Skip to main content

The Big Story: Deal on Medicaid expansion clears first vote in NC Senate.

“While she and other Republicans opposed expansion for many years, now ‘the time is right for North Carolina to expand Medicaid.’”

After all these years, why now?

By David Jarrard

4-minute read

North Carolina is on the verge of expanding Medicaid a decade after the Affordable Care Act made it possible for states to unlock more federal resources to pay for healthcare.

It’s not done yet. North Carolina’s expansion is tied to passage of its budget. But there is reason for optimism.

Why did this political hot potato become cool enough to catch?

The question is more than a disinterested political pondering.

Providers of all stripes and the patients they serve are strapped. Health systems had a tough 2022 and 2023 is a challenge, too – Fitch’s forecast makes the point in blunt terms: Early NFP Hospital Medians Show Expected Deterioration; Will Worsen.

Today, every dollar matters.

  • For uninsured and underinsured patients who need care but can’t or won’t seek it, who are ultimately raising the cost of care when they finally present at the ER with something that could have been avoided with a generic prescription.
  • For providers who don’t have the resources to continue offering some care, including those – especially in rural areas – for whom the challenge is existential and for whom Medicaid expansion could be a saving grace.

What changed in North Carolina, assuming all goes well? What lessons are there for long-suffering expansion advocates in the remaining unexpanded states? (Looking at you, Texas, Florida, Alabama, Mississippi…)

  • “Bad branding” faded, steady advocacy didn’t. As in other states, expansion in North Carolina was an early victim of party politics. Obamacare, anyone? Population and economic changes softened the intensity of that connotation while advocates steadily kept expansion on life support, year after year. For more, see this 2018 one-pager. The need, it appears, finally met the solution.
  • North Carolina was missing out. A decade-plus of seeing hundreds of millions of healthcare dollars go to other states had an impact. Meanwhile, the federal government offered an additional $1.8 billion to “support behavioral health, public safety support, rural health care, and other needs” as part of the overall package. Money matters.
  • The value proposition stayed strong. Over the years, more and more North Carolinians fell into the various gap populations – unable to afford or obtain private/employer insurance and unable to qualify for Medicaid. With expansion, more than 600,000 are expected to obtain coverage. That’s a lot of patients…and a lot of voters.

There are plenty of good lessons in all this. Lessons that advocates know but are still worth refreshing as a dwindling number of states look across the country to peers for modeling and momentum. Here are a few:

  • Start early and stay late. Want to expand Medicaid in 2024? Or ’25? Or ’26? Start now. Lay the groundwork now with stakeholders and influencers (sometimes called “voters”) with an effort that is persistent and patient. Sometimes we see this work start strong but, without a quick win, the commitment fades as other short-term priorities are elevated.
  • All politics is local. Focus on who matters most. Sure, there are massive financial implications here for healthcare provider organizations. But who cares about a building or a brand? Neighbors matter. Make the compelling case to the community that there are folks each citizen knows who need healthcare but can’t get it.
  • The messenger is a message. Don’t assume hospitals are the face for this effort. Trust in all institutions has waned while the belief that hospitals put profits over patients is on the rise. Health systems could be painted as profiteers. While hospitals can convene a cast, other actors can take the lead on this crowded stage. Think business leaders. Social services. Nurses. Churches. Schools. Patients. Mom. Dad. Grandma.
  • Seek to understand rather than overpower the opposition. Listen – and be seen listening – well. Acknowledge the concerns and fears of those who are opposed to expansion – even those you find unreasonable. You may not win them over, but you will signal to watchful thinkers on the sidelines that you are unafraid of a conversation. It’s a compelling position that can set a table for resolution.
  • Give everyone – including opponents – a win. Politics is deeply pragmatic – you know this from dealing with your med exec council. Politics is the “art of the possible.” Be practically productive for your patients. Yes, it’s much easier and often politically safer to be against something than for it. But who doesn’t love a well-couched win? For example, messages like: “We’re for getting our fair share of the federal healthcare spend.” “We’re for taking care of our own.” “We are good health for all.” “We’re for jobs.” “We’re for hospitals, of course.” Be FOR something.

Our metaphorical fingers are crossed for North Carolina’s expansion. No doubt, it’s a complicated series of mechanics, agreements and compromises that led them to this moment and is unique to the state in many ways.

Yet, it’s a bellwether we hope 10 states hear.

Subscribe to Jarrard Insights & News