Reform Update: North Carolina Senate race likely to focus on Medicaid expansion

With North Carolina State House Speaker Thom Tillis the newly crowned Republican nominee for a U.S. Senate seat being contested this fall, expect not only Obamacare, but more specifically, Medicaid expansion to be the focus of hot and heavy campaign rhetoric from both sides.

Tillis is known in the state for his vocal opposition to expanding Medicaid there. He trumpeted that opposition during his primary campaign. Incumbent Democratic Sen. Kay Hagan has argued for getting changes to the Patient Protection and Affordable Care Act, likely to provide herself with some political cover in a state where many voters voice disapproval of Obamacare.

But she also has focused on Medicaid expansion as a key talking point, decrying the Republican decision not to expand Medicaid in her state. Focusing on expansion could become a key strategy for her, and for other Democrats in non-expansion states.

Hagan picked up that drumbeat Thursday during a confirmation hearing for presumed future HHS Secretary Sylvia Mathews Burwell, saying, “Last year in North Carolina, our state Legislature and governor decided against expanding the state's Medicaid program. And as a result, about 500,000 people who would have qualified for coverage through Medicaid are now not able to do so.”

“There's still a lot of controversy on the decision not to expand Medicaid,” said Jonathan Oberlander, professor of social medicine and health policy and management at the University of North Carolina at Chapel Hill. “I think while Tillis is probably going to link Hagan to Obamacare, she's going to link him to the Medicaid expansion controversy.”

While an April poll from Elon University found that healthcare is the third most important issue for North Carolina voters, behind the economy and jobs, Obamacare still remains unpopular among most North Carolina voters. Approximately 44% of respondents believed Obamacare would make the healthcare situation worse in the state, while only 35% thought it would improve matters.

This data seems to be in juxtaposition to recent healthcare exchange data that ranks North Carolina as the state with the fifth most enrollees in health plans (PDF).

Public opposition in the state seems to be abating, said Kenneth Fernandez, director of the Elon University Poll.

“We have seen that the animosity toward Obamacare changes over time. It probably reached its peak late in 2013 when all of the missteps of the rollout happened. Once those were alleviated and you saw some success stories, it seems that we've seen the lowest level of animosity,” he said.

“Healthcare is going to play a major role in the Senate race,” he said. “It's going to be a healthcare election.”

Tillis won the North Carolina Republican primary May 6, garnering 45.7% of the vote over his more conservative opponents. He's already called Hagan a "rubber stamp for President Obama's liberal agenda."

Given what's seen as Hagan vulnerability and Republican efforts to capture control of the Senate this November, outside money is pouring into the campaign. The ultra-conservative Americans for Prosperity have spent more than $7 million to attack Hagan while the Democrats' Senate Majority PAC has spent roughly half that much in the race, the Los Angeles Times reported.

"Voters have very clear differences to make choices between. Here we see some very real opposition to each other's ideas that aren't just necessarily disagreements over details, they're disagreements over fundamentals,” said Jason Husser, assistant professor of political science and policy studies at Elon University.

In Kentucky, the Senate race will likely be between Alison Grimes, Kentucky's secretary of state and the leading Democratic candidate, and incumbent Republican Sen. Mitch McConnell. Democratic and Republican primaries occur May 20. While McConnell has supported repeal of Obamacare, Grimes has been shying away from the topic because of the low presidential approval rating in Kentucky right now, said Kyle Kondik, managing editor of Sabato's Crystal Ball at the University of Virginia Center for Politics.

"I think if McConnell is going to lose, it is because he himself is really unpopular. But my sense of the race is that in a state like Kentucky, in a mid-term year where Republicans have some sort of a generic advantage across the country, it's just really hard to see how Kentucky throws out an incumbent Republican," he said.

Under the Patient Protection and Affordable Care Act, businesses with 50 or more employees must offer health insurance to their workers or be subject to a penalty. The mandate takes effect in 2016 for those with 50 to 99 employees and in 2015 for larger employers. But new research from the Urban Institute and the Robert Wood Johnson Foundation finds that eliminating the controversial mandate would not have a significant impact on the number of people covered by insurance.

If the employer mandate is fully implemented, 251.1 million people would have insurance by 2016. If it is repealed, 250.9 million people would still have insurance coverage—a difference of 200,000, the research contends. Though elimination of the employer mandate would mean 500,000 fewer people would receive employer-provided health insurance, the majority would be able to find coverage through Medicaid or the individual marketplace, many with the help of subsidies, it says.

Also, many employers would continue to provide health insurance coverage voluntarily because of tax benefits, it hypothesizes. Workers who receive nontaxable employer health insurance contributions may do so in lieu of a higher salary that would then be used to purchase coverage on the open market to comply with the individual mandate. Eliminating the mandate would help lessen business opposition to the ACA and decrease the likelihood of negative hiring practices that include hiring fewer workers, cutting hours to part-time employment and reducing wages, the research argues.

Rebecca Kern is a Washington, D.C.-based freelance journalist.