A Republican-backed Medicaid expansion bill passed the North Carolina Senate at the beginning of June. After more than a decade of opposition, GOP state senators pushed the legislation through the chamber in little more than a week.

But Republicans in the North Carolina House have been less receptive. House leaders made their own proposal on Medicaid expansion Thursday, pushing any potential vote on expanding Medicaid to December.

Now, there are two different bills that could potentially expand Medicaid and give health care coverage to hundreds of thousands of people in North Carolina.

One of the bills has passed the Senate but not the House. The second, being debated by the House, would make the state negotiate with the federal government before any up-or-down vote on Medicaid expansion.

Congress cleared the way for states to expand Medicaid more than a decade ago during the Obama administration. It was part of the Affordable Care Act, also known as Obamacare.

The federal law gives states the option to extend health care coverage under Medicaid to people and families making up to 138% of the federal poverty level. For a single person, that's $18,754 a year, and $38,295 for a family of four.

Medicaid expansion would add 600,000 people to the health care program in North Carolina. About 300,000 people in that group are currently covered by COVID funding, but they would lose that coverage when the funding goes away.

North Carolina is one of a dozen states that has not expanded Medicaid.

As part of last year’s American Rescue Plan, Congress approved new funding to give states more incentives to expand Medicaid. The incentives essentially offer North Carolina an extra $1.5 billion to expand health care coverage.

The federal government will cover 90% of the bill for Medicaid expansion, and it would be budget neutral for North Carolina, Senate Leader Phil Berger said while introducing the bill.

“Medicaid expansion has evolved to the point that it’s good state fiscal policy,” Republican Sen. Ralph Hise said as the Senate voted on its bill. “We will not get a better deal to expand Medicaid than we have right now,” he said.

Berger, a Republican, said that after more than 10 years of lawsuits and legislation challenging Obamacare, he’s confident the program and the federal funding are not going away.

“First, we need coverage in North Carolina for the working poor. Second, there is no fiscal risk to the state budget moving forward with this proposal,” he said.

The Senate bill expands Medicaid to give coverage to anyone making at or below that 138% poverty level threshold.

The bill does more than expand health care coverage. It does away with most hospital certificates of need, essentially state permits for hospitals that want to add new facilities or big equipment like MRI machines.

The bill would allow nurses with advanced training to treat patients without a doctor’s supervision, which both Republicans and Democrats say would help expand access to care in rural areas.

One major point in the Senate bill is that it sets work requirements for people to get Medicaid coverage. But state leaders are not sure if that is legal, and there’s an ongoing lawsuit to decide that question. That appears to be a major sticking point stopping House Republicans from getting on board with the Senate bill.

The House bill does not expand Medicaid. It gives Department of Health and Human Services Sec. Kody Kinsley the power to negotiate with the federal government on expanding Medicaid to get a deal before the General Assembly votes on the expansion.

“This thing’s been too much of a political football from day one,” House Speaker Tim Moore, a Republican, said Thursday. “They’re buying a car without test driving it.”

He said DHHS could negotiate with the federal government and come back with a deal on things like work requirements or work training provisions before state legislators give it an up-or-down vote.

“There are too many incentives for folks to stay home and not work instead of get a job,” Moore said.

Presenting the bill in the House Health Committee Thursday, Moore said the bill would set up a December date for the legislature to vote on expanding Medicaid.

The House version also dedicates $1 billion in federal funding to help with substance abuse and mental health treatment.

The Senate has already passed its bill, but it doesn’t appear to have a chance getting through the House. Next, it will be up to House Republicans in the General Assembly to debate their new bill.

If the House can pass its proposal, the Senate would have to take up the bill to get it passed and sent to the governor. This is all happening as legislators on both sides of the aisle are watching the clock with plans to adjourn the session by the end of June.

It could be a tall order to get a Medicaid expansion bill done with about a week to go, but GOP leaders in the House and Senate have shown they can get things done quickly once there’s a deal in place.