Last month, my colleague Adam Searing wrote a blog post about the status of Medicaid expansion in five states (South Dakota, North Carolina, Wyoming, Missouri, and Mississippi) twelve years after the passage of the Affordable Care Act. This week, we’re taking a closer look at one of these states, North Carolina, which is on a unique and potentially promising path to expanding Medicaid.

Unlike most other states yet to expand Medicaid (with the exceptions of Kansas and Wisconsin), North Carolina has a bipartisan controlled state government – with a GOP led legislature and Democratic Governor – showing that the state has both an opportunity and necessity to come to a bipartisan agreement on how to increase healthcare access and coverage for North Carolinians.

The Governor of North Carolina, Roy Cooper, is a proponent for Medicaid expansion and has proposed expanding Medicaid twice already in his state budgets for 2020 – 2021 and 2022 – 2023. In neither case did the GOP led legislature include the expansion in the final budget. However, opinions towards Medicaid among members of the North Carolina GOP appear to be shifting, with GOP State Senate leader Phil Berger indicating a new openness to considering expansion.

This year’s budget bill did include a step forward through the creation of a bipartisan committee, the Joint Legislative Committee on Access to Healthcare and Medicaid Expansion. This committee, composed of eighteen members of the House and Senate, will consider Medicaid expansion and “the various ways in which access to health care and health insurance can be improved for North Carolinians.”

The committee has met four times since the start of the year, hearing presentations on topics ranging from rural hospitals to the health workforce, and of course, the impact of expansion. The committee even heard testimony from former Ohio GOP Governor John Kasich urging Medicaid expansion to help those in need, in addition to case studies on expansion in Indiana and Michigan. Most recently, the committee heard presentations on increasing the practice authority of nurses as a way to improve access to healthcare.

What is to come from the committee remains to be determined. North Carolina’s legislative “short session” (the second convening of its regular legislative session) will begin in May this year and it is possible that there may be a vote on Medicaid expansion. GOP Representative and Co-Chair of the committee, Donny Lambreth, has also stated that a package of health care access initiatives from the committee could come up for a General Assembly vote in September or October.

Addressing the committee, Medicaid Director Dave Richard noted that Medicaid expansion is a “good deal” for North Carolina, and makes “great sense” to improve the health of the state’s population, particularly given the increased enrollment in Medicaid during the coronavirus pandemic and federal financial incentives to expand Medicaid through the American Rescue Plan Act of 2021 (ARPA). North Carolina would receive an estimated $1.5 billion to $2 billion in federal funding to fund expansion through ARPA.

North Carolina has significant gaps in healthcare coverage that need to be addressed. In 2019, the state had the ninth highest uninsured rate in the country, with 11.4% of the population without coverage. Currently, parents with incomes up to 41% of the Federal Poverty Line (FPL) are eligible for Medicaid in North Carolina. Adults without dependent children are not eligible for Medicaid, regardless of their income. If the state were to expand Medicaid to 138% FPL, an estimated 500,000 uninsured nonelderly adults would become eligible for coverage. Medicaid also constitutes a significant source of health insurance for children in North Carolina, covering 41% of individuals under 18 years old. However, almost 6% of children in the state are still uninsured. Covering parents would likely have a “welcome mat” effect for children.

In the twelve states that have not expanded Medicaid under the Affordable Care Act, expansion is a source of continuing debate. North Carolina’s work to address healthcare access and coverage this year shows bipartisan efforts around expansion can move the debate forward.