My years as a hospital executive taught me many things, but what stuck with me was a simple truth: thousands of North Carolinians were being left behind when it came to access to affordable health care and health coverage.

Prior to the North Carolina General Assembly’s (NCGA) passage of Medicaid expansion through House Bill 76, thousands of North Carolinians earned too much to qualify for traditional Medicaid, yet not enough to afford private insurance.1 Many of these were people working in some capacity—in child care, retail, restaurants, hospitality, home health care, construction, and other essential jobs.

For myself, and many others throughout the NCGA, we knew we could help serve our constituents better, which is why I spent years pushing for expansion. Thanks to the support of our membership, the bill passed in March 2023 with strong bipartisan support.

Since its formal launch in December 2023, nearly 700,000 North Carolinians have enrolled and have access to full health coverage through Medicaid expansion. Thanks to incentives offered by the federal government, and an innovative funding model created in partnership with our North Carolina hospitals, expansion comes with no costs in state dollars.

Since expansion, the coverage gap continues to decrease for North Carolinians, especially in our rural communities. In fact, over 244,500 people in rural North Carolinian counties have enrolled in Medicaid, which makes up more than 1 in 3 of all newly eligible people.2

Closing the coverage gap can look different from community to community, and even family to family. For North Carolina families, closing the coverage gap has translated to (data provided by the North Carolina Department of Health and Human Services):

  • Over 11 million prescriptions filled for heart health, diabetes, seizure disorders, and other illnesses.

  • Over $146 million in claims paid for dental services.

  • Visits to emergency departments due to overdose have decreased by 14% from 2024 to 2025.

  • Over 135,000 members screened for various cancers, including breast cancer, cervical, and colon cancers.

And these are not the only success stories. Most of our major hospitals are netting positive revenue for serving expansion patients, receiving almost $5 billion collectively in net revenue from federal reimbursements to provide care at rates closer to the cost of care (data provided by the NCGA Fiscal Research Division). This also encourages growing provider participation in Medicaid and helps strengthen our rural hospitals—a true win for both patients and providers.

Though there is much that Medicaid and expansion are doing well, incoming changes resulting from the 119th Congress’ House Resolution 1 (HR1), the “One Big Beautiful Bill Act,”3 are providing states a unique opportunity to assess their Medicaid programs and find ways to serve their people better while stabilizing costs for the program long-term.

Prior to HR1’s passage, I introduced legislation focused on addressing the long-term sustainability of the Medicaid program and ensuring North Carolina was ready to act should work requirements become allowable by the federal government, the latter of which became law.

Since I started pushing for expansion, I have always been in favor of including a work requirement for the program. Work requirements serve an important purpose, providing potential connecting opportunities for able-bodied adults on Medicaid to the social service, workforce development, and holistic health professionals that can help move them and their family forward towards self-sufficiency.

There is dignity in work, and the benefits of secure and stable employment on health cannot be overstated. We recognized this when passing House Bill 76, which included language requiring the state’s Departments of Commerce and Health and Human Services, with help from various health and workforce stakeholders, to develop a comprehensive workforce program to connect Medicaid beneficiaries to employment opportunities.

Recent data from the U.S. Bureau of Labor Statistics shows that there are more open jobs than unemployed people to fill them in North Carolina.4 We can, and should, be working on all fronts to connect our people that can, and want to, work with these growing opportunities in our state. Helping move North Carolinians towards sustaining wages is critical to addressing long-term poverty and improving health outcomes.

My colleagues and I are also looking to our fellow states for ideas on new and innovative ways to connect those in our expansion population who can and are working towards more growth opportunities and career tracks with higher earnings and benefits.

This work now becomes more important than ever as we look to respond to HR1, but there are other major hurdles we will need to address as new requirements and deadlines inevitably come down from the U.S. Department of Health and Human Services. These include programmatic funding, shoring up error rates and improper payments, and making use of new federal dollars to help our rural communities.

All in all, I see it as an important opportunity to help our programs working for North Carolinians work even better.

Declaration of interests

The author has no conflicts of interest to declare.