Medicaid Expansion

Together, we did it! Our hospitals, lawmakers, communities, and more came together to expand Medicaid coverage for over 600,000 North Carolinians [1],[2]. That’s more than the population of Raleigh and Asheville combined. These are our neighbors and co-workers. They are farmers who help feed us, veterans who protect us, and healthcare workers who heal us.

North Carolina hospitals believe they deserve health insurance and are covering the costs to create health coverage for:

Without Medicaid expansion, there was a “coverage gap.” People who earn too much to qualify for Medicaid, but not enough for subsidized insurance fall into this gap. In the coverage gap, health insurance is virtually impossible to afford – so people go without it.

Now, by extending who Medicaid can cover, North Carolina is closing that gap to ensure access to life-saving health insurance.

Hospitals Support Medicaid Expansion in North Carolina

Our hospitals believe so strongly in the importance of health insurance for our communities that they finance the state portion of expansion, an estimated $500 million dollars per year [3]. Expanding Medicaid is an investment that will repay all North Carolinians. Studies from other states that have expanded Medicaid show that increased state spending is nearly or completely offset by savings and increased state revenue [2],[4],[5].

Click to See a Timeline of Key Events in Medicaid Expansion

Supreme Court Ruling on ACA

The Supreme Court in June upholds the penalty on people who lack health insurance but lets states decide whether to expand Medicaid.

NC Institute of Medicine releases plan to implement healthcare reform in NC


NC Declines Medicaid Expansion

North Carolina enacted legislation declining Medicaid expansion and directing state agencies and institutions not to participate in the implementation of a health benefits exchange in North Carolina. See S.L. 2013-5, summarized here.

Care4Carolina Founded

Care4Carolina was founded by Carla Obiol to advocate for expanded healthcare in North Carolina. By the time Medicaid Expansion was passed in 2023, 176 organizations including hospitals and health systems join Care4Carolina to advocate for Medicaid Expansion.

Advocacy Collaborations Continue to Support Medicaid Expansion

Ongoing work by multiple advocacy groups, including the  North Carolina Justice Center, NC Child, the American Cancer Society, North Carolina Healthcare Association, North Carolina Medical Society, helped to organize citizens, tell their stories, and influence perceptions of Medicaid statewide.

Governor Calls for Expansion

Mr. Cooper called for expanding Medicaid when he ran for governor in 2016. Soon after he took office, he submitted a proposal designed to expand Medicaid coverage.

NC Lawmakers Sue to Stop Expansion

Medicaid Transitions to Managed Care

In 2015, the NC General Assembly enacted legislation directed DHHS to transition Medicaid from fee-for-service to managed care. Under managed care, the state contracts with insurance companies, which are paid a predetermined set rate per enrolled person, to provide all services.

Medicaid Managed Care Takes Effect

Most Medicaid beneficiaries began receiving the same Medicaid services in a new way. Called “NC Medicaid Managed Care,” beneficiaries choose a health plan and get care through a health plan’s network of doctors.

Federal Government Incentivizes Expansion

With the American Rescue plan act of 2021 (aRpa), the federal government provided large financial incentives, on a permanent basis, for states for the first two years that they choose to newly expand Medicaid.

HASP Reform Supports Expansion

HB 76 also enacts the Healthcare Access and Stabilization Program (HASP). Under HASP, North Carolina hospitals and health systems will receive up to $1.8 billion in federal dollars to improve access to care for Medicaid patients provided that the program is approved by CMS.

We All Benefit by Closing the Health Insurance Gap

Expanding Medicaid reduces avoidable deaths [6], increases preventable care utilization [7], and helps people afford care when they need it [8].

But the benefits are not just limited to improvements in healthcare and wellness. Medicaid Expansion also drives economic improvements, such as increasing local and state revenues and creating new jobs both inside and outside the healthcare industry. These economic development impacts include [9]:


people now eligible for Medicaid


new jobs that will be created


increase in annual gross state product


annual increase in state tax revenue


annual increase in county tax revenue

Estimated Impact of Medicaid Expansion in North Carolina

Getting healthcare coverage:

  • reduces economic losses to sick time and medical bankruptcy,
  • prevents costly avoidable care,
  • reduce risk to vulnerable rural providers and strengthen our local communities,
  • helps create thousands of new jobs, and more.

For North Carolina, these benefits could exceed $10 Billion [5], fueled by returned state taxes [10], increased federal funds [3], creation of tens of thousands of new jobs [5], and greater workforce participation [4].

a flow chart showing the compounding benefits of Medicaid Expansion

North Carolina currently has the 10th-highest proportion of uninsured people in the country [8]. Expanding Medicaid coverage for those who fall in the coverage gap will help North Carolina reap the enormous financial and wellness benefits other Expansion states are already getting.

Click to learn more about the multiplier effect

Source: Leighton Ku and Erin Brantley, The Economic and Employment Effects of Medicaid Expansion Under the American Rescue Plan (Commonwealth Fund, May 2021).


  1. Centers for Disease Control and Prevention (CDC). National Health Statistics Report. Nov 2022.
  2. The Implications of Medicaid Expansion in the Remaining States. May 2018.
  3. Joint Legislative Committee on Access to Healthcare and Medicaid Expansion. Medicaid Expansion Fiscal Background. March 2022.
  4. Hemi Tewarson. North Carolina Council on Health Care Coverage: First Council Meeting 2020. 
  5. Kaiser Health Foundation. Americans’ Challenges with Health Care Costs. Jul 2022.
  6. Erica Palmer Smith, Kathryn Horneffer, Peg O’Connell. Uninsurance in North Carolina: Progress and Opportunities. North Carolina Medical Journal. vol. 83, no. 3.
  7. What Expanding Medicaid Would Mean for North Carolina. 2022. North Carolina Department of Health and Human Services
  8. US Census. 1-Year American Community Survey Estimates. 2022.$0400000&d=ACS+1-Year+Supplemental+Estimates&tid=ACSSE2021.K202701 
  9. Leighton Ku, Brian Bruen, Erin Brantley. The Economic and Employment Benefits of Expanding Medicaid in North Carolina. 2019. Milken Institute School of Public Health.—2019.pdf 
  10. Care4Carolina. Community Education Handbook. 2022
  11. US Census. 1-Year American Community Survey Estimates. 2022.$0400000&d=ACS+1-Year+Supplemental+Estimates&tid=ACSSE2021.K202701 

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