Medicaid expansion goes live in North Carolina today, opening up the government-run health insurance program to hundreds of thousands of low income adults.
The state's Republican-controlled legislature had for years rejected expansion, part of the Affordable Care Act that passed during President Obama's administration and derided by opponents as "Obamacare."
This year, however, the Tar Heel state changed course.
State Senate leader Phil Berger, a Republican and one of the most influential politicians in the state, said he initially opposed expansion because he was unsure that the federal government would hold true to its promise of covering 90% of the medical costs of the expansion population. For those in North Carolina already on Medicaid, the federal government covers only two-thirds of the medical costs, with the rest falling to the state. The difference between two-thirds and 90% amounts to hundreds of millions of dollars per year, and Berger had said he didn't want the state to be saddled with that additional cost.
But over the years, lawmakers on both sides of the aisle passed through Congress and the White House without changing that provision. And that left Berger feeling confident the federal government would, in fact, cover costs at 90%.
Additionally, the expansion in North Carolina does not include a work requirement, as some other states have proposed. Berger said he looked at the population that would become newly eligible and determined the bulk of those people already work at least 30 hours per week.
Federal incentives seal the deal
North Carolina joins 39 other states that have already expanded Medicaid across the country. Under President Biden's administration, the federal government has added even more incentives to help convince the remaining holdout states. Thanks to those additional incentives, North Carolina hospitals are getting $2.6 billion, and the state legislature is investing $835 million in behavioral health, including the first reimbursement rate increase for behavioral health services in more than a decade.
"Medicaid Expansion is the most significant investment in the health of North Carolina in decades and represents billions of dollars of investment each year that helps keep clinics, providers and hospital doors open," said state health secretary Kody H. Kinsley.
Health advocates cheered the arrival of expansion day, something they say has been a decade coming.
"Our team has been pulling really long nights and days to get everything pulled together for day 1 of Medicaid expansion," said Hyun Namkoong, deputy project director of the Health Advocacy Project of N.C. Justice Center, a liberal-leaning think tank and advocacy group. "But it has completely been worth it. This is what we've been working for, for the last 10 years."
Namkoong's group has already scheduled more than two dozen community events all over North Carolina to raise awareness that expansion is live and get the word to people who might not realize they qualify.
Who qualifies for Medicaid now?
North Carolinians between the ages of 19 to 64 who make up to 138% of the federal poverty line now qualify for Medicaid. That’s any single adult who makes less than $20,000 per year, or a family of three with an income below $34,000 combined. Until now, full Medicaid coverage in North Carolina was available only for low-income residents who were: disabled, elderly, children, and pregnant people through the first year of a child’s birth. Some very low-income parents could also qualify.
"Finally expanding Medicaid in North Carolina is a monumental achievement that will extend health insurance to people who need it," said North Carolina Governor Roy Cooper, a democrat who has pushed for expansion throughout his two terms.
He added: "This means better health care, including those with mental health and substance abuse disorders, hope for rural hospitals struggling to stay open and billions of dollars for our economy. This action is long overdue, and we aren’t wasting a moment in beginning enrollment in North Carolina."
A first in the South
North Carolina becomes the first state east of Louisiana and south of Virginia to expand Medicaid. Advocates in other southeastern states hope that North Carolina making the move might lead other states to follow. But while there has been some increased chatter about expansion in some states, no state seems likely to imminently pass such a bill.
South Carolina Governor Henry McMaster has long opposed expansion and on Nov. 27 his communications director confirmed that the "governor's position remains unchanged."
In Tennessee advocates are pointing to North Carolina in an attempt to convince lawmakers, but have so far not found success. The state is missing out on these additional federal funds that North Carolina will be receiving, said Tennessee Justice Center Executive Director Michele Johnson, adding that much of the state's business community supports expansion.
"All those things show that it absolutely, positively is better for states to do this, and we can't even have a conversation about it," she said. "It doesn't give me a whole lot of hope."
Still, Johnson says she's an "eternal optimist" and that pitching expansion as a way to solve the state's workforce shortages could be a winning argument.
"We definitely think that having the example of North Carolina is moving to people who think we can't do this," she said.
