Abstract
COVID-19 has fundamentally changed how society delivers health care, provides services, and cares for and educates our children. Entrenched problems that seem insurmountable are laid bare for all to see as we weather the pandemic. We cannot afford to tinker around the edges anymore. We must be creative, innovative, and bold to address systemic issues that impact our most under-resourced communities.
Introduction
By the numbers, where I grew up—rural Robeson County—is one of the most impoverished areas of our state, but I would never describe my community that way. I was surrounded by family, teachers, preachers, and neighbors who gave their time and talent to our small town of Lumberton and to me. Rural residents care deeply about their communities and the people who live there. I went on to become a pediatrician, state health director, and foundation president. A strong, vibrant rural community helped me become who I am today. But in my community and so many others in our state, systemic racism and lack of access to opportunity and health care are preventing our outstanding rural residents from reaching their economic potential and living long, healthy lives.
Four million people—more than 40% of our state’s population—live in rural North Carolina. These communities have poured decades of resources into our state through manufacturing, agriculture, natural resources, and sheer talent. And yet, our state has disinvested in these communities and not returned what has been extracted from them.
Through the Kate B. Reynolds Charitable Trust’s long-term work in rural communities, known as Healthy Places NC, we see a similar story: robust communities, strong leaders, and beautiful counties full of resources and people who want to see North Carolina thrive. But these communities often lack resources found in abundance in urban areas: high-paying jobs, grocery stores, adequate hospitals, and health care providers. And if these resources do exist, community members often don’t have the access needed to use them.
Because of long-term disinvestment in rural North Carolina and policies that favor urban areas, we see unacceptable disparities: rural county residents die from the top five causes of death more frequently than urban county residents [1]; the life expectancy in urban Orange County is 81 years, compared to 73 in rural Swain County [2]; between 2000 and 2018, private employment grew 30% in large urban North Carolina counties, but fell 6% in rural counties [3].
On top of these disparities, even as some rural communities are still reeling from natural disasters, rural North Carolina is now being disproportionately impacted by COVID-19.
Recent reports show that in North Carolina’s rural counties, people are dying from COVID-19 at higher rates than in the state’s urban and suburban counties [4]. And for rural residents of color, the situation is worse. According to the Centers for Disease Control and Prevention, people of color are disproportionately impacted by COVID-19 [5]. They’re more likely to be hospitalized or die from the disease. Compared to whites, Latinos are almost three times as likely to be uninsured, and African Americans are twice as likely to lack insurance [5].
In April, North Carolina’s Secretary of the Department of Health and Human Services Dr. Mandy Cohen said the primary reason for COVID-19 disparities by race was “structural racism” [6].
We can change this. Structural racism and inequities are manmade and can be undone. These disparities are being exacerbated by COVID-19, but they existed long before the pandemic.
At the Trust, we believe the way to ensure thriving communities and residents, equitable access to health care, and equitable health outcomes is to change the systems that have intentionally held rural areas, communities of color, and residents with low incomes back for far too long.
We were on this journey before COVID-19, and today we find ourselves at a critical juncture. The Trust has invested $5.2 million in immediate flexible funding to respond to the crisis, but it is only a fraction of what is needed to address long-term challenges facing North Carolina.
The pandemic has fundamentally changed how our society delivers health care, provides services, and cares for and educates our children. Entrenched problems that seem insurmountable are laid bare for all to see as we weather the pandemic. We cannot afford to tinker around the edges anymore. We must be creative, innovative, and bold to address systemic issues that impact our most under-resourced communities.
At the Trust, we believe there are key policies and approaches that can improve health, education, and economic opportunities in rural areas and make our state stronger than it was prior to COVID-19.
Working together, we can expand Medicaid so all North Carolinians have equitable access to health care, build the capacity of rural grassroots organizations, invest in leaders of color, and advocate for policy change to provide equitable opportunities for all.
Closing Insurance Coverage Gaps to Ensure all North Carolinians Can Access Health Care
In 1947, our founder charged the Trust with improving health for financially disadvantaged North Carolinians. Acting on her vision today means increasing access to affordable health insurance. That’s why we have invested more than $13 million since 2010 to increase enrollment in Affordable Care Act health insurance options and to advocate for Medicaid expansion. But there is much work to be done.
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 [7]. North Carolina is now one of only 12 states that has not expanded Medicaid [8].
Numerous studies have shown the health benefits of expanding Medicaid, including narrowing steep racial disparities in infant mortality rates [9]. To address glaring inequities in rural health, opioid overdoses, or COVID-19 disparities, we must collectively seize the opportunity to implement the one policy that would make the most dramatic impact on these issues.
States that have expanded Medicaid decrease the likelihood of a rural hospital closing by 62% because expansion improves hospitals’ bottom line by reducing the amount of uncompensated care [10]. According to a report released in 2020, almost 1 out of every 4 open rural hospitals is at risk of closing [10].
Since 2010, six rural hospitals have closed in North Carolina, and COVID-19 has weakened rural hospitals already in financial distress [11]. By expanding Medicaid, our state can help to ensure that rural residents can afford to go to the doctor and that a hospital or provider exists to care for them.
In September, a Care4Carolina poll found 75% of residents favored expanding Medicaid [12]. Before the pandemic, it was estimated that between 400,000 and 500,000 uninsured residents would be eligible for health insurance if Medicaid were expanded. Care4Carolina now estimates that an additional 178,000 North Carolinians would qualify due to job losses resulting from COVID-19 [12]. The time to expand Medicaid is now.
Building the Capacity of Rural Leaders and Grassroots Organizations
The Trust launched Healthy Places NC in 2012 to improve health in 10 vibrant yet under-resourced rural counties, investing $68 million in the effort to date. The Trust approach centers around a core value of listening to people on the ground who are most impacted by poor health outcomes. After all, they are the experts on what their communities need to thrive.
Where we have invested deeply in community leadership and networks—in places like Beaufort, McDowell, and Halifax counties—communities were better prepared to respond to the COVID-19 crisis.
When the need for food surged in Beaufort County after COVID-19 hit, the Beaufort County Healthy Eating Active Living (HEAL) Collaborative was well positioned to act quickly because they had spent the past eight years working together in new and different ways to increase access to healthy food in their community. They immediately began pooling grant funds from different sources to purchase produce boxes from local farmers to give to residents in need. They provided gas stipends to volunteers delivering food, and they translated information into Spanish to ensure it reached residents who have been marginalized.
Our investments in grassroots groups go beyond funding. As we listened to and learned from community leaders, we asked what they needed to move their work forward. Leadership training from the Center for Creative Leadership; coaching, convening, and other support from our capacity-building partners at Rural Forward NC; introductions to other funders; and media recognition and communications assistance are additional ways we help amplify community leaders’ impact.
While funding is important, it’s not enough to simply make grants in rural areas. We must build the capacity of the people and organizations that are proximate to the problems we are trying to solve and offer them tools to lead the way forward.
Investing in Efforts Led by People of Color
By intentionally investing in the leadership of residents of color, we can begin to address the inequities by race and place in rural North Carolina and throughout the state.
In recent years, the Trust noticed that African American, Native American, and Latinx residents were often not at the table as institutions and nonprofits worked to develop solutions. We became very intentional about identifying rural leaders of color, listening to their experiences, and investing in their capacity to build movements for change in their counties.
In 2016 in McDowell County, the West Marion Community Forum came to life in a small rural church. West Marion residents said their predominantly African American community was isolated from the rest of the county. They were often the last neighborhood to receive snow removal service, and they lacked essential supports like transportation and child care.
West Marion is now one of the first areas to be plowed when it snows, but perhaps even more telling is that the community forum’s model of bridging divides, rallying neighbors, and connecting with county government and leadership has been replicated throughout under-resourced communities in McDowell County. The successes of this grassroots movement are many: extended child care hours at local schools, the passage of a minimum housing standard to protect renters, establishing a local transportation system, and engaging youth in countywide efforts to improve health.
Advocating for Policies That Promote Economic, Education, and Health Equity
There are a myriad of policies and systems we can shift to bolster rural North Carolina. Other experts and communities must weigh in on needed policy change, but as a pediatrician and former public health official, I recommend three specific policies that will advance our state and provide increased opportunities to rural communities.
First, Expand Medicaid. Period.
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Second, Invest in our Youngest Residents
We must commit to our youngest students and change the trajectory for our next generation of leaders by providing universal access to high-quality pre-kindergarten. A study of children who were enrolled in the state-funded NC Pre-K Program showed higher achievement and standardized test scores in both reading and math for students through fifth grade, fewer children requiring special education placement, and fewer retention issues in grades 3, 4, and 5 [13].
While some rural counties are serving most eligible children through the state’s NC Pre-K Program, other rural counties only serve 11%-20% of eligible children [14]. We must provide access for all 4-year-old children. Research shows that every $1 invested in Pre-K provides approximately $7 in economic gains [15].
Third, Invest in our Public Health Infrastructure
North Carolina’s 85 public health departments are on the front line of the pandemic, but they are woefully under resourced. North Carolina ranks 40th in the nation for spending on public health [16]. In the mid-2010s, North Carolina was one of a handful of states where public health spending shrank [16].
For many rural residents, especially those who lack health insurance or documentation, a public health department is their best chance to get a COVID-19 test or to see a medical professional if they are sick.
Public health departments are working overtime to test residents, release critical information, conduct contact tracing, and spend time in the community to help leaders and institutions prepare and respond. They will be instrumental in vaccine distribution. Without adequate funding, North Carolina’s public health infrastructure does not have the tools necessary to battle COVID-19, putting our state’s most vulnerable residents at higher risk during a health crisis.
Collaborative, Concerted Action is the Way Forward
Working together, funders, government, businesses, and residents can chart a new course for rural North Carolina and the entire state. And we must start immediately.
Will it take a significant investment of time and resources to include all voices in the solutions? Absolutely. But experience shows us we can tackle difficult problems together. COVID-19 has taught us the stakes of inaction and disinvestment are equally high.
By investing in bold ways, North Carolina has an opportunity to build a future where we are stronger than we were before, with an equitable system that supports all residents and reinvests in the rural counties that make up the fabric of who we are today and who we are becoming. Together we can build an equitable future for our families, our neighbors, and our children.
Acknowledgments
Potential conflicts of interest. The author reports no conflicts of interest.
- ©2021 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
In this issue
Jump to section
- Article
- Abstract
- Introduction
- Closing Insurance Coverage Gaps to Ensure all North Carolinians Can Access Health Care
- Building the Capacity of Rural Leaders and Grassroots Organizations
- Investing in Efforts Led by People of Color
- Advocating for Policies That Promote Economic, Education, and Health Equity
- Collaborative, Concerted Action is the Way Forward
- Acknowledgments
- References
- Info & Metrics
- References