One Year Later: Lessons Learned From Medicaid Expansion

A 42-year-old man dies with untreated colon cancer.

A 54-year-old woman who never had a mammogram dies of breast cancer.

A 28-year-old suffers an anoxic brain injury after an unintentional overdose.

A 19-year-old has a new HIV diagnosis.

Suicides. Amputations. Blindness.

These are just a sample of the people I have cared for whose lives could have been much different if they had had timely and comprehensive access to health care. You know these people. Maybe they are your family members, someone who volunteers with you in the community or your neighbor.

A decade after the first state expanded Medicaid under the authorization of the Affordable Care Act in 2014, the North Carolina legislature provided bipartisan authority to expand on Dec. 1, 2023. Now, a year after the launch of Medicaid expansion in North Carolina, the learnings from my state are great and continue to offer hope for the 10 states, largely across the Southeast, that have not adopted Medicaid expansion.

Prior to expanding, North Carolina anticipated approximately 600,000 people — the majority of them young and working age, living in rural areas, and from historically marginalized populations — would benefit from expansion. At the one-year anniversary, the data clearly demonstrates that the impact has been transformative, and 609,811 people were enrolled in just one year. But were the predictions right?

In exceptional planning and with the priority of data integrity, North Carolina launched a public-facing expansion dashboard on day one. Nearly 19% of the state’s population lives in rural areas, but these residents represented 36.7% of newly covered beneficiaries. Similarly, Black people comprise 22% of the state’s population, but represented 36.5% of the expansion in year one.

The largest demographic to benefit from expansion in the first year was people aged 19-29 years. This was likely influenced by an impressive action by North Carolina Medicaid, which allowed more than 265,000 people in the limited family planning benefit to be automatically enrolled in full coverage on day one without any effort on their part.  

Who else was impacted by expansion? At least one in 10 patients in the new expansion population met the criteria for the Tailored Plans, which means they have a diagnosis of intellectual and developmental disability, severe and persistent mental illness, or severe substance use disorder, placing them at tremendous risk for poor health outcomes. In just a year, 4.15 million prescriptions were filled for expansion members, and $62.2 million in claims for much-needed dental services were covered by Medicaid for the expansion population alone. 

As someone who spent a decade advocating for Medicaid expansion and served as CMO of North Carolina Medicaid at the time of expansion, I asked some of my primary care physician peers in our state what they are seeing in their communities following expansion.

"Our care managers complete welcome calls to expansion members as they enroll. These outreaches give our care managers the opportunity to evaluate member health, social determinants of health, and safety needs and further allow us to begin referrals to providers and community organizations as needed,” said Genie Komives, M.D., CMO of WellCare of North Carolina. “For example, we identified a member with poorly controlled diabetes with complications. We connected them with a primary care physician, got them enrolled in a diabetes nutrition program, and provided financial incentives for staying current with their HgA1c and primary care visits, including obtaining an overdue cervical cancer screening.” 

This example, one of thousands, is someone who had been completely lost to care. The impact on lives is immediate, measurable and transformative the moment coverage is expanded.

In fact, pediatrician Janelle White, M.D., M.H.C.M., of North Carolina Medicaid said that 26% of new Medicaid beneficiaries who enrolled at expansion launch (and had no prior coverage in past two years) accessed primary care within three months. At five months, the number increased to 34%. The link to a medical home is a door opener, as we all know, to whole person care.

Brittany Watson, M.D., a family physician at a federally qualified health center in Winston-Salem and an associate medical director at North Carolina Medicaid, shared this recent patient experience:

“Not only does having more insured patients seeking care in the safety net provide needed financial support, but it matters so much to those patients,” she said. “I recently saw a woman in her early 60s who retired early to care for her mother and brother, who both have complex medical conditions. She had struggled to afford her own medications and care until she realized she qualified for coverage under Medicaid expansion.”

There is established data that shows that more than 60% of adults with Medicaid are in the workforce, and the majority of those who are not are ill, disabled, caregivers or students. North Carolina is working to illustrate the impact of expansion on employment rates, absenteeism and other critical factors during the first year of expansion. It is important that states that have already expanded maintain comprehensive benefits, but we also should work together to help bring along those states that have not yet benefited from expansion.

Here is my truth as a family doctor: Expansion is a salve for health care burnout. When I am in clinic at a local health department and see someone who is uninsured with a problem and will need external supports, I now feel a whole new level of hope. Have they applied for Medicaid? How can our clinic get them enrolled? Although not everyone will qualify for coverage, I no longer feel the immediate wave of despair that I used to in those moments. Medicaid expansion has given many people access to life-saving resources, and now I can save my peer-to-peer pleas for help for the patients who remain uninsured.

Are you in an expansion state? How have you seen lives changed? Please share your stories in the comments below.