This move is expected to benefit not only the long-term uninsured but also hospitals and local economies.
This year, North Carolina officials agreed to expand Medicaid, providing government-funded health insurance to adults aged 19 to 64 who earn too much to receive traditional Medicaid but not enough to benefit from public subsidies for private health insurance. As per the 2010 Affordable Care Act, the federal government will cover 90% of the cost.
The expansion is expected to qualify more than 600,000 North Carolinians, with approximately half to be automatically enrolled as of Friday. This will enable them to access annual checkups, prescription drugs, and other services with minimal or no out-of-pocket expenses.
Among the residents set to benefit from this expansion is Carrie McBane, who has struggled for years to navigate the gap between earning too much for Medicaid and too little to afford private insurance. The 50-year-old resident of Sylva, a small mountain town located 290 miles west of Raleigh, has been paying out-of-pocket for medical services. Despite her deteriorating health due to Type 2 diabetes, her monthly income was still about $100 too high to qualify for Medicaid.
McBane expressed her frustration, saying, "It's the worst feeling in the world when you don't know what's happening with your body but you know something's terribly wrong and you've gotten zero help through the medical industry. And as you get sicker, the bills pile up."
North Carolina's decision to opt into the expanded Medicaid program makes it the 40th state to do so, along with the District of Columbia. Some Republican-led states have recently considered expansion after years of opposition, primarily due to concerns that federal policy might change and require states to pay a higher percentage of the expense. The 10 remaining non-participating states are mostly Republican-controlled and are concentrated in the South and Midwest.
The expansion is expected to reduce the percentage of North Carolina’s adults under age 65 who are considered uninsured. A 2022 report from the National Center for Health Statistics estimated North Carolina’s uninsured population at 17.6%, significantly above the national average of 12.6%. The state currently has 2.9 million enrollees covered by some form of traditional Medicaid.
Kody Kinsley, Secretary of the state Department of Health and Human Services, hailed this as a "phenomenal moment for North Carolina and for North Carolinians," adding that it would bring peace of mind to many, knowing that healthcare would not drive them into debt.
Democratic Governor Roy Cooper had been advocating for expanding Medicaid since taking office in early 2017. However, Republican legislative leaders were initially skeptical, expressing concerns about more government insurance and the possibility that Congress might reduce its financial contribution.
Their stance changed in 2022 when the federal government offered a $1.8 billion bonus over two years if North Carolina agreed to the expansion. By March, the Republican-dominated General Assembly passed the legislation, which was then signed into law by Governor Cooper. The law stipulates that North Carolina hospitals cover the state’s 10% share of expenses through increased assessments that began in November, according to the DHHS.
Participation in the Medicaid expansion and another federal program under the new law should bring $8 billion in federal funds into the state annually, state officials said. This money is expected to help reimburse rural hospitals that treat high numbers of uninsured people and may also generate economic benefits through the healthcare system.
To qualify for Medicaid under the new guidelines, a single person can earn up to $20,120 annually in pretax income, while a household of four can earn up to $41,400 for an adult to benefit.
McBane, who has been without health insurance for nearly 18 years, is now looking for a job that will allow her to take care of her health while staying within the income range that will keep her in the program.
Many of her neighbors work in fast food or construction jobs that do not provide healthcare, and they face stress and stigma whenever they have to visit a doctor. Much of western North Carolina exists in the Medicaid coverage gap, and its citizens are "absolutely left behind," McBane said. She expects the expansion will not only ease the financial burden on her community but also make many low-income residents feel more welcome in exam rooms.
The state has added social workers and improved technology to review Medicaid eligibility for all enrollees now that a COVID-19 policy barring states from removing anyone from Medicaid has ended. DHHS is also working with religious organizations, civic groups, and other trusted local voices to inform people newly qualified for publicly funded care, Kinsley said.
"They’re working. They’re taking care of their kids," he said. "And so we’re going to need to meet them where they are and use every tool we have to help them get connected to this important tool that they need for their health."