How is NC’s historic health care expansion going so far? A Q&A with Secretary Kinsley

Medicaid expansion launched on Dec. 1, opening the doors for hundreds of thousands of North Carolinians to gain health care coverage.

The News & Observer sat down with state Department of Health and Human Services Secretary Kody Kinsley to hear how the historic health care expansion is going and his priorities going into next year.

“Out of the gate, (we’re) feeling really good about the number of folks enrolled,” said Kinsley, who said as of Dec. 12, there were 280,000 Medicaid expansion enrollees. Of those, 273,000 were people who had been enrolled in a limited-benefit family-planning Medicaid program and were moved into full coverage automatically on Dec. 1.

Another 56,000 people have also applied, and about 8,000 of those applicants have already been approved, he said.

DHHS is a cabinet agency under Democratic Gov. Roy Cooper. After years of GOP resistance, the Medicaid expansion bill passed into law with bipartisan support in the Republican-controlled General Assembly and was signed by Cooper.

This interview has been shortened and edited for clarity.

Q: A big portion of new enrollees are those who came from the family-planning benefits. Now, some of the cases you’re getting are newly eligible or people who hadn’t had Medicaid before. So how are those cases progressing?

A: In the first 12 days we’ve had 56,000 applications for Medicaid. Some of those people will be normal Medicaid eligible; they’ll be eligible under the historic limit. Some of those people ... we know 8,000 of them were eligible for expansion.

We’ll have to finish their applications before we will be able to tell you how many of them were approved, how many were denied, and exactly which bucket they fell in. So we’re going to — much like with our redetermination process — it will take us two or three months to have a rolling average of kind of, what is the normal number that comes out of each period.

But in the first 12 days, early indicators are that people are kind of coming forward full speed ahead.

Note: After an application is submitted, county social services offices need to determine applicants’ eligibility. According to a 2022 report by the Fiscal Research Division, which provides analysis services for the General Assembly, the annual statewide percentage of Medicaid applications processed in a timely manner was 94%. The statewide monthly average number of days to process all Medicaid applications ranged from 27 to 35 days, with an annual average of 30 days, according to the report.

Q: Can you share what DHHS will be doing next year and beyond to make sure people are aware of expansion?

A: We are doing a bunch of things: One, we will continue all of our engagement efforts with civic leaders, faith-based organizations, holding webinars, going into communities.

I’ll be spending a lot of time at social service offices, federally qualified health centers and other organizations to bring more local awareness to this opportunity.

We’ll also be starting a paid media campaign in the new year to remind folks that Medicaid now covers ... more people, which allows more access to providers, more prescriptions, and that’ll be rolling out throughout the year.

And then we built a strategy around a number of things that will happen throughout the year on how to touch people digitally, in print, on billboards, and a number of different ways to reach folks because 80% of the folks that will benefit from expansion are in working families.

Q: What are some things that are being done to reach people in rural areas?

A: 273,000 of those who were able to auto enroll are disproportionately in rural communities. That’s great, because we just got a lot of people who ... got a letter in the mail in those communities saying you’re eligible and here’s what you need to know. They then of themselves are powerful ambassadors to the program and letting folks in their community know about this.

Our communications campaign, the media campaign that we’re crafting will highly focus on rural communities, we’ll be working with multi-language outlets, we’ll be sponsoring local radio ads.

And then we’ll be out in the state and on the ground. We already have a broad base of connections with civic organizations throughout the state and we’re gonna continue to work with them.

Q: In conversations you’ve had so far with North Carolinians, are they aware of expansion? What are you hearing?

A: So I think there are a couple things happening. One is that (since) we have not had Medicaid expansion for a very long time in our state, people have learned to live without health insurance in a very kind of demoralizing way. They’ve tried to figure it out, they’ve tried to apply, and nothing’s worked.

So really, so much of our communications are built around busting those myths, that it’s different now. It’s different. If you’re a single individual and make $20,000, you’re probably you’re going to qualify. And that surprises a lot of people when we tell them.

I think the other thing is using this moment to remind people that look, you may make $22,000, you may not qualify, but because you kind of opted out so long ago and because the subsidies on the marketplace plan are higher than in previous years, than you may actually get more subsidies now than you ever thought you could. And so health insurance may be within reach through the marketplace, through going to healthcare.gov.

Q: The Medicaid expansion bill passed into law increased eligibility but it also had various other provisions. Of these, is there one to highlight?

A: I think a big part of what brought a lot of folks to the table around Medicaid expansion was finally the recognition that we are not going to really tackle mental health issues in our communities in North Carolina without Medicaid expansion.

And as part of that conversation, the governor put forward a billion-dollar investment road map for behavioral health, and I’m grateful that the General Assembly used that signing bonus to fund about $835 million for behavioral health.

Note: To encourage states that had not expanded Medicaid to get on board, the federal government allotted a $1.6 billion or so “signing bonus” to new states.

We raised, just a few weeks ago, the rates that we pay our Medicaid providers for behavioral health for the first time in a decade. Some rates were increased 90%, massive increases relative to what’s done with rates.

Because our goal for Medicaid expansion is to get people covered, but then to get them care. And the way that the health system works is that you’ve got to have a provider available to serve you. That means you have to have a provider that is reimbursed sufficiently to run their business.

Just to make it real, on any given day 350 people are sitting in emergency departments in North Carolina waiting for inpatient psychiatric care. At the same time, we have about 120 empty psychiatric beds. Empty beds, people waiting. Why? Often, because the amount of money that Medicaid or frankly, private insurance will pay for that care is insufficient. And so the rate for inpatient psychiatric care in North Carolina used to average less than $500 a day; we’ve increased it to $900 a day.

Because we want more of the operators of these beds, these providers, to be resourced to hire enough staff, to be able to have the expertise and the stability to provide the really critical life-saving complex care.

Q: The legislative short session is upcoming. Is there anything that you’re hoping to achieve this April?

A: Our child care system is at the brink. We had over $800 million from the federal government invested in it during COVID, to try to prop it up. That money is running out.

Note: These funds were provided through grants, which increased compensation to staff and were aimed at keeping child care costs down.

We’ve all seen stories of child care facilities, especially in the western part of the state right now, closing. We’ve got to do things to shore that up, to stabilize the system. We also need to think about how to really reinvent it and reinvest in it for the future.

There are still improvements to our laws that kind of govern how mental health is managed in our state, or that are called 122C, and they were last codified when I was born. I think it’s time to do a bit of a deeper dive into it, especially thinking about the justice-involved population and giving judges more tools to help support getting individuals connected to treatment.

Also, part of the funding we were given in the budget was to invest in a pilot for how individuals that are involuntarily committed (for psychiatric admission) are transported. Right now in North Carolina, most of the time, people are transported in police cars.

So they’re going to be handcuffed, put in the backseat; there’s a whole lot of other inefficiencies that happen, the law enforcement is too busy, they don’t have time, maybe you lose the bed. And its not trauma informed; that doesn’t support a pathway to healing.

Note: The budget provided more than $20 million over two years to fund a non-law enforcement pilot program for transporting patients for voluntary and involuntary psychiatric admissions..

I think we should look at that again. I think that this is a health care issue, not a law enforcement issue. I think that we need to support our law enforcement with more resources around working with folks with mental illness.