North Carolina has agreed to expand Medicaid, reversing its longstanding opposition

North Carolina’s Medicaid expansion deal received final legislative approval Thursday, ending a decade of debate over whether the politically divided state should accept federal government coverage for hundreds of thousands of low-income adults.

North Carolina is one of several Republican-led states that have begun to consider expanding Medicaid after years of steadfast opposition. South Dakota voters approved the expansion in a referendum in November. And in Alabama, advocates are urging lawmakers to take advantage of federal incentives to expand Medicaid in order to provide health insurance to thousands of low-income people.

When North Carolina’s Democratic Gov. Roy Cooper, a longtime advocate of expansion, signs the bill, it will leave behind 10 states in the United States that have not adopted expansion. North Carolina has 2.9 million participants with traditional Medicaid coverage. Advocates estimated that the expansion could help 600,000 adults.

“Medicaid expansion is a one-in-a-generation investment that will make all North Carolina families healthier while strengthening our economy, and I look forward to signing this legislation soon,” Cooper wrote on Twitter.

The state assembly voted 87-24 in favor of the deal, after minor debate. Some of the members applauded after he passed, which is normally not permitted under the Chamber’s rules. The North Carolina Senate approved the legislation last week.

The final agreement also included provisions that reduce or eliminate regulations that require state health officials to sign off before medical providers open certain new beds or use equipment. Senate Republicans have demanded “certificate of need” changes in any deal.

Republicans in charge of the General Assembly for years had been skeptical of the expansion, which stemmed from 2010 federal Affordable Care Act. But they’ve been getting around to the idea over the past year, deciding that Congress isn’t likely to repeal the law and not raise the low 10% required for coverage.

The fiscal sweetener in the COVID-19 Recovery Act means North Carolina will also get an estimated $1.75 billion in cash over two years if it expands Medicaid. Lawmakers hope to use much of that money for mental health services.

There is no set start date in the law for expansion under the legislation, but it also comes with one caveat: It can only happen after the state budget is approved. This usually happens in early summer. Cooper criticized the ruling, which could give GOP leaders leverage to include unrelated elements he might strongly oppose.

The state’s share of 10% of Medicaid expansion recipient expenses will be paid for by hospital evaluations. Hospitals are also expected to receive greater compensation for treating Medicaid patients through a federal program that the state is required to include in legislation.