North Carolina has ended years of opposition and opted to expand its Medicaid program in 2024, meaning four in five U.S. states have embraced a key plank of Obamacare as opponents find it harder to resist federal funding and voters force a series of red states to extend coverage.

State Senate Republican Leader Phil Berger’s decision to back expansion marked a turning point and set the stage for legislative approval in Raleigh on the 13th anniversary of the Affordable Care Act’s passage last week.

“Medicaid Expansion is a once in a generation investment that will make all North Carolina families healthier while strengthening our economy, and I look forward to signing this legislation soon,” North Carolina Gov. Roy Cooper, a Democrat, said on Twitter.

For a decade, many GOP leaders have resisted Obamacare’s expansion of Medicaid, the federal-state insurance program for the poor. Extending coverage to persons earning above the poverty level would put able-bodied people on the government dole and strain state budgets, they said, even if the federal government picks up 90% of the tab for the expansion population.

But only 10 states are holding out at this point, compared with 19 that refused expansion at the end of the Obama administration.

States are finding it harder to resist the federal dollars that underpin Medicaid expansion, which the Supreme Court made optional for states in 2012 before it was implemented the following year.

For one thing, Obamacare doesn’t seem to be going away. A 2017 repeal-and-replace effort failed, and the law has survived multiple legal challenges. Studies find that expansion states have slashed their uninsured rates while driving revenue to rural hospitals that need support.

“Unlike previous years, there’s not the same debate on the table of broader ‘repeal and replace.’ There’s continuing evidence of positive outcomes relative to expansion,” said Robin Rudowitz, a vice president at the Kaiser Family Foundation and director of its program on Medicaid and the uninsured.

Virginia decided to expand Medicaid five years ago and, since then, voters have forced red-state leaders to adopt expansion through ballot measures.

South Dakota Gov. Kristi Noem opposed Medicaid expansion but the Republican is implementing a voter-approved plan later this year.

“In all seven states where voters have had the opportunity to vote on a ballot measure to expand Medicaid — Idaho, Maine, Missouri, Nebraska, Oklahoma, South Dakota, and Utah — they have passed it,” said Kelly Hall, executive director of the Fairness Project, a leading champion of the ballot measures.

Obamacare allows states to expand eligibility for Medicaid coverage to those making up to 138% of the federal poverty level.

Mr. Berger, a one-time opponent in North Carolina, told PBS Newshour that the federal government has upheld its pledge to fund 90% of the expanded population through multiple iterations of party control in Washington. He also said the expansion seemed to have popular support and he believes many of the people who benefit from expansion are working full-time.

Tarheel State legislators were drawn to the benefits for rural hospitals, which will see revenue from newly insured patients. And as COVID-19 recedes, states are combing through their rolls and kicking off persons who are no longer eligible for Medicaid, increasing pressure on lawmakers to figure out who should be covered.

Further, President Biden used an early virus-relief package to sweeten the deal for states mulling expansion.

The American Rescue Plan Act of 2021 incentivized states to expand Medicaid by offering a two-year, 5-percentage-point boost in the federal matching rate for the state’s traditional Medicaid population. 

The share of the population that is regularly covered under Medicaid is far larger than the population added by Obamacare, so it is a significant enticement.

“There are already a lot of fiscal incentives, and then ARPA added an additional fiscal incentive,” Ms. Rudowitz said.

Roughly 600,000 North Carolina residents are expected to become eligible for Medicaid when the expansion goes into effect in 2024. Implementation of the North Carolina plan is contingent on the state approving a budget, something that typically happens over the summer.

Once finalized, North Carolina’s decision will leave Alabama, Georgia, Mississippi, Florida, Kansas, South Carolina, Texas, Tennessee, Wisconsin and Wyoming as the states that have refused to expand Medicaid.

Wisconsin extended coverage to persons making the federal poverty level but hasn’t embraced the full Obamacare expansion.

An expansion bill in Wyoming advanced out of a committee this year but didn’t get a vote on the state House floor. Kansas Gov. Laura Kelly, a Democrat, has pressed the legislature to take up expansion but the GOP-controlled legislature is resisting.

“If Medicaid is expanded, Kansas would see 328,000 able-bodied adults enrolled at a state-only cost of $13 billion over the next 10 years,” Kansas House Speaker Dan Hawkins, a Republican opponent of expansion, tweeted in January.

The Obama and Biden administrations have pressed Florida and Texas, in particular, to expand, saying those states are so large it would slash the national uninsured rate.

That’s unlikely to happen anytime soon. Republicans control all levels of government in both states and Florida Gov. Ron DeSantis is expected to jump into a bruising GOP primary for president.

Fairness Project spokeswoman Georgia Parke said of the remaining non-expansion states, only Wyoming and Florida have a legal process in place for citizen-driven ballot measures. Mississippi used to have a process in place but it was overturned by a state’s Supreme Court decision in 2021 and the legislature has not reinstated the process.

Florida and Wyoming have requirements that make passing ballot measures “uniquely challenging,” Ms. Parke said.

Notably, Florida requires a 60% supermajority to approve ballot measures and its sizable population means about 900,000 signatures would be needed to qualify for the ballot.

Florida Decides Healthcare, a leading champion of a ballot initiative on Medicaid expansion, is eyeing the 2026 cycle for putting the question to voters.

“We are thrilled to see the bipartisan support for Medicaid expansion in North Carolina, which demonstrates that healthcare access is not a partisan issue, but a human one,” said Jake Flaherty, campaign manager for Florida Decides Healthcare. “We believe this momentum will carry over to Florida, where our residents are eager to see a similar expansion and reap the benefits of a healthier, more productive population.”

• Tom Howell Jr. can be reached at thowell@washingtontimes.com.