The Uninsured Work Group identified the following priorities for action planning. Work group members engaged in discussions and review of best practices related to Medicaid eligibility criteria, financial support for community health workers, health clinic sustainability, and opportunities to leverage savings from Medicaid transformation.

• Determine the need for expanding and sustaining financial support for Community Health Workers
• Determine the need for sustaining health clinics for the uninsured
• Expand Medicaid, including expanding recipient eligibility criteria
• Repurpose savings and surpluses created by Medicaid transformation and expansion and leverage the community benefit programs of health systems to fund programs for the uninsured

The Uninsured Work Group's priority recommendations are included below.

Priority: Expand Medicaid, including expanding recipient eligibility criteria

• Strategies and Action Plans
  • Develop an awareness campaign on the characteristics of the uninsured population in North Carolina, including the numbers of uninsured remaining after Medicaid expansion, their demographic information and employment status.
  • Develop strategies for addressing the large numbers of current Medicaid recipients who will lose coverage through Medicaid redetermination efforts commencing in May 2023 due to termination of continuation of coverage provisions in federal law.
  • Increase awareness of the impact of current healthcare workforce shortages on the limitations of health insurance as a solution for the uninsured (i.e., having insurance doesn’t guarantee access).

Priority: Determine the need for expanding and sustaining financial support for Community Health Workers

• Strategies and Action Plans
  • Develop emergency strategies and action plans for addressing the cessation on December 31, 2022 of federal and state funding for community health workers (“CHW”) resulting in immediate lay-offs for hundreds.
  • Explore with NCDHHS and NC General Assembly other funding models for expanding and sustaining the CHW workforce.
  • Develop a common definition of a community health worker.  The definition used by the American Public Health Association is recommended by the work group.

Priority: Determine the need for sustaining health clinics for the uninsured

• Strategies and Action Plans
  • Focus on sustaining the human and operational capacity of existing free and charitable clinics, community health centers, donated care networks and other safety net providers as a first priority.
  • Develop strategies and action plans to expand services to the uninsured through existing free and charitable clinics, community health centers, donated care networks and other safety-net providers in counties without the infrastructure to support and sustain new clinics.

Priority: Repurpose savings and surpluses created by Medicaid transformation and expansion and leverage the community benefit programs of health systems to fund programs for the uninsured

• Strategies and Action Plans
  • Develop strategies and action plans to utilize the $1.8 billion in recurring revenues projected for the state due to Medicaid expansion and the community benefit programs of health systems for the benefit of the uninsured.

Developmental Policies for Additional Consideration

• Designate “ownership” of the uninsured problem in North Carolina. Responsibility for the uninsured is fragmented in our state and not focused on a single agency. Appoint a safety-net provider collaboration, a public-private coalition or a state agency to own and address issues affecting care for the state’s uninsured population, including improving data collection about the uninsured and addressing social drivers of health services for the uninsured.

April 17, 2023, 10:00 to 11:45 AM, Work Group Meeting

Co-Leaders: Chris Shank, Randy Jordan, and Mark Snuggs

Attendees: Elizabeth Byrum, April Cook, Brandy Bynum Dawson, Abby Carter Emanuelson, Honey Yang Estrada, Kathy Hodges, Richard Hudspeth, Alice Salthouse, Kristen Spaduzzi, Sally Wilson

Discussion:

• Reviewed and discussed comments related to the prioritized policies, strategies, and action plans.
  • Policy: Expand Medicaid, including expanding recipient eligibility criteria
    • Strategies and Action Plans:
      • Develop an awareness campaign on the characteristics of the uninsured population in North Carolina, including the numbers of uninsured remaining after Medicaid expansion, their demographic information and employment status.
      • Develop strategies for addressing the large numbers of current Medicaid recipients who will lose coverage through Medicaid redetermination efforts commencing in May 2023 due to termination of continuation of coverage provisions in federal law.
      • Increase awareness of the impact of current healthcare workforce shortages on the limitations of health insurance as a solution for the uninsured (i.e., having insurance does not guarantee access).
  • Policy: Determine the need for expanding and sustaining financial support for Community Health Workers
    • Strategies and Action Plans:
      • Develop emergency strategies and action plans for addressing the cessation on December 31, 2022 of federal and state funding for community health workers (“CHW”) resulting in immediate lay-offs for hundreds.
      • Explore with NCDHHS and NC General Assembly other funding models for expanding and sustaining the CHW workforce.
      • Develop a common definition of a community health worker.  The definition used by the American Public Health Association is recommended by the work group.
  • Policy: Determine the need for sustaining health clinics for the uninsured
    • Strategies and Action Plans:
      • Focus on sustaining the human and operational capacity of existing free and charitable clinics, community health centers, donated care networks and other safety net providers as a first priority.
      • Develop strategies and action plans to expand services to the uninsured through existing free and charitable clinics, community health centers, donated care networks and other safety-net providers in counties without the infrastructure to support and sustain new clinics.
• Decided the following policy should be moved from a developmental policy for additional consideration to a prioritized policy.
  • Policy: Repurpose savings and surpluses created by Medicaid transformation and expansion and leverage the community benefit programs of health systems to fund programs for the uninsured
    • Strategies and Action Plans:
      • Develop strategies and action plans to utilize the $1.8 billion in recurring revenues projected for the state due to Medicaid expansion and the community benefit programs of health systems for the benefit of the uninsured.
• Reviewed the following developmental policy for additional consideration.
  • Designate “ownership” of the uninsured problem in North Carolina. Responsibility for the uninsured is fragmented in our state and not focused on a single agency. Appoint a safety-net provider collaboration, a public-private coalition or a state agency to own and address issues affecting care for the state’s uninsured population, including improving data collection about the uninsured and addressing social drivers of health services for the uninsured.

January 23, 2023, 10:00 to 11:45 am, Work Group Meeting

Co-Leads: Chris Shank, Mark Snuggs, and Randy Jordan

Attendees: Abby Emanuelson, Alice Salthouse, April Cook, Ashley Rink, Brandy Bynum Dawson, Honey Estrada, Kristen Spaduzzi, Patrick Brown, Sally Wilson

Presenters: Kathy Dail

Discussion:

• Kathy Dail acknowledged the work group had done exactly what they needed to do within the scope of work of Healthy North Carolina 2030 with the proposed policies. As the work group wraps up this year’s work, the work group is empowered to make decisions to pursue the prioritized policies, designate lead organizations, and identify others that should be a part of this work group. All work group members are invited back for the next year of the work group.
• Reviewed and discussed the comments from subject matter experts received prior to the meeting about the approved priorities. Discussion highlights are included below each policy.
  • Policy: Expand Medicaid, including expanding recipient eligibility criteria
    • Reasons why Medicaid has not expanded yet: lack of awareness of the voices of the people that do not have access, lack of information, and politics
    • Importance of all sharing the same story and numbers of uninsured and those that would remain uninsured after Medicaid expansion.
    • Concerns about redetermination issue of Medicaid eligibility and the devasting impact on patients.
    • Awareness that having insurance does not guarantee access.
  • Policy: Determine the need for expanding and/or sustaining financial support for Community Health Workers
    • Contracts between the Department of Health and Human Services (DHHS), the Office of Rural Health, and their vendors ended as of December 31, 2022. Several hundred community health workers (CHWs) are now out of jobs.
    • North Carolina Community Health Worker Association is continuing to have conversations with DHHS and legislation to fund this workforce and to explore models occurring across the nation.
    • Recommendation to keep both sustaining and expanding CHWs included in the policy. All work group members were in favor of putting forward a common definition for CHWs.
  • Policy: Determine the need for expanding and/or sustaining health clinics for the uninsured.
    • Recommendation to expand programs in existing free and charitable clinics. Counties without free and charitable clinics do not have the infrastructure to support the clinics.
    • Focus on increasing the human and operational capacity of existing health clinics as a first step. All work group members were in favor that the priority should be sustaining existing health clinics.
• Reviewed the two developmental policies:
  • Repurpose savings and surpluses created by Medicaid transformation and expansion and leverage the community benefit programs of health systems to fund programs for the uninsured.
  • Designate ownership of the uninsured problem, including improving data collection about the uninsured and addressing Social Drivers of Health services for the uninsured.
• Asked work group members to consider who else should be invited to the next meeting on April 17, 2023.

November 16, 2022, 1:00 to 2:00 pm, Co-Lead Planning Meeting

Co-Leads: Randy Jordan, Chris Shank (Absent), and Mark Snuggs

Others Present: Anshita Chaturvedi

Discussions:

• Reached a consensus on which ongoing priorities to continue and which ones to move to developmental policy status. Revised wording of ongoing policies and clarified which policies required additional input from external sources to allow to moving forward with strategies and action plans for each ongoing priority.
• Approved Policy Priorities:
  1. Expand Medicaid, including expanding recipient eligibility categories. Randy Jordan to contact the Division of Medicaid to learn of possible Medicaid recipient eligibility requirements that could be expanded under Medicaid.
  2. Determine the need for expanding and/or sustaining financial support for Community Health Workers. Randy Jordan to contact Honey Estrada of the NC Association of Community Health Workers on the question of whether the presence of CHWs needs to be expanded or sustained or both. Mark will also contact John Resendes of NC ORH for input on this question.
  3. Determine the need for expanding and/or sustaining health clinics for the uninsured. Randy Jordan to contact the NCCHCA and NCAFCC for input on the questions of whether more health clinics are needed for the uninsured and whether funds are needed to sustain existing health clinics.
• Developmental Policies:
  1. Repurpose savings and surpluses created by Medicaid transformation and expansion and leverage the community benefit programs of health systems for funding programs for the uninsured. Medicaid expansion is projected to create a surplus of $1.7 billion for NC and community benefit (i.e., charity care) programs sponsored by health systems are being reviewed to monitor the extent of charity care being provided.
  2. Designating ownership of the uninsured problem, including improving data collection about the uninsured and addressing Social Drivers of Health services for the uninsured. It was acknowledged that there is no centralized place either in or outside of state government for issues and accountability about the uninsured to reside. 
• Eliminated or Repositioned Policy Proposal:
  1. Increase the number of bilingual healthcare and insurance providers. NC AHEC used to have programs that focused on language competency and training, but has since discontinued the program. It was suggested that provider associations and groups seem to be in the forefront for fostering this type of training. This issue, while still important, may not be as sensitive to policy decisions as first thought.
  2. Improve data collection about the uninsured. It was acknowledged that absence of measurable and reliable data is an issue in developing policies for the uninsured. This issue has been incorporated into another proposed developmental policy.
  3. Extending the reach of existing safety-net programs for the uninsured. Safety-net providers indicated that the existing safety-net covers all 100 counties. The question of extending safety-net services is the subject of another approved policy priority.
  4. Other topics. The topics of support for CHWs and addressing social drivers of health for the uninsured are incorporated into another approved developmental policy.

October 17, 2022, 10:00 to 11:45 am, Work Group Meeting

Co-Leads: Randy Jordan, Chris Shank, and Mark Snuggs

Attendees: Abby Emanuelson, Anshita Chaturvedi, April Cook, Elizabeth Byrum, Honey Estrada, Hugh Tilson, Jessica Alexander, Richard Hudspeth, Sally Wilson, William Massengill, Zenobia Edwards

Presenters: Brieanne Lyda-McDonald and Mark DeHaven

Discussions:

• Received the following presentations:
  • Brieanne Lyda-McDonald, MSPH-MPH, Project Director, NCIOM (staffed Healthy North Carolina 2030), shared how and why the Healthy North Carolina 2030 uninsured indicators was selected. 
  • Mark DeHaven, PhD, Dean W. Colvard Distinguished Professor, College of Health and Human Services, UNC Charlotte; Director, Academy for Research on Community Health, Engagement and Services (ARCHES), shared about the UCITY Family Zone: A Community Health Science Approach.
• Reviewed approved policy priorities and related strategies and action plans. Discussed questions and clarifications needed to move forward.
  • Expand Medicaid eligibility criteria. It was suggested that this policy priority be paired with "expanding Medicaid" until such time as Medicaid expansion is approved by the General Assembly. The Division of Medicaid was identified as a state agency that should be contacted about developing strategies and action plans around the Medicaid eligibility issue and Care4Carolina about the Medicaid expansion issue.
  • Expand community health workers to empower communities to ensure all individuals can access healthcare. Received input that a better definition of what is a community health worker is needed for this policy priority to have value. The question of whether the presence of CHWs needed to be expanded or sustained or both was also explored. The state's Community Health Workers association and the relevant section of the NC Office of Rural Health were identified as good resources to further explore strategies and action plans for this policy priority.
  • Leverage community benefit dollars from Medicaid Transformation to meet the needs of the uninsured. It was suggested that two themes were conflated: Community benefit dollars from hospitals and new funds invested through Medicaid Transformation that might be used indirectly to benefit the uninsured (i.e., Health Opportunity pilot programs). It was suggested that the Division of Medicaid was the best place to start. NCHA might be the best source on hospital-based community benefit. Strategies and action plans cannot be developed until this policy priority is better understood.
  • Determine need in communities for more health clinics to serve the uninsured. While this policy priority is clear, the question of whether more clinics are needed should be paired with a proposed policy of how to best extend the reach and sustain existing safety-net programs for the uninsured. It was suggested that NCCHCA and NCAFCC are good resources for this topic. 
  • Increase the number of bilingual healthcare and insurance providers and staff. Targeting who within the state government or otherwise might be addressing this issue needs to be determined. It was suggested that provider associations and groups seem to be in the forefront for fostering this type of training. The relevance of having bilingual insurance providers as a priority was also questioned as it seems that market forces would address this issue. This topic needs more exploration and discussion before strategies and action plans can be pursued.
• Reviewed proposed policies.
  • Improve data collection about the uninsured. It was acknowledged that an absence of measurable and reliable data was an issue in developing policies for the uninsured. Further discussion on this topic is merited.
  • Extending the reach of existing safety-net programs for the uninsured. Safety-net providers indicated that the existing safety-net covers all 100 counties.  There may still be pockets where primary care requires excessive travel, but the infrastructure for a competent safety-net system already exists and could expand if properly funded. There is a provider distribution and recruitment and retention problem, that is not answered by simply creating new clinic sites.

September 12, 2022, 4:00 to 4:30 pm, Co-Lead Planning Meeting

Co-Leads: Randy Jordan, Chris Shank, and Mark Snuggs

Others Present: Rebecca Hayes

Discussion:

• Decided to advance 5 existing policy priorities for future consideration and consider 1 policy priority for further development.
  • Current Policy Priorities
    • Expand Medicaid eligibility criteria
    • Expand community health workers to empower communities to ensure all individuals can access healthcare
    • Leverage community benefit dollars from Medicaid Transformation to meet the needs of the uninsured
    • Determine need in communities for more health clinics to serve the uninsured
    • Increase the number of bilingual healthcare and insurance providers and staff
  • Proposed Policy Priorities to be Developed
    • Improve data collection about the uninsured to assist in health policy planning (e.g., how many uninsured currently have a medical home)
• Discussed continuing to review the policy priorities as work continues to assure that each priority has a reasonable expectation of making progress. All the policy priorities will be reviewed at the next work group meeting and any new policy priorities will be considered.
• Discussed making inquiries of relevant state agencies and stakeholders to request their proposals regarding strategies and action plans for each priority.
• Finalized the meeting schedule for the Uninsured Work Group. The next meetings will be from 10:00 to 11:45 am on October 17, January 23, and April 17.

August 15, 2022, 1:00 to 3:00 pm, Work Group Meeting

Co-Leads: Randy Jordan, Chris Shank, and Mark Snuggs

Work Group Members & Others Present: Abby Emanuelson, Alice Salthouse, Anshita Chaturvedi, April Cook, Brandy Bynum Dawson, Charlene Green, Don Holloman, Erica Palmer Smith, Honey Estrada, John Resendes, Kathy Hodges, Katye Griffin, Khristian Curry, Kristen Spaduzzi, Richard Hudspeth, Sally Wilson, Savannah Junkins, Torie Keeton, William Massengill, Jr., and Zenobia Edwards

Discussion: 

• Received the following special presentations: 
  • Medicaid Expansion – Abby Emanuelson, Care4Carolina 
  • Remaining Gaps in Care for the Uninsured – Randy Jordan
    • oral health, behavioral health, specialty care, geographic distribution of these services (Persistent Rural Problem), health care coverage expansion needs,  medical home gaps, social service gaps, undocumented people, data collection gap
    • Who owns the problems?
  • Connections to Care – Kathy Hodges and Khristian Curry, Office of Rural Health, CHW Program
• Reviewed 7 proposed policies and advanced 6 of 7 policies for strategic planning. Refer to proposed policies tagged Uninsured below. 
  • Expand Medicaid eligibility criteria (10 votes)
  • Expand community health workers to empower communities to ensure all individuals can access healthcare (9 votes)
  • Leverage community benefit dollars from Medicaid Transformation to meet the needs of the uninsured (9 votes)
  • Determine need for more community health clinics by employing data analysts (7 votes)
  • Increase the number of bilingual healthcare and insurance providers and staff (3 votes)
  • Increase publicity and navigator funding to provide instruction and access for open enrollment (1 vote)
  • Support bans or limitations on short-term health plans (0 votes)
• Discussed possibility of new policies related to: 
  • Capacity to serve more patients by expanding the reach of existing programs
  • Designating ownership of the wicked problem – no health care
  • Expanding data collection on uninsured