After long holdout, NC Medicaid expansion nets thousands

Nearly 1,000 residents a day are signing up for Medicaid expansion in North Carolina according to North Carolina Department of Health and Human Services Secretary Kody Kinsley. While the expansion had been agreed upon months earlier, delays in the General Assembly passing the current state budget meant that expansion did not begin until Dec. 1.

As of the start of the month 346,408 residents statewide have enrolled in Medicaid since the expansion period began. The state said that number is more than half of the anticipated 600,000 people who are newly eligible for coverage.

In Surry County 2,739 adults have enrolled under the expansion with the highest number of new enrollments happening when the period first began. In December 1,839 people enrolled with another 997 in January and 353 so far this month. The state said that 6.6% of the adult population has enrolled during expansion.

North Carolina residents qualify for Medicaid expansion if they are between 19 and 64 years old, a citizen, and have a household income up to 138% of the Federal Poverty Level.

For clarity, the state explained for an individual that means an annual income of less than $20,120. A family of two with income under $27,214 will qualify as would a family of three earning up to $34,307. A family of four qualifies under $41,400 and each additional person in the family raises that minimum threshold by $591 per month, or $7,094 a year.

According to state health department, the federal government will pay 90% of the cost of people enrolled in expanded Medicaid while the rest is covered by hospitals and other entities. None of the money for it comes out of the state budget.

Halfway there

"In the first two months we have already enrolled over half of the eligible people," said North Carolina Health and Human Services Secretary Kody H. Kinsley. "These individuals and families are seeing providers, utilizing preventative and specialty care, and getting life-saving prescriptions."

Kinsley said the state estimated it would take two years to enroll 600,000 people so "about 1,000 a day is faster than we expected over a two-year time window."

The rate of expansion seems to be slowing, which would align with Kinsley's assessment that nearly half of eligible parties have enrolled. The department is tracking Medicaid expansion numbers and has provided an interactive mapping tool on their website to track progress.

Statewide in December 272,937 names were added through expansion but that number fell to 41,164 in January. More than 85,000, or 32.3%, of all enrollees were residents between age 19 — 29 and women are outpacing men with 55.9% of new signups.

Comparing Surry County's 6.6% to area counties shows Yadkin County has enrolled 5.4% of adults, Stokes County 5.9%, Alleghany County 6.8%, and Wilkes County outpaces the area with 6.9% of adults enrolling in Medicaid expansion.

Statewide the counties with the highest percentage of expansion enrollees are Robeson County where 13.1% of adults enrolled, Edgecombe County sits at 11.9%, and Swain County is 10.3%.

Some of the wealthier counties in the central part of the state had the lowest percentage of expansion with Chatham County at 3.4%, Wake County at 2.9%, and Orange County at 2.7%. Watauga County bucked that trend and had the statewide low of 2.6% of adults signing up via expansion.

"We launched Medicaid Expansion in record time and are now enrolling people faster than other states," said NC Medicaid Deputy Secretary Jay Ludlam.

Many people who have enrolled through Medicaid expansion are young adults, work part or full-time, and may live in rural areas. NCDHHS said nearly one in three new enrollees are between 19 and 29 years old, and disproportionately live in rural communities.

Holdout over

North Carolina had been a hold out in adopting Medicaid expansion with state leaders saying they had concerns about what the state's portion of costs may be. Things changed in 2022 when Senate leader Phil Berger announced he was considering expansion after having been vehemently opposed for many years.

Along with the District of Columbia, North Carilina was the 40th state to enact expansion. Only ten states now remain who have not opted in but there has been recent movement in Alabama, Mississippi, and Georgia looking into expansion.

Last March, Berger explained his change of heart saying, "Every attempt in Congress and by the courts to reverse the ACA and Medicaid expansion has failed. It's not going away and refusing to accept that reality hurts North Carolinians and the state's finances."

Kinsley said last year that the state could have lost out on a $1.6 billion "signing bonus" for states that pass expansion. The state plans to spend some of that money on mental healthcare, training doctors and nurses. He called it, "One of the largest investments in mental health that we've seen, perhaps ever."

"North Carolina voters feel that strain every day. That's why 73% of North Carolinians — and 73% of rural North Carolinians — support Medicaid expansion. Republican voters also support expansion to the tune of 55% of all Republicans and 57% of Trump supporters," Berger wrote.

Berger said the expansion would be a positive for the people of North Carolina. "It will increase the number of North Carolinians who have insurance and assert downward pressure on healthcare costs for those who have insurance by reducing the incidence of the cost of uncompensated care being passed along to those that pay."

The Centers for Disease Control and Prevention said a lack of insurance coverage by North Carolina residents was a cause for concern. They said, "Nearly 25 million working age adults in the United States between age 18-64 were without health insurance in 2021. Texas, Georgia, and North Carolina had the highest rates of uninsured among this group."

The National Center for Health Statistics offered a 2022 report that approximated the statewide uninsured rate to be at 17.6% compared to the national average of 12.6% and also estimated the Medicaid roles held 2.9 million prior to expansion and "unwinding."

That 2.9 million number had been artificially inflated for several years because of the pandemic. During COVID anyone who had been on Medicaid or was accepted was able to stay on the program even if they no longer qualified due to the health emergency.

President Joe Biden declared that emergency over on May 11 which started the process of unwinding where states have been dis-enrolling people who gained Medicaid during the pandemic.