Why North Carolina teachers are fighting for Medicaid expansion

Increasing children’s access to health care would improve their educational outcomes

North Carolina teachers have announced a day of action on May 1 to advocate for five reforms to improve our public education system  1:

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  1. Provide enough school librarians, psychologists, social workers, counselors, nurses, and other health professionals to meet national standards.
  2.  Provide a $15 minimum wage for all school personnel, a 5 percent raise for all ESPs (non-certified staff), teachers, admin, and a 5 percent cost of living adjustment for retirees.
  3. Expand Medicaid to improve the health of our students and families.
  4. Reinstate state retiree health benefits eliminated by the General Assembly in 2017.
  5. Restore advanced degree compensation stripped by the General Assembly in 2013.

For some, the demand for Medicaid expansion might seem out of place or — at best — tangential to education for North Carolina students. For moral reasons and the tangible impact of health on academic achievement, the teachers calling on North Carolina to expand Medicaid are 100 percent correct in identifying Medicaid expansion as a vital policy for helping many students realize their potential to lead flourishing lives as adults.

What is Medicaid and how does it benefit children in North Carolina?

Medicaid is a public health insurance program, which is funded jointly by states and the federal government and is designed to provide coverage to low-income individuals and families. North Carolina, as in other states, is responsible for administering its own Medicaid program within federal government guidelines.

Medicaid provides comprehensive, high-quality, affordable coverage for children in low-income families. Currently, 2 out of every 5 children in North Carolina are covered by Medicaid and can reap the benefits of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) that includes access to medical, vision, dental, and hearing services.  2   3

Prior to the Affordable Care Act (ACA), Medicaid was available only to certain groups of people — children, pregnant women, people with disabilities — at specific income levels. The ACA allowed states to expand Medicaid coverage to cover all people below a certain income (138 percent of the federal poverty level), beginning in 2014. States that opted to expand Medicaid receive more federal dollars than they would under traditional Medicaid in order to cover the additional costs. North Carolina is one of just 14 states to have eschewed Medicaid expansion.  4  While Medicaid expansion would not make any children newly eligible for Medicaid, North Carolina students would benefit from expansion in many ways.

Medicaid is something that has completely changed my life. Being able to benefit from government-subsidized health care allows me to get dental cleanings and sports physicals. When I broke my foot and needed surgery, my biggest concern was walking, not medical bills.

“As a recipient of Medicaid, I think it is so important that people who are not covered should have affordable options for health care. My mother, a house cleaner, has been uninsured for a long time. It is scary because if she ever broke a bone or got really sick, we would not only have to fear for her health but also our ability to pay for her medical bills. Families should not have to go through that added stress. –

– Kerwin from Durham, a highschool teacher

Eligible children will gain new coverage

Currently, many children who are eligible for Medicaid coverage remain uninsured, due primarily to parents not knowing that their children are eligible for coverage. However, when parents become newly eligible for Medicaid coverage, their children also gain new coverage. This trend was observed even prior to the passage of the Affordable Care Act (ACA) when some states — recognizing that family coverage benefits children — began extending Medicaid and other publicly-funded health insurance coverage to include parents. Studies on the effects of such strategies found that parental coverage consistently resulted in an increase in coverage for eligible children.  5

In states that have expanded Medicaid, there have been significant declines in the number of uninsured individuals, particularly children, despite the fact that children already were eligible for Medicaid coverage. As a result, Medicaid participation rates for children have increased more rapidly in states that have adopted Medicaid expansion.  6

In North Carolina, the number of uninsured children decreased due to implementation of the ACA;  7 however, in recent years the number has increased. As shown in Figure 1, an additional 20,000 North Carolina children were uninsured in 2017 compared to 2015.

Medicaid expansion in North Carolina will help reverse this backward trend. Additionally, many studies show that parental coverage led to greater use of health care, including preventive services, and to decreased feelings of discrimination. 8  There is ample research that shows that providing parents with health insurance coverage has substantial positive effects on children by improving the mental and physical health of parents and the financial security of families.

In addition to the health benefits and decreased financial hardship that result from Medicaid coverage, there is evidence of the positive association between Medicaid and school performance. Children who receive Medicaid also experience improved reading test scores  9 and are more likely to complete high school 10 , attend college 11 , and even complete college. Furthermore, improved health and academic achievements allow individuals to fully participate in the workforce, earn higher wages, and contribute more in taxes, resulting in a strong return on investment. 12

Coverage of school professionals and child care workers will improve students’ learning

Medicaid expansion will extend health insurance coverage to school staff in addition to parents. Together with workers in the health care and social assistance industry, individuals working in the education sector make up 23 percent of the workforce and represent nearly 12 percent of North Carolina’s uninsured workers.  13

With the added burden of low wages and the rising cost of health care, being uninsured forces workers to delay seeking care or go without care, due to cost.  14  15  Currently, noncertified school employees in North Carolina can earn as little as $11.75 per hour, which is earned only on instructional days and amounts approximately to $17,000 per year.  16  This reality leads to negative health consequences, particularly for those with chronic conditions who are disproportionately uninsured, and makes it difficult for uninsured adults to remain in the workforce.  17

To ensure that our students can maximize the benefit they receive from school, we must invest in the workforce that allows for that to happen. Medicaid expansion will help the thousands of low-wage school staff to meet their own health needs so they can go to work ready to play their part in students’ success.

Medicaid funds support schools, ensure student success

Public schools in North Carolina receive Medicaid reimbursements for providing certain health services to Medicaid-eligible students. The following services, consistent with the EPSDT program, are included:  18

  • Audiology services, such as hearing screenings, and hearing assistance technology
  • Nursing services
  • Occupational therapy
  • Physical therapy
  • Psychological and counseling services
  • Speech-language pathology services

Medicaid expansion would help offset the costs of delivering these services to an expanded number of students

North Carolina recently received approval from the federal government that would allow schools to provide reimbursable services to more students.  19 Prior to the recent approval, North Carolina schools could seek reimbursement only for services provided to Medicaid-enrolled students with individual education plans (IEPs). However, now services for Medicaid-enrolled students with a section 504 Accommodation Plan, an Individual Health Plan (IHP), or a Behavior Intervention Plan (BIP) also will be eligible for reimbursement. This means that Medicaid expansion will allow more students to access care at their school, and schools will receive the funds necessary to provide those services.

Endnotes

  1. Parmenter, J. (2019). NC school employees will converge on Raleigh May 1 to press for much-needed change. Retrieved from http://notesfromthechalkboard.com/2019/03/24/nc-teachers-will-converge-on-raleigh-may-1-to-press-for-much-needed-change/
  2. Medicaid in North Carolina. (2018). Retrieved from http://files.kff.org/attachment/fact-sheet-medicaid-state-NC
  3. Early and Periodic Screening, Diagnostic, and Treatment (n.d.) Retrieved from https://www.medicaid.gov/medicaid/benefits/epsdt/index.html
  4. Status of state Medicaid expansion decisions: Interactive map. (2019). Retrieved from https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/
  5. Rosenbaum, S, & Whittington, R. P. T. (2007). Parental health insurance coverage as child health policy: Evidence from the literature. Retrieved from https://publichealth.gwu.edu/departments/healthpolicy/CHPR/downloads/Parental_Health_Insurance_Report.pdf
  6. Kenney, G. M., Haley, J., Pan, C., Lynch, V., & Buettgens, M. (2016). Children’s coverage climb continues: Uninsurance and Medicaid/CHIP eligibility and participation under the ACA. Retrieved from https://www.urban.org/sites/default/files/publication/80536/2000787-Childrens-Coverage-Climb-Continues-Uninsurance-and-Medicaid-CHIP-Eligibility-and-Participation-Under-the-ACA.pdf
  7. Ibid
  8. Rosenbaum, S. & Whittington, R. P. T. (2007). Parental health insurance coverage as child health policy: Evidence from the literature. Retrieved from https://publichealth.gwu.edu/departments/healthpolicy/CHPR/downloads/Parental_Health_Insurance_Report.pdf
  9. Levine, P. B. & Schanzenbach, D. W. (2009). The impact of children’s public health insurance expansions on educational outcomes. Retrieved from https://www.nber.org/papers/w14671.pdf
  10. Cohodes, S. R., Grossman, D. S., Kleiner, S. A., Lovenheim, M. F. (2015). The effect of child health insurance access on schooling: Evidence from public insurance expansions. Journal of Human Resources, 51(3), 727-759. doi:10.3368/jhr.51.3.1014-6688R1
  11. Brown, D. W., Kowalski, A. E., &Lurie, I. Z. (2015). Medicaid as an investment in children: What is the long-term impact on tax receipts? Retrieved from https://www.nber.org/papers/w20835.pdf
  12. Ibid
  13. 2013-2017 American Community Survey 5-Year Estimates (Table S2702).
  14. Health care expenditures per capita by state of residence. (2014). Retrieved from https://www.kff.org/other/state-indicator/health-spending-per-capita
  15. Claxton, G., Sawyer, B., & Cox, C. (2019). How does cost affect access to care? Retrieved from https://www.healthsystemtracker.org/chart-collection/cost-affect-access-care
  16. Nordstrom, K. (2019). Effective and equitable: Creating a shared vision for NC schools. Retrieved from https://www.ncjustice.org/publications/effective-and-equitable-creating-a-shared-vision-for-nc-schools/
  17. McWilliams, J.M. (2009). Health consequences of uninsurance among adults in the United States: recent evidence and implications. The Milbank Quarterly, 87(2), 443-494. doi: 10.1111/j.1468-0009.2009.00564.x
  18. Medicaid and Health Choice outpatient and specialized therapies clinical coverage policy No.:10C Local Education Agencies (LEAs). (2018). Retrieved from https://files.nc.gov/ncdma/documents/files/10-C.pdf
  19. Stahl, E. M. (2019). North Carolina secures school-based Medicaid services to keep kids healthy and in the classroom. Retrieved from https://www.communitycatalyst.org/blog/north-carolina-secures-school-based-medicaid-services-to-keep-kids-healthy-and-in-the-classroom

Footnotes

  1. Parmenter, J. (2019). NC school employees will converge on Raleigh May 1 to press for much-needed change. Retrieved from http://notesfromthechalkboard.com/2019/03/24/nc-teachers-will-converge-on-raleigh-may-1-to-press-for-much-needed-change/
  2. Medicaid in North Carolina. (2018). Retrieved from http://files.kff.org/attachment/fact-sheet-medicaid-state-NC
  3. Early and Periodic Screening, Diagnostic, and Treatment (n.d.) Retrieved from https://www.medicaid.gov/medicaid/benefits/epsdt/index.html
  4. Status of state Medicaid expansion decisions: Interactive map. (2019). Retrieved from https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/
  5. Rosenbaum, S, & Whittington, R. P. T. (2007). Parental health insurance coverage as child health policy: Evidence from the literature. Retrieved from https://publichealth.gwu.edu/departments/healthpolicy/CHPR/downloads/Parental_Health_Insurance_Report.pdf
  6. Kenney, G. M., Haley, J., Pan, C., Lynch, V., & Buettgens, M. (2016). Children’s coverage climb continues: Uninsurance and Medicaid/CHIP eligibility and participation under the ACA. Retrieved from https://www.urban.org/sites/default/files/publication/80536/2000787-Childrens-Coverage-Climb-Continues-Uninsurance-and-Medicaid-CHIP-Eligibility-and-Participation-Under-the-ACA.pdf
  7. Ibid
  8. Rosenbaum, S. & Whittington, R. P. T. (2007). Parental health insurance coverage as child health policy: Evidence from the literature. Retrieved from https://publichealth.gwu.edu/departments/healthpolicy/CHPR/downloads/Parental_Health_Insurance_Report.pdf
  9. Levine, P. B. & Schanzenbach, D. W. (2009). The impact of children’s public health insurance expansions on educational outcomes. Retrieved from https://www.nber.org/papers/w14671.pdf
  10. Cohodes, S. R., Grossman, D. S., Kleiner, S. A., Lovenheim, M. F. (2015). The effect of child health insurance access on schooling: Evidence from public insurance expansions. Journal of Human Resources, 51(3), 727-759. doi:10.3368/jhr.51.3.1014-6688R1
  11. Brown, D. W., Kowalski, A. E., &Lurie, I. Z. (2015). Medicaid as an investment in children: What is the long-term impact on tax receipts? Retrieved from https://www.nber.org/papers/w20835.pdf
  12. Ibid
  13. 2013-2017 American Community Survey 5-Year Estimates (Table S2702).
  14. Health care expenditures per capita by state of residence. (2014). Retrieved from https://www.kff.org/other/state-indicator/health-spending-per-capita
  15. Claxton, G., Sawyer, B., & Cox, C. (2019). How does cost affect access to care? Retrieved from https://www.healthsystemtracker.org/chart-collection/cost-affect-access-care
  16. Nordstrom, K. (2019). Effective and equitable: Creating a shared vision for NC schools. Retrieved from https://www.ncjustice.org/publications/effective-and-equitable-creating-a-shared-vision-for-nc-schools/
  17. McWilliams, J.M. (2009). Health consequences of uninsurance among adults in the United States: recent evidence and implications. The Milbank Quarterly, 87(2), 443-494. doi: 10.1111/j.1468-0009.2009.00564.x
  18. Medicaid and Health Choice outpatient and specialized therapies clinical coverage policy No.:10C Local Education Agencies (LEAs). (2018). Retrieved from https://files.nc.gov/ncdma/documents/files/10-C.pdf
  19. Stahl, E. M. (2019). North Carolina secures school-based Medicaid services to keep kids healthy and in the classroom. Retrieved from https://www.communitycatalyst.org/blog/north-carolina-secures-school-based-medicaid-services-to-keep-kids-healthy-and-in-the-classroom