The Washington PostDemocracy Dies in Darkness

Opinion It’s time for the GOP to end this desultory anti-Obamacare crusade

Gov. Roy Cooper (D) delivers his State of the State address on Monday in Raleigh, N.C. (Travis Long/AP)
4 min

Thirteen years after the passage of the Affordable Care Act, North Carolina is poised to become the 40th state to expand Medicaid under the law, thanks to the persistence of Democratic Gov. Roy Cooper and a growing recognition by Republican legislative leaders that their rural base has the most to gain. A breakthrough agreement will expand health-care coverage to an estimated 600,000 residents who make too much to qualify for the traditional Medicaid program, which predated the ACA expansion, but too little to qualify for subsidized private plans on the Obamacare marketplaces.

North Carolina offers a blueprint for breaking the logjam in the 10 remaining holdouts of Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin and Wyoming. Rural hospitals in each of these places have struggled because so many of their patients lack health insurance, which means they don’t get reimbursed unless the state picks up the tab. But GOP lawmakers in these states have held out in a dogged, partisan protest of the ACA, for which their constituents pay.

In places such as the western mountains or the southeastern Sandhills region of the Tar Heel State, as many as 1 in 5 adults are uninsured. A December poll showed 78 percent of North Carolinians in favor of Medicaid expansion, including 64 percent of Republicans. The business community has been strongly supportive.

Nevertheless, this hard-won compromise took years to hash out. Senate leader Phil Berger (R), who was long one of the most outspoken critics of expansion, first expressed openness to a deal in the fall of 2021. Both the state House and Senate passed bills last year to expand Medicaid, but negotiations fell apart. After 10 months of mostly behind-the-scenes talks, and a marathon session one night last week, Mr. Berger and House Speaker Tim Moore (R) agreed to reform state laws that closely regulate North Carolina’s medical industry, loosening rules to ensure the supply of providers will keep up with demand as coverage increases.

Paul Waldman and Greg Sargent: The GOP’s epic defeat on health care is laid bare in North Carolina

The federal government pays 90 percent of the cost of Medicaid expansion, leaving the state responsible for just 10 percent. Under the deal, hospitals will cover that share through assessments levied by the state. The lobbying group for the hospitals, the North Carolina Healthcare Association, endorsed the final deal because of sweeteners, including the Healthcare Access and Stabilization Program, that will offset new costs. “When you put a pen to the back of a napkin, it’s a net break even at worst,” said Mr. Moore, the House speaker. “A net positive, frankly, if you do the math.”

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Unfortunately, the final deal does not include a scope of practice provision that would have let nurse practitioners, instead of doctors, treat patients with certain ailments. That would have lowered costs and expanded competition among qualified medical professionals. But the lobbyists for the physicians kept it out. It can still be adopted in a stand-alone bill next year.

In an interview, Mr. Cooper credited support from law enforcement officers, namely the North Carolina Sheriff’s Association, for creating momentum to get a deal done. “Their deputies are dealing with mental health patients, having to spend time with them and taking them to emergency rooms when they need to be doing their jobs,” he said. “They recognize that they shouldn’t be doing this, and they connected the dots that Medicaid expansion can help alleviate that.”

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The biggest hitch at this point is that Republicans in the legislature plan to include Medicaid expansion as part of a broader budget package at the end of the session. That might not pass until the summer, which could delay the effective date. More concerning is that it increases the odds of a poison pill getting added to the budget, perhaps an abortion ban or permanent limits on the governor’s powers — that Mr. Cooper would feel compelled to veto.

In addition to $8 billion in federal money that will flow annually to North Carolina, federal incentives included in pandemic relief legislation mean that the state can still collect an additional $1.8 billion if a deal gets through this year. Mr. Cooper used his State of the State address, delivered Monday night, to urge immediate passage. He emphasized that the state forgoes $521 million a month in federal funds while waiting for final passage. “No business would make that kind of financial decision,” he said.

Mr. Cooper is right. It’s time to get this done — and not just in North Carolina, but in every other GOP-run state that has refused, for no good reason, to deny Medicaid coverage to its working poor.

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