By GARY D. ROBERTSON

Associated Press

RALEIGH (AP) — North Carolina Gov. Roy Cooper on Monday signed a Medicaid expansion law that was a decade in the making and gives the Democrat a legacy-setting victory, although one significant hurdle remains before coverage can be implemented, thanks to a Republican-backed provision.

At an Executive Mansion ceremony attended by hundreds, Cooper celebrated passage of expansion legislation, which he’s ardently sought since being first elected governor in 2016. It took Republicans in charge of the General Assembly all this time to come around to the idea and agree to offer coverage to more low-income adults, with federal coffers paying for most of it.

North Carolina has been among 11 states who haven’t accepted expansion from the federal government. States with Republican leaders have recently been considering expansion after years of opposition.

“This law, once implemented, will be the working families bill of the decade,” Cooper said. “Today is a historic step toward a healthier North Carolina.”

The measure contains a proviso that Cooper opposed requiring a separate state budget law to be enacted first for expansion to be accepted and implemented. That makes an enrollment start date unclear and gives the GOP leverage in upcoming negotiations.

Still, Monday’s new law should mean government-funded health coverage to potentially 600,000 adults who earn too much to qualify for traditional Medicaid but too little to received heavily subsidized private insurance. Also coming will be billions of dollars annually from Washington into the state. North Carolina currently has 2.95 million Medicaid enrollees, but Cooper said many others suffer in a health care coverage gap, having to ignore treatable and preventative illnesses.

“While a solution sat just out of reach, with this law I’m about to sign, many of them will be close enough to grab it,” Cooper said, standing next to House Speaker Tim Moore, Senate leader Phil Berger and other expansion supporters.

The two legislators earlier this month finalized a negotiated agreement that contains expansion and looser “certificate of need” regulations on health care facilities before they can open more beds or use expensive equipment. The House and Senate approved the deal separately, with the final vote happening Thursday.

Republicans in charge of the legislature had for years knocked down the expansion idea that originated from the 2010 Affordable Care Act. That led to litigation against Cooper and budget impasses between them.

But GOP leaders reversed themselves in recent times, convinced that the state’s Medicaid program was fiscally sound with a switch to managed care, and that Congress would neither repeal the 2010 law nor raise the state’s 10% required share of expenses.

“Now we have a Medicaid system that is stable,” Berger said. “By transforming our state’s Medicaid program, we’re now in a place where our system can handle those additional enrollees.” Republicans also were attracted to an additional two-year $1.75 billion payout for North Carolina from the federal government if it expanded Medicaid.

A persistent coalition of expansion proponents — with the governor and his Cabinet leading the charge — had helped build pressure toward a deal.

“I’m thankful for Gov. Cooper, who has pushed the need for health care since the beginning and didn’t stop until this was completed,” said Cassandra Brooks, who owns day cares near Raleigh and advocated for expansion after two of her teachers lacking insurance died prematurely.

The expansion fight between Cooper and the legislature began during his first week as governor in 2017. Cooper tried to get President Barack Obama’s administration to approve his expansion request before Donald Trump took office. Moore and Berger successfully sued to block the efforts, citing in part a 2013 state law preventing expansion without express General Assembly approval.

In 2019, Cooper’s demand that expansion be negotiated contributed to a state budget deadlock with GOP legislators that never got fully resolved.

The 2021 budget law contained language to convene a legislative blue-ribbon commission that looked at expansion and other ways to improve health care access. The Senate and House approved competing expansion measures in 2022, but negotiations stalled. They resumed this winter.

Requiring the budget’s passage for expansion provisions to be enacted means Republicans could fill the budget bill with unrelated items that Cooper opposes. Republicans are now just one House lawmaker shy of holding veto-proof control at the General Assembly.

“I feel confident that we can work together to get something that we can agree on,” Cooper told reporters after the signing, adding that expanding Medicaid is now a question of “when” and not “if.”

Monday’s legislation directs the state’s expansion expenses be paid with hospital assessments. Hospitals also will get money for treating Medicaid expansion patients, and the law will enter them into a federal program for larger reimbursements.