How This State GOP Completely Changed Its Mind On Medicaid Expansion

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McCrory’s difficult tenure, culminating in a controversial transgender “bathroom” bill that cost North Carolina tourism business, left him politically vulnerable when he ran for reelection in 2016. His opponent was Cooper, who won narrowly in an election that defied the national pro-Republican trend that year ― and probably would have gotten more attention if not for the presidential election and its implications soaking up so much oxygen.

Cooper had campaigned on Medicaid being his top priority. And when he got into office, he kept at it, publicizing stories of people who were struggling and connecting those struggles to the state’s overall well-being — by noting, for example, that early childhood educators were among those frequently in low-wage jobs without coverage.

But there was only so much he could do without the votes. Medicaid expansion simply wasn’t going to happen without significant Republican support.

Donny Lambeth, a Republican from a conservative district in the Winston-Salem area, came to the State House in 2013, just in time for that first vote against expansion. As a former hospital executive, his decision was easy, he told me in an interview. He saw no upside to putting more people into a program he already considered too expensive and hopelessly broken.

Medicaid was a major focus early in his tenure, culminating in a 2015 law that he and other supporters hoped would make the program more efficient by switching to managed care. That transformation also got him thinking about expansion again, he said, because the program felt stronger — and North Carolina’s fiscal situation did too.

The Affordable Care Act was still plenty controversial at that point. In fact, Donald Trump winning the 2016 presidential election led to an all-out repeal effort in Washington — an effort that, famously, came within John McCain’s thumb of going forward.

But the push to undo the law retreated following the 2018 midterms, when Republicans across the country campaigned on their opposition to the health care law and suffered big losses.

If nothing else, those developments seemed to reduce uncertainty about the permanence of Obamacare — and, with it, federal support of Medicaid expansion that North Carolina Republicans had previously called suspect. Phil Berger, the state’s deeply conservative Senate leader who had long opposed Medicaid expansion, was among those who eventually took notice.

Sometime a few years ago ago (accounts about precisely when differ) he began signaling he was open to the idea. In 2022, he gave his full endorsement, touting not just economic benefits to the state and struggling rural hospitals, but also the potential human impact.

He used to worry about rewarding dependency, he said, but had since realized that most of the people who stood to benefit were working. They just couldn’t afford insurance.

“More often than not, what you have is a situation where folks who would be eligible for Medicaid in the expansion population are people that are actually working full time,” Berger said in an interview with PBS NewsHour earlier this year. “Sort of the person that seems to be helped the most would be a single female with one or two children who works a full-time job.”

Lambeth had been saying similar things for a while, and attributed growing GOP support for expansion — in part — to all of the stories and testimonies lawmakers kept hearing from people on the ground, who couldn’t get insurance or who could see the impact lack of coverage had on others.

“We had these people coming down to Raleigh, farmers, business owners, people from rural areas, they were advocating, telling stories,” Lambeth said. “Health care is complicated, and I think it just took some members time to really understand how it would help people.”

Berger is widely considered “the most powerful man in Raleigh,” as The Assembly once dubbed him, and his endorsement was a pivotal movement. But it took still took months of painstaking negotiation to get to an agreement.

Money was a big hang-up, as always, and the final deal involved hospitals picking up part of the cost because they stood to benefit so much from the expansion coverage. The chance to draw on two extra sources of federal money, one of them as part of President Joe Biden’s COVID-19 relief package, greased the skids even more.

One last stubborn dispute was over regulations restricting the construction of new hospitals and outpatient surgery centers, which existing hospitals very much wanted to maintain but many lawmakers, including GOP leaders, wanted to scale back — partly because of the theory that increasing Medicaid enrollment would increase demand for health services, so it made sense to ease up on supply limits.

The hospitals gave some ground, more Republicans came around and a deal finally came together last month.

“It’s been a really long journey,” said Hyun Namkoong, deputy director for health advocacy at the North Carolina Justice Center, one of the groups that has pushed hardest. “We’re working with everyday North Carolinians who are getting crushed by medical debt, who have been dealing with sicknesses that could have easily been prevented … just horrific things that eventually end up being disability or even death.”

“Honestly,” she said, “it’s just a relief.”

The benefits of Medicaid expansion that Republicans have been hailing these past few weeks aren’t new. They were the same benefits that advocates and supporters have been highlighting since 2013. The difference is that Republicans are listening — and agreeing — this time. Pretty much everybody agrees that’s partly a reflection of the changing politics around the Affordable Care Act.

“A lot of our advocacy and coalition work was very much focused on: how do we identify the most effective messengers to resonate with our conservative lawmakers to find some other way forward, so it doesn’t feel like traditional Medicaid expansion, because it was sort of toxic,” Brendan Riley, vice president for government relations at the North Carolina Community Health Center Association, told me.

“We’re just in a different space now, and the fact that we have our lawmakers, who are longtime opponents, are on the floor, talking about it being the right time to expand Medicaid. It’s clear we’re just in a different time,” Riley said.

Cooper credits activists for keeping up the pressure all these years, and individual Republicans for embracing the cause when it was so unpopular in their ranks. He also thinks local organizations with credibility among conservatives, like local business groups touting economic benefits or law enforcement talking about the potential to keep people with mental illness out of the criminal justice system, had a big effect.

Cooper is also a believer in bipartisanship, though he emphasizes it doesn’t come easy.

“It requires hard work and requires listening to people, building coalitions and finding leverage,” Cooper said. “That legislative process can be very difficult, but if you just stay at it, stay determined, you can move the ball forward and get positive things done.”

Lambeth echoed the endorsement of bipartisanship, on at least some issues. “I didn’t go down to the General Assembly as a Republican,” he said. “I had to get elected as a Republican, but I went down to help people, to try and make North Carolina a better state, and one of the best things we can do in North Carolina is to expand Medicaid.”

Assuming expansion unfolds as Cooper and Lambeth and the other champions hope, it will reduce the ranks of holdouts to just 10 states, nearly all of them in the South. That is the part of the country where high poverty levels arguably mean more Medicaid would make the most difference. That is also the part of the country where conservative Republicans have their tightest grip on government.

The two largest states by population are Florida and Texas. Expansion would make more than 1 million people eligible for coverage in just those states alone, according to estimates. But there’s no sign of interest from GOP governors Ron DeSantis or Greg Abbott, or their legislatures either. Change may yet come to those states, but it will apparently take even more time — and more work too.