The 13-Year Climb to Approval of Obamacare

On the 13th anniversary of the law’s passage, North Carolina became the 40th state to approve Medicaid expansion, demonstrating how far public opinion has come on the health care reform.

The North Carolina House overwhelmingly approved, bringing the number of Medicaid-expanding states to 40 on Thursday, March 23, 2023.BILL CLARK/CQ ROLL CALL

They despised the Affordable Care Act, referred to by the then-derisive term “Obamacare,” and the North Carolina state legislature – controlled by Republicans every years since the ACA became law – exercised its own civic disobedience, refusing to expand Medicaid under the federal health care law.

That changed on Thursday when the North Carolina House overwhelmingly approved Medicaid expansion, giving the Tar Heel State federal funds to pay for health insurance for a larger group of low-income citizens and bringing the total number of Medicaid-expanding states to 40.

Although having Roy Cooper, a Democrat, as governor guarantees that the measure will pass, it wasn’t because Republicans lost power. The pressing needs of poorer North Carolinians, most of whom have jobs but still can’t afford to buy their own health insurance, put party politics behind the public interest, advocates of Medicaid expansion in North Carolina say.

“We felt like the tide was turning” when GOP state Sen. Phil Berger, president pro tem and long an opponent of the idea, “came out last year and stated, the ACA’s not going away, and this is good state fiscal policy,” says Care4Carolina’s executive director is Abby Emanuelson. “There’s money on the table for us to do some really good work,” she adds, noting that 76% of those caught in the coverage gap have jobs.

“I understand that it’s challenging for some of my caucus members. They represent their districts,” state As he fought for the bill last month, retired hospital executive and Representative Donny Lambeth said. But “we can make If we proceed with expanding access to care, North Carolina will become a better state.”

On the thirteenth anniversary of the day President Barack Obama signed the legislation, the state legislature of North Carolina finally approved Medicaid expansion as a result of Lambeth’s pleadings.

It means North Carolina will get a hefty federal contribution (90% of the cost) to expand the federal program, which provides coverage to low-income Americans, to a broader group of people. It also represents a turning point for a law that Capitol Hill Republicans have fought to repeal since it was first passed.

“I remember the words I used at the time” to mark the enactment of the President Joe Biden made the statement during a Thursday White House event honoring the first anniversary of Obamacare. “I thought it was a big deal,” the president added, drawing chuckles from a crowd that recalled then-Vice President Biden used an expletive to emphasize the momentous development that day.

“I stand by it. In fact, it was a big deal,” Using no objectionable qualifiers, Biden added on Thursday.

40 million more Americans have access to health insurance as a result of the Affordable Care Act’s insurance exchanges and Medicaid expansion in participating states, according to Biden. In addition, patients have other protections, such as not being denied coverage because they have what insurance companies deem “pre-existing conditions.”

Republicans wanted to quickly weaken or repeal the law by capitalizing on the discontent that many Americans felt regarding the federal requirement to obtain health insurance. Additionally, lawmakers were aware that once voters have grown accustomed to a benefit, it is more difficult to eliminate it.

Democrats made sure the more well-liked provisions of the law—like the clause allowing parents to keep their children on their health insurance plans until they turned 26—were implemented early because they were aware of this.

That appears to have been successful because public support for the ACA has increased since the law’s passage. For instance, ongoing surveys by the apolitical health research organization Kaiser Family Foundation show that in October 2011, 34% of Americans had a favorable opinion of the ACA and 51% had an unfavorable opinion. 55% of Americans had a favorable view of the law in March 2022, the last month KFF polled on the subject, while 42% had an unfavorable view, according to the research group.

Another way that states governed by the GOP resisted Medicaid expansion was to opt out of it. Just five states—California, Connecticut, Minnesota, New Jersey, and Washington—as well as the District of Columbia—had expanded Medicaid as of April 2012.

Republicans made up the majority of the opponents, who claimed that states would be burdened if the federal government ever decided to reduce its contribution. And some people just didn’t want to support the ACA in any way.

As a way to help constituents, many of whom reside in rural areas where hospitals have been closing, North Carolina’s action reflects a growing acceptance of the Affordable Care Act’s Medicaid expansion, if not always an embrace of it. The North Carolina legislation also allows the state to participate in a federal program that will bring more cash to rural hospitals.