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North Carolina health insurance

Tar Heel State passes Medicaid privatization act, not expansion

Despite the fact that much of the political leadership in North Carolina has been opposed to healthcare reform and its governor recently signed an act privatizing its Medicaid program, the state has been touted as one of the most successful HHS-run exchanges, and hundreds of thousands of people gained coverage during the first two open enrollment periods. Public health and access to quality health care play a significant role in long-term health outcomes and quality of life.

Here’s a summary of North Carolina residents’ overall health, access to health insurance, and the state’s approach to healthcare reform:

North Carolina health ratings

In 2014, North Carolina tied with South Carolina for 37th place (down one spot from 36 in 2014) out of the 50 states and District of Columbia on The Commonwealth Fund’s Scorecard on State Health System Performance. Details showing how the state was rated are available in the North Carolina scorecard.

America’s Health Rankings concurred, ranking North Carolina 37th out of the 50 states in 2014. The state faces healthcare challenges that include relatively few available dentists, a high percentage of children in poverty and a high prevalence of diabetes. Lack of health insurance, public funding and disparity in health status among adults with different education levels also negatively impacted North Carolina’s rank. Its rating was helped by high immunization coverage among children, a low prevalence of binge drinking, and a low incidence of pertussis.

Trust for America’s Health also analyzed public health data in North Carolina in their 2015 edition of Key Health Data About North Carolina, which provides information on several specific diseases and health factors.

The Robert Wood Johnson Foundation’s county rating map for North Carolina lets you see how the counties in the state rank against one another based on a variety of health factor and outcome metrics.

North Carolina and the Affordable Care Act


In 2010, North Carolina’s U.S. Senators were divided on healthcare reform. Kay Hagen, a Democrat, voted yes on the ACA, while Richard Burr, a Republican, voted no. In the U.S. House, five Republican representatives from North Carolina voted no, while eight Democrats voted yes. Burr remains in the Senate, but the U.S. House now includes just three Democrats from North Carolina, and ten Republicans.

Gov. Pat McCrory took office in January 2013, becoming the first Republican governor of North Carolina since 1988. His predecessor, Gov. Bev Perdue, had stated that North Carolina would enter into a partnership exchange with HHS, but shortly after he took office, McCrory announced that the state would default to a federally facilitated marketplace.

In addition, MrCrory also decided that the state would not move forward with Medicaid expansion, citing a problematic recent audit of the state’s existing Medicaid program, and noting that the program’s issues needed to be fixed before the state considered expanding it.

McCrory is not a fan of the ACA, but early in the 2014 open enrollment period, he softened his stance a bit in a public announcement to the state’s residents. While he still noted that he was opposed to the ACA, he provided information and resources to help direct people to and enrollment assisters.

In general however, the state’s government has taken a largely hands-off role in terms of promoting and implementing the ACA in North Carolina. But a strong network of community-based public health workers, navigators, and volunteers resulted in North Carolina having the fifth-highest exchange enrollment in the country by the end of the first open enrollment period.

How did Obamacare help North Carolina Residents?

In 2013, the uninsured rate in North Carolina was 20.4 percent; the Tar Heel State was one of 14 states with more than a fifth of their population uninsured prior to Obamacare implementation in January 2014. That number fell nearly four percentage points during the first open enrollment period.

By mid-2014, the percentage of North Carolina residents without insurance was 16.7. One year later, 14.7 percent of North Carolinians were uninsured.

North Carolina’s refusal to expand Medicaid has resulted in an uninsured rate that is considerably higher than it would be if the state had accepted federal funds to make Medicaid available to all legal residents with incomes up to 138 percent of poverty. But the ACA has certainly benefitted North Carolina residents who used the exchange to enroll in Medicaid or private plans. The state was one of six states that enrolled more than half of its potential market through its exchange in 2015.

North Carolina enrollment in qualified health plans

The Kaiser Family Foundation estimated in late 2013 that 1,073,000 North Carolina residents could potentially buy qualified health plans through the exchange and that 684,000 of them would qualify for premium subsidies. By the end of the first open enrollment period, 357,584 people had purchased plans through the North Carolina exchange, with 91 percent of them receiving premium subsidies.

By the end of 2015 open enrollment, 560,357 North Carolinians had made plan selections through the federally facilitated exchange. However, some failed to make their initial premium payments or dropped coverage, and that number dropped to 459,714 by June 30, 2015. Of those remaining enrollees, 91.6 percent were in a plan with an advanced premium tax credit and 64 percent were receiving cost-sharing reductions.

For the 2016 coverage period, four carriers will offer health plans through the North Carolina exchange – there were three in 2015 and two in 2014. They are:

  • Humana
  • Blue Cross Blue Shield of North Carolina
  • Coventry Health Care of the Carolinas
  • UnitedHealthcare

North Carolina’s successful exchange enrollment numbers have been attributed to many factors, including the availability of navigators and advocacy organizations as well as public-private collaboration of various healthcare professionals and community leaders.

North Carolina Medicaid/CHIP enrollment

North Carolina is currently one of 20 states that has not yet expanded Medicaid and has no pending plans to do so. The ACA would have expanded Medicaid to cover all legal residents with incomes up to 138 percent of poverty, but in 2012 the Supreme Court ruled that states could opt out of Medicaid expansion, and Gov. McCrory has thus far refused expansion.

In 2013, McCrory said that it would be unwise for the state to expand Medicaid in light of a recent audit that uncovered fraud and waste in the state’s Medicaid system, but he left the door open for the possibility of Medicaid expansion in the future, as well as a possible switch to a state-run exchange, “if it becomes clear that the current course of action is not the best interest of North Carolina, our health care system and our citizens.”

Most experts agree that states like North Carolina will eventually expand Medicaid simply because of economics – the lure of reducing uncompensated care on a local level via funding that is almost entirely from the federal government will likely make a case that’s too strong to resist. But it could be several years before all of the states get on board.

By mid-April 2014, North Carolina’s existing Medicaid program enrolled 73,898 through the exchange, although another 318,710 could have potentially enrolled if the state had expanded coverage. In 2015, there were 47,920 individuals who enrolled in Medicaid through the state’s exchange. Between 2015 and August 2015, the state’s average monthly Medicaid enrollment grew 20 percent.

Still, because the state refused to expand Medicaid, North Carolina has 244,000 people in the coverage gap, with no access to Medicaid or exchange subsidies. These residents would be eligible for Medicaid if the state were to accept federal funds to expand coverage. But there are no realistic insurance options available for people with incomes below the poverty level who do not qualify for Medicaid under the state’s existing eligibility guidelines: Non-disabled adults without dependent children cannot enroll no matter how low their income is, and parents with dependent children are only eligible if their household income doesn’t exceed 45 percent of poverty (a little over $742/month for a family of three).

Does North Carolina have a high-risk pool?

Before the ACA dramatically reformed the individual health insurance market, coverage was underwritten in nearly every state, including North Carolina. This meant that pre-existing conditions could prevent an applicant from getting coverage, or could result in significantly higher premiums or policy exclusions. The North Carolina Health Insurance Risk Pool was created in 2009 to give people an alternative if they were unable to obtain individual health insurance because of their medical history.

When ACA implementation resulted in a guaranteed issue individual market in January 2014, risk pools were no longer necessary. The North Carolina Health Insurance Risk Pool ceased operations at the end of 2013, and members were able to transition to new, ACA-compliant plans issued on or off-exchange.

Medicare enrollment in the state of North Carolina

North Carolina Medicare enrollment reached 1.7 million individuals in 2015 – about 17 percent of the state’s population. About 17 percent of the nation’s population is enrolled in the program. Of North Carolina’s beneficiaries, 78 percent qualify based on age alone.

Medicare pays about $9,741 annually per North Carolina enrollee. The state ranks 10th in terms of overall Medicare spending with $14.1 billion per year.

North Carolina residents can enroll in Medicare Advantage plans instead of Original Medicare if they want additional benefits. About 30 percent opted to do so in 2015; nationwide, 32 percent selected a Medicare Advantage plan.

Medicare recipients can also select a Medicare Part D for a stand-alone prescription drug plan. About 45 percent of North Carolina Medicare beneficiaries chose Medicare Part D plans, slightly higher than the national enrollment of 43 percent.

State-based health reform legislation

North Carolina passed a law in 2013 prohibiting the state from establishing a state-run or partnership exchange, and also rejecting Medicaid expansion under the ACA. The state legislature has also had a variety of other health and healthcare reform bills in the 2015 session. Here’s a summary: