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N.C. Health News: N.C.'s uninsured gap 9th highest in the nation

Updated: Nov 1, 2019

More than 1 million North Carolinians — or 10.7 percent — did not have health insurance in all of 2018, and the same number as for the year before.

By Liora Engel-Smith

For the third year in a row, the number of people without health insurance in North Carolina remained roughly the same, the annual U.S. Census Bureau report released earlier this month shows.

More than 1 million North Carolinians — or 10.7 percent — did not have health insurance in all of 2018, and the same number as for the year before. In that period, the number of people without medical coverage nationwide increased by about two million, rising from 7.9 percent in 2017 to 8.5 percent in 2018.

The census report attributed that national trend to a decline in Medicaid enrollment. North Carolina’s Medicaid enrollment, by contrast, hasn’t changed significantly in the last three years. North Carolina’s marketplace insurance enrollment declined only slightly over the last two years. The same is also true for the number of people who have health insurance coverage through their employer. 

“We’re not making much progress, [but] we’re not getting much worse,” said Adam Zolotor, who heads the North Carolina Institute of Medicine. 

Still, North Carolina’s uninsured rate is the ninth highest in the nation, according to the report, up one spot from the previous year. Also near the top of that list are other states — such as Texas and Georgia — that like the Tar Heel State have not expanded Medicaid under the Affordable Care Act. 

Medicaid expansion, Zolotor said, would make a significant dent in the state’s uninsured population, decreasing the rate of people without insurance by roughly 3 percent.

The future of Medicaid expansion in the state remains uncertain, at least in the short term.

The General Assembly and Gov. Cooper have sparred over the issue all summer, with Cooper refusing to sign a state budget that doesn’t include expansion. Earlier this month, House Republicans successfully voted to override the veto, but last week, a proposal to expand Medicaid with work requirements was revived in the House. Its future in the Senate is unclear, and even if signed into law, the bill contains several so-called “poison pill provisions” that could grind it all to a halt. 

Though the bill would extend Medicaid eligibility to almost as many adults as the ACA expansion would have, Zolotor said that it has some drawbacks. Monitoring work requirements could be expensive for the state, he said, and if implemented poorly, it could cause enrollees to lose coverage even if they meet the requirements.


If expansion proves to be politically impossible in the short-term, Zolotor said there are smaller, perhaps more palatable tweaks the state could make to close the uninsured gap, including extending postpartum coverage for Medicaid-eligible women from three months after they give birth to six months, for example. 

Other remedies for the gap, such as controlling health insurance premium prices so consumers aren’t priced out of coverage, depend on other players in the health care landscape.

Either way, he said, there’s work to be done to close the uninsured gap. 

No change a ‘small win’

When she talks about North Carolina’s uninsured gap, Willona Stallings prefers to take a slightly longer view. The director of NC Get Covered recalled how excited advocates across the state were in 2014 when people gained health insurance coverage under the Affordable Care Act for the first time.

That year, just under 380,000 North Carolinians signed up for coverage, data from the Centers for Medicare and Medicaid shows. By 2016, that number swelled to more than 600,000, declining somewhat in 2017. During that time, North Carolina’s uninsured gap shrunk by 6 percent, reaching its current levels.

Stallings thinks everyone in the state should have health insurance but said she recognizes there have been many obstacles to that goal.

“Ideally, the [uninsured] numbers would continue to go down,” she said. “But… the fact that we’re holding steady is encouraging.”

Retaining current enrollment levels on the insurance exchange across the state, she said, represents a set of concerted efforts by coalition members to reach out and sign up North Carolinians for health insurance even as the Trump administration slashed the marketing budget for marketplace publicity and outreach. 

“It’s a small win that we’re being steady,” she said. 

Pressure point on rural hospitals

But even at its current levels, the state’s coverage gap affects those who care for the uninsured, said John Holahan of the Urban Institute, a D.C.-based economic and policy think tank. 

With many of the uninsured in North Carolina living in rural areas, particularly in the mountains and southern coastal plains, the gap can worsen financial distress on the state’s rural health care facilities. Expanding Medicaid, Holahan said, could lessen that pressure. 

The impact on North Carolina could be significant. A recent analysis by UNC Chapel Hill researchers found that four rural hospitals in the state were at high risk of financial distress, with an additional nine at a “mid-high” risk. One hospital, Martin General Hospital in Williamston, announced this month it’s dropping labor and delivery services, a needed, but costly service. 

And though financial distress is not necessarily an indication that a hospital will shutter, the consequences of a hospital’s closing or curtailing its services to stay afloat can affect the health of a community as a whole.

“It’s not just a matter of the impact on people’s lives,” Holahan said. “But it’s also the institutions that care for [the uninsured].”

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