Proponents of expanding Medicaid in North Carolina hope to gain traction on Election Day, with Democrats hoping to flip both state chambers and pass Medicaid legislation.

Gov. Roy Cooper, a Democrat, has advocated expansion since winning in 2016, but the Republican-controlled House and Senate blocked attempts to allow more people to qualify for Medicaid, the nation’s health care insurance program for the poor. Some Republicans pitched a scaled-back alternative to expansion, but that also faced setbacks.

Currently, the state Senate has 29 Republicans and 21 Democrats, while the House has 65 Republicans and 55 Democrats. Medicaid expansion advocates hope an influx of supporters could break the logjam.

Under the 2010 health law, states can opt to expand coverage to people earning up to 138 percent of the federal poverty level. In exchange, the federal government provides increased funding — a higher matching rate of 90 percent of the costs.

Despite this, 12 states including North Carolina and Texas have opted to keep eligibility the same, according to the nonpartisan Kaiser Family Foundation, with opponents citing the added cost for taxpayers. North Carolina represents the best chance for expansion among those states, many of which are in the south.

The COVID-19 pandemic and recession has resulted in many North Carolinians losing their jobs and private insurance, which adds more strain on rural hospitals. Some candidates and health advocacy groups are focusing on Medicaid expansion as a way to help both patients and medical providers like hospitals.

Dee Stewart, president and CEO of the Raleigh, N.C.-based conservative political consulting firm The Stewart Group, said closing this coverage gap is overwhelmingly popular.

“COVID has really brought this home. I think that it’s something that folks are concerned about. It’s something that people are going to look for,” said Stewart, a Republican consultant.

A poll by Harper Polling and The Stewart Group in September found 75 percent of registered voters support closing the coverage gap, including 64 percent of Republicans and 84 percent of moderates. When phrased as Medicaid expansion, 77 percent of voters were in favor.

Campaign trail conversations

The possibility of expansion has factored into political campaigns for various state offices. Ronnie Chatterji, the Democratic candidate for North Carolina treasurer, says this election is critical, especially as rural hospitals face financial difficulties.

“The story right now in North Carolina is that we’re really on the verge of expanding Medicaid, but it’s going to take the election to do it,” said Chatterji, an Obama administration alum. “One of the things I want to do is improve the state health plan, which is the largest payer of hospitals, but that can only happen by expanding Medicaid, because so many of our rural hospitals are dependent on a payer mix.”

He recently addressed Medicaid when speaking to voters in Wilmington, Smithfield, Fayetteville, Southern Pines and Lumberton, N.C.

Democrats are largely united behind expansion, and there is some Republican support.

Some candidates are capitalizing on their opponents’ opposition to the policy as a differentiating factor.

Marcus Singleton, a pastor and veteran looking to defeat a state Senate GOP incumbent, released an ad focusing on expansion.

“The federal government has set aside billions of dollars to expand Medicaid for families here in North Carolina. Yet our state senator voted to turn that money away,” he says in the ad.

Rep. Deb Butler, who is running for reelection, said she has brought up expansion every day since she joined the state House in 2017.

“It is foremost on the legislative agenda for Democrats, because we recognize how critical it is for working families who are caught in the coverage gap. Particularly in this pandemic, we see just how many families don’t have access to the health care they desperately need,” said Butler, a Democrat. “If you see Democrats take charge in the Senate or in the House and maybe even just one or the other, I think you’ll see Medicaid expansion is certainly our topline initiative.”

The North Carolina Healthcare Association, which represents hospitals and health systems, has a political action committee that looks to support candidates in favor of Medicaid expansion, although it is not the only criteria, said Cody Hand, senior vice president of government relations.

“A lot more legislative races in suburban areas are also now adding Medicaid expansion as one of their points for their campaign,” said Hand, noting polls showing the public’s support of Medicaid expansion.

He said the House Republican health committee leaders have endorsed some version of expansion, but the Senate has proved more difficult.

“We haven’t seen as much from the Republican side, but obviously every Democrat is a supporter of Medicaid expansion,” he said.

Grassroots lobbying

Momentum toward expansion is being pushed along by grassroots groups, including two coalitions making Medicaid expansion a priority, regardless of who is elected. Critics say Medicaid is already one of the state budget’s biggest expenses and covering more people would be too costly.

Supporters say the pandemic further emphasizes the need to expand coverage.

“There’s been so much discussion about our frontline workers and frontline workers, and they are suffering. But one of the things that’s so critical about all that is many of those frontline workers are in the professions that are least likely to have health insurance coverage and most likely to be in the gap,” said Erica Palmer Smith, the director of Care4Carolina, a 75-group alliance.

She says the coalition plans to raise awareness after the election through efforts including digital and print ads across the state.

“We’ll be making sure that we’re reaching out to the folks who’ll be making those decisions, and making sure the public stays aware of how critical these issues are,” she said.

The North Carolina Justice Center, a progressive community organization, also focuses on expansion. The group holds vigils to highlight stories of individuals in the Medicaid coverage gap who either lost their lives or were unable to get care.

“We really focus on getting stories to all people that are in office to show them that policy decisions really do impact people across the state,” said Rebecca Cerese, health engagement coordinator for the group.

This year, along with activists in seven other non-expansion states, the center formed a coalition called Southerners for Medicaid Expansion to push for the issue.

“It’s really not a partisan issue. It’s been turned into one, and I don’t really understand why,” said Cerese.

Opposition

Despite growing interest, some groups and lawmakers do not see expansion as the solution for the state’s health issues.

Americans for Prosperity North Carolina State Director Chris McCoy said the conversation around health care has changed.

“Once upon a time, you would hear just ‘no’ to Medicaid expansion,” he said. “Now it’s, ‘Here are solutions to help us get us into a better spot.’”

He said lawmakers should instead advocate policies like expanding access to telemedicine and increasing the scope of practice for nurse practitioners and allow them to provide services often offered by physicians.

“I know that they’re not particularly enticing from a standpoint of being able to run a campaign on it, beat that drum and so forth. But at the end of the day, you know if you expand Medicaid, you still have the problems underlying the actual access to care,” said McCoy.

The John Locke Foundation, a Raleigh-based free market think tank, is also voicing concerns about efforts to expand Medicaid, and has pointed to other alternatives like utilizing federal waivers to bring down the cost of coverage of insurance provided through the 2010 law’s marketplaces.

The organization worries that expanding Medicaid is expensive, and that previous cost estimates underestimate enrollment and overestimate potential tax revenue, as well as if rural areas without sufficient providers would really benefit if services aren’t accessible.

“Our big stance on this is that, of course, we sympathize with folks that don’t have health insurance and have lost health insurance. We’re always attacked for being heartless in this regard,” said Jordan Roberts, a government affairs associate with the John Locke Foundation. “It’s just the manner about going about providing different coverage options to folks is where we disagree with a lot of the Democrats and the governor about this.