Gov. Roy Cooper signs NC Medicaid expansion into law. But it comes with an asterisk.

It actually happened.

After years of negotiations between Democrats and Republicans, then just between Republicans, the General Assembly passed a bill last week expanding Medicaid in North Carolina. Democratic Gov. Roy Cooper signed the bill into law Monday in a ceremony at the Executive Mansion in downtown Raleigh, two blocks from the Legislative Building. He was joined by a bipartisan group of lawmakers and supporters.

“With this bill, more uninsured North Carolinians can avoid financial ruin from unpaid medical bills. More rural hospitals will be able to stay open, with their jobs,” Cooper said before he signed the bill into law in a garden ceremony on a sunny spring afternoon at the mansion, amid blooming azaleas and dogwoods.

“Businesses won’t lose as many good workers to illness or to care for a sick family member,” Cooper said. “Insured people can pay lower premiums because there will be fewer uninsured people who can’t pay. And people will have access to more doctors, nurses and mental health professionals because there will be more people who can pay them. It’s clear that this legislation I’m signing today will have a positive effect for all working families, even if they don’t directly get Medicaid.”

The bill’s passage is a bipartisan victory, but Medicaid expansion’s implementation — providing health insurance coverage to 600,000 more North Carolinians — comes with a significant asterisk: Republican bill writers tied it to the state budget.

While some parts of the bill are effective upon signing, much of Medicaid expansion cannot roll out until the 2023 state budget passes. And that won’t be for another three months.

“I think what’s important about this is that we have agreed on how to expand Medicaid, and it’s only a question of when and not if,” Cooper told reporters after the ceremony. “And I think that’s where we are right now. We know that this is going to happen. It’s just a question of when, and the House in the Senate seem to be excited about going ahead and doing a budget early. So that’s good to hear. We’ll just see how that goes.”

Budget football

Passing the state budget has been a game of political football over the past several years as Cooper and General Assembly Republicans, who control the legislature, dug in over policy priorities, including Medicaid expansion and raises. This year is likely to be different with Republicans only one vote short of a veto-proof supermajority and Cooper incentivized to sign the budget because it includes Medicaid expansion.

As top the state’s top leaders — Cooper, Senate President Pro Tempore Phil Berger, House Speaker Tim Moore, Senate Minority Leader Dan Blue and House Minority Leader Robert Reives — spoke about the bill, other lawmakers stood behind them. One significant Republican supporter of expansion, Sen. Jim Burgin of Harnett County, was holding a football and basketball. The basketball had HB 76, which is the expansion bill, written on it.

Reives told the crowd he was thinking about all the people who will benefit from Medicaid expansion.

“If you’ve grown up in North Carolina — and you’ve either grown up in a rural community or been touched by rural community — and I think about all of those family members whose lives will now be saved,” he said.

Reives said the bill is also “another sign that tells us who we are as North Carolinians. That our people matter over everything else.”

Berger talked about managing the influx of people enrolling in Medicaid and what more he’d like to see.

“While this is a momentous occasion, our work is not done,” Berger said.

“We need to continue to forge ahead with additional supply-side reforms,” he added. “We were able to make a good dent in reforming our state’s certificate of need laws, but we can do more to remove the red tape that healthcare facilities and providers face in North Carolina.”

Once the state budget becomes law, Medicaid expansion in North Carolina will start soon thereafter. Expansion will extend eligibility for the federal health insurance program to all adults with incomes up to 138% of the federal poverty level.

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