As the 2019 legislative session gets underway, the drumbeat from all corners of the media, business, and political establishment is sure to grow louder for Medicaid expansion.

Gov. Roy Cooper has signaled that he will put it in his budget, and some GOP legislators are either openly or privately supportive of the effort.

Yet despite a parade of op-eds, news stories and quotes saying this time it’ll be different, make no mistake: Expanding Medicaid will create massive debt for negligible return. North Carolina needs to continue saying thanks, but no thanks, to Medicaid expansion.

Why is 2009 important to Medicaid expansion?

That is when North Carolina, along with many of states, began borrowing money to pay for unemployment claims.

The recession was hitting hard and state budgets were being stretched thin. At one point, our state was borrowing upwards of $20 million per day to cover those expenses. This borrowing created an over $2 billion debt to the federal government. The situation was dire, and this had multiple negative effects on our state’s finances.

As some may have already forgotten, this debt was paid off in 2015 thanks to disciplined spending and tough decisions by Gov. Pat McCrory’s administration and legislative leadership.

Photo by NCDOT

Fast forward to today. We have an over $2 billion budget surplus, which is helping eastern North Carolina recover from Hurricane Matthew and Hurricane Florence.

Is taking on billions in new debt really something policymakers want to do again? Where would these recovery efforts be if not for the rainy day fund?

Allowing Medicaid expansion – in any form – will create billions in new debt. In every state that has expanded Medicaid, the costs are always more than anticipated. In those states, Medicaid spending is double the normal rate of growth with no sign of slowing down.

The areas that suffer from this increase? Education, public safety, and transportation, for starters. How will that impact a potential school bond in 2020? I’ll let you figure that one out.

Consider what other states have done. A July 2018 article in Governing details what 13 states have done to cover costs. Want to guess what they are? Tax increases, hospital fees, higher insurance premiums, and in many cases, a combination of the above. There’s no way out of the cycle once Medicaid expansion is enacted.

Left out in all of this is the health side: Does expanding Medicaid work?

Research shows that the seven states with the highest opioid overdose deaths – West Virginia, New Hampshire, Kentucky, Ohio, Rhode Island, Pennsylvania, and Massachusetts – are all Medicaid expansion states. There’s also a 2013 Oregon study in which the researchers concluded expansion “had no significant effect” on health outcomes vs. being uninsured.

At every level of government, we can do better in healthcare. Medicaid expansion is not that vehicle.

Finally, the federal government will force states to start paying more for Medicaid expansion. That is currently slated to begin in 2020.

We’re $22 trillion in debt as a nation as it stands today. Medicaid expansion is a multi-level marketing scheme where the taxpayers end up suffering the most.

Our leadership needs to stand strong in the face of the coming onslaught and continue to reject expansion.

Cover photo of UNC Hospitals by William Yeung via Flickr (Creative Commons)


  1. More recent data re: the opioid epidemic in expansion states:

    More recent data on the coverage, access to care, and economic impact of Medicaid expansion:

    More info re: how states are paying for it:

    Solid policy recommendations should be based on the results of current research rather than collecting bits of data to support predetermined opinions – that’s the opposite of the scientific process.

    As a retired health care professional who strongly supports Medicaid expansion until we have a national health care policy with universal coverage and a single non-profit payer, I appreciate the insight this article provides into what areas of advocates need to address in order to provide legislative decision makers with updated information and dispel unfounded beliefs. Thank you for sharing that information.

  2. Matt, given the thoughtful, clear, updated references Ms Rieser has provided, I initially thought they might impact your reasoning in your opinion piece, moving forward. Then I read your link to the July 2018 piece in Governing, and saw you cherry-picked information there, leaving out key data points such as (when referring to Maine’s estimated costs for expansion) “Those numbers, however, don’t include the millions in savings expected by the Office of Fiscal and Program Review.”

    In fact, as noted in the updated info posted by Ms Rieser, in many places Medicaid expansion has resulted in boosting state economies, rather than being a budget drain (not to mention preventing many rural hospitals from closing).

    If you were going to state your case against expanding Medicaid, a more balanced argument would be more useful to voters reading such a widely-read resource such as this. That would require you to make your argument persuasive using all the facts, a tenet of evidence-based thinking.


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