A new statewide poll out Thursday shows that a majority of Republican primary voters oppose expanding North Carolina’s Medicaid entitlement program. Once the details of Medicaid expansion are offered to respondents their opposition climbs, pointing to a potential messaging hole for expansion opponents.

North Carolina is one of 12 states nationwide that has not expanded the program as outlined in the Affordable Care Act. The Civitas Poll revealed that 58% of likely Republican primary voters agree to that decision by N.C. lawmakers. Expansion would extend government-funded Medicaid coverage to mostly healthy, working-age adults with no children. When that point is explained in the survey, 65% of voters say they would be less likely to support expansion.

“Medicaid expansion is still an electoral loser for legislative Republicans,” said Donald Bryson, president of the John Locke Foundation.  “Aside from expansion being bad policy, it makes incumbents vulnerable to primary challengers and is unlikely to create new Republican voters in a general election.”

In the poll, 56% of respondents said they would be less likely to support Medicaid expansion when learning that expansion could not be tied to work requirements, due to the Biden administration’s stop to waivers.

Waivers for work requirements or copays were a big part of the “carrot” from the Obama Administration to entice some states to expand Medicaid in the early years of the ACA. At the time, states could apply for a waiver to implement a work or volunteer requirement, or charge a small co-pay so that the Medicaid expansion recipients had some “skin in the game,” but few actually got them under Obama. Under the Trump administration, those waivers were often approved and expansion continued with some states customized the expansion to fit their budgets and population.  However, when the Biden Administration took over the executive branch in 2021, DHHS stopped approving the waivers and rescinded the ones signed under the Trump administration.

In 2019, H.B. 655 was filed by Republican lawmakers and would’ve expanded Medicaid with limited work requirements and a capped co-pay, but the bill was relegated to the Senate Rules Committee and never came for a full vote. Today, those work and co-pay requirements would not be allowed under the Biden Administration.

The Republican-led N.C. General Assembly had been steadfastly opposed for years citing an existing broken Medicaid system, and the uncertainty that the fed would keep paying 90% of the expansion cost, one day leave North Carolina taxpayers with the full tab of expanding coverage to 621,000 working-age adults with no children. As the program stands today, about 2.6 million people are covered under Medicaid.  Expanding the program would cost 10% of the expansion costs falls to the state, which means N.C. could face a funding gap between $119 and $171 million in the first year. The Biden administration recently offered to kick in that amount through the federal $1.9 trillion American Rescue Plan.

Now, North Carolina lawmakers are investigating Medicaid expansion in North Carolina, after the issue became sticking point with Gov. Roy Cooper, and the current Medicaid program transitioned to managed care.

Senate Leader Phil Berger indicated during the last legislative session that his opposition to expansion is softening.  The legislative committee studying expansion has had two meetings so far where lawmakers heard from health officials from states that have expanded Medicaid.  However, most of those states expanded with waivers that are not available to North Carolina. Dr. Jennifer Sullivan spoke to the committee on her experience as the former Indiana health secretary. Sullivan now works for Atrium Health in Charlotte. She told lawmakers that Indiana’s hospitals picked up the state’s cost of expansion through a fee, something that North Carolina hospitals have agreed to do as well.

Also among the proponents of Medicaid expansion who spoke to N.C. lawmakers was former Ohio governor and GOP presidential primary candidate, John Kasich. Kasich focused less on the cost to taxpayers, and more on the legacy.

“When you die and go to heaven, you’re going to see St. Peter, and St. Peter is not going to ask you, ‘Did you balance the budget?’ He’s going to ask you what did you do for the least of those,” Kasich told the committee.

“If I get to Heaven and anyone asks about Medicaid expansion, I will be very surprised,” said Bryson. “I believe the Lord wants us to personally care for each other, not appropriate tax dollars to make other people do it.”

The next Joint Legislative Oversight Committee on Medicaid and NC Health Choice is scheduled for April 12.