Abstract:
In 2017, newly elected North Carolina Governor Roy Cooper inherited a state deeply divided over Medicaid expansion. Though the Affordable Care Act had offered states the opportunity to expand coverage to low-income residents years earlier, North Carolina's Republican-led legislature remained staunchly opposed. Cooper, undeterred, launched an ambitious campaign to close the coverage gap for an estimated 600,000 residents. His early efforts to bypass the legislature were blocked in court, but he used the moment to signal his administration's long-term commitment to expansion. Over the next several years, Cooper and his team worked to reframe Medicaid expansion not as a partisan extension of "Obamacare," but as a financially sound, morally urgent policy that could support rural hospitals, improve public health, and bolster the state's economy.
Success required building unlikely alliances. Through persistent engagement, Cooper's administration won support from sheriffs, county commissioners, business leaders, and eventually key Republican lawmakers. Secretary of Health and Human Services Kody Kinsley played a critical behind-the-scenes role, focusing on fiscal arguments and relationship-building with skeptical legislators. After years of stalled negotiations, budget standoffs, and shifting political tides, a compromise was finally reached in 2023. North Carolina became the 40th state to expand Medicaid--an achievement born of political resilience, strategic coalition-building, and a willingness to find common ground in one of the nation's most politically polarized states.
Learning Objectives:
This case allows students to explore how deeply polarized political issues can evolve into bipartisan policy solutions. It highlights the tools and trade-offs of bipartisan negotiation, particularly when early efforts face legal and institutional roadblocks. Through the lens of Governor Cooper's Medicaid expansion campaign in North Carolina, students analyze how policy narratives can be redefined and how power can be exercised even in constrained political settings. The case is well suited for courses on leadership, political strategy, and state-level policymaking.
