Despite being billed as an “alternative” to Medicaid expansion, a new bill put forward by a group of Republicans in the N.C. House is fundamentally the same as the controversial program.

Called “NC Health Care for Working Families” and supported by 11 House Republicans, the bill aims to extend health insurance coverage to several hundred thousand low-income, childless adults who currently don’t qualify for Medicaid.

It does so using the exact same mechanisms as “Medicaid expansion,” a term that refers to the provision in President Obama’s Affordable Care Act that allows states to decide to expand eligibility for the government healthcare program while getting partial reimbursement from federal coffers.

Forsyth Rep. Donny Lambeth was careful to present his new bill as something distinct and different from Medicaid expansion. That’s because many members of his own party — including Senate President Pro Tem Phil Berger — have been vociferously outspoken against it.

In reality, it’s exactly the same. Here’s why.

Same eligibility criteria. Medicaid expansion applies to childless adults making 133% of the federal poverty level or less. So does the House bill.

Same funding mechanism. Medicaid expansion is currently paid for with 90% federal dollars and 10% state dollars. So is the House bill.

Same coverage benefits. States were required to come up with “Essential Health Benefits Benchmark Plans” for Medicaid expansion. Those benchmarks are what would be used under the House bill.

Same requirements. House bill sponsors point to two things as evidence that their plan is different from Medicaid expansion: Work requirements and premium payments for individuals. However, both of these are allowed under Medicaid expansion, and several states require them under their Medicaid expansion plans. Five states require premiums to be paid, usually a flat fee of $10 or a percentage of income (North Carolina’s bill would require 2% monthly). Other states have implemented work requirements, though they are tied up in the courts.

[Longleaf story: The quick case against Medicaid expansion in North Carolina]

This Medicaid expansion bill has a (very slim) chance to pass. Here’s how.

This healthcare bill will struggle, but it does have a slim chance to pass if N.C. Democrats get on board. The Republican majorities in both houses shrank in the 2018 elections, meaning fewer Republicans would have to support the bill to pass.

State Democrats have already said Medicaid expansion is their top priority in this legislative session. Their first response to the new House bill was to oppose it because it includes the work requirements and premium payments.

But if they want a chance to actually pass legislation that accomplishes 90% of what they want to do, they might change their mind. The fact that courts have been striking down work requirements makes that an easier sell.

Republicans hold a 65-55 majority in the N.C. House. We already know 11 House Republicans are on board, so if Democrats join in — they easily have the votes to pass the chamber.

The state Senate will be much, much tougher. The chamber leadership is very much opposed to Medicaid expansion and might prevent the House bill from coming to a vote.

However, Republicans hold just a 29-21 majority in the Senate this session, meaning only 6 Republican Senators would need to come on board if Democrats support it. The bill doesn’t have a champion in the Senate to my knowledge and these defections would be a major rebuff of leadership, so don’t count on it.

But should it pass there, this feels like the sort of compromise bill that Gov. Roy Cooper would readily sign.

Cover image of the General Assembly building by James Willamor via Flickr (Creative Commons


  1. Question:

    As I understand it, Medicaid expansion’s goal is to bridge the gap between people who make too much money to qualify for Medicaid and too little money to qualify for Obamacare subsidies. If these people have some income, aren’t they already working? Why is the work requirement such a hang up? I can’t imagine that there would be very many caught in the coverage gap who are not working.

  2. Hey Andy, If you’re right…that the “House GOP Healthcare Bill is Definitely the Same as Medicaid Expansion”… why doesn’t the NCGA just pass the Medicaid expansion legislation Gov. Cooper/Dems have been trying to pass for years? And stop screwing with an estimated 503,000 of our most vulnerable friends, relatives and neighbors who desperately need healthcare? (Asking for a friend.)

  3. “Longleaf Politics is the premier source for the vital news and information North Carolina’s political leaders need.” Curios how Longleaf bills itself as a “premier” source of “vital” news, yet these opinion pieces ntime and time again fail to generate any comments. Hmm…

  4. Wasn’t trolling. I simply asked what I thought was a legitimate question.

    Calling people who comment without being abusive “trolls” isn’t really a good strategy for growing a podcast/blog. The fact that people you disagree with are reading your material is pretty much proof that we are at least open minded enough to try and understand the other side. That is more than I can say for most conservative voters I come across. 90% of the views articulated on this site are straight out off of Fox News or out of Sen Bergers office.

    I read the blog to understand those I disagree with. I also like open discussion of the topics. That is what you said was your vision of this project. When you consider people who comment questioning your viewpoints “trolls”, not sure how that promotes discussion. There are a zillion websites for conservative viewpoints. MSM definitely has a liberal bias. Nobody is trying to bridge the gap. I was hoping that this project would promote that.

      • But Jeff’s right. He and I are the only two to comment, yet you claim to be a “premiere” news source. That’s not trolling. That’s what journalists call “fair comment and criticism”. You slurring me only makes my point.

          • “No, no, sorry: That was a direct response to Stephen’s comment, not to yours.” Hmmm…Anyway, I’d still appreciate your answer: If the GOP bill is “definitely” the same as Medicaid expansion, why have the Republicans opposed that expansion for so long? A fair-minded political observer would hav asked that.

            Here’ the point: I agree with Jeff. I was hoping yours was going to be a lively, fair-minded, objective commentary on NC politics. Sadly, your blog falls far short of that. (And is hardly a premiere source of political news!) Pity….with its rampant political tribalism the state could use such a voice.


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