[Editor’s note: A new and powerful report  authored by policy analyst Brendan Riley of the North Carolina Justice Center’s Health Advocacy Project shines a bright light onto the hundreds of thousands of North Carolinians who are suffering as the result of the General Assembly’s ongoing refusal to close the state’s Medicaid gap. In “Profiling North Carolina’s Uninsured: How Expanding Medicaid Can Make a Difference,”  Riley details precisely who it is that’s currently covered by Medicaid and who isn’t (including loads of demographic details), why people are uninsured, and who would benefit from expansion. The report is a “must read” for anyone who seeks to understand this complex and vitally important topic. The following ins from the opening section of the report.]
With one of the largest uninsured populations in the country, North Carolina is home to far too many people who lack the regular health care access and financial security that comprehensive health care coverage provides. In an economic landscape in which employers consider health outcomes in their location and expansion decisions, North Carolina’s 10.7 percent uninsured rate—the 10th highest in the nation—makes us less competitive. Moreover, it limits the ability of our residents to thrive. After all, having health insurance improves the health and economic security of individuals and communities. When people have coverage, they are more likely to have a source of regular health care, get the quality care they need, and report better health outcomes. When uninsured people gain coverage, they are less likely to face high out-of-pocket costs and less likely to incur medical debt, giving them a better shot at prospering in today’s economy.
In this report, we use the Census Bureau’s American Community Survey data to provide an updated profile of the uninsured in North Carolina. The uninsured include men and women of all ages and backgrounds in all parts of the state. Many of these individuals work in critical industries like construction and food service, and for small businesses that don’t offer health coverage to their employees. Hundreds of thousands of these uninsured North Carolinians are stuck in a coverage gap because they don’t qualify for Medicaid under North Carolina’s current eligibility rules, but they earn too little to qualify for subsidies to afford their own private plan.
By adopting Medicaid expansion, North Carolina can vastly reduce the uninsured population, thereby putting more money into the pockets of North Carolina households and improving health outcomes in our communities.
Who’s Currently Eligible for Medicaid in North Carolina (and Who’s Left Out?)
To qualify for Medicaid today, a North Carolinian must both earn a limited income and fall into one of several narrow eligibility groups (shown in Figure 1 below). Because North Carolina Medicaid uses this restrictive eligibility, only some non-elderly adults with limited means can qualify.
Whereas Medicaid covers roughly two in five North Carolina children, Medicaid is only available to adults in our state who are elderly, blind, pregnant, living with a Social Security-certified disability, or living with dependent children.
While Medicaid does provide time-limited coverage to pregnant women, the scope of coverage is limited to treatment for conditions that affect the pregnancy.” That means that pregnant women may not be able to get coverage for all necessary care unrelated to the pregnancy through Medicaid for Pregnant Women. Moreover, a better way to invest in maternal and child health is to ensure that women of reproductive age can access health care before they become pregnant—currently, 15.9 percent of adult women of reproductive age are uninsured in our state—and that mothers stay covered after delivery, as Medicaid for Pregnant Women only lasts until 60 days post-partum.
Thus, for nonelderly adults to qualify for full Medicaid in North Carolina, they must either have a qualifying disability or dependent children in the house. Even then, the income eligibility threshold for parents—$8,004/year for a family of three, which is less than half of the poverty line—is so low that many uninsured parents in poverty cannot qualify.
For all other adults, Medicaid coverage is unavailable regardless of how low their incomes are. As a result, hundreds of thousands of North Carolinians living in and near poverty cannot qualify for health coverage through Medicaid and instead go uninsured.
As of January 2019, Medicaid covered 294,878 enrollees based on a qualifying disability. However, not all non-elderly North Carolinians who have a disability and limited incomes can qualify for Medicaid, and there is a significant population of uninsured North Carolinians living with disabilities.
There are several reasons why some people with disabilities near poverty may be uninsured and uncovered by Medicaid in our state: (1) not all people with disabilities or chronic illnesses meet the strict Supplemental Security Income disability standard used by Medicaid; (2) the income eligibility threshold for this category is set at 100 percent of the Federal Poverty Level (FPL); and (3) Medicaid requires otherwise eligible people with disabilities to meet an asset test, so a modest life insurance policy or savings account can disqualify them.
After Michigan expanded Medicaid, it found that 23 and 20 percent of expansion enrollees had functional impairments related to a physical disability or a mental disability, respectively.
Click here  to read more about precisely who would benefit from Medicaid expansion and the rest of this report.