How the battleground state of North Carolina expanded Medicaid to thousands after long fight

More than a decade after the Affordable Care Act was passed, more than 600,000 adults in North Carolina are now eligible to receive benefits through an expansion of Medicaid that the state, like 10 others, long resisted.

The change in policy was bipartisan, since North Carolina, a perpetual battleground state, has a government divided between Democrats and Republicans.

And while North Carolina is the most recent state to adopt the Medicaid expansion that became possible under the ACA starting in 2014, it's potentially not the last: Republican officials in other holdout states like Alabama and South Carolina have signaled openness to the possibility.

"Medicaid expansion is not going anywhere. So why should we turn down the federal tax money that we've already paid in Washington? Why should we prevent North Carolinians from benefiting from that?" the state's governor, Roy Cooper, a Democrat, told ABC News in an interview.

The expansion was signed into law in March 2023 -- with nearly two-thirds of the state House's Republicans and even more state Senate Republicans backing it -- and went into effect in December, making North Carolina the 40th state to opt into the program.

The newly qualified residents are adults from 19 to 64 years old who earn too much money to receive traditional Medicaid but generally not enough to afford public subsidies available for private health insurance.

Under the new guidelines, coverage expands to adults ages 19 through 64 who earn up to 138% of the federal poverty line, which means a single person earning about $20,000 or a family of three earning about $34,000 annually can now qualify for routine check-ups, prescription medication and other medical services without out-of-pocket expenses.

A 2022 report from the National Center for Health Statistics estimated that 17.6% of the state's 10.7 million residents were uninsured. The Medicaid expansion will cover about 5.6% of North Carolinians.

After years of debate, here's how North Carolina agreed on expanding Medicaid.

A change of heart over time

Cooper had advocated for providing more Medicaid coverage since he took office in 2017, despite facing what he called "stiff resistance" from Republican state leaders.

Those conservatives had long said they were not in favor of expanding Medicaid, citing concerns over government-funded insurance and the possibility that Congress could cut the financial contribution through the ACA that initially made the expansion possible. Under the ACA, the federal government pays for 90% of the cost of the expansion; individual states pay for 10%.

But if Congress one day ended the federal payments, critics said, state governments could be suddenly saddled with unworkable new bills.

Then, in 2022, the federal government offered a new financial incentive -- a nearly $1.8 billion bonus over two years to any of the remaining states who decided to expand Medicaid.

There are no restrictions on how the additional money can be spent, allowing state lawmakers to decide how it should be allocated.

Cooper told ABC News that Republican legislators in North Carolina and across the country also warmed up to the idea of expansion when they realized that the ACA, also known as "Obamacare," would not be repealed.

North Carolina state Sen. Phil Berger, a leading Republican in the chamber, echoed that in a local op-ed column published in 2023.

"Since it was enacted, every attempt in Congress and by the courts to reverse the ACA and Medicaid expansion has failed," he wrote then. "When Donald Trump was president and Republicans controlled Congress, they did not repeal or significantly alter the ACA. It's not going away, and refusing to accept that reality hurts North Carolinians and the state's finances."

The ACA did not have majority approval from the public in the first years after it was passed, but that changed after 2016, according to Gallup polling.

There is still skepticism about expanding Medicaid in the remaining 10, largely Republican-led states, however.

Georgia Gov. Brian Kemp has linked it to "failed one-size-fit-none policies" and Mississippi Gov. Tate Reeves, who narrowly won reelection in the fall after a race that turned in part on the issue of Medicaid, has suggested he thinks it will be bad for the state's workforce if Medicaid expands and "able-bodied Mississippians [are added] to the welfare rolls."

Cooper said he hopes that other state leaders will see North Carolina as an example for change.

"This is the same self-examination that should occur in Texas and Florida and Alabama, and these places that need health insurance for their people," he told ABC News.

In Kansas, Democratic Gov. Laura Kelly is renewing her push for lawmakers to expand Medicaid to provide health care to about 150,000 low-income residents, and she has proposed adding a work requirement to the program.

Building unlikely alliances

North Carolina Department of Health and Human Services Secretary Kody Kinsley, a native of Wilmington, played a key role in advocating for Medicaid expansion in the state.

Kinsley met with leaders in the health care industry while collaborating with Republican and Democratic legislators to plan town halls on improving access to mental health resources.

He previously worked in the Obama White House during the implementation of the ACA, which was both historic -- in how it overhauled the health insurance system -- and divisive, sparking fierce criticism from Republicans. In the years since, however, public attitudes have changed and softened on the ACA, as Gallup found.

Kinsley said he made it his "mission" for Medicaid expansion in his home state to become a reality.

"I grew up without health insurance," he told ABC News. "And so getting to today has been a personal mission for me and something I'm really proud of, to pay it forward."

"My parents got health insurance for the first time in their lives," he continued. "Right now we know we've got folks that are getting health insurance for the first time in their lives here in North Carolina."

Through his years of advocacy work, he created alliances in unlikely places.

Kinsley, a Democrat and the state's first openly gay Cabinet member, said he spent years "working across the aisle" with numerous leaders in the health care industry, fellow Democrats and Republican legislators to find common ground on health-related issues.

"We've traveled all across the state," Kinsley said. "We're committed to trying to find a way in areas where we do agree, charting a path forward to make a difference for the people of North Carolina."

Kinsley built key relationships like with state Rep. Donny Lambeth, one of the primary sponsors of the bill last year that expanded Medicaid. The pair bonded over their shared commitment to improving mental health care in North Carolina.

"Secretary Kinsley has been an exceptional partner in supporting legislators in our policy work," Lambeth told ABC News in a statement. "He was a valuable resource to me during my work on Medicaid Expansion. I, along with my primary bill sponsors, would seek his advice on timing of implementation particularly and details about the federal waiver process."

"He was our link to the federal staff on key issues that we incorporated in the Bill such as the jobs training program," Lambeth added. "He always made himself available to us as we needed his assistance."

A 'positive impact in rural North Carolina'

The Medicaid expansion looks set to provide a particular boost for the state's rural areas, where many residents fell in the insurance coverage gap, Kinsley said.

North Carolina has the second largest rural population in the country, according to census data. According to the state health department, the majority of adults 19 to 64 years old who are newly insured under the Medicaid expansion live in rural areas live in rural areas.

"I'm particularly happy that we're seeing a disproportionately positive impact in rural North Carolina," Kinsley said. "To see some of our rural communities where people have had historic lack of access to health care be some of the biggest gainers proportionately in the number of covered folks is such an important investment in their health and in the health system in those communities."

Rural residents like Carrie McBane say they have been making ends meet for years while navigating the challenges that can come without health insurance.

McBane, 50, lives in the small town of Sylva along the ridges of the Plott Balsam Mountains. She worked as a restaurant server for several years and said she earned too much to qualify for traditional Medicaid but not enough to afford private insurance.

"In small towns, it's a lot of restaurants and construction," McBane said. "So the pay rate, the wages per hour are very low. The cost of living now is very high. It's a struggle."

McBane said she was working long hours, at times 10-to-12-hour shifts, to support herself until she suddenly became very ill.

"I knew that something was wrong," she recalled. "I had very bad dry mouth, my hair started falling out, my vision changed backward … this just kind of hit me all at once."

After visiting several doctors who could not identify her illness and paying for those visits out of pocket, she was ultimately diagnosed with Type 2 diabetes, she said. Without insurance, she struggled to pay for insulin and other life-saving medications.

"When you're really sick, and you don't know what to do -- I can't afford it, so basically I'm robbing Peter to pay Paul," she said.

"I was just exhausted," she added. "I just felt like nobody was listening to me."

Her health journey inspired her to become an advocate and help spread awareness about health coverage options in her community. She said she did not qualify for traditional Medicaid because her monthly income was about $100 too high, thus placing her in the insurance coverage gap like many other families in her town.

"When you don't have health care coverage, the struggle is real and it is dire," she said. "We want the recognition you know, we're not second-class citizens because we live in the mountains."

But now, McBane says she hopes that expanded Medicaid coverage will help aid others like her who faced the same barriers to health care access, including limited resources and costly medical expenses.

"The advocacy work is getting the information out there, trying to help people understand what's required, trying to not be afraid of the system and just to give support," she said. "Our next steps are they're just going to have to be fluid. It's a broken system. Winning big steps to get this work done -- it will happen."