RALEIGH, NC — People who follow North Carolina politics say Phil Berger, a Republican who calls himself a fiscal conservative and “social traditionalist,” is the most powerful man in the state. As the top Republican in the state Senate, he blocked North Carolina’s Medicaid expansion under the Affordable Care Act for years.

But at a sunny outdoor ceremony at the governor’s mansion late last month, when the dogwoods bloom to signal spring, Mr. Berger looked on with pride as Gov. Roy Cooper, a Democrat, signed the Medicaid expansion into law. State officials estimate the expansion will cover more than 600,000 North Carolinians.

Thirteen years after President Barack Obama’s Affordable Care Act was passed, Republicans are abandoning their opposition to Medicaid expansion. Lingering reservations about the welfare state and the cost of the expansion are giving way to arguments about Medicaid as an engine of economic growth and a lifeline for struggling hospitals.

Mr. Berger cites a number of reasons for the change of heart: North Carolina, where the legislature is controlled by Republicans, has overhauled its Medicaid program to one that relies on managed care, making it financially stable. New federal incentives made expansion difficult. Hospitals that will benefit from Medicaid reimbursement will pick up 10 percent of the cost of the new program — typically paid by the states — and the federal government will pay the rest. Most of the North Carolinians who will benefit from this have jobs.

“I felt that I had a certain responsibility — that if the reasons I expressed for 10 years ceased to exist, then I had a responsibility to be honest with myself and to be honest with others about that,” Mr. Berger said in an interview. “So I spoke to my members and told them where I was—and why.

That leaves ten states where Republicans have refused to expand Medicaid, most of them in the South, leaving an estimated 1.9 million uninsured adults in the so-called coverage gap. Too poor to qualify for subsidized private insurance through the Affordable Care Act but ineligible for traditional Medicaid, they are forced to make do with patchwork charity care or skip care altogether. They are disproportionately people of color.

Nationally, the coverage gap is expected to grow in the coming months the end of pandemic-era politics which provided additional funding to states in exchange for a guarantee that Medicaid recipients would not lose coverage.

As of 2017, voters in seven states— most recently South Dakota — passed a ballot measure to expand Medicaid, despite longstanding Republican objections. The question now is whether North Carolina will be the turning point.

State Rep. Donny Lambeth, a North Carolina Republican who has pushed for Medicaid expansion, said he was approached by Republican lawmakers in Tennessee, “interesting how we did it.” Supporters of the expansion look to Alabama, where Gov. Kay Ivey, a Republican, can act without legislative approval.

“This is the beginning of the end of the Medicaid expansion story,” said Lawrence O. Gostin, an expert on public health law at Georgetown University. Noting North Carolina’s place as a traditionally conservative state in the South, he added, “Acknowledging that even a Republican state legislature would sign off on Medicaid expansion will begin to break the reluctance of conservative states.”

For Penelope Wingard, 59, who worked with children with behavioral problems until she was diagnosed with breast cancer in 2013, the Republican turnaround is life-changing. Ms. Wingard lost Medicaid when she completed radiation treatment and is now uninsured; she put together charity care when she needed eye surgery and racked up $50,000 in medical debt. She turned to advocacy, shared her experience, but it was painful, she said.

“I’m proud that I didn’t give up,” said Ms. Wingard, who lives in Charlotte. “I wanted to give up. I didn’t want to talk about it anymore. I was so upset. But today I can say I cried all day, tears of happiness, because I never thought this would happen in North Carolina.

Years of advocacy

North Carolina Republicans didn’t change their mind on Medicaid overnight. The story of how they got from no to yes is one of intense patient advocacy, smart messaging, policy change, a determined Democratic governor and a handful of quirky Republicans. Support from local officials and sheriffs, as well as eager hospital executives, has also played a role, as has Mr. Obama’s waning presence.

“If they had any hangover from the ACA, my guess is it’s probably worn off,” Steve Lawler, president and chief executive of the North Carolina Healthcare Association, a trade group for hospitals, said of Republican lawmakers.

Progressives set the table for expansion, in part by helping to elect Mr. Cooper, said the Rev. Dr. William J. Barber II, a prominent civil rights leader and longtime pastor in North Carolina. He described Mr. Berger as a “very regressive force” in state politics.

“They didn’t just change,” said Dr. Barber on Republican lawmakers. “They were forced to change.

In addition to creating marketplaces to buy private insurance, the Affordable Care Act also required states to expand Medicaid to cover people earning up to 138 percent of the federal poverty level — currently about $41,000 for a family of four. The program was designed to benefit states, with the federal government first picking up all costs and ultimately paying 90 percent of them, a higher share than traditional Medicaid.

But conservative state officials have balked, saying they don’t trust the federal government to uphold its end of the bargain and don’t want to contribute to what they see as a welfare state. A group of states filed suit, arguing in part that forcing states to expand Medicaid was unconstitutional. In 2012 the Supreme Court upheld the Affordable Care Act but decided that states could not be required to accept expansion.

The following year, Dr. Barber leads demonstrations every Monday at the North Carolina General Assembly to protest cuts to unemployment benefits, education and Medicaid. “Moral Monday” made national news; as the weeks and months passed, thousands turned up and hundreds were arrested.

Riding the tea party wave to help his party win control of the State Senate for the first time in more than 100 years, Mr. Berger had little desire to bend. Republicans had a supermajority—enough votes to override the governor’s veto. Mr. Berger said unpredictable Medicaid costs have driven the state into the red.

“The thought of signing Obamacare when the memory of that budget debacle was so fresh in our minds was not very appealing to us,” he said.

Hospitals, especially rural ones, were struggling and desperate for Medicaid reimbursement dollars. In the summer of 2014, the Republican mayor of tiny Belhaven, North Carolina, made a a two-week trek to Washington to try to save a hospital that was closed. Dr. Barber went part of the way with him.

Mr Lambeth, a Republican state representative who recently retired after a long career as a hospital director, was keen to use his own experience. He led the effort to transform Medicaid in North Carolina from a fee-for-service program in which doctors are paid for each service they provide to a managed care system with a fixed budget and metrics to track health outcomes.

Mr. Berger and Mr. Lambeth say their work to fix what they called a “broken system” cleared the way for expansion. Their critics accuse Republicans of breaking Medicaid by starving it of cash so they can claim to have fixed it.

But Mr. Cooper said in an interview: “I don’t think there’s any doubt that we’ve made Medicaid more efficient.”

Republican turnaround

The initial push for Medicaid expansion in North Carolina came from the political left, led by the North Carolina Justice Center, a progressive research and advocacy group that recruited Ms. Wingard and others to tell their stories. But Peg O’Connell, a longtime health policy adviser, said supporters need a less liberal view. She helped start a new group, Care4Carolina, which took the lead.

“The most important thing we did,” she said, was to get rid of the phrase “Medicaid expansion” and replace it with “closing the coverage gap” — a message that conservatives could embrace. She knew it worked when a Republican lawmaker told her, without a trace of irony, “I will never vote to expand Medicaid, but I will vote to close the coverage gap.”

Mr. Cooper called for Medicaid expansion when he ran for governor in 2016, and after taking office the next year, he tried to fulfill that goal by working with the outgoing Obama administration. That didn’t sit well with Mr. Berger and North Carolina House Speaker Tim Moore, a Republican.

“They immediately sued me in federal court to stop me,” Mr. Cooper said. “And at that point we could have put it aside, but we insisted, and that’s because we knew it was too important.”

In the House of Commons, Mr. Lambeth and a small group of colleagues worked on the legislation. They looked at Indiana, which expanded when Mike Pence, a former vice president, was governor. They scouted Ohio and later invited John Kasich, the Republican who oversaw the state’s expansion when he was governor, to speak.

Mr Lambeth had taken “a lot of grief” from his fellow republicans, he said. But he found an ally in Republican state Sen. Kevin Corbin, who was in the insurance industry and tired of not being able to help working people.

“We would see it all the time,” Mr Corbin said. “A 27-year-old single mother comes in. She has two kids and makes $15 an hour.” Her children are already on Medicaid; he doesn’t have insurance. So I give her an offer and it’s $600 a month, and she won’t do it because she has to pay rent.”

until 2020 research confirmed what proponents of Medicaid expansion were saying; health outcomes were better in expansion states. Mr. Cooper tried to build bipartisan support by partnering with Republican county commissioners and sheriffs who supported expansion. After President Biden took office in 2021, Congress passed a coronavirus relief package that offered states additional financial incentives to expand.

But the most important thing that happened, people in the state agree, is that Mr. Berger changed his mind. That opened the door for other Republicans to get in line.

“It’s like Nixon going to China,” Ms. O’Connell said.

Adam Searing, a health policy expert in Chapel Hill, N.C., who is affiliated with Georgetown University, sees politics at work. Surveys show Medicaid expansion is popular. Mr. Cooper is more than halfway through his second term and cannot run again because of term limits, and Mr. Searing said Republicans seeking to regain the governorship wanted to “take Medicaid expansion off the table.”

The extension will not take effect immediately. It is tied to the approval of the state budget. But in the days following the signing ceremony last month, the mood in the North Carolina General Assembly was upbeat. As lawmakers and lobbyists congratulated her, Ms. O’Connell beamed. Mr Lambeth said he had received a call from Mr Kasich, the former governor of Ohio, to congratulate him.

The expansion bill includes Mr. Berger’s priority: a provision aimed at encouraging competition in health care by making it easier for companies to open new surgery centers and MRI clinics.

Even so, Mr. Berger still has concerns. He worries that a shortage of health care providers has already limited access to care. What good is having coverage, he asks, if you can’t find a doctor? Medicaid is not a system he would create, he said, if he had a “blank slate.”

But he said he was able to reconcile his support for expansion with his philosophical opposition to big government programs: “We don’t live in a perfect world.”