The ancient Roman historian Tacitus wrote that, “It is the singularly unfair peculiarity of war that the credit of success is claimed by all, while a disaster is attributed to one alone.” In the spirit of this observation from 97 AD, I’ll happily admit to trying for at least some historical involvement in North Carolina’s Medicaid expansion debate. After all, it was “only” a decade ago I wrote a solemn op-ed explaining why expanding Medicaid in North Carolina “ought to be a ‘no-brainer.’” I was, of course, wrong. As in many states, the road to finally expanding Medicaid in North Carolina has been a long one but it seems enactment is finally going to happen. Last fall, Jade Little and I detailed how former opponents of expansion in NC had changed into very public supporters – and now a bill is close to passage in the North Carolina General Assembly.  The bill will start expansion after the enactment of a state budget for this fiscal year. Even with this delay and the budget condition, most observers expect expansion to be enacted in North Carolina.

The politics around this change in North Carolina are quite interesting. This is a very big deal. North Carolina is one of the four states with the largest population of residents who will be eligible for expansion coverage, a total of around 600,000 people in North Carolina alone. The other non-expansion states with the largest affected populations are Georgia, Florida, and Texas. The effects of this bill will be significant on the health and financial security of a very large number of people and North Carolina, including especially its rural hospitals, will benefit substantially financially as well – the state’s federal incentive bonus for expanding is approximately $1.8 billion.

North Carolina is also notable as the first state since Virginia in 2018 to expand Medicaid through the legislative process rather than a ballot measure. Political leaders in non-expansion states have generally been much more reluctant than voters themselves to expand Medicaid. Voters, if given a chance, have passed expansion ballot initiatives by wide bipartisan margins in multiple states. However, after South Dakota voters passed a Medicaid expansion ballot measure this year, there was speculation that this would be the last state to expand in this way. North Carolina’s expansion shows the move toward expansion is no longer confined to ballot states as it has been over the past five years. More leaders are finally moving towards the pro-expansion position where many of their voters across the political spectrum have been for a while. And most of the remaining ten non-expansion states must expand legislatively as they have no mechanisms for voter-driven ballot initiatives.

What are the issues that moved many North Carolina policymakers who were some of the staunchest Medicaid expansion opponents in the nation to finally embrace expansion? In my view there isn’t really one reason but a combination of factors that came together to make this change possible:

1. A very supportive Governor kept Medicaid expansion hopes alive.  North Carolina’s Governor, Roy Cooper, has made Medicaid expansion a centerpiece of his policy agenda for years. This has kept the issue at the front of NC political debates and given support to much of the other efforts detailed here.
2. GOP leaders in North Carolina reorganized the Medicaid program over multiple years to include more Medicaid managed care. This was a substantial change and many legislative leaders, right or wrong, contend that they had fixed a system they saw as “broken.” With their stamp on Medicaid system “improvement” they felt more comfortable expanding the program.
3. Policymakers heard from folks back home again and again and again. Over the years, multiple advocacy groups from the North Carolina Justice Center to NC Child and the Care for Carolina Coalition to groups like the American Cancer Society spent time and countless hours in rural and urban districts organizing constituent meetings, getting to know people in the coverage gap and helping many, many people tell their own stories about how expansion would affect them. This includes people like the amazing DonnaMarie Woodson and the persistent Ricky Clay. This changed both media coverage and perceptions of Medicaid both locally and statewide and is a major reason Medicaid has become such a popular program.
4. Groups across the state also worked with local hospitals, local governments, local chambers of commerce, local businesses and business groups and slowly built a consensus around the need for expansion as a key component of helping working people, especially in rural communities and small towns.
5. Rural hospitals are hurting, and were vocal about the crisis they face when so many people walking in their doors can’t pay their bills. Rural hospitals aren’t just a place to get care but also a key employer in many rural communities. 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.
6. Unwinding of Medicaid continuous coverage protection adds extra pressure as many parents who qualified for Medicaid coverage are likely to lose it unless Medicaid expands.
7. Federal incentive payments make a strong financial case for expansion and continued success of Medicaid expansion in other states was reassuring. The generous federal financial incentives for expansion helped the state’s bottom line. The continued success of Medicaid expansion in other states debunked the doom and gloom warnings issued by Medicaid opponents and reassured policymakers that Medicaid expansion was here to stay.
8. Seeking political advantage? Next year North Carolina will hold statewide elections for Governor, Attorney General and other major offices. Medicaid expansion – or lack thereof – has become an important issue in these statewide races. Taking the issue off the table removes expansion from the political debate. And seeking a leg up on a statewide policy debate, the effort to change certificate of need laws governing health care operations got a political boost from their inclusion in the expansion bill.
9. The research helped. There are hundreds of studies on the effects of Medicaid expansion, that overall point toward the “positive effects of expansion across a range of increasingly complex and specific categories” from mortality to economic impact to maternal health. This is hard to ignore.
10. Even in our current environment, don’t discount dedicated, thoughtful politicians reaching beyond ideology for solutions. Lack of health coverage is a real problem. North Carolina House Representative Donny Lambeth, a years-long conservative proponent of expansion, said it best:

“We’re fighting to pass this bill to help people in North Carolina have a better standard of living (and) get better health care,” Rep. Donny Lambeth, a Forsyth County Republican and chief bill sponsor, told the House Health Committee. “Let’s really make a difference in North Carolina.”