Health Policy · North Carolina · Medicaid
Dying for coverage
In rural North Carolina, having Medicaid doesn't mean you can actually get care. Here's why — and what the state can do about it.
These figures operate at different scales — the 2,600 diagnoses are national; the life expectancy gap compares two NC counties; the odds ratio captures rural treatment access within the state; the 10.5% reflects Robeson County on December 1, 2023. Together, they trace one argument: expansion works, but Robeson residents remain structurally blocked from its benefits.
Coverage is not care
In North Carolina, your zip code can determine whether a cancer diagnosis is survivable. The same person who cannot get a primary care appointment in Robeson County can walk into the Duke Cancer Center in Durham and be seen within days. That gap is not a matter of personal choice — it is a product of policy.
The evidence is clear: Medicaid expansion saves lives. States that expanded Medicaid under the ACA saw roughly 2,600 fewer late-stage cancer diagnoses and 1,600 fewer cancer deaths between 2015 and 2019. About 60% of that mortality benefit came simply from catching cancer earlier — when survival rates are dramatically higher.
"Medicaid expansion can save lives and prevent cancer deaths. These data add to an ever-growing body of evidence that increasing insurance coverage, especially to more vulnerable populations, matters."
— Dr. Justin Barnes, lead author, JNCI 2023Two counties, one Medicaid card
Robeson County is home to roughly 117,000 residents. It is North Carolina's least healthy county, with a poverty rate nearly twice the state average and a cancer mortality rate among the highest in the state. Its population is triracial — Lumbee/Native American, Black, and white — and each group faces documented barriers to cancer screening. The Lumbee Tribe, the largest Native American tribe east of the Mississippi, lacks federal recognition, which excludes tribal members from Indian Health Service benefits and deepens their reliance on Medicaid. One study found that 33% of Lumbee women had never had a Pap smear.
Durham County, home to Duke's health system, offers a dense and highly integrated network of providers. A low-income Medicaid patient there can get a mammogram, a biopsy referral, and an oncology appointment within weeks — on a bus route. In Robeson, that same person may have no nearby mammography site, no oncologist in the county, and no reliable transportation — even if their Medicaid card theoretically covers all of it.
A gauntlet at every step
There is a specific logic to why rural patients only seek care in acute distress. It is not lack of desire for health. It is a series of structural barriers — each individually survivable, together lethal.
Enrollment requires documentation many residents struggle to produce. Finding a primary care provider means navigating a federally designated Health Professional Shortage Area, where a patient's managed care organization may make the nearest willing doctor technically out-of-network. Screening requires travel that working families cannot easily arrange. And even after a diagnosis, getting to treatment is its own battle.
Who Medicaid actually serves
A persistent political narrative frames Medicaid as a program for people who don't work. In Robeson County, nearly 57% of all residents are enrolled — farmers, day care workers, restaurant workers, agricultural laborers — people employed in sectors that rarely offer employer-sponsored insurance. Medicaid covers 38% of all NC births and 30% of rural NC children. It funds over 60% of North Carolina nursing home stays. It is not a welfare program in the pejorative sense. It is economic infrastructure.
Five things the state can do now
None of these recommendations require major legislation. They are administratively feasible, evidence-supported, and tied directly to the barriers described above.
Eliminate or expedite PA requirements for mammograms, colonoscopies, and standard imaging. Several states use "gold carding" — automatically waiving PA for high-approval-rate providers — reducing administrative burden without sacrificing clinical oversight.
Establish minimum performance requirements for non-emergency medical transportation brokers, with penalties for missed appointments. Explore mileage reimbursement for patients in counties with no NEMT provider at all.
FQHCs and Rural Health Clinics already receive enhanced rates. This recommendation targets independent rural physicians and small practices in shortage areas facing standard Medicaid rates well below Medicare — the providers most likely to leave or never come.
CHWs embedded in clinics, health departments, and faith communities have proven effective at increasing enrollment and supporting treatment adherence — particularly in communities where trust in institutions is fragile.
Fund mobile mammography and co-located screening services in counties with documented disparities — Robeson, Scotland, Halifax, and Edgecombe — to reach women who cannot travel to static screening sites.
People in Robeson County do not wait until they are dying because they do not value their health. They wait because the system requires them to prove that they need help before it will give it — and by the time they can prove it, the cancer has spread. The goal is not just to insure people. It is to create a system where a low-income person in Robeson County can catch cancer early and survive it, just like a low-income person in Durham.