Policy Position

Medicaid Expansion

in Health Care


Medicaid is a program jointly funded by the state and federal government. Its core functions include paying medical providers for services rendered to low-income parents, children, pregnant women, the elderly, the blind, and the disabled.

The federal government currently funds two-thirds of North Carolina’s $14 billion Medicaid program. The Patient Protection and Affordable Care Act (ACA), commonly known as Obamacare, gives states the choice to expand Medicaid eligibility to individuals earning up to 138 percent of the federal poverty level. This figure equates to an individual earning $16,642 per year or a family of four earning $33,948. North Carolina is one of 18 states that have not expanded Medicaid.

If North Carolina had chosen to expand Medicaid, the federal government would have fully funded its cost through 2017. States would then be responsible for financing a portion of the total expense, reaching a maximum of 10 percent by 2020.

The experiences of states that have expanded Medicaid should temper the enthusiasm of those who champion expansion. For example, Arizona’s expansion in 2002 originally projected slow enrollment growth, maintainable costs, a reduction in the number of uninsured, and reduced uncompensated care. Instead, the expanded population (mostly childless adults) ended up costing two to four times more than the cost of covering low-income parents. Similar outcomes occurred in other expansion states, including Oregon, Delaware, Maine, Washington, D.C., Utah, and Vermont.

Key Facts

  • Fully funding Medicaid expansion and other health care entitlements will necessitate either higher levels of deficit spending, which adds to the multi-trillion-dollar federal deficit, or substantial increases in taxes, which impedes economic growth.
  • Medicaid expansion would cost North Carolina an estimated $6 billion between 2020 and 2030. To pay for the expansion, the North Carolina General Assembly would need to reduce provider payments, divert resources from other important parts of the budget such as education or transportation, or greatly increase taxes.
  • Expanding Medicaid eligibility puts traditional program enrollees at risk. Low-income parents, children, pregnant women, the elderly, the blind, and the disabled would have to compete for access to health care with an estimated 500,000 people added to Medicaid rolls, 82 percent of whom are able-bodied childless adults.
  • Currently, 25 percent of physicians in North Carolina do not accept new Medicaid patients, because, in part, of below-market reimbursement rates. Physicians and providers who serve Medicaid patients would compensate for the expansion by negotiating higher payment through private carriers, ultimately passing on the cost of expansion to non-Medicaid consumers in the form of higher premiums for private insurance.
  • With less access to physicians that accept new Medicaid patients, new enrollees will likely turn to hospital emergency rooms for service. A Colorado Hospital Association report found that emergency room usage was higher in expansion states than in non-expansion states.
  • Expanding eligibility levels for government health insurance programs crowds out access to private coverage. Studies indicate that the crowd-out effect contributes to the fact that six out of 10 people on Medicaid once had private coverage.
  • The 2008 Oregon Health Insurance Experiment (OHIE) is known as the “gold standard” of studies that assess Medicaid’s overall effectiveness. Researchers randomly assigned eligible patients to the state’s Medicaid program. Two years later, the authors concluded that Medicaid had no statistically significant effect on major measures of health outcomes between those who had been chosen to participate and those who had not.


  1. North Carolina should not expand Medicaid.
  2. Congress should restructure Medicaid to grant states more budgetary flexibility, including the use of block grants to distribute federal funding.
  3. Congress and North Carolina lawmakers should relax Medicaid rules and regulations. Regulatory relief would stimulate competition in the insurance market and allow individuals to purchase affordable plans that best meet their needs.
  4. Congress should offer a refundable tax credit to able-bodied, working Medicaid patients and their dependents. This would offset the cost of private health insurance for the expansion population.


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