Medicaid Expansion in North Carolina.

Enacted as part of the Social Security Amendments of 1965, Medicaid served as a partnership between state and federal governments to provide healthcare access and coverage to low-income individuals across the nation. Since 1965, states have not only adopted Medicaid but also expanded the initial bill to cover more individuals, creating a safety net for underserved communities in all 50 states. However, not all states have implemented policies expanding Medicaid: Wyoming, Wisconsin, Texas, Kansas, Tennessee, Mississippi, Alabama, Georgia, South Carolina, and Florida have not yet adopted Medicaid expansion policies while South Dakota and North Carolina have adopted but not yet implemented Medicaid expansion. (1)

On March 27, 2023, North Carolina Governor Roy Cooper announced House Bill 76, expanding Medicaid in the state as part of the IHOPE (Improving Healthcare Outcomes for People Everywhere) Plan. (2) Thus, North Carolina has become the 40th state to expand Medicaid. This bill has expanded Medicaid eligibility to almost all adults making less than 133% of the poverty level (1.33*federal poverty level). But what sparked this move and what repercussions can we expect from Medicaid expansion?

Prior to Medicaid expansion, North Carolina Medicaid programs covered children, disabled adults, “Medically Needy” individuals, and older individuals living below the poverty line. Children younger than 19 years who live in households earning under 211% of the poverty level (2.11*poverty line) would be eligible for Medicaid coverage. (3) Additionally, individuals over the age of 65 living below the poverty line (in 2023, this was roughly $13,000 for 1 person and $17,500 for a couple) would be eligible for full coverage. Furthermore, Medicaid would also cover disabled individuals with low incomes. (4) Finally, individuals who do not meet the income requirements necessary for full coverage but still struggle paying medical bills would be able to receive partial or “Medically Needy Coverage.” (5)

So what are the benefits of Medicaid coverage and what does this mean for North Carolina residents?

Medicaid coverage provides consumers with a wide variety of benefits from inpatient and outpatient services, x-rays, diagnostic screenings, family planning services, prescription drugs, physical and occupational therapy, and personal care. (6) Not all of these services are fully covered, however. With some exemptions for certain populations, Medicaid plans may fully or partially cover healthcare services or enable cost-sharing where the Medicaid beneficiary (person receiving coverage) is responsible for a smaller portion of the full cost (they may be responsible for copayments, deductibles, coinsurance, etc.). (7) While Medicaid coverage does not make healthcare “free”, the scope of healthcare services covered as well as the significant benefits provided to beneficiaries make this plan essential for maintaining access to healthcare amongst underserved families.

Taking a break from the policy and focusing on the data, let’s take a look at the populations affected by Medicaid expansion and the benefits provided. Research suggests that there are roughly 178,000 uninsured adults in North Carolina who would be covered by Medicaid expansion, representing approximately 2.93% of the North Carolina adult population. (8) Furthermore, Medicaid expansion would provide over 600,000 North Carolinians with more affordable healthcare coverage. Without Medicaid expansion, there are three types of coverage: individuals who can afford healthcare coverage (above the poverty line), individuals with low-incomes that rely on Medicaid coverage, and individuals who cannot pay healthcare expenses but are also not covered by Medicaid. We say that individuals in this third group are in the “Medicaid gap.”

Below is a graph from the North Carolina Medical Journal, comparing healthcare access between these three populations. (9) Individuals in the Medicaid gap are more likely than individuals in the other two groups to avoid taking medications and skip physician checkups. Furthermore, these individuals are less likely to have received preventative health services including dental care, cholesterol checks, and influenza vaccines.

Clearly, the research shows that expanding Medicaid has many health benefits in the state of North Carolina, including improved access to preventative and mental health care to low-income adults and reducing the number of uninsured individuals. (10, 11) In fact, data suggests that failing to adopt Medicaid expansion may result in the deaths of up to 1,145 North Carolinians every year. (12) Medicaid expansion also has economic repercussions, adding thousands of government and healthcare jobs, while improving the quality of life of many low-income individuals.

However, like any healthcare policy, Medicaid expansion comes with a few tradeoffs. Medicaid is a federal-state partnership and thus, Medicaid expansion would result in increased state spending. In 2020, the federal government decided that individual states would have to pay 10% of Medicaid costs while the federal government would pay 90%; thus, a significant portion of Medicaid expansion comes at the cost of North Carolina’s state government. (13) Additionally, increased government spending on Medicaid may result in additional taxes levied on all individuals, including Medicaid beneficiaries.

With that background out of the way, what specific Medicaid Expansion policy did the government of North Carolina adopt? While most Medicaid Expansion states have expanded their programs via ballot measures, North Carolina governor Roy Cooper chose to expand Medicaid via legislation, specifically House Bill 76 titled “Access to Healthcare Options''. (14) This bill received bipartisan support, passing the North Carolina House of Representatives by vote of 87-24. (15)

The bill itself serves as one rope in a larger safety net meant to provide access to preventative, primary, emergency, and palliative care for individuals throughout the state. For example, Medicaid expansion particularly helps rural families as rural individuals are 40% more likely to be uninsured and eligible to receive care under HB 76. Furthermore, roughly 40% of North Carolina overdose patients in emergency departments across the state are uninsured. Medicaid expansion provides these patients with a lifeline where before they had none and were forced to persist without care. Moving forward, we can only hope that healthcare equity and accessibility become a focus in North Carolina and in states across the nation so that we can create a future where all individuals can receive quality care without worrying about paying exorbitant healthcare costs.