
To learn more about North Carolina’s stance on abortion, explore the interactive infographic below and check out the full Civitas Poll here. Note: Per industry standard, the poll crosstabs are weighted to reflect the demographic makeup of the North Carolina electorate. The infographic below was generated using raw, unweighted survey result data. Minor divergences may result.