Regina Goddard is an open, affable woman, given to cackling when she’s amused. But she wasn’t laughing last summer. The house she and her 13-year-old daughter were renting in Aurora, North Carolina, had become increasingly dilapidated, but despite two electrical fires, a caved-in septic tank, and a leaking roof, the landlord refused to fix it up.
“The health department could’ve condemned the place, and we’d have been homeless,” said Goddard, 55.
Goddard has hernias, many of them. She used to work: “I’m a certified mechanic, a crane operator, and a journeyman ironworker,” she said. “That’s why I have all the problems I do, because I worked so hard in my life. I’m a female but I worked like a man.” A pregnancy at 42 worsened her hernias, and she’s been disabled ever since. She and her daughter live on $841 a month from disability payments, plus government food benefits.
She’d found another place to rent—a trailer in rural Beaufort County, about 10 miles from Aurora—that seemed suitable and was within her monthly budget. But she didn’t have enough saved to pay the first and last months’ rent up front.
She told that to the nurse when she received her monthly check-in call from Wellcare. “I was saying, ‘I’m tripping out, I’m about to be homeless,’” said Goddard.
Wellcare is a private health insurance company, one of five that began covering NC Medicaid members in 2021. That’s when the state’s Medicaid program transitioned to managed care, using for-profit businesses to administer the giant public health care program in an effort to keep costs down. The Wellcare nurse ensures that Goddard gets the medical care and support she needs, including a home health aide who comes over daily to help her bathe, get dressed, and clean her house.
But this call was different. The nurse asked some questions about Goddard’s situation and referred her to Cornerstone Community Based Programs, a nonprofit in nearby Washington, N.C. An employee there briefly interviewed Goddard, drove out to take a look at the trailer, and then cut a $900 check for the new landlord covering first and last months’ rent.
“I’m tickled to death,” said Goddard, now comfortably settled in her new home. While unremarkable on the outside, its interior is spacious and cozy. “It’s been nothing but up since I met those people.”
Though it is church-based, Cornerstone isn’t a charity. It’s a nonprofit that the North Carolina Department of Health and Human Services has contracted with as part of a new initiative that public health experts around the country are watching.
The Healthy Opportunities Pilot, or HOP, is a $650 million, five-year program focused on a simple concept: living conditions influence people’s health more than anything else.
The idea is pretty intuitive. If you can’t afford healthy food, if your house has mold or spotty electricity, if you don’t have a car and struggle to get to doctors’ appointments, all the medical care in the world might not be enough to keep you well.
Those conditions—food, housing, transportation, as well as less-tangible elements like stress—are known as social determinants of health. For the past decade, public health and medical fields have increasingly focused on them.
Hospitals and health care organizations around the country have started supplementing traditional care with offerings like free produce and transportation, and some are even investing in affordable housing.
Ultimately, it’s an effort to reduce the cost of health care. If Goddard and her daughter became homeless, her health would likely worsen. She would require more medical attention, which could cost Medicaid tens or even hundreds of thousands of dollars. The $900 for rent becomes a great deal.
That’s why Medicaid, a public health insurance program for low-income people that’s administered at the state level and jointly funded by states and the federal government, is wading into the arena.
Other states are running similar pilots, but North Carolina’s is the most ambitious. “This offers a much broader range of services to a much broader group of Medicaid beneficiaries than has ever been done,” said Amanda Van Vleet, associate director of innovation at N.C. Medicaid.
But in just these first months, Van Vleet and her team have found that moving from a traditional health care model to something more radical has been an onerous undertaking.
A Slow Start
In the public health world, there’s little debate that lacking sufficient food or a safe, clean, temperature-controlled home worsens people’s health.
These social determinants of health, experts say, account for around 80 percent of outcomes—far more than aspects like doctors’ visits or medication.
“There’s no dispute about that,” said Seth Berkowitz, a professor of medicine at UNC-Chapel Hill and researcher at the Cecil G. Sheps Center for Health Services Research, at a virtual event about the HOP program in July. Around the country, 500 people tuned in for the event. “The best way to address them is less clear. There’s no doubt that we should be doing something, but we don’t know exactly what.”
That’s what North Carolina is trying to figure out. Dr. Mandy Cohen, the former NC DHHS secretary, began designing the program in early 2017; the federal Centers for Medicare and Medicaid Services (CMS) approved it in October 2018. The pilot, which covers 33 counties across three regions, officially launched in March 2022.
It was supposed to begin when the state Medicaid program transitioned to managed care, but a budget impasse between Democrats and Republicans in 2019 caused delays to both. North Carolina is providing roughly a third of the pilot’s funding; state funding for HOP—$92 million so far, covering a share of the program’s first two years—didn’t arrive until 2021.
To support the new Medicaid pilot, state administrators have had to create a complicated new system that joins giant, for-profit institutions with tiny, hyper-local nonprofits. It aims to improve health and well-being among low-income North Carolinians while simultaneously investing in local economies.
It’s been a lift, to say the least.
Here’s how it’s supposed to work: For one of the state’s 1.6 million Medicaid managed care beneficiaries to be eligible for HOP, they have to live in one of the pilot’s three regions, have at least two chronic conditions or repeat ER or hospital visits, and have an additional risk factor like food or housing insecurity.
People who qualify for the program are assigned a care manager who assesses their health plan and need for services, then connects the patients with community organizations that can help them. Each region has a network lead, an organization that makes sure things move smoothly and the community groups get paid for their work.
The program includes 29 service categories, from transportation vouchers and weekly produce boxes to parenting classes and help finding housing. Assistance to those experiencing domestic violence is another service the administrators are still rolling out.
When the network leads and their regions were announced in May 2021, some observers were surprised that they were all relatively rural. The pilot is running in North Carolina’s northeast, southeast, and far western regions, leaving out cities like Charlotte, Raleigh, and Greensboro.
DHHS says the three organizations best qualified to act as network leads happened to cover largely rural areas of the state. In many ways, that has made HOP significantly more challenging to implement. The state’s urban regions have bigger health care systems and sophisticated nonprofits. North Carolina’s rural residents are generally poorer, less healthy, and often have a harder time accessing medical care.
In the northeast region, for example, eight out of the nine counties in the program have health outcomes ranked in the state’s lowest fifth. Roughly 20 percent of residents there are below the poverty line; statewide, the number is 14 percent.
This has also impacted the availability of service organizations, since HOP was designed to work with nonprofits already rooted in their communities. Network leads spent four months identifying and training organizations, work that has continued with additional nonprofits after the pilot’s launch.
Berkowitz and other researchers from the Sheps Center will be evaluating the pilot’s effectiveness over its five years. They will be looking for outcomes like reduced emergency room usage and better management of chronic conditions like high blood pressure—things that, research shows, can strongly respond to improvements in patients’ living conditions.
Berkowitz underscores that this program is an experiment. It could become an example for Medicaid programs across the country—but because no other state has done anything quite like this, there’s no model to follow.
‘You Spend More Time, You Get To Know Them’
Organizational difficulties have generally been surmountable. What’s dogging the program now is getting people in the door.
Cornerstone, for example, has helped only one other person with housing besides Goddard. In the northeastern town of Ahoskie, Roanoke Chowan Community Health Center has just one person receiving services so far. And in Hertford County, only about 30 people are getting food from Cultivator, a local nonprofit.
DHHS reports that about 4,200 referrals have been made for HOP services and that fewer than 13,000 people are eligible for the pilot, meaning it’s reaching roughly a third of those who qualify. That’s a start, but the Centers for Medicare and Medicaid Services initially approved a plan for 25,000 to 50,000 eligible members. DHHS leaders say that was a rough estimate created before the pilot’s regions had been selected, and its actual locations have smaller target populations.
“We’re disappointed, but we understand this is a pilot project,” said Michelle Lewis, Roanoke Chowan Community Health Center’s population health and integrated care administrator. “We’re here to work out kinks and provide feedback.”
Many of the health policy experts watching the program echoed that. “This is all being done for the first time, so I think there’s a recognition that it’s going to be impossible to get everything perfect,” said William Bleser, assistant research director at Duke’s Margolis Center. “It’s not going flawlessly, but it’s a learning process.”
As Miranda Catania explains how she gets people to talk in HOP screenings, she illustrates a reason referrals have been slow.
“When people are in need of help, they’re too embarrassed to ask,” she said. “Nobody’s going to blatantly come out and say, ‘Hey, I need help with food.’”
Catania is a care manager with NC Community Health Center Association in Raleigh. She spends all day talking to potential HOP participants, asking them careful questions to glean details about their living situations. “Some people are hesitant, so I feel like it’s my job to break that shell and get them to tell stories,” she said. “You spend more time, you get to know them. They always have more than one social determinant of health [need].” So far, every referral she’s made has been approved.
Her association represents clinics that treat mostly low-income patients. Employees at the clinics in participating regions have flagged the patients she talks to as potentially needing help.
Most of the other care managers in the HOP program work for hospital systems and health insurance companies. Many are adding these screenings, which can take up to an hour, to their existing workloads. For Catania, it’s her full-time job.
The process is opaque. No one seems to know exactly how many care managers there currently are, for example, but some observers have questioned whether those care managers are able to give the referrals the focus they require.
“It’s possible there’s a lack of incentive to push or pull referrals to the care manager,” said Fred Johnson, who ran a Wake County Medicaid plan for disabled adults and has worked in the field for years. HOP’s assessment and eligibility requirements create an additional layer of tasks for a care manager. “That’s the pivotal worker in the HOP pilot, but they have other patients and outcomes to meet.”
Leaders of the community organizations The Assembly spoke to agreed that many Medicaid beneficiaries might need a little more attention during screenings.
“They don’t know what to ask for. And then they get a litany of questions,” said Harry Crews, executive director of Green Rural Redevelopment Organization, which provides food services to participants in four northeast counties. “The client will get frustrated with all the questions. They’re thinking, ‘I don’t want to lose my Medicaid, I don’t want to lose my food stamps,’ so they hang up.”
“People need their hand held sometimes,” he said.
Getting the Word Out
In Halifax County’s Scotland Neck, volunteers met at Dawson Elementary School on a Friday in September. The school has been closed for a few years, but the local organization A Better Chance A Better Community (ABC2) is converting it into a “resiliency hub” to offer food assistance, small business support, and some emergency services to residents.
ABC2 is one of the nonprofits in the pilot program, and the site is the designated spot for community members to pick up food boxes. The program currently has about 50 clients—a good number for a rural community like Scotland Neck. ABC2 founder Chester Williams says it took some effort to get to this point.
“Many in our community, even myself, we thought Medicaid was only to pay your doctors’ bills,” he explains. “This is news to a lot of folks.” Williams and his staff have talked up the program at churches and local events, and brought in HOP representatives to speak to the community.
Rural residents tend to be hard to reach, and many North Carolinians have never heard of HOP. That includes the doctors, nurses and health care administrators who could connect Medicaid recipients to the program.
“In my clinic, there’s only 10 people enrolled so far,” said Dawn Daly-Mack. Today, she’s at Dawson Elementary School as a volunteer, but during the week, she works as a nurse and care coordinator at Rural Health Group in nearby Roanoke Rapids.
Daly-Mack brought flyers advertising the initiative to her clinic, which sees largely low-income people, and explained it to the administrators, who were unfamiliar with it.
The program has already benefited ABC2 and other organizations in the pilot, many of which have deep roots in their communities but very little funding; ABC2, for example, reported its 2020 revenue as $82,000, according to Guidestar, a nonprofit database. Of the initiative’s total allocation, $100 million is dedicated to capacity-building and overhead for the three network leads and the nonprofits in their networks, which currently total around 150.
“It’s huge, game-changing,” said Peter Skillern, executive director of Durham-based Reinvestment Partners, one of the only organizations in the program that serves all three regions. “We threw out 20-year-old donated furniture and actually got desks. My computer was thrown away and I got a new one.”
That money is boosting local economies, too. ABC2, for example, has finally been able to bring many of its longtime volunteers on staff and invest in things like kitchen renovations and a refrigerated truck. It used some of the funding to develop deeper relationships with local farmers, whose produce is now showing up in the food boxes.
But the capacity-building funding only lasts 24 months, and then organizations are expected to be self-sustaining. They’re paid by the program every time they provide a service to an individual, but to succeed, they’ll need far more referrals.
“You have to get to volume,” said Skillern. He pointed to one of the HOP services his group administers: $40 worth of fruit and vegetables that participants can redeem at Food Lion or Walmart. Medicaid pays the $40, and Reinvestment Partners receives $5.25 as a service fee per person every month. Even if 1,000 clients used the benefit, the organization would only earn $5,250 a month. “It’s still not quite enough to run a program. That’s part of the challenge.”
The pilot needs more participants so it can be effectively evaluated, too. Even if the program results in several hundred Medicaid beneficiaries better managing their diabetes, HOP will never go statewide if researchers can’t translate those benefits into reduced Medicaid costs in a statistically significant way.
Even that might not be enough to expand the program across North Carolina; federal regulators would also have to approve it, and the General Assembly would have to provide a portion of the funding. DHHS has not given an estimate on how much it would cost to run the program statewide.
A key question for both of them will be whether this complicated, hands-on, community-focused program can demonstrate cost effectiveness.
“That’s a lot of money to prove that giving people food security and transportation and a safe place to live makes them healthier,” said state Senator Jim Burgin, a Republican co-chair of the Joint Legislative Oversight Committee on Health and Human Services. He supports the program but questioned whether the $650 million would be better and more quickly used if it was applied to the whole state, rather than just the three regions. “We have a limited time to spend it. I don’t want to waste it.”
But DHHS—which intends to ask the legislature for $102 million in the upcoming budget to fund the next two years—says the program is gaining momentum. “We did purposefully ramp up the pilots slowly; we wanted some time to iron out the kinks before we had an influx of enrollees,” said Van Vleet. “Now that we see they’re OK, we’re working with all of our partners to try to grow enrollment from many different angles.”
For providers on the ground, the immediate impacts seem clear. “I’ve had people tell me the boxes are a blessing to them because now they can afford their medicine,” said ABC2’s Williams. “They’re saying they’re eating better, losing weight. Before, it was too expensive.”
And they are telling others, he said. “They say, ‘This is really nice produce…A real healthy box.’”
Amanda Abrams is a freelance journalist in Durham, N.C.