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If lawmakers expanded Medicaid, 634,000 people—59% of the state’s uninsured population—would gain health care coverage by 2022.

Nearly 13% of North Carolinians lacked health insurance in 2018, well above the national average, according to a new national report from the Kaiser Family Foundation. In other words, about 1.08 million nonelderly people were uninsured in North Carolina, a minor increase over 2017, and well above the 10.4% national rate. 

A key driver of the state’s uninsured rate, according to North Carolina Justice Center policy advocate Hyun Namkoong, is North Carolina’s failure to expand Medicaid under the Affordable Care Act.

“If our General Assembly was to finally prioritize health care and the lives of people over hyper-partisan politics, then Medicaid expansion would more than halve our uninsured population as a state,” Namkoong told COURIER in a phone interview. “But unfortunately, year after year our state legislature continues to reject the federal government funding 90% of Medicaid expansion.”

According to the Kaiser report, 46.9% of North Carolinians have employee-sponsored health insurance, 14.8% have Medicare, and 14.9% get coverage through Medicaid or the Children’s Health Insurance Program (CHIP). Nationally, the rate of coverage through Medicaid and CHIP is higher and sits at 17%, thanks to the 37 states that have expanded Medicaid.

If North Carolina were to finally expand Medicaid, 634,000 people—59% of the state’s uninsured population—would gain healthcare coverage by 2022, reports a 2019 study from the Kate B. Reynolds Charitable Trust and the Cone Health Foundation.

Democrats in the state have pushed for expansion, and current Democratic Gov. Roy Cooper tried to do so on his own after taking office in 2017, only to have his effort blocked by the courts. Cooper has continued to advocate for expansion and in June 2019, vetoed the state budget proposed by the Republican-controlled legislature, partially over their refusal to expand Medicaid. 

State Senate Majority Leader Phil Berger (R-Rockingham) has repeatedly refused to expand the public insurance program, expressing concern that the federal government may one day stop covering 90% of the administrative costs associated with Medicaid expansion. Rockingham and his peers in the state House have even refused to take up a Republican proposal from Rep. Donny Lambeth (R-Forsyth) that would expand Medicaid but require a work requirement.

As a result, North Carolinians are about twice as likely to be uninsured as residents in nearby Kentucky or West Virginia, which expanded Medicaid, the Cone Health Foundation’s report found.

North Carolina’s failure to expand Medicaid has disproportionately harmed rural residents, who are more likely to be uninsured than their urban counterparts. A 2018 study found that while rural areas contain 54% of the counties in North Carolina, these areas account for 20 of the 22 counties with the highest percentage of residents without health insurance.

“The job markets in those rural communities just aren’t very robust,” Namkoong said. “That problem is even more exacerbated when our state has failed to expand Medicaid, and we see rural hospitals being more likely to close in states that haven’t expanded Medicaid.”

Of the 76 rural hospitals that closed across the nation in from 2014 to May 2019, 83% were in states that did not expand Medicaid, while only 17% were in the more numerous states that expanded Medicaid, according to data from the Sheps Center at the University of North Carolina.

During that period of time, six rural hospitals in North Carolina shut down. These hospital closures make it even more difficult for rural residents to get insurance, Namkoong says. 

“What employer wants to invest in a community that doesn’t have a hospital?” she said. “You’re seeing rural areas being affected even more because they’re unable to attract employers that can provide good-paying jobs and benefits like health insurance.”

Gov. Cooper highlighted the impact Medicaid expansion would have on rural communities during a January meeting with eastern North Carolina leaders. “Closing the healthcare coverage gap and providing health insurance for working people who can’t afford it would strengthen our rural communities and hospitals by improving access to care and boosting local economies,” Cooper said. “Saying yes to expansion should be one of the easiest decisions a policymaker can make, and it’s time to stand up for our rural communities.”

Dr. Mandy Cohen, secretary of the North Carolina Department of Health and Human Services, agrees that Medicaid expansion is critical. “The single best thing we can do in North Carolina to decrease our uninsured rate and improve health is expand Medicaid,” Cohen told COURIER in an emailed statement.