At the end of June, North Carolina's Governor Roy Cooper announced that he would veto the budget that legislators had spent the past few months hammering out. The reason? It wouldn't include Medicaid expansion, arguably his number one priority this year.

It's doubtful the state House and Senate will be able to muster enough votes to override the veto. What that means, then, is gridlock—or compromise. There are already signs that in the House, at least, a version of Medicaid expansion could pass. Whether it can make it through the Senate, though, is another story.

But even still, the real question that remains is why legislators from poor, rural districts repeatedly vote against the indisputable needs of their constituents—and how they nonetheless cruise to re-election.

"Medicaid expansion? I haven't heard of it, but that'd be good for a lot of people here," says Rachel Hoilman. She's getting gas at the Exxon on Highway 226 in Bakersville, North Carolina, a small mountain town near the Tennessee border. "I hear it all the time from people: 'I can't afford to go to the doctor.'"

Hoilman herself suffers from anxiety attacks, which is a real bummer when you can't afford insurance. "If I see a doctor, the visit and medication, that's $400 right there," she says. "I had an ER visit recently for a panic attack; that was $1,379." A truck driver for 15 years, she's now filing for disability, which would make her eligible for Medicaid. But that's still a ways off.

"I hear it all the time from people: 'I can't afford to go to the doctor.'"

In Mitchell County, where Bakersville is located, 13 percent of the population is uninsured, and it's easy to find people without coverage. Nearby at the Dollar General, Kimberly Ledford is in a similar situation. She has rheumatoid arthritis and struggles to manage her symptoms without insurance. "I hurt all the time. I can't sleep at night, my hands are always shot," she says. Ledford works at McDonald's as a biscuit maker, which is manageable for her body, but the money's not great.

Neither Hoilman nor Ledford is aware of it, but a big push is happening over in Raleigh, the state Capitol. North Carolina is one of 14 states that still hasn't expanded Medicaid, and over a million residents lack health insurance. But in 2018, after nearly a decade of full-on Republican rule, Democrats finally won enough seats in the General Assembly to force some compromises. Governor Cooper is a Democrat, too—and he's promised to make Medicaid expansion a central issue.

Which makes this year supporters' best shot at finally expanding Medicaid in North Carolina.

To the healthcare groups and anti-poverty advocates focused on the issue, it's a no-brainer. Expansion would cover roughly 300,000 uninsured people, plus another 300,000 who may switch over from private insurance, and the federal government would foot 90 percent of the bill; the rest could be covered by monies levied on healthcare institutions, which would profit from expansion. Many analysts believe the policy would add jobs and spur economic growth, to boot.

But to the state's Republican leaders, Medicaid expansion is just another swollen entitlement program. And it means buying into Obamacare, which many believe is faltering and could be struck down in court—potentially leaving the state to pay the entire tab.

A number of Republican legislators from rural districts actually support Medicaid expansion: they see how their constituents have worse health outcomes and yet are more likely to be uninsured. They've also seen how their hospitals and clinics suffer financially from providing the uncompensated care that's typical among uninsured populations.

But the positions of the rank and file don't necessarily matter. What matters is what the General Assembly's leaders want. And despite efforts by a range of moderate and liberal organizations across the state, they still seem to be largely against expanding Medicaid.

That group of inner-circle leaders includes Senator Ralph Hise: one of the most powerful men in the Senate, and a resident of Mitchell County.

An MCHP nurse working up a patient for an appointment.

There's just one health facility in Bakersville: Mountain Community Health Partnership (MCHP), a clinic with branches in nearby Spruce Pine and Celo. It's one of the only medical options in Mitchell County, and is many residents' saving grace. Whether insured or not, everyone is welcome, and services are priced on a sliding scale according to income.

"I don't know what I'd do without them," says Ledford. She visited the clinic that morning and paid only $15 to see a nurse practitioner; the center helps her with prescriptions as well.

The clinic is one of 41 community health centers across the state that provide a wide range of services to a region's poorest residents. The facilities are funded by federal dollars and revenue from patients, who are often uninsured.

The centers, which serve about half a million North Carolinians, are designed to respond to the needs of the communities where they're based, meaning that no two centers offer the exact same experience. Mountain Community Health Partnership provides primary care as well as behavioral health services, opioid treatment, and outreach to residents.

The Mitchell County clinics have great outcomes, but like the state's other community health centers, they can only do so much. For instance, 14 percent of the Bakersville clinic's patients pay on a sliding scale; if they were insured by Medicaid, the center would be getting fully reimbursed, not just the percentage that patients can pay.

Locals struggle with diabetes, obesity, and high blood pressure, and opioid addiction is a major issue.

"It would give us more revenue that would allow us to do more," says Chuck Shelton, Mountain Community Health Partnership's CEO. With that money, the Bakersville clinic could hire more community health workers to check on residents with chronic health conditions, and could expand its medically-assisted treatment for opioid-addicted residents. "That's a much-needed program, and very few in the area are offering it," says Shelton of the drug treatment initiative; currently, the center's program is full to capacity.

That's the thing: economically, Mitchell County isn't doing particularly well, and its residents have a range of concomitant health conditions. Locals struggle with diabetes, obesity, and high blood pressure, and opioid addiction is a major issue. A community health assessment performed in 2016 listed the county's rate of overdose death as among the worst in the country.

Physician Assistant and Community Health Workers attend Health Fair, to educate the community about MCHP services.

The area's backstory is like that of many rural areas around the U.S. Good jobs in manufacturing started disappearing in the late 1990s as companies outsourced labor overseas. These days, most young people leave after high school. The ones who remain face tough job prospects. Some can't pass a drug test; for others, $8 an hour at Ingles supermarket doesn't cover the cost of childcare and transportation.

As a result, the region has become increasingly poor. Bakersville's median household income is $21,500—which is less than half that of the state's—and over a third of residents live below the poverty line.

Many receive government benefits to survive, and that exacerbates a divide in the population. Among some longtime residents bred into the mountain culture and its code of self-reliance, "there's a sense that the young people have this entitlement mindset," says Brandon Roberts, editor and publisher of the Mitchell News-Journal. And those older residents tend to be the most consistent voters.

The area has always been reliably conservative—Mitchell County has never once supported a Democratic nominee for president—and that seems to have held steady or even increased as poverty has grown. Trump won the county by 57 points in 2016, and both legislators representing the district, Senator Hise and Representative Josh Dobson, are Republicans. Hise in particular is one of the most conservative members of the NC General Assembly.  

Hise is known for his deep opposition to Medicaid.

"I've been serving in the General Assembly for nine years. There's an area of the budget you don't get to control, and that's Medicaid," says Hise at a panel event organized by the Civitas Institute, a conservative think tank. He's explaining his longtime dislike of the federal program.

North Carolina Senator Ralph Hise opposes medicaid expansion even though many of his constituents are uninsured.

The government has repeatedly pledged to match state funding for Medicaid, he says, but then reneges on its promises. "And then we as budget writers at the General Assembly are stuck. We have to pull money out of the budget and put it in Medicaid, because the federal government backed out." Although this is a common refrain among conservatives around the country, it's not true. The federal share of funding given to each state for traditional Medicaid (as opposed to Medicaid expansion) fluctuates depending on a state's per-capita income—richer states get less from Washington than poor states—and this has been the case since Medicaid's inception in 1965.

Still, citing data and dollars, technicalities and policy details, Hise sounds wise, like the statistician he is. He talks about the low rate of Medicaid reimbursements and how adding more Medicaid enrollees could be the undoing of rural hospitals.

Hise (who didn't respond to repeated requests for comment) does seem to worry about healthcare needs in his district. But he also sponsored legislation this spring that would impose work requirements on current Medicaid recipients. It's a policy that's been proven ineffective, since the vast majority of people on Medicaid already work or are disabled, and they would face more bureaucratic hurdles under the new rules.

At no point during the panel event does he reference the bind that rural institutions like Mitchell County's Blue Ridge Regional Hospital are in. Legally obligated to treat everyone, many are going broke responding to an unhealthy, uninsured population. Since 2010, six of the state's rural hospitals have closed. That's a blow from a health perspective, but it also hugely affects a region's economy, as hospitals tend to be major employers.

And Hise never utters a word about poor, uninsured North Carolinians and the impossible struggles they face. Only this: Medicaid, he says, "isn't supposed to be about giving the latest entitlement program to able-bodied adults."

Mitchell County residents who observe the political scene there don't have any clear answers to why Hise doesn't support his constituents' interests and why he's nonetheless so popular. No one wants to speak on the record; Mitchell County is a small area where everyone knows everyone. Some think religious, socially conservative voters put up with the small-government stuff because they support Hise's opposition to abortion and LGBTQ rights. Others think residents don't want to oppose a system they might view as unfair, lest they be tagged as "outsiders."

In the spring, Representative Josh Dobson, Mitchell County's other legislator, sponsored a bill with three other Republicans that would essentially expand Medicaid while requiring recipients to work at least 20 hours per week and to pay 2 percent of their income in premiums. The month before, a similar Arkansas law was found unconstitutional by a federal judge, but North Carolina's legislators pressed ahead. Dobson isn't as ideologically charged as his colleague Hise; analysts think he added the work requirement to make the legislation more palatable to Republican leaders.

Hise never utters a word about poor, uninsured North Carolinians and the impossible struggles they face.

Some advocates say they'd settle for Medicaid expansion with strings attached. Others, like the North Carolina Justice Center, point out that work requirements applied in other states have resulted in thousands of people losing Medicaid coverage: the reporting demands are just too intense.

The work requirements bill was stuck in committee for several months. It was only when Cooper vetoed the budget that House leaders revived it. There's a good chance it could pass that body, but there's still great opposition to it in the Senate. There, any movement will depend on private decisions by the body's leaders: Hise and his upper-echelon peers.

But Cooper is still pushing for straight Medicaid expansion, sans work requirements or payments. He's pledged that the legislative session won't end until Medicaid expansion has been achieved, and for now, he's holding strong by holding the budget hostage. Can he keep it up, though, if the Senate refuses to play ball?

Meanwhile, the health of Bakersville's residents, and of hundreds of thousands of other North Carolinians, hangs in the balance. Whether or not Hise and his fellow legislators care about the well-being of the people they represent, the responsibility for it currently lies squarely in their laps.

Amanda Abrams is a freelance journalist living in Durham, North Carolina.