“They sued me in federal court to stop it,” Mr. Cooper said, “and we kind of set it aside.”
But in the House, Mr. Lambeth and a small group of colleagues were at work on legislation. They looked at Indiana, which had expanded when Mike Pence, the former vice president, was governor. They examined Ohio and later invited John Kasich, a Republican who oversaw that state’s expansion when he was governor, to speak.
Mr. Lambeth took “a lot of grief” from his fellow Republicans, he said. But he found an ally in a Republican state senator, Kevin Corbin, who was in the insurance industry and tired of being unable to help working people.
“We’d see it all the time,” Mr. Corbin said. “A 27-year-old single mother comes in. She has two children and she makes $15 an hour. Her kids are already on Medicaid; she doesn’t have insurance. So I give her a quote and it’s $600 a month, and she’s not going to do that because she has to pay rent.”
By 2020, research was confirming what backers of Medicaid expansion had been saying; health outcomes were better in expansion states. Mr. Cooper tried to build bipartisan support by partnering with Republican county commissioners and sheriffs who backed 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 fall 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. Polls 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 reclaim the governorship wanted to “get Medicaid expansion off the table.”
The expansion does not go into effect immediately. It is tied to passage of the state budget. But in the days after last month’s signing ceremony, the mood in the North Carolina General Assembly was upbeat. Ms. O’Connell beamed as lawmakers and lobbyists congratulated her. Mr. Lambeth said Mr. Kasich, the former Ohio governor, had called to congratulate him.