Republican Support for Medicaid Expansion Comes With Strings Attached

North Carolina state Rep. James Roberson, D-Wake, takes a picture with fellow House Democratic members on the House floor after the chamber gave final approval to a Medicaid expansion agreement in Raleigh, N.C., on Thursday, March 23, 2023. The affirmative vote means the legislation laying out expansion details now goes to the desk of Democratic Gov. Roy Cooper. (AP Photo/ Gary Gary Robertson)

By Michael McElroy

March 24, 2023

GOP leaders in the General Assembly finally budged on expanding healthcare options for 600,000 North Carolinians, but the bill is not without partisan games. 

After 13 years, several attempts and unlimited frustration, North Carolina has finally voted to expand Medicaid, extending a lifeline to 600,000 North Carolinians who currently fall into a deep insurance gap. 

The North Carolina General Assembly officially passed a bill on Thursday to fill that gap, and it now heads to Gov. Roy Cooper, who is expected to sign it as soon as possible. 

It is a life-changing piece of bipartisan legislation, even if that cooperation casually strolled toward an urgent finish line.

The bill will save lives, help prevent the closure of many rural hospitals, and bring in billions of dollars in federal money every year to pay for it all. The votes were lopsided, garnering support from every Democrat who voted and some 70% of the Republicans across both chambers, a showing of rare unity on what had been a severely partisan issue since the Affordable Care Act passed in 2010, making such expansion possible. 

Until this year, Republicans had blocked expansion at every move. But their change of heart is not without strings. 

The expansion will not take effect, according to provisions Republicans added to the bill, until the 2023-24 state budget is approved, even though it is not the state budget that will be paying for the expansion. More than 90% of the total cost will be paid for by the federal government.

So why the caveat? Because it gives Republicans clear leverage in mostly unrelated negotiations over the state’s budget, raising the possibility that if anyone wants expansion to ever actually take place, Democrats may have to make steep concessions in their other priorities, including public school funding, teacher pay, and infrastructure. 

In a statement after the vote, Tim Moore, the NC House Speaker, suggested as much.

Moore praised the bill in a statement after the vote, adding, “I look forward to a passing a strong conservative budget for North Carolina so that expansion can take affect.”

Budget negotiations are often contentious and can drag on for months. The window everyone in the government now wants to open will stay closed until the budget is passed.

That is time many people don’t have. 

  • People without health insurance often skip routine doctor appointments and are unable to afford the medicine they need, meaning they wait until they are too sick for anything but the emergency room, where they still can’t afford treatment but where the hospitals can’t turn them away. That raises costs for everyone. 
  • The number of uninsured people in North Carolina is steadily climbing
  • Several studies have shown that the states that failed to expand Medicaid were far more likely to see increased closures of hospitals, especially in rural areas. North Carolina has lost more rural hospitals in the last 20 years than all but three states in the nation. 

More hospitals could close if the budget negotiations drag on, which seems the whole point of this political calculus.

N.C. Out on a Limb

States have been able to expand their Medicaid rolls, on the federal government’s dime, since the passage of the American Care Act in 2010. And in most other states, expansion was not a partisan issue. Thirty-nine states, many with Republican leadership, at some point took the federal government up on its offer to close their insurance gaps.

But until yesterday, North Carolina was not among them.

Democrats in North Carolina’s state legislature have repeatedly sought to expand.

Instead, in 2014 the Republican-controlled legislature passed a bill rejecting expansion. Then-Gov. Pat McCrory, a Republican, signed it.

The votes were lopsided and entirely on party lines. Every Republican who voted, voted to block expansion, and only 1 Democrat joined them.

When Gov. Cooper took office in 2017, he pushed anew for expansion, and nearly every Democrat was ready to do so. That was six years ago. 

Even with the historic passage of the bill, those 600,000 North Carolinians, it seems, will have to wait some more. 


  • Michael McElroy

    Michael McElroy is Cardinal & Pine's political correspondent. He is an adjunct instructor at UNC-Chapel Hill's Hussman School of Journalism and Media, and a former editor at The New York Times.

CATEGORIES: Uncategorized


Local News

Related Stories
Share This