In March this year, the North Carolina legislature passed Medicaid expansion with bipartisan support, becoming the first state to pass expansion legislatively since Virginia in 2018. In an interesting turn of events, many House and Senate Republicans in North Carolina, who for years staunchly opposed expanding Medicaid, changed their positions leading up to the bill’s passage. We wrote about their reversal in opinion – and the reasons behind it – last September as Medicaid expansion discussions were heating up in the state.

Now with Medicaid expansion legislation signed by Governor Cooper, we’re looking at how Republican leaders in the state justified expansion – at least in the press and their public statements –  after years of opposition. To gain this insight, we listened to GOP legislators speak on the issue and took a close look at media coverage of Medicaid expansion around the time of its legislative approval and signing. Overall, we found three main messages being used by Republican state legislators to justify Medicaid expansion: Expanding Medicaid is now fiscally responsible because of changes we have made in the NC’s Medicaid program coupled with national experience that has convinced us that it is now a financially sound decision; Medicaid expansion will strongly support rural hospitals and individuals in rural communities; Medicaid expansion will support improvements in our mental health system and health care system overall.

1. Medicaid expansion is a fiscally responsible decision for the state of North Carolina because of changes we have made in NC’s Medicaid program and the way we expand.
   [State Representative Donny Lambeth (R-Winston-Salem)] “And I think, when you first talk about expansion, it is like – and this was what they said to me – oh, no, we’re expanding another government entitlement program. The neat thing about this program is, it doesn’t cost the state any money.” (PBS News Hour)[Speaker of the House Tim Moore (R-Cleveland)] “This is something that we can all be very proud of […] What a huge announcement this is for North Carolina. What a huge policy direction this is that will provide help for so many in this state, but it’s going to do it in a way that’s fiscally responsible.” (AP News)

   [State Senator Joyce Krawiec (R- Kernersville)] “We have been talking about this for a long time,” Krawiec said debate last week. “Actually we have been talking about this long before many of us arrived here in the Senate. Many of us were opposed for a very long time. I was one of those. We were dealing with a broken Medicaid cycle in North Carolina. Every cycle we were plugging holes. We had to fix that before going into expanding Medicaid.” She cited nine years of balanced budgets, underscored the negotiated aspects of the bill, called it a “lifeline for rural hospitals” (Fox 8)

2. Medicaid expansion will support rural hospitals and rural communities in addition to people across the state.
   [Congressman Greg Murphy (R-NC)] “As a physician and former state legislator, I am supportive of Medicaid expansion,’ Murphy said. ‘It will go a long way toward helping our middle class. Hospitals, especially our rural hospitals, will have stability.” (WNCT)“State Sen. Joyce Krawiec (R-Kernersville), a co-chair of the Senate Health Committee and a new advocate for the expansion as an opportunity to help rural hospitals, had presented the bill for final approval in the Senate, which came on a vote of 44-2.” (Fox 8)

   “Rep. Wayne Sasser, a Republican from Albermarle and a bill sponsor, said Tuesday expansion would “help our rural hospitals, and North Carolina is still 80% rural.” (News & Observer)

   [State Representative Donny] Lambeth [R-Winston-Salem] told lawmakers earlier this week the bill had “been wildly debated across the state” and had “several associations and groups endorse it” including the N.C. Association of County Commissioners and N.C. Sheriffs’ Association. “Obviously, there’s some who don’t particularly like this bill,” he added. But expansion is about “that person, whether they be a veteran, or a farmer that risks losing their farm because they have some catastrophic health care bill that they can’t pay,” said Lambeth, a retired hospital administrator who said he had worked in health care for 40 years. “It’s really about helping the people of North Carolina,” he said Tuesday. (News & Observer)

3. Medicaid expansion savings will be used to support mental health programs and our expansion will also improve the health system, removing red tape for health care facilities and providers.
   [State Representative Kristen Baker (R-Cabarrus), speaking on a proposal on how to use $1 billion in one-time federal funds, received through Medicaid expansion, to improve mental health care for kids] “We stand united before you, committing our resources against a common enemy, and it’s an enemy that threatens us. It threatens to steal our joy, it threatens to steal our children, threatens to steal our lives.” (News & Observer)[State Representative Wayne Sasser (R-Stanly)] “Sasser said the legislature was in conversation with the state Department of Health and Human Services about using funds from expansion for mental health programs. He said the bill would provide “a lot of money that will help mental health, which is the biggest health issue that not only in North Carolina, but in the United States.” (News & Observer)

   [Republican Senate President Pro Tempore Phil] Berger (R-Eden) talked about managing the influx of people enrolling in Medicaid and what more he’d like to see. “While this is a momentous occasion, our work is not done,” Berger said. “We need to continue to forge ahead with additional supply-side reforms,” he added. “We were able to make a good dent in reforming our state’s certificate of need laws, but we can do more to remove the red tape that healthcare facilities and providers face in North Carolina.” (News & Observer)

And encompassing all three of these justifications, “​​[Donny] Lambeth, a Forsyth County Republican, said Wednesday that expansion ‘makes financial sense for our state.’ Expansion would help ‘rural North Carolina, which continues to struggle with health care’ as well as ‘our mental and behavioral health care system which is in need of reform and funding,’ Lambeth said.” (News & Observer)