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Ten years ago, Republicans in the North Carolina state House were lining up to vote against Medicaid expansion for their state.
They had an opportunity to open up the program to anybody with income below or just above the poverty line, with the federal government picking up most of the cost through the Affordable Care Act. They passed it up, arguing that the existing Medicaid program was too expensive and too broken. They warned that the federal government might reduce its contributions in the future, and that offering more people Medicaid would give them less incentive to work.
Then they said that voting for expansion was tantamount to voting for “Obamacare,” which was politically toxic among Republicans, and even some non-Republicans as well.
Wow, have things changed.
This week, Republicans in the North Carolina House lined up to vote on another expansion bill ― and this time most of them voted for it, with the legislation passing by a total margin of 87 to 24. The vote came a week after the GOP-controlled Senate approved the same proposal by an even more lopsided, 44 to 2, margin.
Now the bill heads to the desk of Roy Cooper, the Democratic governor and longtime champion of Medicaid expansion, who has pledged to sign it. The expansion can’t take effect until ― and unless ― the GOP legislature and Cooper agree on a separate budget deal, which is no small thing given a recent history of standoffs and the opportunity for mischief by individual legislators hoping to undermine agreement for one reason or another.
But the overwhelming margins behind Medicaid expansion and investment in it by the state’s most powerful elected officials mean it is likely to happen, by most accounts ― that it’s probably a question of when, not if, an estimated 600,000 low-income residents will soon have a chance to get health insurance.
That’s a lot of people whose lives are about to change. Studies have found all sorts of benefits of Medicaid enrollment, from a reduction in debt and credit problems to better school attendance for kids. Then there is peace of mind ― and, quite possibly, better health ― that comes when people don’t have to ration their heart medication or go without much-needed joint surgery because they can’t afford it.
“This has been a long process,” Cooper told me in an interview, “but this is a perfect example of Dr. King’s assertion that the arc of the moral universe is long, but it bends towards justice.”
So how did this transformation take place?
Over the last few days, I put that question to some of the people who know best, including the governor, a key GOP legislator and some longtime advocates. I also checked the local coverage in outlets like the Charlotte Observer, North Carolina Health News and The Assembly.
The story that emerges is a case study in how change in America takes place nowadays ― or, at least, how it can take place when the circumstances are just right. It’s also an indicator of the shifting political conversation about health care, specifically the Affordable Care Act, which just happened to turn 13 years old on the same day the North Carolina House took its final vote this Thursday.
The law’s architects, including former President Barack Obama, always hoped the program would get some kind of bipartisan support ― enough, at least, to allow widespread, relatively smooth implementation. It hasn’t worked out that way in many places.
But it may finally be happening in North Carolina.
The Toxic Politics of ‘Obamacare’
Medicaid expansion itself was never supposed to depend so much on the goodwill of state officials. It was supposed to be the “easy” part of the Affordable Care Act, because all it required was states changing eligibility levels for a program that they already operated, with the feds picking up most of the tab.
The catch was that the federal government can’t simply order states to change their laws, so the Affordable Care Act as originally written took advantage of federal leverage to make it happen: If states declined to expand eligibility, then they would lose all federal Medicaid funding ― a potential financial calamity none of them could afford. It was the ultimate offer they couldn’t refuse.
Or at least it was supposed to be. In 2012, the Supreme Court struck down that threat as unconstitutional, giving state officials the ability to stick with their previous, stingier eligibility guidelines.
“That legislative process can be very difficult, but if you just stay at it, stay determined, you can move the ball forward.”
The Affordable Care Act’s champions hoped most states would expand anyway, if not for the sake of helping so many low-income residents than for the chance to draw so much extra federal money into their states, buoying the health care sector and economy as a whole. Neither incentive proved especially effective in states where Republicans held sway over government.
Instead, it was mostly reliably blue states like California and Maryland that expanded Medicaid initially. More came around over time, starting with a group of swing states where GOP governors touted the economic benefits and (in the notable case of Ohio Gov. John Kasich) biblical obligations to help the poor.
More recently, even some deeply red states like Idaho, Missouri and South Dakota have expanded Medicaid, though in those cases it was via ballot referendum. Medicaid expansion has always polled well; even staunchly conservative voters value the program and the chance to get health care.
But it’s been a while since expansion won support from a Republican legislature. The last time was 2018 in Virginia, and that was only after an election that left GOP majorities razor-thin ― and fearful of further losses.
A Democratic Governor Focused On Medicaid
Prospects for legislative expansion in North Carolina looked pretty bleak back in 2013, when Republicans in the Assembly first voted against expansion. But activists didn’t sulk after that setback. They got to work, embarking on what would become a persistent, patient campaign to raise awareness about the benefits of Medicaid expansion ― and, ultimately, to change minds in the legislature.
There were reports and rallies, with some serious policy work and a lot of storytelling, put together by a loose coalition that included social justice organizations and patient advocates. Medicaid expansion was also a focus of the “Moral Monday” protests that Rev. William Barber launched in 2013 to protest a variety of policies from the newly elected GOP governor, Pat McCrory, and his allies in the legislature.
Barber, a leader in the Civil Rights Movement, framed expansion as an urgent cause for equality ― and attacked McCrory for “stonewalling” it.
McCrory’s difficult tenure, culminating in a controversial transgender “bathroom” bill that cost North Carolina tourism business, left him politically vulnerable when he ran for reelection in 2016. His opponent was Cooper, who won narrowly in an election that defied the national pro-Republican trend that year ― and probably would have gotten more attention if not for the presidential election and its implications soaking up so much oxygen.
“Health care is complicated, and I think it just took some members time to really understand how it would help people.”
Cooper had campaigned on Medicaid being his top priority. And when he got into office, he kept at it, publicizing stories of people who were struggling and connecting those struggles to the state’s overall well-being — by noting, for example, that early childhood educators were among those frequently in low-wage jobs without coverage.
But there was only so much he could do without the votes. Medicaid expansion simply wasn’t going to happen without significant Republican support.
A Republican Convert ― And Then Another
Donny Lambeth, a Republican from a conservative district in the Winston-Salem area, came to the State House in 2013, just in time for that first vote against expansion. As a former hospital executive, his decision was easy, he told me in an interview. He saw no upside to putting more people into a program he already considered too expensive and hopelessly broken.
Medicaid was a major focus early in his tenure, culminating in a 2015 law that he and other supporters hoped would make the program more efficient by switching to managed care. That transformation also got him thinking about expansion again, he said, because the program felt stronger — and North Carolina’s fiscal situation did too.
The Affordable Care Act was still plenty controversial at that point. In fact, Donald Trump winning the 2016 presidential election led to an all-out repeal effort in Washington — an effort that, famously, came within John McCain’s thumb of going forward.
But the push to undo the law retreated following the 2018 midterms, when Republicans across the country campaigned on their opposition to the health care law and suffered big losses.
If nothing else, those developments seemed to reduce uncertainty about the permanence of Obamacare — and, with it, federal support of Medicaid expansion that North Carolina Republicans had previously called suspect. Phil Berger, the state’s deeply conservative Senate leader who had long opposed Medicaid expansion, was among those who eventually took notice.
“We’re working with everyday North Carolinians who are getting crushed by medical debt, who have been dealing with sicknesses that could have easily been prevented ... it's just a relief.”
Sometime a few years ago ago (accounts about precisely when differ) he began signaling he was open to the idea. In 2022, he gave his full endorsement, touting not just economic benefits to the state but also the potential human impact.
He used to worry about rewarding dependency, he said, but had since realized that most of the people who stood to benefit were working. They just couldn’t afford insurance.
“More often than not, what you have is a situation where folks who would be eligible for Medicaid in the expansion population are people that are actually working full time,” Berger said in an interview with PBS NewsHour earlier this year. “Sort of the person that seems to be helped the most would be a single female with one or two children who works a full-time job.”
Lambeth had been saying similar things for a while, and attributed growing GOP support for expansion — in part — to all of the stories and testimonies lawmakers kept hearing from people on the ground, who couldn’t get insurance or who could see the impact lack of coverage had on others.
“We had these people coming down to Raleigh, farmers, business owners, people from rural areas, they were advocating, telling stories,” Lambeth said. “Health care is complicated, and I think it just took some members time to really understand how it would help people.”
Republicans also heard a lot about the financial struggles of rural hospitals, which play a vital role in so many of their districts.
“Rural hospitals aren’t just a place to get care but also a key employer in many rural communities,” Adam Searing, an associate professor at the Georgetown University Center for Children and Families, explained in a recent briefing paper. “A hospital at risk of closure focuses local political attention on what can be done to help – and Medicaid expansion became an important part of the solution.”
Negotiations And ― Eventually ― A Deal
Berger is widely considered “the most powerful man in Raleigh,” as The Assembly once dubbed him, and his endorsement was a pivotal movement. But it took still took months of painstaking negotiation to get to an agreement.
Money was a big hang-up, as always, and hospitals agreed to pick up part of the cost through an “assessment.” (They’ll still come out ahead, because the expansion provides so much revenue.) The chance to draw on two extra sources of federal money, one of them as part of President Joe Biden’s COVID-19 relief package, greased the skids even more.
One last stubborn dispute was over regulations restricting the construction of new hospitals and outpatient surgery centers, which existing hospitals very much wanted to maintain but many lawmakers, including GOP leaders, wanted to scale back — partly because of the theory that increasing Medicaid enrollment would increase demand for health services, so it made sense to ease up on supply limits.
The hospitals gave some ground, more Republicans came around and a deal finally came together last month.
“It’s been a really long journey,” said Hyun Namkoong, deputy director for health advocacy at the North Carolina Justice Center, one of the groups that has pushed hardest. “We’re working with everyday North Carolinians who are getting crushed by medical debt, who have been dealing with sicknesses that could have easily been prevented ... just horrific things that eventually end up being disability or even death.”
“Honestly,” she said, “it’s just a relief.”
New Politics, And Old
The benefits of Medicaid expansion that Republicans have been hailing these past few weeks aren’t new. They were the same benefits that advocates and supporters have been highlighting since 2013. The difference is that Republicans are listening — and agreeing — this time. Pretty much everybody agrees that’s partly a reflection of the changing politics around the Affordable Care Act.
“A lot of our advocacy and coalition work was very much focused on: how do we identify the most effective messengers to resonate with our conservative lawmakers to find some other way forward, so it doesn’t feel like traditional Medicaid expansion, because it was sort of toxic,” Brendan Riley, vice president for government relations at the North Carolina Community Health Center Association, told me.
“We’re just in a different space now, and the fact that we have our lawmakers, who are longtime opponents, are on the floor, talking about it being the right time to expand Medicaid. It’s clear we’re just in a different time,” Riley said.
Cooper credits activists for keeping up the pressure all these years, and individual Republicans for embracing the cause when it was so unpopular in their ranks. He also thinks local organizations with credibility among conservatives, like local business groups touting economic benefits or law enforcement talking about the potential to keep people with mental illness out of the criminal justice system, had a big effect.
Cooper is also a believer in bipartisanship, though he emphasizes it doesn’t come easy.
“It requires hard work and requires listening to people, building coalitions and finding leverage,” Cooper said. “That legislative process can be very difficult, but if you just stay at it, stay determined, you can move the ball forward and get positive things done.”
Lambeth echoed the endorsement of bipartisanship, on at least some issues. “I didn’t go down to the General Assembly as a Republican,” he said. “I had to get elected as a Republican, but I went down to help people, to try and make North Carolina a better state, and one of the best things we can do in North Carolina is to expand Medicaid.”
Assuming expansion unfolds as Cooper and Lambeth and the other champions hope, it will reduce the ranks of holdouts to just 10 states, nearly all of them in the South. That is the part of the country where high poverty levels arguably mean more Medicaid would make the most difference. That is also the part of the country where conservative Republicans have their tightest grip on government.
The two largest states by population are Florida and Texas. Expansion would make more than 1 million people eligible for coverage in just those states alone, according to estimates. But there’s no sign of interest from GOP governors Ron DeSantis or Greg Abbott, or their legislatures either. Change may yet come to those states, but it will apparently take even more time — and more work too.