PUTTING A FACE ON MEDICAID EXPANSION
IN NORTH CAROLINA
Gene R. Nichol, Matthew Norchi and Heather Hunt
October 2016
Legend
Gene Nichol, Heather Hunt and Matthew Norchi
North Carolina Poverty Research Fund Ÿ October 2016
PUTTINGAFACEONMEDICAIDEXPANSIONINNORTHCAROLINA
Acknowledgments
We are immensely grateful for the support of the A.J. Fletcher Foundation, the Z. Smith
Reynolds Foundation, the Triangle Community Foundation and an array of other private
individual and foundation donors for this project—sustained by the North Carolina Poverty
Research Fund. Tim Henderson contributed important research. Ciara Zachary and Nicole
DozieroftheNorthCarolinaJusticeCenterandKatelynMoteandKristenDubayoftheNorth
CarolinaCommunityHealthCenterAssociationhavebeeneffectiveandgenerouspartners.And
thanks, especially, to the patients and doctors, named and unnamed, who discussed these
matterswithussocandidly.
More Information
Gene R. Nichol is Boyd Tinsley Distinguished Professor Of Law at the University of North
CarolinaSchoolofLaw.HeatherHuntisResearchAssociateatCarolinaLaw.MatthewNorchiis
currentlya2LatCarolinaLaw.TheresearchandpublicationworkofNicholandhiscolleaguesis
supported by the North Carolina Poverty Research Fund of the University of North Carolina
SchoolofLaw.Moreinformationisavailableathttp://www.law.unc.edu/centers/poverty.
MaponcovermadewithQGIS.Source:2014AmericanCommunitySurvey5-YearEstimates.
SonyaTaylor,a55-year-oldmotherandgrandmother,livesinAhoskie,NorthCarolina.Shehales
fromafamilyofsharecroppers.“Itwasinstilledinmeataveryyoungage,ifyouwanttoeat,you
havetowork,”shesays.Ms.Taylorhasworkedfulltimeherwholelife,asabookkeeperormanager
foravarietyofretailers.Butin2011,shewasforcedtoendureasix-hourfusionoperationfor
scoliosis.Twometalrodsandfiveplateswereinsertedinherback.Losinginsurancecoverageafter
thesurgery,shehadtoforgophysicaltherapytreatmentsbecauseshecouldn’taffordthem.Ms.
Tayloralsohaslonghadabrokenplateinhermouth,inhibitingherabilitytosmile.Asshesays,“it’s
hardtohaveconfidenceinyourselfwhenyouhavenoteethinthefrontofyourmouth.”
Sonya’sfamilyhasalong,worrisomehistoryofcancer.Inthepastfewyears,she’shadtroubling
symptomsinhergastrointestinaltract,bowelandintestines.Butshenowhasnoaccessto
screeningsbecauseshedoesn’thaveinsuranceandcan’taffordtopayfortheprocedures.Sheand
mostofherfamilyaresituatedinNorthCarolina’slargeMedicaidcoveragegap.Herkids’father
wasdiagnosedwithcancerinSeptember,2015.Hewasn’teligibleforhealthcarecoverageuntilhe
wasterminal.HepassedawayinFebruary,2016.“Iliveinfear,”shesays.“Mykidsdealwiththe
constantworrythatthey’regoingtolosetheirmother.IfeellikeI’mfightingformylifeandthe
stateofNorthCarolinacouldcareless.”
“IfIwokeuptomorrowandgotanemailtellingmeIqualifiedforsometypeofinsurance,it
wouldchangemylife.Itwouldbesuchagodsendtomeandmyfamily.It’sdishearteningnow,
becausemykidsseeIhavetofightforeverybitofmedicalcareIget.I’vegotgrandkids.Iwantto
seethemgrowup.”
—SonyaTaylor,HertfordCounty,NorthCarolina Introduction
NorthCarolinaisoneofnineteenstates,mostlysouthern,thathavesofarrefusedtoacceptthe
expansion of Medicaid under the provisions of the federal Patient Protection and Affordable
CareAct(ACA).1Themassivehealthreformlaw,asinterpretedbytheUnitedStatesSupreme
Court,2givesstatestheoptionofextendingMedicaidcoveragetothoselivingbelow138%of
the Federal Poverty Level (FPL) ($33,534 for a family of four in 2016). Under the ACA
framework,from2014through2016,thefederalgovernmentprovides100%ofthefundingfor
expansion;from2017through2020,theratedropsgraduallyto90%,whereitwillremain.The
2016 (non-expansion) Medicaid matching rate for North Carolina is about 2:1, meaning that
statepaysapproximately34%ofthetabwhilethefederalgovernmentcovers66%.3
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In 2013, the North Carolina General Assembly passed, and Governor Pat McCrory signed,
legislation prohibiting the state from accepting Medicaid expansion.4 The decision to reject
expansionhasnotbeenofficiallyrevisited.Initswake,hundredsofthousandsoflow-income
North Carolinians have been denied health care benefits who would otherwise have been
eligibletoreceivethem.Thedeterminationtorefusethelargelyfederallyfundedexpansionof
health insurance coverage, for good or ill, is surely one of the most consequential in North
Carolinahistory.Thisreportconsidersitsimpactonthestateandthelivesofthosedeniedthe
profferedcoverage.
Muchpowerfulworkhasbeendone,inNorthCarolinaandaroundthenation,toexplorethe
economic, social, demographic, hospital-based, health-outcome driven, and systematic
consequences of our state’s rejection of Medicaid expansion. Kaiser Family Foundation
studies,5amassiveConeHealthFoundation/KateB.ReynoldsCharitableTrustreport,6Harvard7
andGeorgetownanalyses,8andthoughtfulreportsbyourcolleaguesatWakeForestUniversity9
areprobingandcompellingexamples.
We draw, initially, on such studies here. But our purpose and methodology is fundamentally
distinct from these efforts. In the first section, we will briefly outline the key results of these
formal and overarching reports. They demonstrate, broadly speaking, that by continuing to
rejectMedicaidexpansion,NorthCarolinapaysverysubstantialcosts,notonlyinlostfederal
health care funding, but also in employment, tax revenues, support for hospitals’
uncompensated care, system-wide health care infrastructure expense, rural and urban
economic development, and, most important, the mental and physical well-being of North
Carolina residents. The medical, emotional, economic, social, financial, humane and
developmentalcaseforMedicaidexpansionmadeinthesestudiesisunambiguous.Theyalso
revealthatinthelongercourse,acceptingMedicaidexpansionlikelywouldnotonlysavelives
bythethousands,butstateexpendituresbythemillions.Itisnotaclosecase.
But the principal thrust of this study, set forth here in the decidedly more expansive second
section, moves past the (admittedly crucial) assembled data to explore, largely through
narrative testimony, the actual, daily-lived and experienced impact of restricted Medicaid
coverage on the lives and health of various low-income North Carolinians. We do so mainly
through extendedinterviews with patients caught in the noted Medicaid gap and an array of
doctors who make it no small part of their lives’ work to serve them. We have found these
discussionstobebothwrenchingandcompelling.Often,theyputflesh,bloodandsubstanceon
the empirical data. They indicate, even if imperfectly, the stunning human cost of North
Carolina’s rejection of expanded federal support for Medicaid coverage for poor Tar Heels.
Turningawaytheexpandedmedicalcoverageisnomeredemographicorideologicalmatter.It
touches, dramatically and unforgivingly, the fabric, character, dignity and humanity of North
Carolinalife.
2
I. Overview of Medicaid Expansion
The ACA and Medicaid Expansion
ThePatientProtectionandAffordableCareAct(ACA)changedthehealthcarelandscapeinthe
UnitedStates.U.S.citizensandlawfullypresentresidentswithincomesbetween100-400%of
the Federal Poverty Level (FPL)10 became eligible for significant income-based tax credit
subsidiestoenrollinprivatehealthinsuranceofferedthrougheitherastate-createdexchange
orafederalexchange.11Theseexchangesoperateasonlinemarketplacestoallowapplicantsto
shop for different insurance plans offered by private insurance companies. Additionally, the
legislationcalledforthemandatorystateexpansionofMedicaidtothosebelow138%ofFPL.
The U.S. Supreme Court, however, struck down the mandatory nature of the Medicaid
provision in National Federation of Independent Business v. Sebelius.12 States are now free,
therefore,toeitheracceptMedicaidexpansionortorejectit.
NorthCarolinaisoneofaminorityofstatesrefusingtoexpandMedicaid.13Thereasonsgiven
for non-expansion are hard to pin down but appear to evince skepticism toward Medicaid,
President Obama and the federal government generally.14 The Speaker of the North Carolina
HouseofRepresentatives,TimMoore,explained,“ExpandingMedicaidisnottherightdecision.
We’re grappling with trying to control Medicaid spending we already have. Creating more
expensedoesn’tseemtheprudentcourse.”SenatePresidentPhilBergeragreed.“Nothinghas
changedtoaddressthemultitudeofconcernswithMedicaidexpansion.Wecannotaffordour
current Medicaid system, much less an expanded one.”15 Governor Pat McCrory has
occasionally appeared more amenable to expansion, claiming, “I’m also trying to figure out
whattodowithMedicaidandwhethertoexpandthatornot,becausethefedsareofferingall
thismoney,andyetI’vegottobeconcernedwiththebureaucracythatcouldbegrownbecause
ofthat.”16Still,thegovernorhasnotpressedordemandedexpansion.InSeptember2015,Gov.
McCrory signed legislation to overhaul traditional (non-expanded) Medicaid in North Carolina
by privatizing statewide health insurance plans.17 No step was taken, however, toward
expansion.
The Medicaid “Coverage Gap”
ThemostseriousconsequenceofNorthCarolina’srejectionofexpansionisthecreationofthe
Medicaid“coveragegap.”UndertheACA,personslivingbetween100-400%ofFPLareeligible
to receive subsidies to help purchase health insurance through an exchange. The ACA
envisionedthatthoselivingatorbelow138%ofFPLwouldbecoveredbyMedicaidexpansion.
Asaresultoftheseoverlappingparameters,TarHeelswhomakebetween100-138%ofFPLare
eligibleforsubsidiesorMedicaid,ifitisexpanded.18Thoseunder100%ofFPLwereassumedby
theACAtobecoveredbytheexpansionofMedicaid,sonoprovisionforsubsidieswasmade
forthisincomegroup.19
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Medicaid expansion was a crucial component of the ACA because in its current unexpanded
state,MedicaidinNorthCarolinacoversonlyafewtargetedpopulationsthatmeetincomeand
assets eligibility requirements. These are generally elderly and disabled poor adults, and
qualifyinglow-incomepregnantwomen,children,andparents.Nomatterhowlittletheyearn,
childlessadults(whoarenotover65ordisabled)areineligibleforMedicaidinNorthCarolina.20
Thus, the Medicaid coverage gap refers, fundamentally, to the unavailability of insurance
optionsforthoseatorbelow100%ofFPL.Thoselivingbetween100and138%ofFPL,however,
are also considered to be effectively in the gap because, although they qualify for subsidies,
manyhaveahardtimeaffordingfoodandrent,nevermindthecostsofhealthcare,andwould
bebetterservedunderexpandedMedicaid.
TheKaiserFamilyFoundationestimatesthatthereare244,000NorthCaroliniansearningbelow
100% of FPL who would have qualified for Medicaid under the ACA.21 Kaiser finds, also, that
including those between 100-138% of FPL raises the number of uninsured adults eligible for
Medicaid expansion in North Carolina to 463,000. Table 1 describes those in North Carolina’s
coveragegap.Almost70%ofthosewithoutinsuranceliveinafamilywithsomeonewhoworks,
whileover50%ofthoseinthegapworkthemselves.Whitescomprisethemajorityofthosein
thecoveragegap(52%),whileoverhalfare35yearsorolder.22
TABLE1.DemographicsofIndividualsInNorthCarolina’sCoverageGap
Characteristic
Percent
Agegroup
19-24years
29
25-34years
20
35-54years
34
55-64years
17
Gender
Female
53
Male
47
Race/Ethnicity
White
52
PeopleofColor
48
ParentalStatus
Withdependentchildren
18
Withoutdependentchildren
82
IndividualEmploymentStatus
Employed
56
Unemployed
44
Family’sEmploymentStatus
Atleast1familymemberworkingfulltime
35
Atleast1familymemberworkingparttime 32
Nooneworkinginthefamily*
34
*Percentageaddsto101percentduetorounding.
SOURCE:TheHenryJ.KaiserFamilyFoundation,TheCoverageGap:UninsuredPoorAdultsinStatesthatDoNotExpand
Medicaid–anUpdate(2016)
The lack of adequate health care kills hundreds of people in North Carolina annually and
debilitatesmanymore.ResearchersfromHarvardUniversitypublishedastudyreportingNorth
4
Carolina’srefusaltoexpandMedicaidlikelyresultsin455to1,145deathsannually.23University
ofNorthCarolinamedicalschoolprofessorCharlesvanderHorsthasestimatedthenumberof
preventable deaths per year as a result of non-expansion to be between one and two
thousand.24 The Harvard study concluded that if North Carolina accepted Medicaid, there
wouldbe:
• 45,571fewercasesofuntreateddepression
• 27,044morediabeticsusingdiabetesmedications.
• 12,051morewomenage50-64havinghadamammograminthepast12months
• 27,840morewomenage21-64havinghadapapsmearinthepast12months
• 14,776fewerpersonsfacingcatastrophicmedicalexpenditures.25
Economic Impacts of Non-Expansion in North Carolina
Medicaid expansion would provide a significant economic stimulus to North Carolina through
increasedrevenue,jobcreationanddiminishedstatecosts.Becausethestatedidnotexpand
Medicaid in 2014, it has already forfeited billions of dollars and thousands of jobs. Still, huge
economicpayoffsforexpansioncanbeachieved,evenifbelatedly,forthedecadesahead.
Expansionwillresultinimpressiveincreasesinstaterevenue.InareportfundedbytheCone
Health Foundation and Kate B. Reynolds Charitable Trust (“Cone report”), researchers
concludedthatNorthCarolinahasalreadylostanestimated$6.02billioninfederalfunds.26It
standstoloseanadditional$21billioninfederalfundsbetween2016and2020ifitcontinues
to refuse expansion.27 State and local governments also lose tax revenue that Medicaid
expansionwouldgeneratethroughnewbusinessactivityandjobs.In2014and2015,thestate
would have gained an additional $228 million in revenue; counties would have seen an extra
$40million.28IfMedicaidisnotexpanded,cumulativestatetaxrevenuefor2016through2020
willbe$862millionlessthanitwouldhavebeenhadexpansionoccurred.Countytaxrevenue
willbereducedby$161million.29
An array of independent and nonpartisan experts have estimated that had North Carolina
expandedMedicaidin2016,itwouldhavegeneratedbetween20,000and40,000newjobsby
2020.30TheConereportestimatedthatalmost30,000jobshavealreadybeenlostin2014and
2015 and, if the state continues to refuse expansion, 43,000 jobs in total will be forfeited by
2020.31 Roughly half of these jobs would be in the health care sector, with the remainder in
fields such as construction, retail, service and government (Table 2).32 Employment benefits
would be felt throughout all one hundred counties and—critically for the large swaths of the
stateoutsidemetropolitanregions—wouldbethesameforbothruralandurbancounties.33
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TABLE2.EstimatedNumberofJobsCreatedinNorthCarolinaifMedicaidIsExpandedby2016
IndustrySector
AmbulatoryHealthCareServices
2016
9,849
2017
15,650
2018
16,385
2019
17,129
2020
18,339
Hospitals
2,675
4,243
4,438
4,634
4,954
Construction
1,712
3,473
4,377
4,806
5,017
Retail&WholesaleTrade
1,412
2,288
2,439
2,523
2,623
FoodServices&DrinkingPlaces
484
833
957
1,062
1,175
Professional,Scientific&TechnicalServices
597
996
1,093
1,159
1,233
SocialAssistance
268
443
487
527
578
State&LocalGovernment
1,891
3,125
3,413
3,623
3,862
AllOtherSectors
3,282
5,195
5,375
5,421
5,535
22,170
36,245
38,964
40,886
43,314
Total
SOURCE:Kuetal.,TheEconomicandEmploymentCostsofNotExpandingMedicaidinNorthCarolina
Expansionwouldalsoreducethecostofuncompensatedcareforhospitals.34Underexpansion,
state-owned hospitals (the University of North Carolina hospital system, for example) would
receiveMedicaidpaymentsforthousandsofpatientswhowouldotherwisebeunabletopay.
Expertsestimatethatathirdofuncompensatedcarecostsforstate-ownedhospitalsinNorth
CarolinacouldbeavoidedwithMedicaidexpansion,resultinginapproximately$250millionin
savings between 2016 and 2020.35 The state would save an additional $934 million through
avertedcoststomentalhealthprogramscoveredunderMedicaid.36
Because the costs of expansion are borne almost entirely by the federal government for the
firstfewyears,NorthCarolinacouldseenetgainsfromMedicaidexpansion.37Thatmaychange
in2020,whenthefederalmatchingratedropsto90%.AccordingtotheConereport,thedirect
cost of expansion to the state in 2020 will be approximately $604 million.38 Most, if not this
entiresum,however,wouldbeoffsetbythefinancialbenefitsofexpansion.39Oneconservative
estimate has calculated that North Carolina could gain financial benefits of $556 million,
comparedtothecostof$604million(Figure2).40
FIGURE 1. Medicaid Expansion Costs vs. Benefits in 2020 (in millions)
$800
ReducedCostsforExisqng
Government-fundedHealthPrograms
$600
$231
$400
$604
$200
$60
$265
$0
StateCost
6
StateGain
ReducedUncompensatedCarefor
StateHospitals
IncreasedStateandCountyTax
Revenue
SOURCE:HallandShoaf,MedicaidExpansionCostsinNorthCarolina,usingdatafromKu,etal.,TheEconomicandEmployment
CostsofNotExpandingMedicaidinNorthCarolina
Evidence from Other States
Medicaidexpansionhashadaprofoundlypositiveeffectinstatesthathavechosentoexpand.
This effect was underscored by a study comparing access to health care, utilization and selfreported health status in three states in the southern United States: Arkansas, Kentucky, and
Texas.41 Arkansas and Kentucky each adopted its own version of Medicaid expansion; Texas
declinedtoexpand.42ResearcherssurveyedworkingageU.S.citizenswithincomesbelow138%
ofFPLbetween2013and2015inthesethreestates.TheyfoundthatArkansasandKentucky
experiencedsharpdeclinesinratesoftheuninsured,whilethedropinTexaswassubstantially
smaller. Arkansas’s uninsured rate dropped from 41.8% to 14.2%, Kentucky’s dropped from
40.2% to 8.6%, while Texas’s only fell from 38.5% to 31.8%.43 Other studies, surveying the
effectsofMedicaidexpansiononanationalscale,havenotedsimilarimprovementsinhealth
carecoverageforexpansionstates.44
Thethreestatestudylookedatexpansioninitsearliestdays.Nonetheless,significantchanges
inaccesstocarewerealreadyunderway.Expansionwasassociatedwithanotableincreasein
thelikelihoodofhavingapersonalphysician(12.1percentagepoints),anincreasedlikelihood
ofacheckup(16.1percentagepoints),andadecreasedrelianceontheemergencydepartment
asausuallocationofcare(-6.1percentagepoints).45AU.S.DepartmentofHealthandHuman
Services(DHHS)literaturereviewconcludedthatcommunityhealthcentersinexpansionstates
experienced a 46% increase in visit rates, compared to a 12% increase in non-expansion
states.46Further,theDHHSreviewfoundthatuseofpreventativehealthservicesincreased41%
in expansion states, while non-expansion states experienced no change.47 Medicaid
prescriptionratesincreased25.4%inexpansionstates,butonly2.8%innon-expansionstates.48
Simon,Soni,andCawleyreportthatMedicaidexpansionwasassociatedwitha20%increasein
the probability of visiting a dentist, a 16% increase in receiving a mammogram, and a 14%
increaseinreceivingaclinicalbreastexam.49
Medicaidexpansionalsoremovesfinancialbarrierstocareforpatients.TheDHHSreviewfound
that the overwhelming majority (78%) of post-expansion Medicaid enrollees that visited a
doctor would not have been able to afford their care if expansion had not occurred.50
Additionally, the review found that the percentage of low-income adults reporting problems
paying medical bills declined by 10.5 percentage points (34.7% pre-expansion to 24.2% postexpansion).51Thethreestatestudyconcludedthatby2015therehadbeenan18.2percentage
pointreductioninpatient-reported,cost-relatedbarrierstocare,aswellasan11.6percentage
point decline in patients skipping prescription medications for financial reasons and a 14%
decline in difficulty with medical bills.52 Finally, Simon, et al. found that expansion was
associatedwithan8%reductioninworkabsencesduetohealthissues.53
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PUTTINGAFACEONMEDICAIDEXPANSIONINNORTHCAROLINA
II. Putting a Face on the Rejection of Medicaid Expansion in
North Carolina: The Words of Doctors and Patients
Data, demographics and economics tell only part of a story. They can remain distant and
bloodless. They can miss the intense and distinctly personal, and often familial, wounds that
result from restricted health care coverage—leaving mothers, fathers, sisters, brothers,
struggling souls, left out, in the shadows of an advanced and often seemingly miraculous
medicalsystem.Deniedhealthcare,closeup,canprovemorewrenchingthanabudgetsheet
or cost calculation reveals. This report, then, turns from the demographics and economics of
Medicaid expansion to the narratives of North Carolina doctors and patients, and those who
seek,unsuccessfully,tobecomepatients.Itoutlinestheoftencrushingimpactonthelivesof
low-incomeTarHeelsofexclusionfromhealthcarecoverage.
Thestoriesdepicttheterriblepricefrequentlypaidbysufferingandvulnerablemembersofour
community.Theyspeakofavoidableandtreatablediseasesthatinflictbrutalandunnecessary
harms. Ignored symptoms, canceled or unfilled medications, barred specialists and devices,
foregone therapies; unavailable tests and screenings such as mammograms, colonoscopies,
sonograms and stress tests; missed treatments for diabetes, asthma, blood pressure and
arthritis—allofwhichcancauseuntoldsufferingandresultinoverwhelmingemergencyroom
costs.Thenarrativesspeakofessentialhumaneservicesdenied,toooften,tothosewhowork
hard, sacrifice, attempt to care for their families and friends, and otherwise serve their
communities. They illuminate gaps in a health care system that are seemingly thought
acceptableonlybecausemostofusdon'tactuallyknowtheyexist.
Asmallbutillustrativesamplingfollows.
Dr. Stephen Luking – “Watching My Patients Pay A Terrible Price”
SteveLukingisafamilyphysicianwhohaspracticedmedicineforoverthirtyyears,almostallof
itinRockinghamCounty,NorthCarolina.Dr.Lukingandhisbrother,Scott,runabroadfamily
practice,servingabout6,000patients.Whenwespoke,heindicatedhisyoungestpatientwas
threedaysold,theoldest102.Heoftencaresforfourgenerationsofasinglefamily.About35%
ofLuking’spracticeispediatrics.Mostofthepoorkids,thankfully,areonMedicaid.Manyof
theirparents,though,arenot.Uninsuredadultsmakeupabout10%ofthepeoplehesees.He
says, in his decades working in Rockingham County, he has come to understand why nearly
everyindustrializedcountry(excepttheUnitedStates)providesabasiclevelofhealthcarefor
allofitscitizens.
8
Formorethanthirtyyears,Ihavewatchedmypatientswithnoinsurancepaya
terribleprice.I’veseenwomendieofinvasivebreastcancerandcervicalcancer
when they couldn’t afford mammograms and preventative checkups. I’ve
hospitalizedpatientswhostoppedtheirmedicinessotheycouldpayotherbills.
I’ve spoken to the next of kin in funeral homes about symptoms regretfully
ignored by those afraid of the cost of evaluation. You name just about any
cancer or serious disease, and I can tell you about uninsured patients who
delayed coming to see me, often with disastrous results. The slow death by
invasive colon cancer in the patient who could not afford a colonoscopy, the
diabeticwhocouldnotpayforinsulinandtheresultingdialysis,thefamiliesleft
bankrupt and depressed after a serious illness, and on and on. Despite what
people say, the emergency room doesn’t provide the care these folks need.
When was the last time someone received a pap smear or a screening
colonoscopyinanemergencyroom?
Dr.Lukingspeaksofparticularpatientsandtheirunyieldingchallenges:
Ithinkofthecaring,middle-agedmanIsawrecentlyinmyoffice.Heoncehad
goodinsuranceandafull-timejobatafactorybuthadtoquithisjobandcome
homewhenhismothersufferedadevastatingillness.Otherwise,shewouldhave
been forced into a nursing home. I had placed him on several medicines for
healthissues.WhenIaskedhimifhehaddonehisbloodwork,hestartedtocry.
Hetoldmehenowhadnoinsurance.Thefolksatsocialserviceshadtoldhimhe
wasn’t earning enough to qualify for insurance subsidies [under the ACA]. He
now works for minimum wage 25 hours per week and told me he has been
skippingmedicinesinordertomakeendsmeet.
AnotherpatientIsawlastmonthisawomaninherthirties.Idiagnosedherwith
rheumatoidarthritislastyear.Shecamebacktoseemebecauseshecouldnot
afford visits to her specialist. She also had stopped her costly
immunosuppressant medicines, yet these meds are her only hope to avoid the
gnarledhandsanddeformedjointsthatwillinevitablycomeherway.She,too,
didn’t qualify for insurance support at her low wage. She was advised at the
governmentcenterthatheronlyhopewastoquitherjobandgoonpermanent
disability.
Lastweek(September,2016),Lukingsawachild,oneofhisregularpatients,whocamein,late
intheday,strugglingwithavarietyofearinfection-relatedissues.ItwashardforLukingnotto
notice,though,thatthechild’smotherseemedtobeinevenworseshape.Sheindicated,under
hisprobing,thatshe,too,hadbeenillforseveraldays.Heaskedifshehadseenherdoctor.The
mother explained that she didn’t have a physician. She was uninsured, though she had been
workingforovertenyearsforoneofthecounty’slargestbusinesses.Formanyyears,shehad
onlybeenabletoget26hoursaweek,thoughsheconstantlyrequestedmorework.Thesame
wastrue,shesaid,ofmostofherfriendsatthestore.ShehadtriedtogetMedicaidbutwas
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PUTTINGAFACEONMEDICAIDEXPANSIONINNORTHCAROLINA
told she didn’t qualify and she was unable to receive subsidies under the ACA. So she knew
seeing a doctor was out of the question. Luking indicated he sees patients in similar
circumstances about a half dozen times a week. Another comes to his office, once a year,
essentially to continue her limited medications. Though her family has a strong history of
cancer, she, in her early fifties, has never had a mammogram or any other screening test
because she can’t afford them. Luking worries that her effective exclusion from the medical
systemwilleventuallyprovetragicforbothherandherfamily.
Dr. Luking has come to have a particularized vision of the low-income community he is so
frequentlycalledupontoserve.Forhim,thereislittleechoofthestereotypesthatoftenmark
ourpoliticaldiscourse.Hispatients,morefrequently,inspireandtransform:
Twenty years ago in the middle of the night after an emergency C-section, the
obstetricianatAnniePennHospital[inReidsville]handedmeanewborninfantin
needofresuscitation.Ididmyjob,thoughIwastakenabackbytheswollenhead
twice the normal size of a healthy newborn. Since that night, I have seen that
childasapatienthundredsoftimesintheofficeandhospital.Throughdozensof
hospitalizations, some of which I seriously thought may be his last, I have
watchedapurekindofloveemanatingfromhismotherthatdefiesdescription.
My patient cannot walk, or see, or talk. His feeding tube, brain shunt and
permanent tracheostomy, along with fifteen medications, sustain his bodily
functions.Buthismothersustainshissoul.
Always at his bedside, she has sacrificed her life to the loving attention of a
severelycompromisedson.Withthehelpofhomenurses,shehascaredforhim
athome.Iconsiderherasaint.Herhusbandworksasafarmlaborer;herlife’s
work is a labor of selfless love. Together they earn less than the threshold for
insurance coverage and would qualify for insurance coverage in most other
states. She has skimped on her own health care. Her husband last year
developed potentially ominous symptoms but declined a referral from the
emergencyroomtoaspecialistbecausehealreadyhasoutstandingmedicalbills.
“Theyaren’t‘takers’lookingforahandout.Theseworkingpoorareourcousinsandourneighbors.They
sitwithusinthepews onSunday,theirchildrenandgrandchildrengoto school withours.Somehave
watchedwell-payingjobsflytoMexicoorChina.Some,throughpersonalorfamilycircumstancesearn
meagerwages.Somehaveemployerswhocraftilymaintainthemunder‘temp’statusorkeeptheirhours
worked under 30 hours per week to avoid insurance obligations. Some have reached their God-given
potential. Who are we to pass judgment? The fact is that near-poverty has left them all uninsurable
withoutMedicaid.SomeinRockinghamCountywillsurelydie—iftheyhaven’talready—becauseofthe
decisiontorejectMedicaid.”–Dr.StephenLuking
Dr. Steve Luking “works one day, one patient, at a time,” trying to serve the people and
community he has grown to deeply love. He became so distressed about the impact on his
patientsofNorthCarolina’sdecisiontorefuseMedicaidexpansionthatafewmonthsagohe
10
wroteapowerfullettertohissenator,PhilBerger,andGov.McCrory,outliningthedevastating
effects he sees daily in his practice. The letter was eventually published in the Greensboro,
ReidsvilleandEdennewspapers.54Neitherleadereverreplied.
Dr. Pradeep Arumugham – “She Would Be Alive Today If We Accepted Medicaid
Expansion”
Dr. Arumugham is a heart specialist in Kinston, North Carolina. Kinston, and Lenoir County
whereKinstonislocated,areamongthestate’spoorestplaces.Hehashadbigcityoptionsbut
prefers the quiet, friendlier life of eastern North Carolina. He has a thriving practice that
includesaselflessandpotentcommitmenttoimpoverishedresidentswhoareuninsuredand
can’t pay the fare. They are, he explains, typically hard-working folks who struggle
economically—waiters, maintenance workers, cooks, laborers, retail employees. He also says,
asaheartdoctor,hetriestoseehispoorestpatientsonamonthlybasisbecause“theytendto
beatgreaterriskofdying.”
The failure to expand Medicaid, he reports, has had a devastating impact on his low-income,
uninsuredpatients.Themostwrenchingofthoseconsequencesoccurredlastyearwhenoneof
hispatients,whomadeabout$10,000ayearworkinginalocaldiner,facedseveredangerof
heartfailurefromatroublinggeneticabnormality.Dr.Arumughamhadtreatedherinitiallyin
the emergency room at Lenoir Memorial Hospital. He was able to stabilize her and send her
home,butherheartremainedveryweak.Shewasinherearlysixties.Hersisterhaddiedfrom
the same malady. She needed a defibrillator, which for an uninsured patient could cost over
$80,000. She couldn’t get coverage on the open market because she didn’t have enough
money.Shecouldn’tqualifyforsubsidiesundertheACAbecauseshewastoopoor.
Dr. Arumugham saw her for several months but he
“Itreatedherforfreeandthe
was unable to secure a defibrillator. As a result, the
waitressdied.“Wecouldhavesavedher,”hesays.“I medicinessheneededweren’tthat
treated her for free and the medicines she needed expensive,butwecouldn’tgetthe
weren’t that expensive, but we couldn’t get the devicesheneeded.”Shewould“be
device she needed.” She would “be alive today if we alivetodayifwehadacceptedthe
had accepted the Medicaid expansion.” That’s the Medicaidexpansion.”
“simplefact.”
Arumugham speaks of another patient, Shelton, a truck driver with serious heart disease. His
heart function had dropped to about 35%, so it wasn’t possible, any longer, to drive a truck
professionally. He lost his job and his health insurance. He has attempted to get disability
benefits, but has been unsuccessful. He can’t walk for more than a few minutes without
becoming exhausted. He needs a pacemaker, which, of course, he can’t afford. The trucker’s
sonisautistic,sohiswifecan’twork,needingtocareforhimathome.Dr.Arumughambelieves
Shelton’sadvancedproblemscouldhavebeenavoidedwithearlier,propertreatment.Nowthe
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doctorandthepatientfearforhisfuture—andthatofhiswifeandson.And,ofcourse,with
Medicaidexpansion,hecouldbefullytreated.
Charles, 64, worked for years repairing tractors. He had a heart attack in 2007, eventually
resultinginbypasssurgery.Thenhehadastrokein2011.Charlesneedsaspecialisttoreceive
catheterization,butthatwouldcostthousandsofdollarsthathecannotafford.Thushishealth,
and perhaps even his survival, are threatened. In over 30 other states, he would qualify for
federally funded Medicaid. Sandra, 53, the manager of a local bingo hall, makes less than
$10,000ayear.Shehasasthmaandhasrepeatedlybeenforcedtogototheemergencyroom,
andsometimes,whilethere,hasbeenplacedonaventilator.Shespendsmanyofherscarce
dollarsoninhalersandmedicines.Medicaidexpansionwouldnotablyrelieveherplight.
Dr.ArumughamknowsthatmuchofthepoliticalleadershipinRaleighisadamantinopposition
toexpansion.Hesays,“IwishtheywouldcometoKinstonandmeetmypatients.”
“Every day, every single day, I see the way we allow
these people to suffer, just because they don’t have
“We’reonlysaying,youare
moneyandwewon’tletthemhaveinsurance,”hesays.
sick,oryouareinjured,and
“Iknowpeoplesay,‘I’magainstgivingthemmoneythey
wearegoingtotrytofixyou. don’tdeserve,’asiftheywerebeinghandedsomekind
Whyisthatseenassomething of generous disability check,” the idealistic doctor
radicalorextraordinary,oras reports. But that’s not what is happening, he says.
“We’reonlysaying,youaresick,oryouareinjured,and
somethingahumanbeing
we are going to try to fix you. Why is that seen as
doesn’tdeserve?”
something radical or extraordinary, or as something a
humanbeingdoesn’tdeserve?”55
Dr. Evan Ashkin – “Rationing By ‘Wallet Biopsy’ – A Doctor’s Excruciating
Balance”
Evan Ashkin is a doctor of family medicine at the University of North Carolina School of
Medicine. He serves patients at Prospect Hill Community Health Center in southern Caswell
County (among other clinics), where a majority of the North Carolinians he sees are Spanish
speaking and poor. Almost half are farmers (black, white and Latino). A quarter are on
Medicaid,thirtypercentgetMedicare,andfortypercentareuninsured.
Ashkinnoteshispatientsdon’tfittheoftencommonstereotypeoflazyfreeloaderslookingto
game the system and get a free handout. “That viewpoint is possible only if you have never
worked with anyone in this patient population.” These are people who “are simply in
excruciating circumstances, in intense distress arising from circumstances beyond their
control.” They are waiters, gardeners, farm hands, motel workers, dishwashers, day laborers,
retailemployees,housekeepers,and,ironically,homehealthcareworkers.Familieswithyoung
12
kids, part-time students trying to work and finish community college. Maybe policymakers
oughttocomedownhereandmeetthem.
“Poorfolkspayaterriblecostfornothavinghealthcare
coverage—it takes a terrible human toll,” Dr. Ashkin explains. When you can’t get care, your health suffers “Whenyourhealthispoor,you
markedly. “When your health is poor, you frequently frequentlybecomepoorer,you
become poorer, you are more likely to become, or to aremorelikelytobecome,orto
stayunemployed,yourfamilyismoreapttosuffer,there stayunemployed,yourfamilyis
is more harm to kids and to their communities,” he moreapttosuffer,thereismore
notes. And, of course, there is more harm to North harmtokidsandtotheir
Carolina. “Right now we are paying a terrible cost as a communities,”henotes.
statebynotexpandingMedicaidandbroadeninghealth
carecoverage,”hesays.Itis“morallyindefensible.”
Ashkinhelpsoverseeaspecialclinicaltrackforyoungdoctorswhocometothemedicalschool
at UNC explicitly to learn to work in these distressed and marginalized communities. “The
studentscomeherewantingtoserve,wetakethemtotheseclinicssotheycanlearntodothis
kind of health care work, to make the kind of excruciating decisions poverty doctors have to
make.”Theyknowwhattheyaregettinginto,hesays,“theyarebravesouls.”Theylearnasad,
tryingandunacceptablereality.“Theyhavetobetrainedtodealwithit.”
Ashkin describes the untenable choices that restricting
Medicaidtriggers.Amancomesinwithchestpains,buthe’s
“Wesaywecouldn’tstand
uninsured.Dowegivehimthestresstestwewouldofferifhe
tohaveatwo-tierhealth
could pay? The clinic can’t afford to continually pay for
expensive procedures. So maybe the patient gets the test,
systemortohave
maybe not. What if the doctor guesses wrong and he has a
rationing,”Ashkinnotes.
heart attack? “We say we couldn’t stand to have a two-tier
“Butthisisrationing,it’s
healthsystemortohaverationing,”Ashkinnotes.“Butthisis
justrationingvia‘thewallet
rationing,it’sjustrationingvia‘thewalletbiopsy,’theworst
biopsy,’theworstpossible
possiblebasistoallocatecare.”Itis“giganticallyimmoral,the
basistoallocatecare.”
worst criterion.” He tries to be ethical, “but why should a
doctorbemakingsuchdecisions?”Whyisadoctorexercising
“thisexcruciatingbalance?”
OneofAshkin’spatientsisundocumented,havinglivedheresevenyearsafterfleeingviolent
abuseinMexico.Shewasinsignificantdistressearlyinapregnancy—bleeding,badlyinneedof
an ultrasound, presenting the serious possibility of an ectopic pregnancy. Because of
constraints on public funding for her care, even if Medicaid is expanded, the clinic is hard
pressedtoprovideaneededultrasound.And,ifitprovidesanultrasoundnow,theclinicmay
not be able to provide important scans later in the pregnancy, essential to protect both the
mom and the baby. The baby, of course, will be a citizen, as is his sibling—suggesting how
artificial non-citizen funding restrictions can be. “So I have to help the mother through this
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wrenchingchoice—achoicethatnomothershouldeverberequiredtomake,”Ashkinsays.“No
one but a poor person would ever have to make such a choice; we want to avoid an early
sonogrambutifweguesswrong,itmightprovedisastrous.”Ashkinthinksofwhathecallsthe
“brother-sistertest”:“WouldIthinkittolerablethatmysisterhadtomakesuchachoice?”But
we force this dilemma on a “hugely vulnerable population—pregnant women, uninsured,
sometimestheparentofacitizen,whoisn’toneherself.”Heandhismedicalcolleaguesmake
decisionslikethat,hesays,everyday.
Andbecauseofthecabiningrestrictions,Ashkinsayslargenumbersofhispatientsrollinand
outofMedicaid.IftheyhaveMedicaid,butthengetajob,theycouldlosecoverage.Orifthey
losetheirjob,ortheygobankrupt,theirMedicaidstatuschangesback.Butapatientwhohas
asthmaneedsaninhaler,insuranceornot.WhenhegoesoffMedicaid,hecannolongerafford
it. Or a patient needs blood tests, or diabetes medicine, or heart pills or high blood pressure
medicine.Then,becausethepatientgetssicker,Ashkinnotes,she,perhaps,losesherjob.Asa
result,shegoesbackonMedicaid.Thenshegetstheinhalerortheinsulinorthebloodpressure
medicine,but“permanentdamagehasoccurred”inthemeantime.“Ihearthesestoriesevery
week,”Dr.Ashkinsays.Theyrepresent“animmenselydestructivewaytopracticemedicine.”A
way that is also “hugely inefficient—people get sicker, the family suffers, the community
suffers, the tax base suffers.” Every month, Ashkin “sees patients who get much worse
outcomes,andwholatertriggermuchhigheremergencyroomcosts,becausetheymoveinand
outofMedicaid.”Withexpansion,hesays,thatwouldn’thappen.
Another of Ashkin’s uninsured patients, in his late forties, has multiple sclerosis. He couldn’t
qualify for Medicaid because he makes a little too much money. But he doesn’t make nearly
enoughtobeabletoaffordhisMSmedications,whichcombatthediseaseeffectively,butare
pricey.Sohehadtogooffhismedicationforoverayear,whiletryingtogetacceptedintoa
charitable care program. If he gets accepted, he will have suffered “real and permanent
damageintheinterim.”Similarly,ayoungguyAshkinsees,outofprisonforayearandahalf,
haddiabetes.Ironically,ofcourse,hehadgoodhealthcarewhilehewasincarcerated.Having
had no medical care since he was released, he developed advanced diabetic foot disease.
Becausehehadnohealthinsurancecoverage,when“hefinallycameintoseeushe’dlosta
tremendous amount of weight, was throwing up all the time, and, eventually, may require
amputation.”HehadtobeadmittedtoUNCfordialysisandtheinstallationofafeedingtube.
The hospital, Dr. Ashkin reports, will eventually have to spend over $100,000 on his care—
becauseitwasimpossibletocomeupwitharelativefewdollarsearlier.Itis,sadly,“avery,very
typicalstory.”ByDr.Ashkin’slights,“it’sabizarrewaytoallocatehealthcare.”
“Ibelievethathealthcareisahumanright.Ialsobelievethatonapurelyeconomicbasisthe
argumenttoextendMedicaidisunassailable.Locally,regionally,statewide.Wearedoing
ourselvesahugedisservice.Ideologyisovercomingrational,commonsensedecision-making.
AnditistakingahideoustollonsomeofthemostvulnerablepeopleinNorthCarolina.”–Dr.
EvanAshkin
14
Dr. Julius Mallette – A “False Economy Courts Disaster” and Makes Impossible a
“Civilized Medical System”
Dr.MallettehasbeenthechiefmedicalofficeratKinstonCommunityHealthCenterforseven
years. He also has a private practice as an OB/GYN in Lenoir County. Mallette explains that
communityhealthcentersinNorthCarolinaworktofillthegapforthosewithouteitherprivate
insuranceorMedicaid.TheKinstonCommunityHealthCenterchargespatientsonanincomebasedslidingscale,cappedat125%oftheFederalPovertyLevel(oralittleover$30,000ayear
for a family of four in 2016). A lot of folks in Kinston, he says, can’t meet the sliding scale,
modestasitis.Heestimatesthatabout10%ofpatientshavetobeturnedawaybecausethey
can’tpaythefee.
Butspecialistneedsareaslargeproblemforthepooranduninsuredasnotbeingabletoget
intothedooroftheCenterinthefirstplace.AsDr.Mallettedescribes:
Wehaveagreatscreeningprocess,figuringoutwhatpatientsneed.Butreferrals
to specialists, which are often critical, are problematic for our non-Medicaid
patients. First, there may be large transportation costs from Kinston to East
Carolina[University]orotherlargermedicalcenters.Manyofourpatientscan’t
pay to get to the referral. Then, there is the specialist’s fee. They typically
demand several hundred dollars up front, so our patients accept a suggested
referral but often don’t go because they can’t afford it without insurance. So
they aren’t able to get the specialized heart or obesity or diabetes or
dermatology or dental treatment they need. We can tell them the treatment
that would help them, but we can’t secure it because the patients can’t afford
theprogramsorthespecialistsneeded.Ifyouareuninsuredandobese,withthe
challengesfromit,wecan’tgetyouintoaprogramoftreatment.Andthen,of
course,theobesitytiesintoalotofotherchronicconditions.So,foralotofour
patients,ifwecan’tgetthemMedicaid,wecan’tfullytreatthem.
Even with small referrals like dermatology,
Mostofourself-paypatients
ninety percent of our folks can’t afford the upfrontfee,sotheyendupgettingdiseasesintheir knowtheycan’tactuallyuse
systems and, eventually, needing hospital care. thereferrals.Somefolksin
Most of our self-pay patients know they can’t theirfiftiesjustsortofgiveup,
actually use the referrals. Some folks in their knowingtheywon’tactually
fifties just sort of give up, knowing they won’t haveaccesstohealthcare,so
actuallyhaveaccesstohealthcare,sotheydon’t theydon’tthinktheyareever
thinktheyareevergoingtogetwell.Ourreach goingtogetwell.
andeffectivenesswouldbemuch,muchwiderif
weexpandedMedicaid.
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Then there are all the other services that the Center has difficulty providing poor, uninsured
patients. “Women need mammograms, but if our patients aren’t on Medicaid, they can’t get
them.” Blood pressure medicines “are very effective,” Dr. Mallette notes, “but our patients
can’t afford them if they aren’t on Medicaid.” Even if some could get help with half the
medicineorscreeningcosts,itwouldoftenbeenoughtomakethedifference,hesays.Sothey
go without essential medications, and, too frequently, “we see them later in the emergency
roomafterthey’vehadastrokeoraheartattack.”Then,ofcourse,thecosttothehealthcare
systemwillbe$90,000or$100,000.“It’safalseeconomy,”hesighs.
Diabetes medications, he notes, are expensive for uninsured patients. With insurance, the
patientmightincuronlya$5co-pay.Butwithoutinsurance,the“medsmaycost$500.”They
ask, “do I pay my rent or do I pay for my diabetes
medicine?” Then, he says, shaking his head, “we see
Theyask,“doIpaymyrentordo them later in the intensive care unit which costs
Ipayformydiabetesmedicine?” everyone four or five thousand bucks, but it’s all
because they didn’t get diabetes medicine in the first
place.”
Yesterday,Dr.Mallettenotes,oneofhispatientsfinallyclearedfortraditionalMedicaid.Last
year,hesays,shewenttotheemergencyroomsixtimes,costingthesystemawholelotmore
thanitwassupposedlysavingbyturningheraway.
“ItwouldbeahugebenefitinKinston,”Dr.Malletteargues,ifMedicaidwereexpanded.There
is still a “big mindset here” that “I won’t go to the hospital unless I’m at death’s door.” That
costs everyone in the long course, he notes. “I practiced in South Africa when I was younger
and you really saw it there.” Pregnant women would wait weeks or months to see a doctor,
oftenleadingtodisaster.Itmeans,“youcan’treallyhaveacivilizedmedicalsystem,”hesays.
“Wearecourtingdisasterandwearenotlivinguptoourideals.”
Running a rural community health center, and thinking about the almost 500,000 people
excludedfromMedicaid,Dr.Malletteiscertainthat“expansionwouldnotbeafinancialburden
but would instead prove to be of tremendous fiscal benefit, as the federal tax dollars we
already pay would return to support our rural and urban hospitals, create thousands of jobs
that we need and promote a healthier workforce and community.” It would also help us,
Malletteobserves,actuallyhavethekindofhealthsystemweallsaywebelievein.
Dr. Charles van der Horst – “A Powerful, Direct and Devastating Impact on My
Patients”
Dr. Charles van der Horst, an internationally renowned AIDS researcher and recently retired
professorattheUniversityofNorthCarolinaSchoolofMedicine,hasworkedandvolunteered
for years at clinics in Raleigh and the Triangle to serve low-income, uninsured Tar Heels. The
patientsheseestherearelargelyyoungandworkingpoor:“thosewhobuildourhouses,feed
16
us, sew our clothes, teach our youngest children, serve our burgers, answer our phones and
take care of our elderly parents.” Because of our refusal to accept Medicaid expansion, he
explains,hispatientsoftenhavelittletoassisttheminavoidingtheravagesoflife-threatening,
chronicdiseases.
Whenwemet,likethescientistheis,vanderHorstbroughtthenumbers.Amongtheroughly
450,000 North Carolinians in the Medicaid gap, two-thirds live in families where at least one
familymemberworks.Theseworkingbutpoorfamilies,vanderHorstnotes,areourneighbors.
Almost 60,000 are construction workers, 56,000 work in food service, 46,000 are in retail,
43,000arecleaningandmaintenancefolks,36,000aretextileandlaundryworkers,34,000are
busandtaxidrivers.Stunninglyperhaps,16,000workinhealthcare.56Forthem,heexplains,
theevidenceisclear:
For people without insurance, or who have high deductibles, they go to the
doctor much less often. We know that if people have insurance, they do see
doctors and they enjoy an understandably greater peace of mind. For people
whodon’thaveinsurance,theyjustdon’tgotoaphysician,orgoonlywhenthey
can’t manage otherwise. But even young healthy people need to go to the
doctor for preventative screenings—cholesterol, diabetes, blood pressure,
mammograms,colonoscopies—orforvaccines,orsmokingcessationtreatments.
Diseasescanbepreventedoutrightifthesymptomsarecaughtintime.Wehave
setstandardsinplacethatdecreasedisease,andwe’vehadamajorimpacton
diseasethroughpreventativetreatments.
Butthatdoesn’thappenifpeoplearen’tscreened.Itisbadforthosepeopleand
it’s bad for all of us. If you are diagnosed with HIV, and get on a treatment
regime,you’llhaveanormallifeexpectancy.You’llwork,you’llpaytaxes.Ifyou
aren’tscreenedanddiagnosed,you’llhaverepeatedhospitalizations,areduced
worklifeandlifeexpectancy.Undiagnosedanduntreatedhypertensionresultsin
strokes, kidney failure and dialysis, which cost lots and lots of money to treat.
Privatelyinsuredpeopleenduppaying10%moreinpremiumsbecausehospitals
havetojackupcostsinordertocovertheexpensesoftreatingtheuninsured.
Toillustrate,Dr.vanderHorstmentionsarecentpatienthe’dbeentreatingataclinic.Anolder
man,atax-payingfarmer,cameinwithsymptomsofliverdisease.Eventually,theylearnedhis
liverwasriddledwithcancerduetometastaticesophagealcancer.Hehadnoinsuranceanddid
notseektreatment.“Hediedinaweek,”vanderHorstsays.Ifhehadhealthinsurance,hislife
could have been saved; these were treatable conditions. Plus, he would have had a notably
betterqualityoflifeashestruggledwithillness.“Peopledon’tgetcarebecausetheyfeellike
theyhavenochoices,”hesaid.
Anotherpatientworkedforyearsforalocalbankthatconsolidatedandmovedoperationsto
Charlotteduringtherecession.Shelostherjobbecause,givenfamilyobligations,shecouldn’t
move.Shelooked,unsuccessfully,fordecentsubstituteemploymentformanymonths.Inthe
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meantime,shebecameillandstarted“lettingthingsgo.”Herteethwereverybadand,working
in customer service, no one seemed willing to hire her—as she said, “her smile not being so
good.” Having lost employment and health care coverage, she had also run out of her blood
pressuremedicine.Effectsonherhypertensionweresubstantial.Dr.vanderHorstrecallsthat,
assheexplainedherplight,shesobbedinhisarms.Heindicatesthatpatternisn’tuncommon.
Inseeingahalfdozenorsopatientsonanafternoonvisit,oneortwowouldlikelyburstinto
tears. In part, he thought, they cried because someone was listening and trying to help, but
mainly they were just beaten down by the crush of poverty. Having health care coverage, he
notes,wouldpointedlyimprovethequality,andoptimism,oflife.
OneyoungmanvanderHorstwasseeinghadworkedforanumberofyearsinastable,full-
timejobwithhealthcarecoverage.Hehadseverehypertensionthatrequiredtreatmentwith
four different medications—but which had, in turn, successfully controlled his high blood
pressure.Thenhedevelopedacomplicationthataffectedhisbalance.Hewasadamanttokeep
working:“he’sagoodguywhoworkshardandenjoysworkingbecausehewantstocontribute
tosociety.”Withthenewdisability,though,hewasunableto
secure full-time work. In quick succession he lost his job, his health insurance, and had run out of his blood pressure “Forthewantoffour
medicine.Hisbloodpressuresoaredandhestartedtodevelop inexpensivemedications,”
kidneydamage.Throughtheworkofthevolunteerclinic,they hestates,“thehealthcare
wereabletogethisbloodpressurebackundercontrol.Butif
systemmaybeonthe
theforecastproveswrongandhedevelopskidneyfailure,he’ll
hookforhundredsof
needdialysis,whichwillcost$75,000ayearormore.“Forthe
want of four inexpensive medications,” he states, “the health thousands.”
caresystemmaybeonthehookforhundredsofthousands.”
Dr.vanderHorst,sadly,couldgoonandon.The“decisiontorejectMedicaidexpansionhasa
powerful, direct and devastating impact on my patients, leading to avoidable costs,
unnecessarydeaths,andintolerablecruelty,”heconcludes.
Kinston Community Health Center – Patients and Staff
DaphneBetts-HembyisthechieffinancialofficeroftheKinstonCommunityHealthCenter.She
isquicktoexplainhowmuchbettertheCenterwouldbeabletoserveits“particularpopulation
ifwecouldgetMedicaidexpansion.”TheCenteroperatesonagenerous,slidingscalefeebasis
initsefforttoserveuninsured,low-incomepatients.But“alotoffolkscan’tmeettheco-pay
andevenmoredon’tbothertocomeinbecausetheydon’tthinkthey’llbeabletoaffordit.”
And these are often the folks “who need health care coverage the most.” They have chronic
diseases,butthey“can’tgettheirhypertensionmedicineuntilit’stoolate.”It’s“cheapertoget
anoilchangeonaregularbasisthantowaituntilyouhavetoreplacetheengine.”Sheknows
forsome,a$50or$100co-paywouldnotbeamajorbarriertotreatmentorreferral.But“$50
isalotofmoneyforsomeofourpeople,it’slikeaskingfor$10,000.”
18
Otherstaffmembersratifythatconclusion.“Sometimeswecanprovidethediagnosis,butthe
uninsuredcan’taffordthetreatment,sotheystopcomingback,”oneexplains.“Othersgiveup
becausetheythinkadoctorwon’tseethemunlesstheyareabouttodieandthenit’llbetoo
late,” another adds. The “community need in Kinston is intense, and growing, the failure to
expandMedicaidiskillingourfolkseveryday.”FeliciaDaniels,anotherstaffmember,saysalot
ofpeople“maketoomuchmoneytomeetourcriteria,butnotenoughtopayforhealthcare,
sowe’reforcedtoleavepeoplewithouttheservicetheyneed.…Wewillseealadywithalump
inherbreast,but,becausethere’snoinsurance,wecan’torderthemammogram,thenshe’ll
enduphavingtohaveherbreastremovedbecauseshecouldn’tgetMedicaid.”
Ginn,apatientinherforties,explains:“Idon’tliketogototheemergencyroom,theyonlygive
you the least care they possibly can so that they can turn you loose, they only consider the
mostdesperateissues.”And,sheadds,“Ican’tmissworkbecausethenIwon’tgetpaid,soI
havetodecidewhethermyhealthormyfamilycomesfirst.Forme,it’salwaysmyfamily.”
Kent, a Center patient in his thirties, works full-time in the construction industry, but his
diabetessometimeslimitshisworkhours.“IttakeseverypennyIbringinduringtheweekto
manage my household and have something to eat.” As a
result of neuropathy, he suffers from stabbing pains in his It takes “all I’ve got to pay
feet. The Center doctors referred him to a specialist in for housing and food and
Greenville, but the doctor “wanted $195 before he would gas and heat, and health
eventake”anappointment.“I’mintheMedicaidgapandI
careain’tcheap.”Evenwith
don’thaveenoughmoneytopayforaspecialist,”hesays.
diabetes, he says, “you’ve
Ittakes“allI’vegottopayforhousingandfoodandgasand
heat, and health care ain’t cheap.” Even with diabetes, he gottoeat.”
says,“you’vegottoeat.”
KentlivesinfearthattheCenterwon’tbeabletohelpwithhisneuropathymedication.“Ifthey
can’t,I’llbeoneofthosepeopleinthescooteratWalmart,andIwanttowork,”henotes.“I’ve
alsohadtoputmydentalproblemsonhold,becauseIcan’taffordtotakecareofmydiabetes
asitis.Myteethareinbadshapebutit’sbeensolongsinceI’veseenadentist,I’mscaredto
findouthowbadthingsare.”
Chris,ayoungwomanfromKinstonwhoisanotherpatientattheCenter,isdiabeticaswell.As
achildlessadult,shecan’tqualifyforMedicaid,eventhoughshemakeslessthanthefederal
povertyguidelines.Herdiabeteshasledtoacascadeofrelatedhealthchallenges.Still,shehas
worked almost her entire adult life at various retail and food service operations. Most of her
employers haven’t offered health benefits. Despite that, she managed to graduate from Pitt
CommunityCollegewithafocusinbiotechnology,hopingtobecomealabtechnician.Butshe
has been unemployed for over a year and has difficulty standing on her feet for significant
periods of time. She has developed severe Carpal
Tunnel Syndrome and her pain, she reports, is
I’m just waiting for death to come “constant.”Andshelivesinfearshewon‘tbeable
and takeme,but I wish Ididn’t have to continue to afford the limited medications she
tobeinsuchpainwhileI’mwaiting.”
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nowreceives.Whenweaskedherhowoftenshethinksaboutherhealthcaredilemmas,she
answered,“everyfewhours.I’mjustwaitingfordeathtocomeandtakeme,butIwishIdidn’t
havetobeinsuchpainwhileI’mwaiting.”
Conclusion
CarefulstudieshavelongindicatedthatNorthCarolina’sdecisiontorejectMedicaidexpansion
isanextraordinarilycostlyone.Notonlydoesthestateforgotensofbillionsoffederalhealth
caredollars,hundredsofmillionsofstateandlocaldollarsintaxrevenue,tensofthousandsof
jobs, hundreds of millions of savings for uncompensated hospital care, but, more directly,
463,000lowincomeTarHeelswouldreceiveneededhealthcarecoverageunderexpansion.As
a result of rejecting expansion, huge numbers of poor residents will be denied routine
medications for treatable conditions such as diabetes, high blood pressure, depression. They
will not receive essential tests and screenings—for mammograms, colonoscopies, sonograms,
andthelike—essentialtomaintainingreasonablehealth.Accordingly,asmanyas1,145deaths
mayoccurprematurelyandmanythousandsmorewillsufferneedlessly,triggeringsoaringand
disproportionatemedicalcostsforemergencyprocedures.
Still,thesesomberdatadon’treflectfullythetragedyofrejectingMedicaidexpansiononthe
lives,familiesandconditionsoflowincomeTarHeels.AsDr.EvanAshkinexplains:
Poor folks pay a terrible cost for not having health care coverage—it takes a
terrible human toll. When you can’t get care, your health suffers markedly.
Whenyourhealthispoor,youfrequentlybecomepoorer,youaremorelikelyto
become,ortostayunemployed,yourfamilyismoreapttosuffer,thereismore
harm to kids and to their communities. And, of course, there is more harm to
North Carolina. Right now we are paying a terrible cost as a state by not
expanding Medicaid and broadening health care coverage. It is morally
indefensible.
AstheReverendMartinLutherKing,Jr.saidinaspeechtotheMedicalCommitteeforHuman
Rightsin1966:“Ofalltheformsofinequality,injusticeinhealthcareisthemostshockingand
inhumane.”
20
Endnotes
1
PatientProtectionandAffordableCareAct,42U.S.C.§18001etseq.(2010).
NationalFederationofIndependentBusinessv.Sebelius,132S.Ct.2566(2012).
3
TheHenryJ.KaiserFamilyFound.,FederalMedicalAssistancePercentage(FMAP)forMedicaidandMultiplier,
KFF,http://kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier.
4
AnAct(1)ToClarifytheState’sIntentnottoOperateaState-Runor“Partnership”HealthBenefitExchange,(2)
ToProvideThatFutureMedicaidEligibilityDeterminationsWillBeMaebytheStateRatherThantheFederally
FacilitatedExchange,and(3)ToRejecttheAffordableCareAct’sOptionalMedicaidExpansion,Sess.Law2013-5
(2013).
5
SeeRACHELGARFIELD&ANTHONYDAMICO,THEHENRYJ.KAISERFAMILYFOUND.,THECOVERAGEGAP:UNINSUREDPOORADULTS
INSTATESTHATDONOTEXPANDMEDICAID-ANUPDATE(Jan.2016),http://files.kff.org/attachment/issue-brief-thecoverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update-2;TheHenryJ.Kaiser
FamilyFoundation,HowWilltheUninsuredinNorthCarolinaFareUndertheAffordableCareAct,KFF(Jan.6,
2014),http://kff.org/health-reform/fact-sheet/state-profiles-uninsured-under-aca-north-carolina/.
6
LEIGHTONKU,ETAL.,CTR.FORHEALTHPOLICYRESEARCH,THEGEORGEWASHINGTONSCHOOLOFPUB.HEALTH,THEECONOMICAND
EMPLOYMENTCOSTSOFNOTEXPANDINGMEDICAIDINNORTHCAROLINA:ACOUNTYLEVELANALYSIS(2014).
7
SeeBenjaminD.Sommersatal.,ChangesinUtilizationandHealthAmongLow-IncomeAdultsAfterMedicaid
ExpansionorExpandedPrivateInsurance,176JAMAINTERNALMED.1501-1509(2016);SamDickmanetal.,Opting
OutofMedicaidExpansion:TheHealthandFinancialImpacts,HEALTHAFFAIRSBLOG(Jan.30,2014),
http://healthaffairs.org/blog/2014/01/30/opting-out-of-medicaid-expansion-the-health-and-financial-impacts.
8
SeeADAMSEARING&JACKHOADLEY,GEORGETOWNUNIV.HEALTHPOLICYINST.,BEYONDTHEREDUCTIONINUNCOMPENSATED
CARE:MEDICAIDEXPANSIONISHAVINGAPOSITIVEIMPACTONSAFETYNETHOSPITALSANDCLINICS(June2016).
9
SeeMARKA.HALL&EDWINSHOAF,HEALTHLAWANDPOLICYPROGRAM,WAKEFORESTSCH.OFLAW,MEDICAIDEXPANSIONCOSTS
INNORTHCAROLINA:AFRANKDISCUSSION(January2016),http://hlp.law.wfu.edu/files/2016/01/Expansion-Issues-final2b.pdf.
10
SeeU.S.Dept.ofHealthandHumanServices,PovertyGuidelines(January25,2016),
https://aspe.hhs.gov/poverty-guidelines.
11
SeeHenryJ.KaiserFamilyFoundation,StateHealthInsuranceMarketplaceTypes,2016,KFF,
http://kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/(lastvisitedSeptember11,
2016).
12
132S.Ct.2566(2012).UndertheACA,ifstatesdeclinedtoexpandMedicaid,theywouldlosealloftheirfederal
Medicaidfunds.However,theSupremeCourtheldthatthiswas“unconstitutionallycoercive,”andstruckthat
natureoftheprovision.
13
SeeTheHenryJ.KaiserFamilyFoundation,StatusofStateActionontheMedicaidExpansionDecision,KFF,
http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-careact/(lastvisitedSeptember11,2016).Thirty-onestates,aswellastheDistrictofColumbia,havechosento
expand.
14
SeeMarkBarrett,NCmayreversecourseonMedicaidexpansion,CITIZEN-TIMES,Nov.16,2014,
http://www.citizen-times.com/story/news/local/2014/11/15/nc-may-reverse-course-medicaidexpansion/19115499/.
15
MarkBinker,SupremeCourtrulingbringsMedicaidexpansionforNCintofocus,WRAL(June25,2015),
http://www.wral.com/supreme-court-ruling-brings-medicaid-expansion-for-nc-into-focus/14737591/.
16
ReidWilson,NorthCarolinagovernorweighingMedicaidexpansion,WASHINGTONPOST(Oct.31,2014),
https://www.washingtonpost.com/blogs/govbeat/wp/2014/10/31/north-carolina-governor-weighing-medicaidexpansion/.
2
NCPOVERTYRESEARCHFUND
21
PUTTINGAFACEONMEDICAIDEXPANSIONINNORTHCAROLINA
17
AnActtoTransformandReorganizeNorthCarolina’sMedicaidandNCHealthChoicePrograms,Sess.Law2015245(2015).SeeLynnBonner,NCLegislatureApprovesMedicaidPrivatization,THENEWSANDOBSERVER(September
22,2015)http://www.newsobserver.com/news/politics-government/state-politics/article36223626.html.
18
In the first year of expansion, those in the 100-138% of FPL income group can either keep their subsidized
coverageorenrollinMedicaid.However,whentheyre-enrollthefollowingyear,theyareroutedtoMedicaidif
theirincomeisstillatorbelow138%ofFPL.
19
SeeMarkA.Hall,States’DecisionNottoExpandMedicaid,92N.C.L.REV.1459,1463(2014).SeealsoNORTH
CAROLINAJUSTICECENTER,TalkingPointsOn:ClosingtheCoverageGap,
http://www.ncjustice.org/sites/default/files/NCJC--FINALtalkingpoints-closethegap.pdf.
20
SeeHALL&SHOAF,supranote9at1.
21
SeeGARFIELD&DAMICO,supranote5at8.
22
Id.at7.
23
SeeDickmanetal.,supranote7.
24
CharlesvanderHorst,ACAGlory,MedicaidGroan,THENEWS&OBSERVER(Mar.29,2014).
25
Dickmanetal.,supranote7.
26
KU,ETAL.,supranote6at9.
27
Id.at11.
28
Id.at9.
29
Id.at11.
30
SeeHALL&SHOAF,supranote9at4.
31
KU,ETAL.,supranote6at11
32
HALL&SHOAF,supranote9at4.Additionally,thestudynotesthathealthcarepositionsarehighlyvaluedby
communities,astheypaysignificantlymorethanminimumwagejobs,withmanybeingprofessional-level
positions.
33
KU,ETAL.,supranote6at14.
34
Id.at16.
35
Id.
36
Id.
37
Id.at15.
38
Id.
39
SeeHALL&SHOAF,supranote9at6-7.
40
KU,ETAL.,supranote6at15.
41
Sommers,etal.,supranote7.
42
KentuckyimplementedtraditionalMedicaidexpansion,whileArkansasadoptedanalternativeplaninwhichthe
stateusesMedicaidfundstopurchaseprivateinsurancefornewlyeligibleadultsinthemarketplace.
43
Sommers,etal.,supranote7at1503.
44
SeeU.S.DEP’TOFHEALTHANDHUMANSERVICES,IMPACTSOFTHEAFFORDABLECAREACT’SMEDICAIDEXPANSIONONINSURANCE
COVERAGEANDACCESSTOCARE3(2016).SeealsoLARISAANTONISSEETAL.,THEHENRYJ.KAISERFAMILYFOUND.,THEEFFECTSOF
MEDICAIDEXPANSIONUNDERTHEACA:FINDINGSFROMALITERATUREREVIEW(June2016),
http://files.kff.org/attachment/Issue-brief-The-Effects-of-Medicaid-Expansion-under-the-ACA-Findings-from-aLiterature-Review.
45
Sommers,etal.,supranote7at1506.
46
U.S.DEP’TOFHEALTHANDHUMANSERVICES,supranote43at5.
47
Id.at6.
48
Id.at6.
49
KosaliSimon,etal.,TheImpactofHealthInsuranceonPreventativeCareandHealthBehaviors:Evidencefrom
the2014ACAMedicaidExpansions19(Nat’lBureauofEcon.Research,WorkingPaperNo.22265,2016).
50
U.S.DEP’TOFHEALTHANDHUMANSERVICES,supranote43at8.
22
51
Id.
Sommers,etal.,supranote7at1503.
53
Simon,etal.,supranote46at20.
54
StephenLuking,PleaseExpandMedicaid,NEWSANDRECORD(April17,2016),
http://www.greensboro.com/opinion/columns/luking-please-expand-medicaid/article_de8f7c35-5846-5e6c-a2592d3771ea14c2.html
55
SeeNedBarnett,ACaringEasternNorthCarolina’sDoctor’sOrders,NEWSANDOBSERVER(May28,2016),
http://www.newsobserver.com/opinion/opn-columns-blogs/ned-barnett/article80334447.html
56
CharlesvanderHorst,MarchingagainoverNorthCarolina’sfailuretoexpandMedicaid,THENEWSANDOBSERVER
(Feb.11,2016),http://www.newsobserver.com/opinion/op-ed/article59857311.html.
52
NCPOVERTYRESEARCHFUND
23