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Medicaid expansion is close in North Carolina, with the Republican-led legislature passing and the Democratic Governor Roy Cooper signing the Access to Health Care Options legislation to take effect with passage of the state budget for the 2024 fiscal year. A distinctive feature of this result is the strong bipartisan legislative vote. Other states have expanded Medicaid through the legislative process, but with limited bipartisan support, or have used ballot measures. However, it is likely that action in the remaining non-expansion states will depend on engaging legislators from both Republican and Democratic parties.
Here, we describe key contributing factors enabling Medicaid expansion in North Carolina, which could serve as a roadmap for further bipartisan Medicaid reforms. These factors included: building a bipartisan process to address concerns and identify key shared priorities for reform, including improving outcomes while limiting total costs of care and state spending; linking expansion to the adoption of steps to “pay for health” with accountability for care that improves outcomes while limiting costs; and implementing financing steps to limit the fiscal impact of expansion. While deep partisan divides continue to complicate many important health care issues, bipartisanship on health care coverage and payment reforms can enable further progress toward improving health while addressing fiscal concerns.