While campaigning to become the state’s 75th governor in 2016, Roy Cooper said he wanted to help low-income North Carolinians who had been forced to forgo basic medical care because they could not afford health insurance.
He finally achieved that goal six years later when North Carolina expanded Medicaid. The decade-in-the-making measure loosened the program’s strict eligibility requirements, making hundreds of thousands of low-income residents eligible for coverage for the first time.
“When I ran for governor, one of my top priorities was creating a North Carolina where people were healthier and could get the care that they need to have lives of purpose and abundance,” Cooper said in an exclusive interview with NC Health News. “We knew that Medicaid expansion was an important way of making that happen because there were a lot of hardworking people in North Carolina who were making too much money to qualify for Medicaid, but not enough money to qualify for subsidies under the Affordable Care Act.”
Expansion arguably now stands as Cooper’s signature achievement. More than 590,300 people who were previously ineligible for Medicaid have joined the rolls since expansion took effect in December 2023, nearly surpassing the state’s projected enrollment for two years in just 12 months.
“It's exciting that we set the goal of having 600,000 people enroll during the first two years, and now we're almost at that goal in just one year,” Cooper said. “I think it shows that people really needed it, and I'm grateful that we were able to get that for the people of North Carolina.”
But expansion was by no means easy for Cooper. He faced multiple setbacks over his two-term effort to make the measure a reality.
Power in numbers
Cooper said he knew from the beginning that expansion would be an "uphill battle."
The Affordable Care Act, former President Barack Obama’s trademark health care policy, allowed states to enlarge the pool of people eligible for Medicaid, which is largely funded by the federal government, by raising the maximum-allowed income for the program. The Obama administration incentivized states to adjust their income thresholds by offering to cover 90 percent of the cost of insuring the newly eligible beneficiaries.
But the contentious nature of the Affordable Care Act drove North Carolina’s Republican-led General Assembly to pass a 2013 law requiring legislative approval to expand Medicaid in the state.
Shortly after taking office in January 2017, Cooper asked the feds to override that law and implement expansion without the state legislature’s blessing. His request was met with a lawsuit from Senate leader Phil Berger (R-Eden) and House Speaker Tim Moore (R-Kings Mountain), with the court ultimately ruling in the Republicans’ favor.
“I think the biggest hurdle we faced was that Medicaid expansion was part of ‘Obamacare,’ and that made this an extremely political issue for Republicans,” Cooper said, adding that Donald Trump, who was elected the same year Cooper was, spent much of his first term as president working to dismantle the program colloquially named after his predecessor. “We had the challenge of moving Medicaid expansion past the politics of ‘Obamacare,’ and the way we needed to do that was get the constituents of Republican legislators to ask them for it.”
Cooper said his administration managed to “overcome the political headwinds” by building a broad coalition of advocates who could persuasively argue the value of expansion to Republican lawmakers. He also had some help from a handful of Republican House members who proposed a series of bills in support of expansion.
“We had very brave people who had become victims of the medical system, who were working hard for a living but couldn't afford health insurance and therefore were struggling to pay medical bills, who were willing to go and tell their stories,” Cooper said. “We also were able to get tough-on-crime sheriffs who knew that many of the people sitting in their jails needed health care and not handcuffs [… .] A lot of people with substance use disorders and mental illness were requiring a lot of attention from their deputies and officers.”
Rural support
The chorus of voices supporting expansion grew to include chambers of commerce in rural communities, particularly in the western part of the state, where many small business owners could not afford to provide health insurance to their employees. County commissioners in rural areas also warmed to the measure after realizing it could help local hospitals that were at risk of going under.
“Many of these hospitals just simply were treating too many patients who didn't have health insurance,” Cooper said. Local elected officials “recognized that Medicaid expansion would allow a lot of the people who live in their county to get health insurance to help keep these rural hospitals from closing.”
By 2023, the chorus had become hard to ignore. Legislation making North Carolina the 40th state to approve expansion passed that March with bipartisan support, a reversal spurred in part by the promise of more than $1.6 billion in federal financial incentives.
The move paved the way for newly eligible residents to sign up for Medicaid that December after a protracted stalemate among lawmakers over the state budget.
“Finally, we were able to able to get enough pressure on Republican legislators and, to their credit, they ended up putting it in the budget at the end of the day and we were able to sign it,” said Cooper, who was flanked by several of the advocates who had championed expansion — along with some of his longtime legislative opponents — when he signed the measure into law during an event in Raleigh. “It was an important day for North Carolina, and this coalition of people all together helped get the job done.”
‘Political will’
Kody Kinsley, secretary of the N.C. Department of Health and Human Services, believes expansion wouldn’t have passed if not for the governor’s “unrelenting tenacity.”
“He went out chamber by chamber, business by business, sheriff by sheriff, to get them to see what Medicaid expansion meant for them,” said Kinsley, who took charge of NC DHHS, which oversees the state’s Medicaid program, in 2021. “He was building up that coalition of people so that, all of a sudden, it would be hard to find anyone that was against it.”
Cooper’s “political will,” he added, is what “created the fundamentals for the legislative change to happen.”
“I’ve met plenty of other people who, after losing a fight so many times over six years, would have just walked away,” Kinsley said. “He did not, which is why we're the only state in the Southeast that has gotten this done through the legislature in the way that we did it in a long time.”
North Carolina was the first state to adopt expansion through a legislative process since 2019. A handful of other states have expanded Medicaid through executive orders and ballot measures.
Mandy Cohen, currently director of the federal Centers for Disease Control and Prevention, served as secretary of NC DHHS before Kinsley. She worked closely with Cooper during his first term in office to lay the groundwork for expansion.
“When I was interviewing for the job, he had articulated it was a priority of his, so that was something from Day One that was on his mind and on his priority list,” she said in a phone interview. “But he also knew that there was work we needed to do at the department, with the legislature and across the state in order to set the table and make the conditions possible for that to happen.”
Throughout various setbacks and roadblocks, Cohen said Cooper remained “steadfast to his mission” to make North Carolina a healthier place to live.
“I think the biggest thing I learned from working for him is that progress is not necessarily a straight line from A to B,” she said. “Progress happens when you sustain an effort and keep focused on priorities. You build coalitions and relationships, and you do good work and show that we can solve hard problems together if you bring folks to the table.”
Another takeaway from her work with Cooper, she said, was the Nash County native's unwavering devotion to his home state.
“I’ve never met anyone on the planet that loves North Carolina more than Governor Cooper,” Cohen said. “He really embodies that in every, every way. It just was always his North Star — his love for the state, his mission.”
Throwing a lifeline
Medicaid expansion is far from Cooper’s only health care achievement.
Under his leadership, North Carolina launched a first-in-the-nation program that uses Medicaid dollars to address non-medical factors that affect health such as housing, food and transportation. The program was part of a so-called transformation that changed Medicaid from a traditional state-run, fee-for-service program to one run by national insurers — a policy shift that Republican legislative leaders insisted on before even considering expansion.
But expansion is unquestionably Cooper’s most impactful health policy success. It provided a lifeline to people like Henry Medlin, a Beaufort County resident who worked in the aviation industry before quitting his job to care for his aging father.
After he resigned, Medlin lost his employer-provided health plan. He had gone without insurance for nearly a decade when he learned that he was eligible for Medicaid expansion while visiting a free clinic earlier this year to get treated for a broken tooth.
“I didn't believe it, but 10 days later I had a health care insurance card in my mailbox,” he said. “I can’t take care of my dad unless I can take care of me, and having Medicaid means I can take care of me.”
Medlin traveled to ECU Health Medical Center in Greenville on Wednesday for an event organized by the governor's office to mark the one-year anniversary of expansion. Darcy Brown, who lives with multiple sclerosis and has been unable to work for the past 16 years, also spoke about the measure’s impact during the event.
In 2018, Brown was in a vehicle accident that left her hospitalized for two months, causing the premium on the health plan she had signed up for through the Affordable Care Act marketplace to increase from $10 a month to $200. She paid the premium using money from her accident until the company that ran the health plan went bankrupt, forcing her to sign up for a different plan with a $700 monthly premium.
Her payout from the accident nearly depleted, Brown was at risk of losing her health insurance by the end of 2023. Fortunately, she was among the first wave of North Carolinians to be automatically enrolled in Medicaid when expansion went live in December of that year.
“Medicaid is literally saving my life,” said Brown, who noted that the program pays for her medical equipment and visits to specialist providers. “I’d like to thank Governor Cooper for getting Medicaid expanded to the state of North Carolina. I am the person that benefited from it, and I am no different than all the other people that can benefit.”
Cooper’s future
Some cabinet nominees for President-elect Trump’s second administration have expressed interest in reducing or eliminating federal funding for Medicaid. There have also been calls to force participants to work for their benefits.
Cooper believes Medicaid is too “ingrained” in the nation’s health care system to be completely eradicated. He is, however, concerned that Trump will restart his “attempt to get rid of the Affordable Care Act,” which would put expansion in jeopardy.
“I think it is going to be important for the people who have this coverage to continue to plead with their members of Congress and members of the U.S. Senate to keep it in place, because Republicans have no replacement for it,” Cooper said. “They have continued to talk about studying options and reviewing options, but they have no option to replace it with.”
The 67-year-old said he will continue to advocate for health care issues after leaving the executive mansion. He is especially passionate, he said, about increasing preventive services for substance use disorder and expanding treatment for mental and behavioral health.
He also plans to support advocacy efforts in states that have yet to expand access to Medicaid. The holdouts include Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin and Wyoming.
“There are millions of people living in those 10 states that could significantly benefit from Medicaid expansion dollars [going] into their states, and I look forward to talking to more advocates and elected officials in those other states to help them to form these coalitions of people that we know are out there,” Cooper said. “The key is just to channel the positive political force that you already have in these states into effective legislation.”
This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.
North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.
