North Carolina's Republican Legislature Overwhelmingly Approves Medicaid Expansion

The North Carolina state House of Representatives on Thursday morning overwhelmingly approved an expansion of the state’s Medicaid program that would make health insurance available to roughly 600,000 additional low-income residents.

The 87-to-24 vote by the Republican-majority chamber comes a week after the state Senate, also under GOP control, voted for the bill by an even wider margin. Now it heads to Gov. Roy Cooper, a Democrat who has championed Medicaid expansion since first running for office in 2016.

North Carolina would be the 40th state, in addition to the District of Columbia, to expand Medicaid using authority and financing available through the Affordable Care Act.

That law’s architects had once hoped all states would take that step, pushing income eligibility limits to above the poverty line so that millions more nationally would qualify for the program. But a 2012 Supreme Court decision made it easier for states to refuse, and most states where Republican officials had sway over state government did just that, citing their opposition to so-called Obamacare.

In the years since, Medicaid expansion has come to more of those states, either through ballot initiatives or a change of heart by some of those Republican officials. That’s what happened in North Carolina, where key GOP leaders eventually endorsed the idea as good for the state economy and struggling rural hospitals, as well as helpful to working people without access to affordable coverage.

Cooper’s signature wouldn’t be the final step in expansion. The proposal cannot take effect until ― and unless ― the governor and legislature agree on the next budget. Recent history includes some lengthy standoffs, pitting the two against each other.

But the large voting margins and shared commitment to expansion from both GOP legislative leaders and Cooper make it more likely they will find a way to agree on a budget, lest expansion fall apart after so much effort to pass it.

CHAPEL HILL, NORTH CAROLINA – JANUARY 21: Gov. Roy Cooper (D-NC) greets student fans before the game between the North Carolina Tar Heels and the North Carolina State Wolfpack at the Dean E. Smith Center on January 21, 2023 in Chapel Hill, North Carolina. (Photo by Grant Halverson/Getty Images) (Photo: Grant Halverson via Getty Images)