North Carolina expands Medicaid coverage, providing health care to hundreds of thousands in need

A decade after the federal government began offering expanded Medicaid coverage in states that opted to accept it, hundreds of thousands of adults in North Carolina are set to receive benefits, a development that boosters say will aid hospitals and local economies in addition to the long-term uninsured.

North Carolina elected officials agreed this year to expand Medicaid, which will provide the government-funded health insurance to adults ages 19 to 64 who make too much money to receive traditional Medicaid but generally not enough to benefit from public subsidies available for private health insurance. The federal government will pay 90% of the cost, as stipulated under the 2010 Affordable Care Act.

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More than 600,000 North Carolinians are ultimately expected to qualify, with roughly half to be automatically enrolled as of Friday. That means they’ll be able to get annual checkups, prescription drugs and other services with little or no out-of-pocket expenses.

Residents including Carrie McBane have been navigating the gap between earning too much to qualify for Medicaid and too little to afford private insurance for years. She's hopeful that expanded eligibility will revive the state's working class, especially in rural communities like her small mountain town of Sylva, located 290 miles (467 kilometers) west of Raleigh.

The 50-year-old had paid out-of-pocket to see several doctors who couldn't identify her debilitating illness, until one finally diagnosed her with Type 2 diabetes. By then, her organs were failing and she could barely work enough hours as a restaurant server to pay for insulin and her other new prescriptions. Her monthly income was still about $100 too high to qualify for Medicaid, she said.

"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," McBane said. "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. The District of Columbia also participates. Some states with Republican leaders have recently considered expansion after years of opposing it, primarily on the grounds that they worried federal policy would change and require states to pay a higher percentage of the expense. The 10 remaining states that don't participate are mostly Republican-controlled and are concentrated in the South and Midwest.

Expansion should help 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.

"This is a phenomenal moment for North Carolina and for North Carolinians," state Department of Health and Human Services Secretary Kody Kinsley said in an interview. "All that adds up to just the peace of mind, knowing that when they need health care, it’s not going to drive them into debt."

Democratic Gov. Roy Cooper had pressed hard for expanding Medicaid since taking office in early 2017. But Republican legislative leaders weren’t sold, saying they were suspicious about more government insurance and the chance Congress might cut its financial contribution.

They warmed to the idea in 2022, when the federal government offered a $1.8 billion bonus over two years if North Carolina signed on.

By March, the Republican-dominated General Assembly passed the legislation, and Cooper signed it into law. It stipulates that North Carolina hospitals cover the state’s 10% share of expenses through increased assessments that began in November, DHHS said.

Participating in the Medicaid expansion and another federal program that North Carolina hospitals entered into under the new law should bring $8 billion in federal funds into the state annually, according to state officials. The money should help reimburse rural hospitals that treat high numbers of uninsured people. It may also generate economic benefits through the health care system.

To qualify for Medicaid under the new guidelines, a single person can make up to $20,120 annually in pretax income, while a household of four can make up to $41,400 for an adult to benefit.

McBane, who lives alone and has gone nearly 18 years without health insurance, is now searching 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.

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Many of her neighbors work fast food or construction jobs that don't cover health care, and they face stress and stigma whenever they have to visit a doctor, she explained. Much of western North Carolina exists in the Medicaid coverage gap, "and its citizens are absolutely left behind," McBane said. She expects expansion will not only ease the financial burden on her community, but make many low-income residents feel more welcome in exam rooms.

The state has added social workers and better technology to review Medicaid eligibility for all enrollees now that a COVID-19 policy barring states from kicking anyone off Medicaid has ended. DHHS is also working with religious organizations, civic groups and other trusted local voices to get the word out to 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."