Focus on Philanthropy : Investing in the Affordable Care Act and Expanding Medicaid are Critical to Statewide Health

Dr. Don Berwick, a former administrator of the Centers for Medicare and Medicaid Services, often calls the 2010 Patient Protection and Affordable Care Act “majestic.” The legislation's noble intention was to expand health insurance to nearly all United States residents. There were notable and intentional exceptions including immigrants without some form of legal status. Even with its compromises and conditions, the Affordable Care Act promised to give millions of people ongoing access to health care.

Translating the majestic into the mundane is the difficult task of implementation. The Affordable Care Act used three primary pathways to expand coverage. The first restricted the ability of insurance companies to sell skimpy policies or vary prices based on preexisting conditions. Prior to 2010, no individual insurance plans sold in North Carolina included maternity care as part of a comprehensive benefit package; now all insurance plans must cover this and other essential services. The second pathway offered subsidies for purchasing private insurance policies and limited out-of-pocket expenses for families with lower and moderate incomes. The third pathway to greater access extended Medicaid eligibility to almost all residents with low incomes.

In 1947, our founder charged the Kate B. Reynolds Charitable Trust with improving health for financially disadvantaged North Carolinians. Achieving equitable health outcomes today means increasing access to affordable health insurance. To continue working toward our founder's powerful vision, we have invested more than $13 million since 2010 to help the Affordable Care Act succeed.

Early in the life of the law we partnered with national philanthropies like the Robert Wood Johnson Foundation and local funders like the Cone Health Foundation to create a state chapter of Enroll America, a nonprofit that contacted uninsured residents and delivered factual messages to the media during a time of confusion and misinformation. We worked with foundations such as The Duke Endowment, BlueCross BlueShield Foundation of North Carolina, the John Rex Endowment, the Cone Health Foundation, and the Reidsville Area Foundation to help the North Carolina Institute of Medicine convene stakeholders to analyze and negotiate how best to make the Affordable Care Act work in the state [1]. The Trust has consistently invested in enrollment assistance for populations facing unique barriers, such as immigrants and rural residents.

These collaborations have proven successful. North Carolina pioneered important innovations, including the online enrollment scheduler that was scaled nationally. Our state also avoided imposing restrictions on the ability of nonprofits to provide enrollment assistance. North Carolina regularly ranks as one of the top states for Affordable Care Act enrollment. Since 2010, the law has reduced our uninsured rate from about 20% to approximately 13% today [2].

Still, more than 1 million North Carolinians remain uninsured. Our uninsured rate is higher than the national average—primarily driven by state policymakers blocking the provision that expands Medicaid eligibility [3]. When the US Supreme Court upheld the constitutional legitimacy of the Affordable Care Act in 2012, the Justices also clarified that expanding Medicaid to all residents with low incomes is optional [4]. In the intervening years almost every state, from Indiana to Arkansas, from California to New York, has expanded Medicaid coverage. Not North Carolina. There is more to be done.

Numerous studies have shown the health benefits of expanding Medicaid, including narrowing steep racial disparities in infant mortality rates. To address glaring inequities in rural health, or opioid overdoses, or COVID-19 disparities, we must seize the opportunity to implement this one policy that would make the most dramatic impact on these issues. That is why we continue to amplify the voices of people who are unable to partake in the full promise of the Affordable Care Act.

• ©2020 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.