Republicans in the North Carolina Senate have reversed course on Medicaid expansion, moving Wednesday to expand health care coverage to hundreds of thousands more people.

The GOP in the General Assembly have opposed expanding Medicaid in North Carolina since it became possible during the Obama administration with the Affordable Care Act.

“We must do something to improve health care, especially expand access and lower costs,” Senate Pro Tem Phil Berger said Wednesday. “We need coverage in North Carolina for the working poor.”

The Affordable Care Act, also known as Obamacare, gave federal funding for states that chose to expand Medicaid coverage for more people.

The law faced numerous legislative and legal challenges, but most provisions in the law have survived in the dozen years since it was enacted.

Berger said he has been one of the most vocal opponents of Medicaid expansion in North Carolina over the past decade. But things have changed.

“Medicaid expansion has evolved to a point where it is now good fiscal policy,” he said in a news conference Wednesday, flanked by Republican colleagues at the General Assembly.

The Medicaid expansion proposal comes as an amendment to what originally was a bill to expand telehealth services.

The draft does a lot more than expand who is eligible for Medicaid. It includes a work requirement. It reforms the state’s “certificate of need” statutes, which essentially dictate what hospitals can build and where. It also allows nurses with advanced training to prescribe medications and creates requirements for telehealth.

The Medicaid expansion bill would extend health care to hundreds of thousands of people in North Carolina, Republican leaders in the North Carolina Senate said.

The bill would give coverage to any adults 18 to 64 who make up to 138% of the federal poverty level. That would be $18,754 for a single adult and $38,295 for a family of four.

North Carolina’s Medicaid expansion proposal has a work requirement for recipients, with some exceptions for people with disabilities or caring for young children. But there’s still a question on whether states are allowed to build a work requirement into getting on Medicaid.

Eight states have added work requirements to Medicaid since the Trump administration began allowing the practice, according to the Kaiser Family Foundation, which tracks health care policy. Courts have blocked work requirements so far, but there is a case before the United States Supreme Court that could potentially settle the issue.

“The bill as drafted has a work requirement, that is what we would like to see,” Berger said. “We will worry about getting the bill passed, then we will deal with whether or not that’s something we can convince the Biden administration or convince the courts that’s the right thing to do.”

If the work requirement piece ends up in the courts or is denied, people would still be eligible to get health care coverage under the Medicaid expansion bill, Berger said.

In North Carolina, hospitals and other health care providers have to get a Certificate of Need from the state Department of Health and Human Services if they want to add new equipment or build new facilities.

A health care provider needs state approval if they want to add anything from getting a new MRI machine to building a new drug treatment center.

The Certificate of Need process has long been a target of Republicans, who say it increases health care costs for consumers and reduces access to care.

The proposal creates two pathways for new health care projects. Things like air ambulances, emergency rooms, adult care homes and nursing home facilities would still need a Certificate of Need.

For other big expansions or adding services, health care providers would no longer have to show it would not duplicate existing services.

Under the current law, Berger said, “DHHS conducts some sort of a market analysis as to what is needed in the market. I don’t know about you, but I’ve never had a whole lot of confidence in government regulators having an idea how to accurately assess what the private marketplace needs.”

The bill would completely eliminate the DHHS certificate process for converting acute care beds to psychological care beds, drug treatment centers, MRI machines and ambulatory surgical centers, Berger said.

The bill includes provisions to license “advanced practice registered nurses” that could diagnose and treat more patients and prescribe medications. The aim is to increase access to health care in more rural areas.

Sen. Joyce Krawiec said the provision for advanced nurses is one of the changes she’s most excited to see.

“It allows the advanced practice nurses to practice at the top of their licensure, at the top of their training, and that will improve access, we hope, in a lot of rural areas,” she said.

The politics of expanding Medicaid in North Carolina has been divisive in the General Assembly. Republicans have long been united against expanding health care coverage under the federal program.

Just because the leadership in the Senate supports expanding Medicaid, that doesn’t necessarily mean the House Republicans will join in to pass it. Republican House Speaker Tim Moore has not commented on whether he’d support this new proposal.

Berger said he wants to see the bill pass through the Senate and sent to the House.

“I’ve talked to the speaker and we will just see what happens,” Berger said. “What we want to do is send this over to them and we will see what they want to do with it.”

The GOP leader in the Senate said he plans to work with the Republicans who control the House to come up with a bill that they can agree on and take to the governor.

Gov. Roy Cooper, a Democrat, has argued for years for the state to expand Medicaid. But first it has to get through the Republican-controlled legislature.

“If there’s a person in the State of North Carolina who has spoken out against Medicaid expansion more than I have, I’d like to meet that person,” Berger said. “In fact, I’d like to talk to that person about why my view on this has changed, because I think this is the right thing for us to do.

The bill will have to pass both chambers of the North Carolina General Assembly and then get the governor’s signature before it becomes law.