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Hello, my name is Sydney Thayer and today I’ll be speaking about Medicaid expansion within North Carolina and its significance for low-income communities.

Health is determined by income. No matter how we look at it, it’s an unfortunate truth that so many of our health outcomes are reliant on the salaries we make or our monetary status. Overcoming barriers in access to healthcare has become an especially common struggle amongst low-income communities, but the Medicaid program has been established as a way to combat this and provide free health coverage to millions of underprivileged Americans.

Despite the promise this brings and the success of the program, it’s certainly far from perfect, and the existence of what many are calling the “Medicaid gap” has presented the concern that a portion of the population who qualifies as low-income still remains ineligible for Medicaid coverage. Many states have chosen to now expand Medicaid to account for these low-income adults in need of healthcare, but 14 states, including North Carolina, continue to refuse the expansion plan and leave shares of the population vulnerable and unable to afford care. Today, I’d like to delve deeper into the origins and consequences of Medicaid expansion refusal in North Carolina, and hopefully, I’ll shed light on how essential change is within the state.

Beginning in 2010, the Affordable Care Act advocated for the expansion of Medicaid to cover all individuals under age sixty-five in families with incomes below 138 percent of the Federal Poverty Level, yet it was ruled that the states themselves could choose to enact the expansion policy or not without penalty (Spencer et al., 2019). North Carolina chose the latter with the expectation that all those who qualified for Medicaid would be covered and those who were ineligible were able to afford private coverage plans on their own. What was not taken into account, however, was that the subsidies granted to purchase these private plans were not financially viable for those living below the poverty level, leaving nearly 208,000 North Carolina residents without any realistic access to health insurance and still ineligible for free healthcare (Norris, 2020). Without Medicaid expansion within the state, Medicaid isn’t truly able to support all those it was intended for, and instead, North Carolina is left facing considerably high populations of uninsured adults and poorer health among its most vulnerable members.

Within North Carolina alone, data provided by the North Carolina State Center for Health Statistics evidenced that individuals within the Medicaid gap were three times as likely to have no source of regular healthcare when compared to those covered by Medicaid or above the Federal Poverty Guidelines (Spencer et al., 2019). In order to grasp a clear picture of the Medicaid gap’s influence on health outcomes and accessibility, a study completed by Jennifer Spencer, Alex Gertner, and Pam Silberman harnessed representative survey data to characterize different income populations and their corresponding health status. Access to care was measured based on a number of different features, including whether or not citizens held a primary health care provider, how often they attended medical checkups, if they had ever chosen not to make use of healthcare or prescribed medication due to cost barriers, as well as their relative access to preventative care measures.

Following analysis of 14,675 individuals, those within the Medicaid gap reported overall lower care access in all accounts, with sixty-two percent of low-income individuals having no regular health care provider compared to only twenty-one percent of low-income individuals who were provided healthcare through Medicaid (Spencer et al., 2019). Alongside this, those in the Medicaid gap population were twice as likely to report cost barriers compared to Medicaid-covered adults, one and a half times as likely to report not using prescribed medication due to cost, and less likely to have frequent vaccinations and other medical services in use (Spencer et al., 2019). Such extreme disparities in cost barriers and the use of care between these populations cannot be attributed to simple coincidence. Instead, we are seeing the direct impact of limited access to healthcare, an obstacle that is serious for all low-income members but not distributed equally among them. Medicaid gap individuals are consistently in one of the highest risk brackets in terms of health access, and this directly translates in their health outcomes as well.

Missed opportunities in preventative health were evidenced in the fact that the Medicaid gap population was the least likely in North Carolina to receive genetic testing, cancer screening, dental care, and other medical services that are typically considered routine or even essential in many lives (Spencer et al., 2019). These preventative services are known to have incredibly cost-effective impacts on health, and yet they are still restrictive by income for many underrepresented adults. While the prevalence of chronic conditions and reports of poor health are often similar between Medicaid-covered populations and Medicaid gap populations, it’s important to recognize that Medicaid is meant to cover vulnerable groups such as those with disabilities or the elderly. We expect these individuals to have higher medical needs than those in the Medicaid gap or above FPG, and yet, the health status of Medicaid gap individuals is still equivalent, if not worse, to those eligible for Medicaid and their health needs just as severe.

Working to eliminate this gap through Medicaid expansion has the potential to increase coverage for an additional 626,000 in the state and improve health disparities in the process (Norris, 2020). Those states who have accepted expansion are currently exhibiting higher drops in uninsured rates among non-elderly adults, as evidenced by the eighteen percent drop in uninsured rates between 2013 and 2018 in expansion states compared with an eleven percent drop in states who have refused the act (Cross-Call & Broaddus, 2020). Furthermore, research has demonstrated that Medicaid expansion low-income beneficiaries are reporting higher use of prescription drugs and treatments that were not received initially, which has “led to better health outcomes, such as improvements in self-reported health, decreases in the share of low-income adults screening positive for depression, and notably, fewer premature deaths” (Cross-Call & Broaddus, 2020). Many of these impacts have the possibility to completely alter a life, if not save one, and hence expansion is a crucial step on the path towards a more equal health system within North Carolina.

The Medicaid gap population is evidence that change is due, as the current system of Medicaid in North Carolina is inadvertently placing individuals at higher risk for lower health. Expansion action among other states has so far proven to have promising outcomes for limiting the health concerns and barriers consistently faced by the gap population. By truly assessing the situation at hand and the relative health needs of those in the gap, we will undoubtedly be better equipped to address inequities in the health system of North Carolina and safeguard the health of all its citizens, no matter their income.



Cross-Call, J. & Broaddus, M. (2020, July 14). States that have expanded Medicaid are better positioned to address COVID-19 and recession. Center on Budget and Policy Priorities. Retrieved from

Cunningham, P. (2018, September 27). Why even healthy low-income people have greater health risks than higher-income people. The Commonwealth Fund. Retrieved from

Norris, L. (2020, September 14). North Carolina and the ACA’s Medicaid expansion. Healthinsurance.Org. Retrieved from

Spencer, J. C., Gertner, A. K., & Silberman, P. (2019, September 1). Health status and access to care for the North Carolina Medicaid gap population. North Carolina Medical Journal, 80(5) 269-275. Retrieved from


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