Medicaid Expansion is the “North Carolina Solution” Politicians Seek

Polis: Center for Politics
3 min readOct 20, 2022


Juliana Shank (PPS ’24)

Juliana Shank (PPS ‘24)
Juliana Shank (PPS ’24)

For eight years, political wrangling in North Carolina over healthcare coverage has left too many of our residents vulnerable. The state is one of twelve to have not yet implemented Medicaid expansion under the Affordable Care Act, which would give coverage to nearly 600,000 additional residents who are currently without health insurance. Some politicians have long opposed the expansion, but the COVID-19 pandemic and new findings from a legislative committee commissioned by the state to explore Medicaid expansion are warming attitudes. In the upcoming General Assembly legislative session, it is critical that Medicaid expansion be at the forefront of the agenda.

North Carolina Governor Roy Cooper (D) has championed Medicaid expansion for years. Indeed, Cooper went so far as to reject the North Carolina General Assembly’s budget in 2019 because expansion was not included. Thus, the fate of Medicaid expansion is truly in the hands of the General Assembly. When countering Medicaid expansion, some politicians argue that Medicaid is defunct and unreliable; the federal government can technically cut off financial support at any time. Others believed that the focus should be on the transition to managed care–a payment structure where private companies reimburse health providers instead of the government directly paying them–before considering other solutions.

However, Medicaid expansion has been successful in the thirty-nine states that have adopted it over the last eight years, showing stumbling block concerns are unfounded. A review of 400 studies about expansion found that broadening Medicaid led to greater access to care, lower uncompensated care costs for providers, less personal medical debt, and improved health for residents. Medicaid expansion is also here to stay–the Affordable Care Act survived three Supreme Court challenges, and most Americans favor the law.

Furthermore, the concerns about transitioning to managed care have been addressed: North Carolina successfully shifted to managed care in 2021, marking a health policy milestone. The goal of this move was to improve healthcare outcomes and potentially even save money. While admirable, this shift failed to reach the hundreds of thousands of North Carolinians left without healthcare insurance during a global pandemic. The transition to managed care is important but not nearly sufficient. Lawmakers must find solutions that protect the health of all our citizens.

The creation of the Joint Legislative Committee on Access to Healthcare and Medicaid Expansion in 2021 was a big step forward. The committee is looking at other states that have adopted Medicaid expansion with bipartisan support, such as Virginia, as a model for how to answer questions regarding financial stability for other members of the general assembly. When evaluating options for helping the uninsured, the focus is on developing a tailored “North Carolina solution.”

Medicaid expansion is the “North Carolina solution” politicians seek. Simply, there is no better way to improve access to healthcare for so many uninsured people around the state. And now is the time to pursue it–the federal government added another $1.5–2 billion in additional incentives to adopt Medicaid expansion because of the pandemic. Also financially attractive is that expanding Medicaid would help to create 40,000 new jobs in North Carolina and support rural hospitals. Analysis even concludes that Medicaid expansion would be a net surplus for the state budget.

Currently, hundreds of thousands of North Carolinians are caught in the gap of making too much to qualify for Medicaid but too little to afford private insurance. If we have learned anything from this pandemic, it’s that we can’t ignore the importance of investing in our health. We already pay taxes to the federal government that currently help subsidize Medicaid expansion in dozens of other states. So why not use federal funds to finance Medicaid expansion at home? Let’s put politics aside and help all North Carolinians live healthier lives in this next legislative session.

Juliana Shank (PPS ’24) is a Public Policy Undergraduate at Duke University’s Sanford School of Public Policy. This piece was submitted as an op-ed in the Spring ’22 PUBPOL 301 course. This content does not represent the official or unofficial views of the Sanford School, Polis, Duke University, or any entity or individual other than the author.