[Republicans in North Carolina used to be extremely skeptical of
offering the health care program to more low-income residents. That
officially changed this week. ]
[[link removed]]

HOW NC GOP COMPLETELY CHANGED ITS MIND ON MEDICAID EXPANSION  
[[link removed]]


 

Jonathan Cohn
March 24, 2023
Huffington Post
[[link removed]]


*
[[link removed]]
*
[[link removed]]
*
*
[[link removed]]

_ Republicans in North Carolina used to be extremely skeptical of
offering the health care program to more low-income residents. That
officially changed this week. _

Obama returns to the White House to celebrate ACA anniversary,

 

Ten years ago, Republicans in the North Carolina state House were
lining up to vote against Medicaid
[[link removed]] expansion for their
state.

They had an opportunity to open up the program to anybody with income
below or just above the poverty line, with the federal government
picking up most of the cost through the Affordable Care Act
[[link removed]].
They passed it up, arguing that the existing Medicaid program was too
expensive and too broken. They warned that the federal government
might reduce its contributions in the future, and that offering more
people Medicaid would give them less incentive to work.

Then they said that voting for expansion was tantamount to voting for
“Obamacare
[[link removed]],” which
was politically toxic among Republicans, and even some non-Republicans
as well.

Wow, have things changed.

This week, Republicans
[[link removed]] in the North
Carolina House lined up to vote on another expansion bill ― and this
time most of them voted for it, with the legislation passing by a
total margin of 87 to 24
[[link removed]].
The vote came a week after the GOP-controlled Senate approved the same
proposal by an even more lopsided, 44 to 2, margin.

Now the bill heads to the desk of Roy Cooper
[[link removed]], the Democratic
governor and longtime champion of Medicaid expansion, who has pledged
to sign it. The expansion can’t take effect until ― and unless ―
the GOP legislature and Cooper agree on a separate budget deal, which
is no small thing given a recent history of standoffs and the
opportunity for mischief by individual legislators hoping to undermine
agreement for one reason or another.

But the overwhelming margins behind Medicaid expansion and investment
in it by the state’s most powerful elected officials mean it is
likely to happen, by most accounts ― that it’s probably a question
of when, not if, an estimated 600,000 low-income residents will soon
have a chance to get health insurance.

That’s a lot of people whose lives are about to change. Studies
[[link removed]] have found
[[link removed]] all
sorts of benefits
[[link removed]] of
Medicaid enrollment, from a reduction in debt and credit problems
[[link removed]] to
better school attendance for kids
[[link removed]]. Then there is peace of
mind ― and, quite possibly, better health
[[link removed]] ―
that comes when people don’t have to ration their heart medication
or go without much-needed joint surgery because they can’t afford
it.

“This has been a long process,” Cooper told me in an interview,
“but this is a perfect example of Dr. King’s assertion that the
arc of the moral universe is long, but it bends towards justice.”

So how did this transformation take place?

Over the last few days, I put that question to some of the people who
know best, including the governor, a key GOP legislator and some
longtime advocates. I also checked the local coverage in outlets like
the Charlotte Observer
[[link removed]], North
Carolina Health News
[[link removed]] and The
Assembly
[[link removed]].

The story that emerges is a case study in how change in America takes
place nowadays ― or, at least, how it _can_ change when the
circumstances are just right. It’s also an indicator of the shifting
political conversation about health care, specifically the Affordable
Care Act, which just happened to turn 13 years old on the same day the
North Carolina House took its final vote this Thursday.

The law’s architects, including former President Barack Obama,
always hoped the program would get some kind of bipartisan support ―
enough, at least, to allow widespread, relatively smooth
implementation. It hasn’t worked out that way in many places.

But it may finally be happening in North Carolina.

The Toxic Politics of ‘Obamacare’

Medicaid expansion itself was never supposed to depend so much on the
goodwill of state officials. It was supposed to be the “easy” part
of the Affordable Care Act
[[link removed]], because all it required
was states changing eligibility levels for a program that they already
operated, with the feds picking up most of the tab.

The catch was that the federal government can’t simply order states
to change their laws, so the Affordable Care Act as originally written
took advantage of federal leverage to make it happen: If states
declined to expand eligibility, then they would lose all federal
Medicaid funding ― a potential financial calamity none of them could
afford. It was the ultimate offer they couldn’t refuse.

Or at least it was supposed to be. In 2012, the Supreme Court struck
down that threat as unconstitutional
[[link removed]], giving state officials the
ability to stick with their previous, stingier eligibility guidelines.

“That legislative process can be very difficult, but if you just
stay at it, stay determined, you can move the ball forward.”

- Democratic Gov. Roy Cooper

The Affordable Care Act’s champions hoped most states would expand
anyway, if not for the sake of helping so many low-income residents
than for the chance to draw so much extra federal money into their
states, buoying the health care sector and economy as a whole. Neither
incentive proved especially effective in states where Republicans held
sway over government.

Instead, it was mostly reliably blue states like California and
Maryland that expanded Medicaid initially. More came around over time,
starting with a group of swing states where GOP governors touted the
economic benefits and (in the notable case of Ohio Gov. John Kasich
[[link removed]])
biblical obligations to help the poor.

More recently, even some deeply red states like Idaho, Missouri and
South Dakota have expanded Medicaid, though in those cases it was
via ballot referendum
[[link removed]].
Medicaid expansion has always polled well; even staunchly conservative
voters value the program and the chance to get health care.

But it’s been a while since expansion won support from a Republican
legislature. The last time was 2018 in Virginia, and that was only
after an election that left GOP majorities razor-thin ― and fearful
of further losses.

A Democratic Governor Focused On Medicaid

Prospects for legislative expansion in North Carolina looked pretty
bleak back in 2013, when Republicans in the Assembly first voted
against expansion. But activists didn’t sulk after that setback.
They got to work, embarking on what would become a persistent, patient
campaign to raise awareness about the benefits of Medicaid expansion
― and, ultimately, to change minds in the legislature.

There were reports and rallies, with some serious policy work and a
lot of storytelling, put together by a loose coalition that included
social justice organizations and patient advocates. Medicaid expansion
was also a focus of the “Moral Monday” protests that Rev. William
Barber launched in 2013 to protest a variety of policies from the
newly elected GOP governor, Pat McCrory, and his allies in the
legislature.

Barber, a leader in the Civil Rights Movement, framed expansion as an
urgent cause for equality ― and attacked McCrory for “stonewalling
[[link removed]]”
it.

McCrory’s difficult tenure, culminating in a controversial
transgender “bathroom” bill that cost North Carolina tourism
business, left him politically vulnerable when he ran for reelection
in 2016. His opponent was Cooper, who won narrowly in an election that
defied the national pro-Republican trend that year ― and probably
would have gotten more attention if not for the presidential election
and its implications soaking up so much oxygen.

“Health care is complicated, and I think it just took some members
time to really understand how it would help people.”

- Republican State Rep. Donny Lambeth

Cooper had campaigned on Medicaid being his top priority. And when he
got into office, he kept at it, publicizing stories of people who were
struggling and connecting those struggles to the state’s overall
well-being — by noting, for example, that early childhood educators
were among those frequently in low-wage jobs without coverage.

But there was only so much he could do without the votes. Medicaid
expansion simply wasn’t going to happen without significant
Republican support.

A Republican Convert ― And Then Another

Donny Lambeth, a Republican from a conservative district in the
Winston-Salem area, came to the State House in 2013, just in time for
that first vote against expansion. As a former hospital executive, his
decision was easy, he told me in an interview. He saw no upside to
putting more people into a program he already considered too expensive
and hopelessly broken.

Medicaid was a major focus early in his tenure, culminating in a 2015
law that he and other supporters hoped would make the program more
efficient by switching to managed care. That transformation also got
him thinking about expansion again, he said, because the program felt
stronger — and North Carolina’s fiscal situation did too.

The Affordable Care Act was still plenty controversial at that point.
In fact, Donald Trump
[[link removed]] winning the 2016
presidential election led to an all-out repeal effort in Washington
— an effort that, famously, came within John McCain’s thumb of
going forward.

But the push to undo the law retreated following the 2018 midterms
[[link removed]],
when Republicans across the country campaigned on their opposition to
the health care law and suffered big losses.

If nothing else, those developments seemed to reduce uncertainty about
the permanence of Obamacare — and, with it, federal support of
Medicaid expansion that North Carolina Republicans had previously
called suspect. Phil Berger
[[link removed]],
the state’s deeply conservative Senate leader who had long opposed
Medicaid expansion, was among those who eventually took notice.

“We’re working with everyday North Carolinians who are getting
crushed by medical debt, who have been dealing with sicknesses that
could have easily been prevented ... it's just a relief.”

- Hyun Namkoong, North Carolina Justice Center

Sometime a few years ago ago (accounts about precisely when differ) he
began signaling he was open to the idea. In 2022, he gave his full
endorsement, touting not just economic benefits to the state and
struggling rural hospitals, but also the potential human impact.

He used to worry about rewarding dependency, he said, but had since
realized that most of the people who stood to benefit were working.
They just couldn’t afford insurance.

“More often than not, what you have is a situation where folks who
would be eligible for Medicaid in the expansion population are people
that are actually working full time,” Berger said in an interview
with PBS NewsHour
[[link removed]] earlier
this year. “Sort of the person that seems to be helped the most
would be a single female with one or two children who works a
full-time job.”

Lambeth had been saying similar things for a while, and attributed
growing GOP support for expansion — in part — to all of the
stories and testimonies lawmakers kept hearing from people on the
ground, who couldn’t get insurance or who could see the impact lack
of coverage had on others.

“We had these people coming down to Raleigh, farmers, business
owners, people from rural areas, they were advocating, telling
stories,” Lambeth said. “Health care is complicated, and I think
it just took some members time to really understand how it would help
people.”

Negotiations And ― Eventually ― A Deal

Berger is widely considered “the most powerful man in Raleigh,” as
The Assembly
[[link removed]] once
dubbed him, and his endorsement was a pivotal movement. But it took
still took months of painstaking negotiation to get to an agreement.

Money was a big hang-up, as always, and the final deal involved
hospitals picking up part of the cost because they stood to benefit so
much from the expansion coverage. The chance to draw on two extra
sources of federal money, one of them as part of President Joe Biden
[[link removed]]’s COVID-19 relief
package, greased the skids even more.

One last stubborn dispute was over regulations restricting the
construction of new hospitals and outpatient surgery centers, which
existing hospitals very much wanted to maintain but many lawmakers,
including GOP leaders, wanted to scale back — partly because of the
theory that increasing Medicaid enrollment would increase demand for
health services, so it made sense to ease up on supply limits.

The hospitals gave some ground, more Republicans came around and a
deal finally came together last month.

“It’s been a really long journey,” said Hyun Namkoong
[[link removed]], deputy director for
health advocacy at the North Carolina Justice Center
[[link removed]],
one of the groups that has pushed hardest. “We’re working with
everyday North Carolinians who are getting crushed by medical debt,
who have been dealing with sicknesses that could have easily been
prevented ... just horrific things that eventually end up being
disability or even death.”

“Honestly,” she said, “it’s just a relief.”

New Politics, And Old

The benefits of Medicaid expansion that Republicans have been hailing
these past few weeks aren’t new. They were the same benefits that
advocates and supporters have been highlighting since 2013. The
difference is that Republicans are listening — and agreeing — this
time. Pretty much everybody agrees that’s partly a reflection of the
changing politics around the Affordable Care Act.

“A lot of our advocacy and coalition work was very much focused on:
how do we identify the most effective messengers to resonate with our
conservative lawmakers to find some other way forward, so it doesn’t
feel like traditional Medicaid expansion, because it was sort of
toxic,” Brendan Riley
[[link removed]], vice president for
government relations at the North Carolina Community Health Center
Association [[link removed]], told me.

“We’re just in a different space now, and the fact that we have
our lawmakers, who are longtime opponents, are on the floor, talking
about it being the right time to expand Medicaid. It’s clear we’re
just in a different time,” Riley said.

Cooper credits activists for keeping up the pressure all these years,
and individual Republicans for embracing the cause when it was so
unpopular in their ranks. He also thinks local organizations with
credibility among conservatives, like local business groups touting
economic benefits or law enforcement talking about the potential to
keep people with mental illness out of the criminal justice system,
had a big effect.

Cooper is also a believer in bipartisanship, though he emphasizes it
doesn’t come easy.

“It requires hard work and requires listening to people, building
coalitions and finding leverage,” Cooper said. “That legislative
process can be very difficult, but if you just stay at it, stay
determined, you can move the ball forward and get positive things
done.”

Lambeth echoed the endorsement of bipartisanship, on at least some
issues. “I didn’t go down to the General Assembly as a
Republican,” he said. “I had to get elected as a Republican, but I
went down to help people, to try and make North Carolina a better
state, and one of the best things we can do in North Carolina is to
expand Medicaid.”

Assuming expansion unfolds as Cooper and Lambeth and the other
champions hope, it will reduce the ranks of holdouts to just 10
states, nearly all of them in the South. That is the part of the
country where high poverty levels arguably mean more Medicaid would
make the most difference. That is also the part of the country where
conservative Republicans have their tightest grip on government.

The two largest states by population are Florida and Texas
[[link removed]]. Expansion would
make more than 1 million people eligible for coverage in just those
states alone, according to estimates. But there’s no sign of
interest from GOP governors Ron DeSantis or Greg Abbott, or their
legislatures either. Change may yet come to those states, but it will
apparently take even more time — and more work too.

_Jonathan Cohn, Senior National Correspondent at HuffPost, writes
about politics and policy with a focus on social welfare. He is also
the author of SICK (2007, HarperCollins) and THE TEN YEAR WAR (2021,
St. Martin's). Jonathan worked previously at the New Republic and
American Prospect, and has written for the Atlantic, New York Times
Magazine, and Self, among other publications. His journalism has won
awards from the Sidney Hillman Foundation, the Association of Health
Care Journalists, World Hunger Year, and the National Women's
Political Caucus. Jonathan is a member of the National Academy of
Social Insurance, as well as a lecturer at the University of
Michigan's Gerald R. Ford School of Public Policy. He can be reached
at jonathan [dot] cohn [at] huffpost [dot] com._

Don't sit on the sidelines of history. Join the HuffPost community and
support real news that puts people first.
[[link removed]]

* Obamacare
[[link removed]]
* Affordable Care Act
[[link removed]]
* Medicaid
[[link removed]]
* North Carolina
[[link removed]]
* Republican Party
[[link removed]]

*
[[link removed]]
*
[[link removed]]
*
*
[[link removed]]

 

 

 

INTERPRET THE WORLD AND CHANGE IT

 

 

Submit via web
[[link removed]]

Submit via email
Frequently asked questions
[[link removed]]

Manage subscription
[[link removed]]

Visit xxxxxx.org
[[link removed]]

Twitter [[link removed]]

Facebook [[link removed]]

 




[link removed]

To unsubscribe, click the following link:
[link removed]