From the Field: Expanding Medicaid in North Carolina

Three Things

In March 2023, North Carolina became the 40th state to pass Medicaid expansion.

While the passage of the Affordable Care Act (ACA) expanded Medicaid coverage to adults with incomes up to 138% of the Federal Poverty Level, and offered an enhanced federal matching rate to states for their expansion populations, 13 years later, ten states have still not yet adopted expansion, leaving more than four million Americans without healthcare coverage.

While each state’s landscape is undoubtedly unique, there are many shared lessons to be gleaned from North Carolina’s recent decision to expand Medicaid, 13 years after the ACA opened the possibility. 

Since 2017, Down Home North Carolina has been one of the leading grassroots organizations advocating for Medicaid expansion. With over eight member-run chapters across the state, from the mountains to the coast, their members engaged thousands of North Carolinians through deep listening canvassing efforts. 

In conversations with North Carolinians, canvassers heard over and over again that ”working families lacked health insurance, were unable to afford a doctor’s visit or medication, had insurmountable medical debt, and were frustrated that the government has continued to fail to help them”.

Organizing everyday small town and rural residents, and healthcare activists, Down Home members marched, rallied, protested, lobbied and organized for expansion – publishing opinion pieces, writing letters to the editor, speaking at conferences, engaging people in advocacy trainings and educational programs, and leading lobby visits and letter writing campaigns in addition to their deep canvassing work.

Years and years of collective organizing efforts paid off last March, when several Down Home members were at the Governor’s mansion when Medicaid expansion was signed into law. It’s estimated that over 600,000 North Carolinians will now have healthcare through Medicaid.

We asked Down Home North Carolina’s Todd Zimmer (Co-Director) and Gwen Frisbie-Fulton (Director of Communications): what can others in states that have yet to expand Medicaid learn from your experience and what it takes to pass Medicaid expansion in the South? 

In their piece below, Zimmer and Frisbie-Fulton lay out the dynamic landscape of North Carolina, and share firsthand lessons from building a multiracial coalition across rural and semi-rural settings to organize across the state for Medicaid expansion. As they prepare for the upcoming implementation period, slated to begin June 1st, they explain all that it took to get to this moment and the hopes Down Home North Carolina and its members have for the future.

In late March 2023, after years of organizing and negotiation, North Carolina passed a bipartisan bill to adopt Medicaid expansion. More than nine years after the Supreme Court ruled that states could choose to expand Medicaid, North Carolina became the 40th state to do so.*

“I’ve waited for Medicaid Expansion for seven and a half years,” says Dana Bango from Watauga County– a rural mountainous region of the state. “Other North Carolinians have been waiting for five, ten, or even more years. It’s way past time but we finally made it.”

Dana, a single mother caring for her elderly parents, didn’t have health insurance coverage from her employer when she was diagnosed with cancer. In other states and other places, Dana would have qualified for Medicaid, but not in North Carolina. ”I was angry at the thought of leaving my family and this Earth too soon,” she says. 

Dana was able to go to a free clinic for much of her care, but also accrued over $30,000 in medical debt. Medicaid expansion couldn’t have come a moment too soon for her or the 600,000 other Carolinians who now can access affordable care after years of languishing in the Medicaid coverage gap. 

North Carolina isn’t merely the latest domino to fall in a chain of recent Medicaid expansion states, but a blueprint for how to win future expansion. The Washington Post proclaimed “North Carolina offers a recipe for holdout states to expand Medicaid.” And local organizers who were involved in the fight to pass Medicaid expansion here agree.

While the preceding seven Medicaid expansion laws were passed directly by voters, North Carolina’s expansion bill had to be passed by the state general assembly. 

“Expanding Medicaid requires an act of law and in our state the only entity that can approve a law is the General Assembly,” explains Todd Zimmer, co-director and co-founder of Down Home North Carolina. “So we knew we couldn’t move this without moving lawmakers in Raleigh.” 

In other words, North Carolina’s only path to Medicaid expansion ran right through a state government dominated by ardent opponents to the proposal.

Down Home knew that Medicaid expansion was overwhelmingly popular both from statewide polling as well as from the groups own canvassing and door knocking in small towns. “Since we didn’t have the luxury of a direct referendum,” says Zimmer, “It became something that people were going to have to demand.” Down Home North Carolina worked to create the path for people, like Dana Bango, living in the healthcare gap to articulate that demand.

“We set out to make our elected officials understand that Carolinians knew that politicians were the ones blocking it,’ says Zimmer. “It wasn’t a priority for the general assembly like it was for working people– we had to make them feel it like we were feeling it on the ground.”

Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin and Wyoming are the remaining states that haven’t expanded Medicaid. What can they learn from North Carolina? 

For starters, the win in North Carolina shows that rural counties and constituents matter. In a state where 80 of 100 counties are rural, any major policy objective in North Carolina has to include rural support. 

“Passing policy in NC always has to include significant consensus in rural counties,” says Dreama Caldwell, co-director alongside Zimmer at Down Home. “There’s no path to change here that doesn’t run through a small town.”

“Prior to 2017 there was no organized voice for small town and rural people to demand popular and necessary policy,” Caldwell explains. “We set out to build that megaphone.”

Furthermore, the conversation around policy has to shift from pure ideology to the people and practicality. In North Carolina, the general assembly was stuck in partisan based ideological battles about the role of government and this was blocking Medicaid expansion from moving forward. “Part of organizing in rural North Carolina has to be about building multiracial coalitions of working people,” says Caldwell. “You have to have a choir of voices across the difference showing up together to make it feel real and significant and to move past partisan politics.”

Finally, Down Home’s recipe includes demonstrating the large base of support behind the measure. “You have to make sure that representatives see the massive amount of support from people all over their state in order to make them understand how popular this policy is,” Caldwell says. “They have to hear it from everywhere.” Down Home’s statewide footprint of eight local chapters run by local residents was perfect for this work. Their county-based chapters held local rallies and town halls, and also had residents speak out in local settings– such as county commission meetings– about Medicaid expansion to push the message up through their local government to the state. 

“We spent years bringing this public pressure to bear,” reflects Zimmer. “In 2019, we were able to start to make the story more about the impact and less the ideological positions – we were able to lift up the people living in the healthcare gap as the messengers. We shifted the way it was being talked about in the press and made sure that our representatives were hearing directly from their constituents.”

The Human Cost of Non-Expansion

By the time Medicaid Expansion was signed into law in North Carolina a few short months ago, it had bipartisan support. Todd Zimmer was at the signing ceremony, alongside the impacted people like Dana Bango who had fought so hard for so long. One person was not there, however.  Zimmer held a photo of Lyn Carver, an Appalachian woman who started the fight for Medicaid Expansion with Down Home but did not survive to see its passage. 

“Lyn Carver was a beloved Down Home member and a tireless advocate for Medicaid expansion. She was also a Post Office mail carrier, and fell into the Medicaid gap. Had she been able to access the prescription heart medicine she needed, she would have lived to see the fruition of her efforts,” explains Zimmer. “Her fight helped to win care for hundreds of thousands of people, and no one would have been happier to see Medicaid expansion passed. We miss Lyn terribly, and we honor her commitment as we mourn the thousands of Carolinians we needlessly lost due to years of callous government inaction.”

The passage of Medicaid Expansion allows, however, Down Home and the thousands of everyday North Carolinians who fought for it to now move forward. Not only will 600,000 residents gain coverage, but they can now focus on new frontiers in healthcare justice. “We will now turn to the work of helping to enroll our neighbors, but while we do that we will also make sure they are registered to vote,” explains Caldwell of Down Home’s plan moving forward. 

The organization is aware that Medicaid expansion was an important first step to achieve for the state, but still too many working class families lack adequate care or face high premiums and medical debt. Enrolling families will help people access care, but it is also an opportunity to help people closest to the center of the fight organize together for future wins. 

*North Carolina’s Medicaid expansion is contingent on the approval of the 2023-2024 biennial budget, which is expected to pass in June.