Four Republicans in the state House have filed a bill to extend Medicaid health-insurance coverage to more adults, and to charge hospitals to help pay for it.

It’s the first time prominent North Carolina Republican legislators have sought to add adults who now don’t qualify to the government health insurance program.

Thirty-one states and the District of Columbia have expanded Medicaid since the Affordable Care Act provided that option – removing millions from the ranks of the uninsured – but North Carolina under Republican control has been among the holdouts. GOP political leaders have been skeptical of whether the federal government would follow through on its promise to cover the bulk of the costs, and have demanded reforms to how money is spent before expansion.

But this Republican bill proposes a program to be called Carolina Cares – based on the Medicaid expansion then-Gov. Mike Pence enacted in Indiana, which charges premiums to people enrolled in the program. The Carolina Cares plan would also add work requirements.

“I want to do whatever I can to increase access to care for rural areas of our state,” Rep. Josh Dobson of McDowell County said. “I believe the bill will do that.”

Three of the House Health Committee chairmen are co-sponsors: Reps. Donny Lambeth of Winston-Salem, Greg Murphy of Greenville and Dobson. Rep. Donna White of Clayton is the fourth sponsor. Lambeth is a former hospital administrator, Murphy is a medical doctor, and White is a nurse.

Murphy and Dobson referred questions about the bill to Lambeth, who could not be reached Friday. A news conference on the bill is scheduled for Tuesday.

Medicaid is the government insurance program for poor, elderly and disabled people. Most of the 1.9 million people covered in North Carolina are children. Most low-income adults younger than 65 don’t qualify.

Under the bill, adults whose incomes are at or below 133 percent of the federal poverty level – less than $16,000 for a single person – would qualify. They would have to pay annual premiums equal to 2 percent of their household income, with some hardship exemptions. In most cases, adults would have to be working or “engaged in activities that promote employment” to be eligible for the coverage.

The federal government would have to approve a program with work requirements and premium payments.

White, who worked as a public health nurse before coming to the legislature, said the bill is not a Medicaid expansion, but a way for low-income adults to buy health insurance.

“It’s not a Medicaid program,” she said. “It’s an opportunity for the working poor to buy their insurance at a reduced rate.”

The bill also encourages preventative care, White said. “I just believe it’s a model that conservatives will buy in on,” she said.

An estimated 300,000 to 500,000 people would gain health coverage if the state expanded Medicaid without conditions. It is unclear how many adults would gain coverage under the new bill.

The state and federal government currently cover Medicaid costs. Under the bill, assessments on hospitals would cover the state’s share of the expansion costs.

Julie Henry, spokeswoman for the N.C. Hospital Association, said the organization supports expanded coverage. As the health care safety net, hospitals take care of people whether they can pay or not, she said. The association is still evaluating the impact of hospitals covering the state’s costs, she said.

Legislative Republicans for years have resisted expanding Medicaid, passing a bill about four years ago that prohibits expansion without legislative consent. When newly-elected Democratic Gov. Roy Cooper moved in early January to expand Medicaid, Republican legislative leaders sued to stop it and a court blocked the move. Cooper also suggested that hospitals would cover the state’s costs under expansion.

Ken Eudy, Cooper’s senior adviser, said Cooper hopes for a more thorough discussion of health policy than he had with legislators in January.

Expansion would be a boon to economic development, Eudy said. Jobs would be created in rural hospitals, he said, that could spur more job growth because companies want to move to places with good hospitals.

U.S. District Judge Louise Flanagan issued a temporary restraining order that blocked any action on expansion before President Donald Trump’s inauguration.

In late January, Trump’s administration informed the court that it planned to take no action on whether to approve Cooper’s plan for nearly three months.

That put the lawsuit on hold until late last month when the parties involved submitted a status report.

From that report, the judge agreed to give federal officials until April 7 to respond to the Republican leaders.

That response was not publicly available as of late Friday afternoon. State officials sued by legislative leaders have asked for the case to be dismissed from the federal courts.

Anne Blythe and Will Doran contributed.

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NC House Republicans file bill to expand Medicaid