Column: NC's Medicaid Program Is Working But Needs Strengthening to Help Everyone

North Carolina took an important step forward in April, when the General Assembly passed House Bill 696, and Gov. Josh Stein signed it into law, providing $319 million to fund the Medicaid program through the end of the fiscal year.

But while that action provided a short-term solution, there remain longer-term challenges.

Rising costs, including hospital prices, has put pressure on the entire health care ecosystem. The decisions lawmakers make in the months ahead will shape the program for years to come, and one thing must remain at the center of every decision: the real people who depend on Medicaid for their health care.

North Carolina's Medicaid enrollees are not line items in a budget presentation. They are our neighbors. They sit next to us in church, and work on the farms, in the factories, and in the shops that keep our communities running.

Nearly one in four North Carolinians and nearly half of all children born in our state receive their health coverage through Medicaid. That is especially true in rural and underserved communities, where access to affordable coverage has expanded in recent years and plays a critical role in supporting working families. For these families, the program is a lifeline.

More than 40 states have adopted managed Medicaid because it works. Compared to the old fee-for-service approach, managed Medicaid delivers better care coordination, stronger oversight, and more responsible stewardship of taxpayer dollars.

North Carolina's experience is no different. Today, more than 725,000 North Carolinians benefit from Medicaid expansion alone — a powerful measure of how far the program has come, and how much is at stake in protecting it.

State data shows that North Carolina's Medicaid cost growth is running below comparable states, which is a meaningful difference when Medicaid accounts for approximately 20 percent of the state's entire budget.

Since managed Medicaid launched, savings built into annual capitation rates have saved taxpayers $503 million by ensuring members receive the right care, at the right place and time. The managed care plans that administer North Carolina's Medicaid program are central to achieving these results. They work alongside providers and state leaders in every county to ensure financial and operational oversight, and that care is coordinated and appropriate.

Protecting taxpayer dollars is a shared responsibility, and North Carolina's managed care plans take it seriously.

Government agencies and health plans all have a role to play in combating fraud, waste and abuse. Each plan operates its own dedicated fraud, waste and abuse unit, and collectively they coordinate with the state in a unified effort to identify and eliminate fraudulent activity and unnecessary spending.

In 2025, managed care fraud units helped uncover a scheme in Charlotte involving $14 million in false medical claims. More recently, the legislature targeted fraud in autism therapy services, passing new guardrails to ensure treatment is delivered by qualified providers in North Carolina to people who need it.

Health plans have new tools to remove providers who are abusing the system to the detriment of patients and families in need of autism services. Managed care plans are uniquely equipped to combat these rising costs and enforce compliance.

Beyond active investigations, managed care plan technology and processes ensure only eligible members receive services, making sure the state is only paying for those who qualify and isn't overpaying for unnecessary, fraudulent or wasteful services. This rigorous process is a structural safeguard that traditional fee-for-service Medicaid simply does not have.

HB 696 also implements federal work requirements now mandated under federal law, requiring Medicaid expansion adults between 19 and 64 to work or volunteer 80 hours per month, or be enrolled in an education program for 40 hours per month. Through this program, North Carolina's Medicaid plans are helping keep able-bodied residents healthy and working to drive our economy.

As state leaders continue to plan for the long-term sustainability of North Carolina's Medicaid program, they must recognize the benefits our managed Medicaid model brings to our state's residents, particularly those in rural communities where coverage gains have helped expand access to care and strengthen local health systems.

Making Medicaid work better in North Carolina requires that every part of our health care system works together — state and local elected officials, state leaders, health plans, hospitals and physicians, pharmacies and caregivers. This includes urban areas as well as rural communities, which account for nearly 40 percent of the individuals covered by Medicaid.

The North Carolina Association of Health Plans and our member organizations remain fully committed to working with state leaders and other stakeholders to strengthen this program. The people of North Carolina are counting on us to get this right.

Peter T. Daniel is the executive director of the NC Association of Health Plans, Inc. This column originally appeared on ncspin.com.