In this May 2018, file photo, from left, Senate President Pro Tempore Phil Berger, North Carolina Gov. Roy Cooper and House Speaker Tim Moore pause prior to a news conference in Raleigh, N.C. The legislature and Cooper have been bitterly at odds over Medicaid expansion, although this year's election has the potential to break the logjam. (AP Photo/Gerry Broome, File) Phil Berger, Roy Cooper, Tim Moore
In this May 2018, file photo, from left, Senate President Pro Tempore Phil Berger, North Carolina Gov. Roy Cooper and House Speaker Tim Moore pause prior to a news conference in Raleigh, N.C. The legislature and Cooper have been bitterly at odds over Medicaid expansion, although this year's election has the potential to break the logjam. (AP Photo/Gerry Broome, File)

Fundamental questions about health care are defining the races in four state legislative races with the potential to flip control. 

By all indications, North Carolina’s new voting districts will make the state legislature more politically diverse. But is it a new North Carolina? 

Not really. The state has always tended to the moderate side, whether it wandered through Democratic or Republican rule. And even if the state’s urban centers are growing by volumes, courtesy of a more diverse and ostensibly progressive base, North Carolina is as much about those far-flung rural towns and villages in the mountains or on the coast as it is about the Triangle, the Triad and Charlotte. It has always been as much Terry Sanford and Jim Hunt as Pat McCrory or Phil Berger. 

Put simply, this state contains multitudes. 

But there are some commonalities. Whether you live in Brevard or Boone, Washington or Waynesville, Mount Airy or Mount Olive, you care about your health care, your education, your job and your family. 

These are causes often labeled as “progressive” or “conservative,” but some things cross all boundaries.

To that end, Cardinal & Pine is diving into some of the most intriguing districts in North Carolina during the 2020 election, exploring the issues that voters care about and where the candidates stand. 

The districts are intriguing because they have the power to shape control of the NC Senate, the upper chamber of the NC General Assembly. Controlled by Republicans for most of the last decade, Democrats are hoping to win five seats and claim the majority. They can’t do so without districts like these four.

Today, we’ll take a look at one of the most pivotal issues facing these districts: Medicaid expansion.

A state in limbo

North Carolina, which has the 10th highest number of uninsured people in the US, is one of only 12 states to have declined to expand access to Medicaid. The option, a part of the Affordable Care Act, was intended to close the gap between people who earn too much to qualify for Medicaid, but don’t make enough for health care subsidies. 

Supporters have noted that expansion could not only boost health care for low-income residents, but stabilize struggling rural hospitals too.

Most of those 12 resistant states are traditionally conservative, but there are several deep red states—Kentucky, West Virginia, Idaho, Arkansas and Louisiana to name just a few—who have expanded access to some degree. 

In North Carolina, the debate over expansion is rancorous and partisan in the legislature, although not particularly partisan among voters. The 2020 election has an excellent chance of tipping the scale.  

Last year, Gov. Roy Cooper, a Democrat who is up for re-election, and the Republican-controlled General Assembly, which could flip to Democrats this year, virtually locked down over the Medicaid issue. 

Cooper demanded that any state budget include expansion. The Assembly refused. Cooper vetoed the expansionless budget, and while the Assembly Republicans would not budge, they failed to override the veto, leaving the state in limbo.

According to census data, 14% of North Carolinians are in poverty, and 10.7% are uninsured. The numbers are soaring because of COVID-19 and the economic fallout. After the pandemic hit in earnest, there was some support among Assembly Republicans for a limited expansion tied only to COVID, but there is still significant resistance to anything larger. 

Republican leaders have said that expanding Medicaid would not solve any issues and would make others worse.

But public sentiment seems to back expansion. According to a new survey of NC voters, which sampled 612 North Carolinians on Aug. 26-27, 77% of respondents favor expanding Medicaid. And, while only 8% see health care as the most important issue facing the state, 28% say COVID issues are most pressing, and 14% say unemployment and jobs are the top concerns, two issues inseparable from access to affordable care.

Most studies show that some 500,000 people in the state fall in the coverage gap, 60% of whom come from working families. 

Indeed, the NC Healthcare Association, which represents the state’s healthcare systems, wrote on its website that “100,000 full-time workers in our state live between 100% and 125% of the federal poverty level. These hard-working individuals are our state’s farmers, veterans, clergy, and service industry workers. Working individuals and families deserve affordable access to health insurance. Healthier workers mean a healthier economy, which is why coverage is also critical for a strong workforce.”

The ramifications of expansion are complex, of course, and include issues of lost compensation as well as individual health. When people without insurance get sick, they often have to go to emergency rooms, which cannot deny them care in most cases. That care often goes unpaid for. 

Here is a look at how candidates in some key NC races stand on Medicaid expansion and their reasoning, one way or the other. 

NC Senate District 1: Sen. Bob Steinburg (R) v. Tess Judge (D)

Sen. Bob Steinburg (R), left, and Tess Judge (D), right

Sen. Bob Steinburg is in his first term in this eastern NC district. A businessman from Edenton, Steinburg’s term was heavily focused on prison reform after a deadly 2018 prison escape attempt in his district. 

But on Medicaid expansion, the GOP senator was bitingly critical of Gov. Cooper’s demands for expansion in the 2019 budget process. 

“Democrats are cheering hospital layoffs because they hope to score political points, which is sad,” Steinburg said in a Medium post from Berger’s press team this year. “Shifting private insurance patients onto Medicaid would result in a lower reimbursement rate over time, which only puts hospitals on weaker financial footing. If Gov. Cooper would drop his Medicaid expansion ultimatum, we could work toward helping hospitals instead of playing politics with the livelihood of the men and women in eastern North Carolina.”

Steinburg’s opponent, Tess Judge, says however that expansion, and health care in general, is one of the most pressing issues facing rural districts like hers, not only for the residents of eastern NC but the hospitals serving those areas.

“We need to expand access to health care,” Judge told Cardinal & Pine last week. “We’ve had rural hospitals close throughout the state. COVID has been really hard on all of us, but it really has bubbled things to the top that need to be recognized and resourced and funded. Access to health care in these rural communities is the top of that list.”

NC Senate District 11: Lisa Barnes (R)  v. Allen Wellons (D)

Rep. Lisa Barnes (R), left, and Allen Wellons (D), right

This redrawn eastern NC district, including parts of Nash and Johnston counties, is without an incumbent this year as the GOP senator opted out of running for re-election. 

The candidates could not be farther apart on Medicaid expansion.

Allen Wellons, an attorney and farmer from Smithfield, served in the state legislature from 1996 to 2002 but was ousted when lawmakers gerrymandered his district into a conservative one. Medicaid expansion has been a significant component of Wellons’ campaign thus far, and negative advertising aimed at his opponent, Republican state Rep. Lisa Barnes, has focused on her role in a GOP majority blocking expansion. 

“We can make a difference in North Carolina by bringing back a legislature that works for education, that expands Medicaid,” Wellons told Cardinal & Pine.

Barnes did not respond to a C&P interview request, but on her campaign site, the Republican state representative is broadly critical of the Affordable Care Act, the national law that cleared expansion. 

“Health care should be patient-oriented and proactive,” Barnes wrote. “We need not only to try to address the barriers to quality health care, but in conjunction, the barriers to transportation, education, and even the motivation to be healthy.”

NC Senate District 24: Amy Galey (R) v. J.D. Wooten (D)

Amy Galey (R), left, and J.D. Wooten (D), right

This Triad race has been stirred somewhat by an ongoing debate over Confederate memorials in the state, but health care figures to be as crucial an issue in this campaign as in any.

Galey, a conservative attorney who leads the Alamance County commission, is not campaigning however on health care. Her campaign has centered on gun rights, economic recovery, and school choice. She was also behind a debunked mailer accusing her opponent of fraud.  

Wooten, a former US Air Force officer, has been outspoken since running for office in 2018 about the impact the GOP’s opposition to Medicaid expansion has had on North Carolinians, and veterans in particular.

Wooten’s backing of expansion has carried over into this election as well.

“There is no reason anyone needs to suffer from preventable or easily treated illness or disease,” he wrote on his campaign site. “I support the Affordable Care Act, especially its protections for preexisting conditions and the creation of insurance exchanges to buy private healthcare insurance. As a state, we should take advantage of all programs available to us to improve the basic quality of life of our citizens and their health. That starts with expanding Medicaid as allowed under the Affordable Care Act (after all, we have already paid for it!).”

Senate District 31: Sen. Joyce Krawiec (R) v. Terri LeGrand (D)

Sen. Joyce Krawiec (R), left, and Terri LeGrand (D), right

Senate District 31 includes almost 200,000 North Carolinians in the mostly rural and suburban stretches of Davie and Forsyth counties. The district has been dominated by veteran Senate Republican Joyce Krawiec, who, when it comes to the state’s healthcare laws, remains one of the most influential members of the Senate. 

Given the Senate is widely considered the primary obstacle to any form of Medicaid expansion, it is lawmakers like Krawiec holding an outsized power in this debate. 

Krawiec has not responded to multiple Cardinal & Pine requests for an interview to discuss expansion in recent months, although she is an opponent. The senator wrote on her campaign site that she believes expansion could imperil care for those already enrolled in the state. 

“It’s predicted that expansion would add an additional 500,000-600,000 citizens, predominantly able-bodied childless adults,” Krawiec wrote. “Most states have seen their enrollment numbers double, triple and even quadruple predictions and have experienced cost overruns of at least 50%. NC is likely to be no different.”

Cardinal & Pine reported this week on the fiscal impacts of expansion. Researchers have noted many states that expanded ultimately saw a cost-savings as they moved adults from existing state-funded health programs into Medicaid. 

Krawiec’s opponent, Winston-Salem attorney Terri LeGrand, tells C&P she supports expansion.

“It is unconscionable that we have hundreds of thousands of people in the state of North Carolina who are going without health insurance right now when we could do something about it and do it at very little expense to the people of North Carolina,” LeGrand said.

It is at least partly personal for LeGrand, who says GOP opposition to expansion stems from the party’s overall criticism of the Affordable Care Act. Through the ACA, LeGrand said her 22-year-old daughter, who has a chronic health condition, would have to acquire insurance on her own.

“If you’re (a NC lawmaker) sitting there in a privileged position of having health insurance provided to you by the state, it’s inexcusable that you’re not thinking about the many people across our state who do not,” she said.