For more than 10 years, Dr. Karen L. Smith had watched over an elderly couple in her community of Raeford. The husband followed Smith’s advice meticulously, took his medications as prescribed, and tenderly cared for his chronically ill, wheelchair-bound wife.

If ever Smith had an ideal patient, it was him. Yet when Smith mentioned the COVID-19 vaccine early last year, his response was immediate: “No, no, no.” He didn’t like what he’d heard about it from politicians. 

In late 2021, the couple contracted Covid and both ended up in the hospital. After a short time on a ventilator, the husband died of respiratory failure.

A while later, the wife was back in Smith’s office for an appointment. Smith expected an easy conversation about the vaccine because the woman had just lost her unvaccinated husband to Covid. Instead, she was stunned by the woman’s response: “Nope, I’m not getting that vaccine. My spouse didn’t want it, and I’m not changing my mind.”

Over the last year, Smith has seen a similar scene play out two other times. “What do you do?” Smith asked me during a recent phone call. Then she repeated the question with more emphasis, “What do you do?”

For almost three years, waves of pandemic misinformation have rolled across the state, imbuing communities with an intensity of vaccine hesitancy that most providers have never seen. 

Doctors have always offered trusted advice on important and often life-saving health matters. Yet Covid conversations were different. They were tense, political, and emotionally charged. 

But they weren’t impossible. Many patients were just scared. Providers needed more time. Time to listen, clarify misconceptions, and offer reassurance.

Recognizing this, state health officials devised a way for doctors who treat Medicaid patients to be compensated for these challenging, but crucial, conversations. North Carolina’s approach has gained national recognition and inspired others, but even more importantly, it has increased the state’s Covid vaccination rate. 

This isn’t to say the state has solved the vaccine hesitancy problem. In many communities, opposition to the vaccine remains fierce and deeply rooted. Despite Smith’s efforts, her county of Hoke has one of the state’s lowest Covid vaccination rates at 43 percent.

But Smith chooses to see the number as motivating. It’s a reminder to have more conversations, to build more trust, to ask about getting the vaccine just one more time.

Connecting With Patients

Smith, a soft-spoken woman with a gentle smile, arrived in Raeford in Hoke County, just west of Fayetteville, in 1992, fresh off a rural-focused family medicine residency. 

Hoke County was in dire need of family physicians, so Smith agreed to participate in a new program. She would work in the rural health-care desert in exchange for help with her student loans. She planned to stay three years, then return to Maryland to practice rural medicine there.

That was 30 years and more than 10,000 patients ago.

Today, Smith, who just turned 60, is a fixture in Raeford, with a prominent red brick building at the corner of Palmer Street and Prospect Avenue. She’s now caring for the babies of the babies she delivered as a younger doctor.

Dr. Karen L. Smith’s office in Raeford, N.C. (Maddy Gray for The Assembly)
Smith, left, talks with Alicia Barnes, right, after Barnes received her first Covid vaccination during a clinic in October. (Maddy Gray for The Assembly)
Smith’s awards line the shelves in her office. (Maddy Gray for The Assembly)

Smith checks blood pressure and monitors diabetes, but she also asks patients about their children, and whether or not they got that house they wanted. Several years ago, she lovingly, but firmly, told the town drug dealer to clean up his act. And he did.

She named her building “Shangri-La” and leans into her practice motto of “the power of touch.” A banner in her lobby reminds visitors that in 2017 she was named “National Family Physician of the Year.”

In Smith’s way of practicing medicine, healthcare is as much about finding peace and healing through building connections as it is about managing cholesterol.

Which is why so much of the pandemic felt to Smith like living in an alternate universe.

Many patients who’d taken her advice for decades now balked at her insistence that, yes, Covid was real, and yes, they should get the vaccine. Some were scared the vaccine was worse than the virus. Others assured Smith they’d done their own research and didn’t need it.

For those who came riddled with worries and questions, Smith tirelessly answered them all, only to do it again at their next visit with a new round of concerns.

“We never had to go through that extensive discussion with any of the other vaccines,” Smith said. “We were actually amazed at the amount of time just to get to ‘This is good for you.’”

But it is. Today, unvaccinated North Carolinians are 9 times more likely to die from Covid than people who have received the original Covid vaccine plus a booster dose.

Yelling At Doctors

There are many ways to measure time during the pandemic. Weeks spent at home in lockdown, months of public masking, years of educational progress lost. But for many, including doctors, it’s simply before the vaccine and after.

The federally-funded “Operation Warp Speed” produced a vaccine in record time, offering immediate protection against a raging disease. Yet, several months after the vaccine was released, North Carolina Medicaid officials noticed two disturbing trends.

First, doctors who recommended the Covid vaccine were often getting criticized or yelled at. Appointments became political and uncomfortable. Caregiver burnout was getting even worse. Eventually, doctors shied away from repeat vaccine conversations because they were exhausting.

On top of that, the vaccination rate gap between Medicaid patients and privately insured patients was growing. Medicaid patients make up more than 2.8 million people in North Carolina—roughly a quarter of the state—so lower vaccination rates among that group were a big problem.

And it was Dr. Shannon Dowler’s problem to solve.

As chief medical officer for NC Medicaid, Dowler and her team were trying anything to boost vaccination acceptance. The solution they settled on turned out to be so simple and effective that it garnered attention from the federal Centers for Medicare & Medicaid Services, the American Academy of Pediatrics, and a handful of interested states.

The solution was five numbers: 99401.

Tammy Locklear, right, winces as she receives her first Covid vaccine from Debra McLeod, left. (Maddy Gray for The Assembly)
Lisa Bullard, right, claps after receiving hers. (Maddy Gray for The Assembly)
McLeod wears a necklace with the insignia for a registered nurse. (Maddy Gray for The Assembly)

Each time a doctor sees a patient, the physician details the interaction using a series of five digit codes. These codes tell the insurance companies what happened and how to reimburse the provider.

Dowler took a counseling code that had existed since the 1990s—one that NC Medicaid had never before reimbursed—and repurposed it to focus on Covid vaccine hesitancy.

This “new” code allowed North Carolina Medicaid providers to bill roughly $32 for up to 15 minutes of vaccine counseling per patient per day, for as many days as necessary. Providers were incentivized to counsel their Medicaid patient, as well as the patient’s family, and reimbursement didn’t depend on the patient getting vaccinated. 

“A lot of our reimbursements in the medical world are kind of one and done,” Dowler said. “With this Covid vaccine counseling, we actually took those limits off. And we said if you need to counsel somebody ten times to move them to vaccination, we’re gonna pay you for that, because it’s that important to us that they have all the options in front of them.”

Officials rolled out the code in June 2021 and the impact was immediate. In the first three months, North Carolina doctors counseled patients nearly 30,000 times. Those patients were 25 percent more likely to get vaccinated, Dowler’s team found. Among younger patients ages 12 to 17, counseling meant a 50 percent increase in vaccination rates compared to non-counseled patients.

More than a year later, by the end of August 2022, North Carolina providers had used the code nearly 120,000 times. Pediatricians were some of the first providers to latch onto it. 

Christoph Diasio, the then-president of the North Carolina Pediatric Society, knew he couldn’t vaccinate his youngest patients in mid-2021, but he could try to reach the adults in their lives. 

“I’ve been taking care of your kids for a decade, I’m worried about you,” he would tell the parents and caregivers at his Southern Pines office. He knew many of them didn’t have their own primary care doctor, so he stepped in. And many listened.

For Brian Bowman, a pediatrician in Apex, the code was logistically helpful, but also psychologically reassuring. Even when parents yelled at him or rejected his advice, he knew at least the state Medicaid office valued his efforts. That gave him energy to keep asking through the feelings of burnout.

“It’s worth making that extra effort,” he said. “It’s worth having that conversation at every visit…Even if it’s incremental, it’s still helpful.” 

Smith counsels anyone and everyone about getting the Covid vaccine, Medicaid patient or not. But having the 99401 code meant she was able to document some of her counseling efforts in a way she never could before. 

Smith, right, and her daughter Mikara Smith-Hendricks, center, talk with Carrol Olinger of Action NC, left, about incentives to encourage vaccination. (Maddy Gray for The Assembly)
Roberta Handon, 87, receives a Covid booster during an outdoor clinic. (Maddy Gray for The Assembly)

Although it was painful, it allowed her to tell grieving family members that she had repeatedly offered their deceased loved one the vaccine. She could also celebrate with patients who finally agreed after multiple counseling sessions.

Across North Carolina, Dowler and her team calculated that during the first six months of the vaccine rollout in 2021, every 100 counseling sessions resulted in three additional people agreeing to get vaccinated. At $32 for each session, that meant a total cost of $1,067 for each new vaccination.

For adolescents, every 100 counseling sessions would yield seven more vaccinations, at a cost of $457 per vaccination.

As time passed, interest in the vaccine slowed, but patients who are counseled are still roughly 4 percent more likely to get vaccinated. Today the cost to shift one hesitant 12-to-17-year old Medicaid patient to vaccinate is just shy of $4,000—more than the original price tag, but still far below the cost of hospitalization.

Even with a rising price tag, these conversations are still worth having, say officials at the state Department of Health and Human Services. 

The American Academy of Pediatrics applauded North Carolina’s approach, and the Centers for Medicare & Medicaid Services said the state’s strategy “helped them think through stand-alone vaccine counseling” efforts. In June 2022, CMS rolled out their own codes for counseling related to both Covid and other routine childhood vaccinations.

Medical experts know that even as this pandemic fades, vaccine hesitancy will remain—most often directed at childhood vaccinations.

North Carolina’s routine childhood vaccination rate for protection against diseases like pertussis and measles dropped from 73 percent to 72 percent between 2020 and 2021, according to NCDHHS data. Doctors and public health experts say this is not surprising, given logistical pandemic constraints; however, by 2021, 60 North Carolina counties still hadn’t made it back to their 2019 vaccination levels. 

Ongoing, repeated conversations—like the ones 99401 makes possible—may be a key to regaining and even increasing childhood vaccination rates going forward.

Embraced by Raeford

Smith traces her entry into medicine back to childhood. Her mother, Marjorie Ann, developed sarcoid at 17 years old, a genetic condition that attacked her respiratory system. This left Marjorie Ann bedridden and struggling to breathe during flare-ups. 

Smith remembers afternoons spent waiting with her father, brother, and sister in the family’s red Ford sedan until they crowded into a packed doctor’s waiting room. Yet once Dr. Barrington Barnes entered the room, nothing felt rushed.

“He would just be sitting there in the chair, by now it’s dark outside, and he’s asking, ‘How are you all doing?’ and ‘What’s going on,” and then at the end, he might put a few little notes on a pad, but it was more or less a visit,” Smith remembered. “He learned all about us. He was doing more than just taking care of her lung condition.”

Smith’s desire to serve people through medicine came from Dr. Barnes and her mother, but the love of science came from her father, Joseph, the first college graduate in his family and a biochemist for the National Institutes of Health in the National Cancer Institute.

A memorial to Smith’s mother and mother-in-law outside her practice in Raeford. Smith has served the rural community for decades. (Maddy Gray for The Assembly)

As her father completed his education and began his career, the family moved several times, finally landing in Silver Spring, Maryland. It was closer to Joseph’s lab and to Marjorie Ann, who by this point was too ill to leave Holy Cross hospital. 

The first Black family in a predominantly Jewish neighborhood, Smith remembers spending many after-school hours in the homes of her welcoming Jewish friends. It was those friends’ mothers who stepped in when Marjorie Ann died in 1973 at the age of 32. 

Smith was 11. Her older brother was 14. Her baby sister was in kindergarten.

“Here we were…three black children, my dad trying to raise them and the Jewish mothers literally embraced us,” Smith said. This network of love and support prevented the tragedy from derailing young Smith and instead propelled her forward. 

She graduated from Duke with a bachelor’s degree in biology, still unsure about whether to become a doctor or a researcher. 

During a summer internship at NIH, she saw cutting-edge research on patients in the final stages of disease. Yet, despite being surrounded by the best of the best in medical care, Smith remembers wondering what was being done to help individuals process their impending death.

“I didn’t see the science,” she said, “I saw the people.”

She completed medical school in Philadelphia, then returned to North Carolina for a family medicine program residency in Fayetteville. 

The Raeford community has embraced Smith, the only female Black physician in the area. She has her own small practice that is managed by her husband, Michael Hendricks, an Army veteran with a degree in health care administration. 

Most mornings when she arrives at the office, patients are already waiting for her in the parking lot. Yet finances have always been tight. Insurance providers are not as generous to private providers as they are to those who are hospital-affiliated, she said. 

When the pandemic hit, Smith had to make a decision. She knew small practices like hers that closed their doors often never reopened. Her father shipped her a box of N95s he managed to find in Maryland, along with a giant respirator, “because he knew I was going to continue to work,” Smith said.

And she did.

Putting It Off

At 11:03 a.m. on a recent Wednesday in Raeford, the line was already 12 patients deep. 

Some were standing on the sidewalk while others were under the purple canopies in Smith’s parking lot, across the street from West Hoke Middle School.

This was Smith’s eleventh Covid vaccination event at the office this year, and turnout was encouraging. (In total, Smith and her staff have participated in more than 200 other vaccine events statewide and vaccinated more than 5,000 people.)

“I’m scared,” Ziana McKoy, 16, told her aunt, Teresa Robinson, as they waited to get their registration clipboards. This would be McKoy’s first Covid shot.

It won’t hurt, Robinson reassured her. “You get shots, it’s just like any other shot.”

Next in line was Alicia Barnes, who said she’s been “putting it off, putting it off.”

Alicia Barnes waits to receive her first Covid vaccine. Barnes said that despite her hesitance, she trusts Smith would not recommend anything harmful. (Maddy Gray for The Assembly)
Mikara Smith-Hendricks prepares Covid vaccines during an outdoor clinic her mother hosted. (Maddy Gray for The Assembly)

The mother of four, who has an autoimmune disease, has seen Smith once a month for several years. She drives 45 minutes from Rowland because she believes Smith cares about her patients. 

Each appointment begins with Smith asking about Barnes’ family. Then they talk health issues. The appointment ends the same way it’s ended for the last year and a half, with Smith encouraging Barnes to get the Covid vaccine.

“She kept telling me, ‘If you get [Covid], you’ll end up in the hospital,’” Barnes said. 

Barnes would always reply, “I don’t know yet.”

She had heard things about the vaccine from her friends. Some said it changed your DNA. Others said it was the mark of the beast. Barnes’ husband was against it. 

But this sunny October morning, as Barnes sat in Smith’s waiting room for a 10:30 appointment, she said she couldn’t stop thinking about it. “I got four kids,” she said, “I can’t end up in the hospital.”

She listed off their ages—13, 10, 8, and 6. As she talked, she pulled up a picture of her oldest, her only boy. He’s not a little kid anymore, she said proudly, noting he’s now taller than she is. He wants to get the vaccine too, but he wanted mama to get it first.

So she headed outside to the parking lot. And then it was her turn in the vaccination chair. She gazed across the street toward the school and calmly waited for the nurse to get ready.

“Are we doing the right arm, Ms. Alicia?” nurse Debra McLeod asked as she pulled on gloves. Barnes nodded, and the nurse reminded her to relax. In a moment, it was done.

“Your first shot! Look at you!” McLeod handed Barnes the vaccination card and reminded her to come back in 21 days for the second shot.

“It didn’t hurt,” Barnes said with a grin before heading over to grab a bag of Chex Mix and a stick of beef jerky, plus a $25 Walmart gift card from Action NC. The advocacy group and community partner had its own tent in the parking lot to offer support and snacks. 

They’ve found that financial incentives can be motivating. When Barnes returns for her second shot, she’ll get a $50 gift card. 

“I know [Dr. Smith] wouldn’t give me something that would hurt me,” Barnes said later. She was one of the 75 people who got a Covid shot that Wednesday, most of them boosters. Yet, she was one of four women who got their first Covid vaccine. 

An hour later, Barnes was back in the office for her originally scheduled appointment. She broke into a grin when Smith entered the exam room, not waiting for the door to shut before announcing: “I got my vaccine!”

“I’m glad you got it,” Smith said. “Why do all of that hard work for your health and then you get Covid? This is something we can maybe control.” 

But what if Smith hadn’t asked Barnes about it at every appointment for the last 18 months? What if she’d let the third or fifth or tenth “no” derail her?

Barnes said she’s pretty sure she wouldn’t have gotten the vaccine.

“People will finally come through,” Smith said. “She finally came through.”

Sara Israelsen-Hartley is a Raleigh-based journalist and current public policy graduate student who writes about public health problems and solutions. Read more of her work here.