While campaigning to become the state’s 75th governor in 2016, Roy Cooper said he wanted to help low-income North Carolinians who had been forced to forgo basic medical care because they could not afford health insurance.
He finally achieved that goal six years later when North Carolina expanded Medicaid. The decade-in-the-making measure loosened the program’s strict eligibility requirements, making hundreds of thousands low-income residents eligible for coverage for the first time.
“When I ran for governor, one of my top priorities was creating a North Carolina where people were healthier and could get the care that they need to have lives of purpose and abundance,” Cooper said in an exclusive interview with NC Health News. “We knew that Medicaid expansion was an important way of making that happen because there were a lot of hardworking people in North Carolina who were making too much money to qualify for Medicaid, but not enough money to qualify for subsidies under the Affordable Care Act.”
Expansion arguably now stands as Cooper’s signature achievement. More than 590,300 people who were previously ineligible for Medicaid have joined the rolls since expansion took effect in December 2023, nearly surpassing the state’s projected enrollment for two years in just 12 months.
“It’s exciting that we set the goal of having 600,000 people enroll during the first two years, and now we’re almost at that goal in just one year,” Cooper said. “I think it shows that people really needed it, and I’m grateful that we were able to get that for the people of North Carolina.”
But expansion was by no means easy for Cooper. He faced multiple setbacks over his two-term effort to make the measure a reality.
Power in numbers
Cooper knew from the beginning that expansion would be an uphill battle.
The Affordable Care Act, former President Barack Obama’s trademark health care policy, allowed states to enlarge the pool of people eligible for Medicaid, which is largely funded by the federal government, by raising the maximum-allowed income for the program. The Obama administration incentivized states to adjust their income thresholds by offering to cover 90 percent of the cost of insuring the newly eligible beneficiaries.
But the contentious nature of the Affordable Care Act drove North Carolina’s Republican-led General Assembly to pass a 2013 law requiring legislative approval to expand Medicaid in the state.
Shortly after taking office in January 2017, Cooper asked the feds to override that law and implement expansion without the state legislature’s blessing. His request was met with a lawsuit from Senate leader Phil Berger (R-Eden) and House Speaker Tim Moore (R-Kings Mountain), with the court ultimately ruling in the Republicans’ favor.
“I think the biggest hurdle we faced was that Medicaid expansion was part of ‘Obamacare,’ and that made this an extremely political issue for Republicans,” Cooper said, adding that Donald Trump, who was elected the same year Cooper was, spent much of his first term as president working to dismantle the program colloquially named after his predecessor. “We had the challenge of moving Medicaid expansion past the politics of ‘Obamacare,’ and the way we needed to do that was get the constituents of Republican legislators to ask them for it.”
Cooper said his administration managed to “overcome the political headwinds” by building a broad coalition of advocates who could persuasively argue the value of expansion to Republican lawmakers. He also had some help from a handful of Republican House members who proposed a series of bills in support of expansion.
“We had very brave people who had become victims of the medical system, who were working hard for a living but couldn’t afford health insurance and therefore were struggling to pay medical bills, who were willing to go and tell their stories,” Cooper said. “We also were able to get tough-on-crime sheriffs who knew that many of the people sitting in their jails needed health care and not handcuffs [… .] A lot of people with substance use disorders and mental illness were requiring a lot of attention from their deputies and officers.”
Rural support
The chorus of voices supporting expansion grew to include chambers of commerce in rural communities, particularly in the western part of the state, where many small business owners could not afford to provide health insurance to their employees. County commissioners in rural areas also warmed to the measure after realizing it could help local hospitals that were at risk of going under.
“Many of these hospitals just simply were treating too many patients who didn’t have health insurance,” Cooper said. Local elected officials “recognized that Medicaid expansion would allow a lot of the people who live in their county to get health insurance to help keep these rural hospitals from closing.”
Legislation making North Carolina the 40th state to approve expansion passed that March with bipartisan support, a reversal spurred in part by the promise of more than $1.6 billion in federal financial incentives.
The move paved the way for newly eligible residents to sign up for Medicaid that December after a protracted stalemate among lawmakers over the state budget.
“Finally, we were able to able to get enough pressure on Republican legislators and, to their credit, they ended up putting it in the budget at the end of the day and we were able to sign it,” said Cooper, who was flanked by several of the advocates who had championed expansion — along with some of his longtime legislative opponents — when he signed the measure into law during an event in Raleigh. “It was an important day for North Carolina, and this coalition of people all together helped get the job done.”
‘Political will’
Kody Kinsley, secretary of the N.C. Department of Health and Human Services, believes expansion wouldn’t have passed if not for the governor’s “unrelenting tenacity.”
“He went out chamber by chamber, business by business, sheriff by sheriff, to get them to see what Medicaid expansion meant for them,” said Kinsley, who took charge of NC DHHS, which oversees the state’s Medicaid program, in 2021. “He was building up that coalition of people so that, all of a sudden, it would be hard to find anyone that was against it.”
Cooper’s “political will,” he added, is what “created the fundamentals for the legislative change to happen.”
“I’ve met plenty of other people who, after losing a fight so many times over six years, would have just walked away,” Kinsley said. “He did not, which is why we’re the only state in the Southeast that has gotten this done through the legislature in the way that we did it in a long time.”
North Carolina was the first state to adopt expansion through a legislative process since 2019. A handful of other states have expanded Medicaid through executive orders and ballot measures.
This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.