More people in NC will have health insurance on Dec. 1, but there’s more to do to improve access

(NC Newsline, Lynn Bonner) — North Carolina will reach a milestone Dec. 1 when an estimated 600,000 low-income people become eligible to enroll in health insurance under Medicaid expansion.

North Carolina is the 40th state to expand Medicaid and allow people with incomes up to 138% of the federal poverty level to enroll in the government health insurance plan. That’s equivalent to an annual income of $41,400 for a family of four, or $20,120 for an individual.

State officials estimate that 600,000 people will be eligible for the insurance and have prepared to enroll 300,000 people on the first day.

Medicaid expansion became an option for states in 2014 and studies have shown that it has led to improved health. People in expansion states, for example, better manage their diabetes and high blood pressure.

Health care advocates worked for years to convince North Carolina Republican legislators to adopt expansion. Under a law President Joe Biden signed in 2021, the state will receive a $1.6 billion signing bonus over two years. Expansion will come at no cost to the state.

Dr. Karen Smith, a family doctor with a practice in rural Hoke County, is eager to see the broader effects of expansion, including the increased financial security that will come when families just getting by won’t have to channel precious dollars toward high medical bills.

“How can an individual even try to maintain health and get up and go to work, have a job and bring money into that household, and if they become ill, they have to take money out of the household,” she said in an interview.

North Carolina tied with Tennessee as the states with the 10th-highest uninsured rate last year at 9.3%, according to the U.S. Census. The national average was 8%.

Counties with high percentages of people without insurance were much more likely to have many health care consumers with medical debt in collections, an Urban Institute study found.

In a string of counties in eastern and northeastern North Carolina, at least 27% of consumers had medical debt in collections. North Carolina had 12 of the top 100 counties in the nation with the highest rates of medical debt. Two counties, Lenoir and Greene, were in the top 10.

In a presentation the Saturday before Thanksgiving to the Old North State Medical Society, an organization for Black doctors, Smith advised attendees to prepare their practices for newly insured patients.

Smith began practicing in Hoke as part of an NC Medicaid Society Foundation program that recruits primary care doctors to work in rural areas and medically underserved areas. She agreed to a three-year commitment and has been there 32 years.

“I love taking care of the people here,” she said.

Health care in rural counties

Medicaid expansion is expected to be of particular help in rural counties, where residents are more likely to be uninsured.

Getting services to rural residents will be key to fulfilling Medicaid expansion’s promise of a healthier state. It’s in some of those counties, though, where healthcare is contracting.

Martin General Hospital in Williamston closed in August and its operator filed for bankruptcy. At the time, Gov. Roy Cooper criticized the legislature for slow-walking Medicaid expansion. The General Assembly voted for expansion in March, but the move was not final until the budget was finalized in early October.

Last January, ECU Health announced it would close five rural clinics after its rural health system lost $46 million in 2022. The decision was “primarily driven by financial pressures including a disproportionate number of uninsured or underinsured patients as well as labor costs for travel staff,” ECU Health said in a January press release.

ECU said in a statement it had relocated services offered at those five clinics and does not plan to reopen them.

“ECU Health vocally advocated for Medicaid expansion for nearly a decade and has been equally vocal on the need for continued investment in rural health care across the state,” the health system said in a statement.

“We are grateful to legislators for not only the passage of Medicaid expansion, but other vital programs that will support our rural academic health mission. Similar to many other rural health systems across the nation, ECU Health is focused on necessary transformation as we respond to current economic realities and adjust to the continued shortage of nurses and providers.”

Kody Kinsley, state Department of Health and Human Services secretary, said in an interview with NC Newsline editor Rob Schofield that his agency and the state Department of Commerce are preparing a report on the “biggest gaps in the healthcare and caregiving workforce” and steps needed to close them. “It’ll give us more of a roadmap,” Kinsley said.

But those strategies for filling those gaps wouldn’t work if more people didn’t have a way to pay for their care, Kinsley said.

Medicaid expansion and increased Medicaid rates are “the foundational investment that sustains this other stuff,” he said.

Federally funded community health clinics have been working for years in underserved areas. These health clinics see patients whether or not they have insurance and bill uninsured patients on a sliding scale based on their income.

The community health clinics expect to continue treating those patients, but now more of them will have insurance. Having more insured patients will mean the clinics can “reinvest in their communities,” said Alice Pollard, vice president for operations and strategy for the NC Community Health Care Association.

The association’s 43 members saw 750,000 patients last year.

The clinics have been spreading the word about Medicaid expansion and expect new patients will seek them out once they have insurance.

Finding medical care

Increasing access to substance abuse treatment was one of the selling points for Medicaid expansion.

Dr. Michael Baca-Atlas, a family doctor and addiction medicine specialist, said he was thrilled when Medicaid expansion became a reality.

“I’m excited for patients, said Baca-Atlas, who works at UNC REACH Enhanced Primary Care, a Raleigh medical clinic. People will be able to get on life-saving medications and won’t have to worry about not being able to see a specialist because they don’t have insurance, he said.

But the state does not have enough doctors to treat all the newly insured residents who might seek treatment for substance use disorders, he said. Enhanced outpatient services will be critical to meeting the need, he said. The problem will be less pronounced in Wake than in surrounding counties.

“There is absolutely going to be a need to enhance outpatient services across the state,” Baca-Atlas said.

Newly insured residents will be eligible for an array of medical services, including dental care. The problem will be finding dentists who will take new Medicaid patients.

The main reason dentists won’t take new Medicaid patients is because rates have not increased since 2008, said Dr. Steve Cline, vice president of the NC Oral Health Collaborative.

The collaborative works to reduce oral health disparities.

“We fought hard for Medicaid expansion,” he said, but it won’t solve the problem of people being able to secure dental appointments.

The next step for those interested in better oral health for low-income people is to convince legislators that the state needs to increase Medicaid rates for dental care, Cline said.

There is data on how many people go to hospital emergency rooms with dental problems, he said, but that doesn’t tell the whole story.

Pollard, the community health association vice president, said some community clinics are working with the DHHS to increase medication-assisted treatment for opioid use disorders. And clinics are increasingly offering dental services, she said.

“There’s a lot of different puzzle pieces that have to fit together so that we as a state can make sure that people are having access to the care they need where they need it,” Pollard said. “Medicaid expansion is a huge piece of that puzzle. It’s like we can see the image now in the puzzle we have to put together. Having that is such a key in being able to invest in the other solutions.”