When the North Carolina legislative session ends, Jim Burgin, a conservative Republican state senator who serves as chair of his state’s Senate Health Care Committee, will go back to his daily life as a businessman.

The owner of an insurance company and a partner in a local car dealership group, Burgin fully understands the virtue of hard work. That’s why when Medicaid expansion, the federal program that 10 states including Mississippi have refused to pass, came up for debate in his legislature over the past few years, he wasn’t immediately sold.

“I don’t think we ought to have any kind of government program that people stay on the rest of their lives,” Burgin told Mississippi Today in an interview this week. “Like most of my Republican colleagues, I wanted to put a work requirement in. But we realized the feds would never approve it, so we had to think about what we really wanted to do as it related to work.”

Many Mississippi Republican lawmakers currently face the same dilemma. Though Medicaid expansion is being seriously considered here for the first time, Senate Republicans, led by Lt. Gov. Delbert Hosemann, appear convinced that the only way the state should expand Medicaid is if a work requirement is in place. But with the federal government having shot down 13 states’ previous efforts to implement a work requirement, Mississippi Today reached out to leaders in North Carolina, the most recent Republican-led state to expand, to see how they came to an agreement.

READ MORE: Mississippi lawmakers look to other states’ Medicaid expansions. Is North Carolina, Arkansas, Georgia worth copying?

Burgin and his colleagues, knowing the feds wouldn’t allow the work requirement, went to the drawing board to determine if they could come up with a Medicaid expansion bill that still promoted work without requiring it. They started with a “trigger law,” of sorts, to mandate that if the federal government ever changed their policy on allowing states to implement a work requirement, North Carolina would move immediately to adopt one. They also added a separate trigger that allowed the state to immediately drop out of the expansion program if Congress ever defunded it or changed its funding structure.

They also developed some creative ideas for spending the additional federal dollars the state would receive from the expansion program that were designed to promote work. Shortly after they expanded Medicaid, the North Carolina lawmakers designated hundreds of millions in expansion “signing bonus” funds on mental health reform. The state’s mental health system was in crisis with major funding concerns, so Republicans appropriated $835 million — all money they got from the feds to expand Medicaid — to rebuild the crumbled system.

“That’s going to help so many hospitals and law enforcement officers who often had nothing to do with mentally ill people but take them to emergency rooms, whether those people had health insurance or not,” Burgin said. “Hospitals will never have to treat or pay for care for people in those situations in ERs ever again.”

Additionally, North Carolina Republicans in the coming weeks will work on getting the federal government to grant a waiver to spend federal Medicaid dollars on providing free community college — and workforce skills training — to North Carolinians enrolled in the Medicaid expansion program. Additionally, some Republicans want to add child care vouchers to that list of offerings.

“This is all to get people jobs and to keep them working and ultimately to get them off Medicaid,” Burgin said. “Even though it can’t be a requirement, we’re promoting work. We want to make it easier and better for people to get work that they won’t want to stay on Medicaid. They’ll want a job and hopefully eventually get on a group health plan through their employer.”

So what ultimately convinced Burgin, who wanted the work requirement all along, to move forward on expansion even without it?

“Billions of dollars,” he said plainly. “Look, I’m a business guy. I don’t spend money, I invest money. I looked at (Medicaid expansion) as a great investment. I had a fiduciary responsibility to my constituents to take that money. So we wrote a bill that said that if the feds changed the work requirement, if they change anything, we can add it here or opt out of our program altogether.

“I just couldn’t turn down billions of dollars that we needed in so many areas,” Burgin said. “And we get to spend that on a wide variety of things, and all of it is designed to get people across this state working.”

READ MORE: Mississippi leaving more than $1 billion per year on table by rejecting Medicaid expansion

Republican state Rep. Donny Lambeth was the primary author of what became North Carolina’s Medicaid expansion program.

For years before an expansion program actually passed, Lambeth filed numerous expansion bills that included work requirements.

“I was a big advocate for work requirements because, well, I felt like it was just one of those things,” Lambeth said. “We shouldn’t want to just add more people to Medicaid rolls. You have to figure out how to help them and get them off Medicaid and into the workforce. But when we talked to people in Washington, it was obvious there was no way, if we went through all the trouble to get votes and get it passed, we would get a work requirement.”

READ MORE: How Medicaid expansion could have saved Tim’s leg — and changed his life

So Lambeth, like Burgin, went to the drawing board. They wrote into their expansion plan a provision similar to red-state Montana: State government agencies would work with private partners who had experience with job training to create a program that would pay for Medicaid enrollees to get job training. They couldn’t require people to participate, but they could make it worth their while.

“We looked at what other Republican states that had expanded had done,” Lambeth said. “What we came up with in lieu of the work requirement was an optional jobs training program. The idea was that even though you’ve got the vast majority of people on Medicaid working, they’re working in low-income jobs. They couldn’t afford health insurance even though they worked.  The theory is that if you take advantage of expansion dollars from the federal government with a job training program like this, you can go back and further your education. You can then get a better job, have a higher standard of living, get off Medicaid and be able to afford your health insurance.”

Peg O’Connell, a health care advocate and consultant who for several years led North Carolina’s push to expand Medicaid, explained how the jobs training program worked in Montana before her state included it in its program.

“A man had been a hit-or-miss carpenter and really wanted a commercial drivers license,” O’Connell said. “So the Montana caseworker under their expansion program helped get him his CDL. They paid for him to take the classes as well as lodging when he had to travel to take his exams, and they even bought him a pair of work boots. This man is now doing what he wants to be doing, he’s got full-time employment with health insurance, and he has worked himself off the Medicaid program. That’s the idea behind our program here.”

Lambeth, like Burgin, is a small business owner. He owns a logistics contracting company, and he “can’t afford to offer my employees health insurance,” he said.

“Are there some quote-unquote deadbeats, people who are not working, playing off the system? Sure,” Lambeth said. “But we were able to identify the farmers in the east part of the state, small, mom-and-pop businesses that were growing at significant rates but couldn’t quite afford to offer health insurance, hard-working people who desperately wanted and needed health insurance but couldn’t afford it. We saw that the vast majority of these people are working, and the ones who weren’t working, we felt like if we could get them training or education and child care, that would help get them off Medicaid.

“If we’re really all about getting people working, then let’s figure out ways to work within the system, draw down those billions of dollars, and use them to get them working,” he continued. “It was really that simple.”

READ MORE: Gov. Roy Cooper, the most recent state leader to expand Medicaid, has advice for Mississippi lawmakers

Burgin and Lambeth both supported work requirements but saw they wouldn’t get approval from the federal government. They listened to their constituents, they considered the heart of their desire to get North Carolinians working and they found creative solutions.

As Mississippi lawmakers consider Medicaid expansion over the next few days, what advice might the North Carolina Republicans offer to their counterparts here in the Magnolia State?

“You tell any of the hardest nos, the most conservative ones, that if they have any doubts, give them my number. My cell is 919-207-7263,” Burgin said. “I’ll be happy to answer any question they may have and talk to them about why this is so beneficial. I’ve been tracking Mississippi. I testified the other day to Kansas lawmakers. We’ve already talked to folks in Georgia, Florida, Kansas and now Mississippi. All of these holdout states are looking at the same thing saying, ‘We’ve put it off. Why did you do it?’ For me and my Republican colleagues, it came down to a business decision. How could we, in good faith, leave billions on the table?”

Lambeth answered the question with an anecdote.

“I heard from just dozens and dozens of North Carolinians while we were debating this,” Lambeth said. “But I got one letter, in particular, from a Christmas tree farmer in Ash County. She couldn’t afford health insurance, and she was worried they were going to lose their farm because of out-of-pocket medical bills they had.

“These are real people. They’re not the traditional Medicaid where they’re poor and not trying to improve their lives. They are hard-working people just not able to afford health insurance. I promise the average Mississippian is not much different than the average North Carolinian in that way. Why would we be in the positions we’re in and not help them? I mean really, why?”

READ MORE: The Christian argument for Medicaid expansion

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