My home state of North Carolina enacted the Affordable Care Act (ACA) Medicaid expansion in December 2023 with strong bipartisan support. Nearly two-thirds of the state House’s Republicans and even more state Senate Republicans backed the legislation. The measure comes after years of debate on how to address North Carolina’s relatively high rate of uninsured adults and address healthcare inaccessibility, an issue that came to the forefront in the wake of the COVID-19 pandemic.
According to the latest findings from the Centers for Disease Control and Prevention, as of 2022, the uninsured rate for adults under the age of 65 in North Carolina was 17.6%, higher than the national average of 12.6%.
North Carolina was the 41st state to adopt this type of legislation, including Washington, D.C., and is the largest state since Pennsylvania in 2015 to expand Medicaid. Those earning up to 138% of the federal poverty line (i.e., singles earning about $1,730 or families of three earning about $2,970 per month) can now qualify. As of June 4, 479,153 adults aged 19 to 64 had enrolled. The expanded coverage is comprehensive and includes hospital stays, maternity care, dental and vision care and mental healthcare, among other services.
The following will focus particularly on mental health access as it is an issue our nation continues to contend with and one that I have witnessed as a lifelong resident of the Tar Heel State.
This author had the opportunity to speak with an organization, Shackle Free Community Outreach Agency, Inc., which works to address barriers to healthcare access and improve public health services rural eastern North Carolina counties. This area has historically grappled with these issues.
“Most notably, in the rural communities that we serve, there is a significant deficit of mental health professionals,” said Chiquitta W. Lesene, MS, NCRT, I/O Psy and CEO of Shackle Free Community Outreach Agency, Inc.
“Geographical barriers create unique challenges, not just with service affordability but also with access to sound care and treatment options for mental health concerns. So, our challenge is not simply that the system is overwhelmed, although it certainly is. It is more so that mental health providers are a commodity that is not regularly available to those with limited resources, such as the vulnerable individuals that we serve in rural NC. With that, as more individuals seek mental health treatment, as we hope that they will with the NC Medicaid expansion, we anticipate a greater scarcity of resources available to meet the needs of rural communities within an already overwhelmed system. We expect that this strain will likely be amplified in communities with greater need.”
Chiquitta W. Lesene
According to the National Alliance on Mental Illness, as of February 2021, 44.7% of adults in North Carolina reported symptoms of anxiety or depression, with 22.1% being unable to get needed counseling or therapy. Furthermore, 2,670,849 North Carolinians reported living in a community that does not have enough mental health professionals.
In a related issue, the opioid crisis continues to cause adverse health outcomes in North Carolina, with rural counties having seen significantly higher rates of drug overdose deaths than urban ones.
Lesene and Shackle Free are on the frontlines of mental health and addressing the opioid crisis that eastern North Carolina counties are dealing with. According to Lesene, mental health and substance misuse are often correlated and linked to broader issues such as housing instability, poverty and a lack of understanding of mental healthcare.
“In Eastern North Carolina, we have the opportunity to engage with and support a diverse array of communities,” said Lesene. “Being situated between several military installations, post-traumatic stress disorder (PTSD) is prevalent among our active duty and large veteran populations. Additionally, substance use has become an increasing concern, particularly regarding the opioid crisis in New Hanover County. Many of the individuals that we serve also experience difficulty navigating significant stressors, such as poverty and housing instability, contributing to increased rates of depression and anxious distress in our communities.”
Lesene went on to address that Duplin County, N.C., is dealing with elevated rates of teen pregnancy relative to other counties. She noted these youths experience difficulties transitioning to parenthood, further contributing to increased distress and mood disturbances. But for Lesene and Shackle Free, these concerns are just the tip of the iceberg.
“There are other significant barriers and issues that exist, such as poor mental health literacy for communities of color and stigma that reduces help-seeking behaviors, which ultimately exacerbate mental health concerns in the communities that we support,” said Lesene.
The Medicaid expansion for North Carolina adults is still in its infancy. Time will indeed tell if it will improve the overall healthcare accessibility for North Carolinians and to what extent. The number of adults enrolling continues to rise steadily. Though the ACA remains a hotly contested issue in the upcoming presidential election, no changes to the Medicaid expansion in North Carolina and other states have been announced. Lesene and Shackle Free are optimistic yet vigilant as the expansion rolls on.
“Currently, we are in the budding stages of improved access to mental health treatment in the state of North Carolina,” Lesene continued. “On paper and in policy, the expansion has improved an individual’s ability to receive care, but that does not necessarily translate to access. Although our communities might find that they meet the eligibility requirements for mental health treatment through Medicaid expansion, that only solves part of the problem.”
Lesene went on to explain that other systems and resources must be in place to allow eligible individuals to take advantage of and utilize their Medicaid benefits. Lesene believes that only then will these communities see tangible and meaningful change.
“For instance, other needs that must be addressed to improve access include digital equity to increase access to teletherapy services and crisis intervention for rural community members,” Lesene noted. “Additionally, based on qualitative data from Shackle Free’s Community Consultation Studios, there is a need for better specialty care for patients, including mental health treatments. Community members have voiced that they are seeing challenges in accessing specialty care such as neurologists, cardiologists and rheumatologists.”
According to Lesene, some residents in the communities they serve who have Medicaid reported facing numerous roadblocks in accessing specialty care, advanced diagnostic procedures and novel therapies. Lesene believes that while North Carolina is expanding Medicaid, the state must do more to ensure equitable access to all treatments that offer patients the best medical and mental healthcare possible.
“Shackle Free sees that having designated patient navigators to support this need would be helpful, especially in rural communities,” said Lesene. “Nevertheless, we are hopeful that treatment coverage under Medicaid expansion will incentivize more clinicians to provide services to the insured, considering that the reimbursement rates are comparable to those received in the self-pay private sector, to improve access to mental healthcare, as well as telehealth on a larger, more sustainable scale.”
Ten states, including Texas, Wisconsin, Tennessee, Georgia, South Carolina and Florida have yet to adopt Medicaid expansion. However, earlier this year, some lawmakers in Alabama considered covering more people through some form of a state-run health insurance program that would be a joint effort of the public and private sectors. Whether these other states ultimately choose to move forward with an expansion remains to be seen. For Lesene, she considers the Medicaid expansion in North Carolina as a starting point for getting more people health coverage and believes other states should get on board.
“Although there are still gains to be made, we absolutely endorse Medicaid expansion being adopted across the U.S.,” said Lesene. “Shackle Free firmly believes that we have to start somewhere, and that begins with lifting the red tape that excludes and limits access to care for countless Americans. Adopting Medicaid expansion in all states would ensure that more people have access to essential healthcare services, which supersedes not being eligible for services at all. We also believe that this expansion has the capacity to significantly improve health outcomes, reduce mortality rates and provide stability for low-income individuals and families. With time, we are hopeful that Medicaid expansion can alleviate the burden on emergency services and hospitals, leading to a more efficient and equitable healthcare system overall. Therefore, we unequivocally recommend that all states adopt Medicaid expansion.”
Featured image: Photo by micheile henderson on Unsplash
Edited by: Steven London & James Sutton
