When President Barack Obama and a Democratic Congress enacted the Affordable Care Act in 2010, states got the option of expanding Medicaid programs. Most took the offer of building on their joint federal and state programs, which help cover medical costs for some low-income people.
But several states have declined to expand Medicaid under Obamacare, though that's shifting somewhat. South Dakota voters in 2022 passed a ballot initiative to do so. Another holdout, North Carolina, is changing course via the legislative process rather than a voter referendum. These late-in-the-game embraces of Medicaid expansion offer examples to the remaining holdout states if there is eventual interest: Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming.
MEDICAID EXPANSION IS IN SIGHT FOR NORTH CAROLINA
In those places, which are red bastions except for swing-state Georgia, political leaders have cited what they say are soaring medical costs in other states after Medicaid expansion, along with an adverse impact on vulnerable patients already on Medicaid who may be forced to compete with expansion enrollees for limited available medical services.
President Joe Biden’s administration has offered a $1.5 billion bonus to incentivize states that haven’t expanded their programs. That played a role in North Carolina's change of heart, as GOP legislators say they’ve found a way to expand the state's Medicaid program without raising taxes or compromising quality of care. On March 2, state House Speaker Tim Moore and state Senate President Phil Berger announced a Medicaid expansion agreement.
In a joint statement, the Republican pair expressed confidence that the bill would pass through the North Carolina General Assembly in the coming weeks. If enacted, nearly 600,000 more residents will be eligible for healthcare coverage. The proposal also has a broad swath of support from Democratic lawmakers in a state where the legislature tilts Republican but has become a political battleground, as former President Donald Trump in 2020 only beat Biden there 49.93% to 48.59%.
FINAL STEPS
Current drafts of the legislation specify that expansion would only go into effect when the Tarheel State’s budget is signed into law. That provides leverage to legislators unwilling to compromise if the budget includes measures they oppose.
Both legislative leaders also said they have not yet spoken about the Medicaid expansion agreement with Gov. Roy Cooper (D-NC). Yet Medicaid expansion has been a priority for Cooper since he was first elected as North Carolina's governor in 2016. And if the proposal passes the General Assembly, Cooper is expected to sign it into law by the fiscal year’s end on June 30.
The Medicaid expansion deal also embraces other changes to the state’s healthcare system. At the top of the priority list for many legislators is an overhaul of the state’s certificate-of-need regulation, a law that requires healthcare regulators to grant permission on hospitals' plans for expansion, how much they can spend, and where they may build.
However, not everyone’s a fan of the Medicaid expansion proposal.
“In what can only be deemed as the largest expansion of entitlements in state history, the Republican-majority legislature has decided to saddle North Carolina taxpayers with significant financial burdens and drive up healthcare wait times for our state’s neediest and most vulnerable citizens,” said Donald Bryson, the president of the John Locke Foundation, a conservative think tank.
And political leaders in the Medicaid expansion holdout states aren’t convinced, either. In Florida, Gov. Ron DeSantis (R-FL) has steadfastly opposed expanding Medicaid. As a congressman in 2017, DeSantis voted to repeal the ACA. In DeSantis’s four-plus years as governor, state Republican leaders have joined him in rejecting Medicaid expansion, citing concerns about access to care and its potential cost.
According to the Commonwealth Fund’s 2019 Scorecard on State Health System Performance, Florida ranks near the bottom of states based on measures of access and affordability. And it has the highest rates of uninsured adults and preventable hospitalizations. Some say Medicaid expansion could help mitigate those problems.
DeSantis, a probable 2024 Republican presidential candidate, doesn't have much political incentive to change his approach to Medicaid expansion now. So, if Floridians do wish to follow through with Medicaid expansion, it’s only likely to happen through a ballot initiative process. That’s a difficult logistical procedure to navigate that has even caused activists to push off initiative efforts to 2026.
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The topic isn’t going away, though. Biden has been ratcheting up pressure on congressional Republicans to avoid cutting Social Security and Medicare in their attempts to cut the federal budget deficit and national debt. Biden often includes Medicaid in that basket of social insurance programs, which voters balk at shrinking, per years of polling on the issue.
If a state-level, bipartisan compromise could somehow be reached in the states that haven’t expanded Medicaid, North Carolina’s burgeoning model would be a place to start.