Q. Where do the 9th District candidates stand on health care? A. Not on the same side.

Democrat Dan McCready and Republican Dan Bishop
Democrat Dan McCready and Republican Dan Bishop

Even before the Affordable Care Act went on trial in New Orleans this week, health care was a top issue in the special election in North Carolina’s 9th Congressional District.

Republican Dan Bishop has made it a focus of his campaign. Democrat Dan McCready just barnstormed the district on what he calls his “Affordable Healthcare Tour.”

The election, which includes two third-party candidates, is Sept. 10.

The race comes as the 5th Circuit Court of Appeals considers a challenge to the constitutionality of the Affordable Care Act, known as Obamacare. Nearly a decade after its inception, polls find Americans split on the ACA with Democrats heavily in favor and Republicans strongly against.

The two main 9th District candidates couldn’t be further apart on ACA, Medicaid expansion and other health care issues. Here’s where they stand:

The Affordable Care Act

Bishop has called the ACA a “disaster that needs to be repealed and replaced.” He believes the 20 million people now covered by the law could find affordable coverage in a new competitive market.

For him, that market would include popular parts of the ACA such as coverage for pre-existing conditions and the ability for young adults to stay on their parents’ policies through age 26. Those, he said, could still be required by government.

“What we need is robust, wide-open competition,” he told the Observer. “But there will always be a role for regulation of insurance coverage. . . . There is uniform support on both sides for policies to require coverage of pre-existing conditions (and young adults).”

McCready likes the ACA but would “fix” it. He says that would include making subsidies more available and enticing young people into the system by offering catastrophic plans. He would shift pricing from a fee-for-service model to a “value-based” one where patients are charged not by procedure but by outcome.

Striking down the ACA, he believes, would mean an end to affordable coverage for people with pre-existing conditions.

Health care costs

Bishop said unfettered competition could bring down costs.

“America’s story is how market economics make thing affordable, from the Model T to the modern-day smartphone,” he said, adding that health care services.

He said government could help by demanding price transparency from drug makers, giving consumers choices through a health savings account and ending laws like the one that requires N.C. hospitals to get state approval before adding new facilities. (He introduced a bill that would end that so-called Certificate of Need requirement.)

McCready says he would reduce costs by bringing more people into the ACA by adding plans like catastrophic coverage, lowering prescription drug costs, bringing more and expanding Medicaid in North Carolina. Advocates say expanding Medicaid would reduce costs in part by reducing spending to treat the uninsured.

Medicaid expansion

Since adoption of the ACA, North Carolina is one of 14 states that have not expanded Medicaid, the health program for the poor. One study said expansion would mean coverage for 634,000 North Carolinians by 2022. The federal government would pay 90% of the costs. The other 10% would be paid by hospitals and health plans, Democratic Gov. Roy Cooper says.

“It is a no-brainer,” McCready says. “It’s economically the right thing to do. It’s morally the right thing to do.”

Critics like the John Locke Foundation cite the cost of expansion to federal and state governments as well as the low reimbursements to providers that they say could result in higher costs for those with private insurance.

Bishop calls expansion “a pig in a poke.”

“The answer is bring in . . . competition,” he said. “The wrong answer is bringing in more government to destroy the market even more.”

Bishop said he’s reserving judgment about a Republican House bill called NC Health Care for Working Families that would expand Medicaid but add a work requirement. But he called the current bill “a capitulation to a terrible idea.”

“Medicare for all”

Several Democratic presidential candidates and lawmakers are calling for “Medicare for all,” with proposals ranging from a single-payer health system to a public option. Neither 9th District candidate wants that.

“I’m interested in things we can actually get done working with both sides of the aisle,” McCready says. “And many of these plans are unrealistic.”

Bishop sees it as a wholesale government takeover.

“If Obamacare has been a disaster, that would be a thermonuclear disaster,” he said.

Prescription costs

Last month McCready went to a Mint Hill pharmacy to introduce his 10-point plan to lower prescription drug costs. The plan would address high prescription prices, mostly by regulating middlemen who negotiate them. He would build on federal legislation that lifted the ban on pharmacists being able to discuss lower-cost alternatives with patients.

He also would allow Medicare to negotiate prices with pharmaceutical companies, something it’s now prohibited from doing. According to the Kaiser Family Foundation, Medicare accounts for 29% of retail pharmaceutical spending.

Bishop opposes allowing Medicare to negotiate drug prices. Instead he’d consider steps such as indexing U.S. drug prices to those of other countries and forcing drug makers to be more transparent in pricing. He also would look at changing patent rules that can keep lower-cost generic drugs from the market for years.

“Striking the right balance between intellectual property and patents is worth reviewing,” he says.

McCready has attacked a pair of Bishop’s health care votes.

In 2017 Bishop was the only senator to vote against the final version of a bill called the Pharmacy Patient Fair Practices Act. Now law, it allows pharmacists to talk to patients about lower-cost alternative drugs. However, he had voted for an earlier Senate version and has said he didn’t vote for the House bill because he hadn’t had time to review it.

In 2015, Bishop, then in the House, was one of just 10 members to vote against the Cancer Treatment Fairness Act, which would have required health plans to charge cancer patients no more for oral chemotherapy than for standard intravenous treatment. Bishop has called it “a pro-big pharma bill” that would “increase the cost of insurance by adding mandates for expensive new drugs . . . rather than allowing proven and effective older drugs to be used first.”


More than 13,000 North Carolinians have died of opioid overdoses in the last two decades, according to state officials.

This week Cooper signed a bill similar to one Bishop sponsored that would increase penalties on people who distribute controlled substances when that distribution results in death. He’s open to government regulation if needed.

I don’t think there’s a single magic bullet that will fix it, he said of the problem.

McCready says while it takes a multi-pronged approach of prevention and treatment options, Medicaid expansion would bring needed services to more people.

Rural hospitals

Six rural hospitals in North Carolina have closed since 2010, according to N.C. Health News. According to the National Rural Hospital Association, nearly 700 across the country are in danger of closing.

In April the CEOs of seven rural N.C. hospitals told the governor they could close if Medicaid is not expanded. To McCready, the answer to the health of rural hospitals “is as simple as Medicaid expansion.”

But critics such as the Civitas Institute argue that expanding Medicaid, with its low reimbursement rates to providers, would not solve the problem. Instead, they argue, it would put additional strain on rural hospitals.

“How do you improve the lot of rural hospitals by making them lose money on more patients?” Bishop says.

Jim Morrill, who grew up near Chicago, covers state and local politics. He’s worked at the Observer since 1981 and taught courses on North Carolina politics at UNC Charlotte and Davidson College.