Gauging the impact of Medicaid expansion in North Carolina

On December 1 of 2023, North Carolina became the 40th state, along with the District of Columbia, to expand Medicaid. Within the first week, the state Department of Health and Human Services reported 280,000 new enrollees.

It’s estimated that more than a half-million low-income parents and childless adults will soon gain access to health care coverage. The new law’s impact on individuals and families seeking treatment, and the medical professionals who care for them will be closely monitored. 

Each year, for roughly 110,000 patients, their first point of contact with the health care system is the Atrium Health Wake Forest Baptist emergency room. Bret Nicks heads the emergency medicine department, and has led health care advocacy efforts for years as past president of the North Carolina College of Emergency Physicians.

He estimates that the number of patients he and his colleagues treat who are actually experiencing an emergency is probably less than 5%. Nicks says he’s looking forward to a focus on health care rather than a dependence on sick care, but he says there’s a caveat.

“Until recently we didn’t have urgent cares nearby that were open 24/7 at all,” says Nicks. “And so, in the off hours what may be perceived as an urgency in the absence of any other care options, becomes an emergency. And so, many of those ones we see in the overnight hours that would otherwise be fine to wait until their primary doctor or go see an urgent care that may be open, they may choose to come in because all of a sudden, the stimulus of the day has gone.” 

If recent history is any guide, it’s not clear if Medicaid expansion to more than 500,000 North Carolinians will alleviate the strain on emergency room physicians and staff. The state of Oregon for example showed a 40% increase in emergency department visits within a year and a half of its expansion. Those with underlying conditions or long-term illnesses took advantage of their new access to health care through a route they were already familiar with: emergency care.

Nicks says he expects a slight increase here as well, but one that’s likely to change over time.

“The hope is that you’re creating an opportunity to transform health care,” says Nicks. “Now that they have been identified and they have access as far as the insurance is concerned, can we plug them into the system in a location that is proximal to them to help eliminate some of these disparity issues [like] transport? ‘How do I get there during the day if I don’t have a car?’ Trying to address those concurrently really helps to amplify the population health impact.” 

Transforming health care means more people having insurance for uncertain and potentially catastrophic expenses like cancer treatments, but also for small things, like eyeglasses that those with robust insurance plans may not even consider.

Wake Forest University economics professor Tina Marsh Dalton calls it the "Costco card effect." 

“I get much better prices because Blue Cross BlueShield is negotiating for me,” says Dalton. “And they have a huge amount of enrollees and so they get really good negotiated prices. If I just as an individual want to go try to pay for my expenses out of pocket, I don’t get that Costco card effect. I don’t get the discounts.” 

Dalton says understanding the health impacts of Medicaid expansion is complicated. One Oregon study, conducted over a year and a half, compared patients who received expanded Medicaid through the state’s lottery and those who did not. She says they were unable to find any discernible physical improvements, but what they found was that the participants who received Medicaid self-reported much better health.

Dalton says it could be that they’re reporting better health that might be seen later on, or that blood pressure, cholesterol levels and the like compared for just 18 months isn’t enough time to draw conclusions. However, there is potential for promising long-term physical outcomes for Medicaid recipients. In one study, patients substantially increased their preventive care visits, with cholesterol monitoring up 50% and a doubling of mammograms. 

And Dalton says one positive short-term measure was found: declining money worries. 

“Out-of-pocket medical bankruptcy went down,” she says. “Having to borrow to pay your medical bills went down. And then the participants reported a lot less stress about their finances. So, that can also feed into health just on a general level.” 

For many people being uninsured or underinsured means going without. Robin Epperson has been living with shoulder pain for years. She long suspected it was the result of a torn rotator cuff, but in order to confirm that, a doctor said that she would need an MRI and additional tests. And those are just some of the hurdles she faced with her bare-bones coverage plan prior to Medicaid expansion.

“I would have had to pay out of pocket too much money for testing, and if I were to have to go into the hospital and have to have a surgery I would still have to pay,” says Epperson. “There was no way I was going to meet my deductible through this whole past year, or last year, because my deductible was way high.” 

Acute financial stresses like these — medical bills that can be a huge percentage of the household income — are being felt every day by tens of thousands of North Carolinians. And they often carry with them devastating consequences, says Wake Forest University assistant professor of family medicine Brittany Watson.

“Say you go to the emergency department because they have to see you there,” says Watson. “You know you can’t pay that bill that comes. They know you can’t pay that bill that comes. So, you get sent to collections, now you have poor credit. It’s hard for you to get housing for your family or buy a car for reliable transportation to get to work, or to school. And with people who may have an acute illness or even a chronic illness like high blood pressure or diabetes, they’re not able to receive the care that they need in order to function and feel better. So, that has impacts on the family. It’s more than just that isolated health event.”

Many health care advocates in North Carolina lament the fact that it has taken nearly a decade to get this done.

Care4Carolina is a statewide non-partisan coalition that’s been committed to expanding Medicaid since 2014. Executive Director Abby Emanuelson says this state has paid a steep price through its years of inaction on filling in the coverage gap.

“We’ve lost rural hospitals over this last ten years,” says Emanuelson. “We’ve lost lives and we’ve made health conditions more expensive because we didn’t have access to those pieces of treatment. We know that we’ve lost people to substance use, and mental health issues that didn’t get treatment because people didn’t have a way to get access to care.”

Today, that access is within sight for hundreds of thousands of North Carolinians like Robin Epperson. She says for years not being able to meet her deductible meant pricey copays for doctor’s visits, higher costs for the medications she needs to fill every month and deferring expensive treatment for her shoulder injury. Now, with full coverage on the way, she says she’s looking forward to that changing.

“So, with Medicaid, my understanding is that I’ll get assistance with that,” she says. “You know I can go to the ... I don’t have to be in fear of I can’t have a test if I need it, or I can’t afford a prescription.”

Epperson is currently awaiting final approval for comprehensive coverage. She says once she’s given the green light, she’ll finally be able to schedule her MRI.