The initial charge of the Kate B. Reynolds Charitable Trust was to provide medical care for people who couldn’t afford it. Seventy-five years later, that work has evolved and intensified as the Trust continues to work toward a system where all North Carolina residents can access equitable care regardless of race, place, ethnicity, or socioeconomic status.
“When Kate B. Reynolds started the Trust, it was to benefit families of the region and the state who lived with low incomes, who were marginalized, disenfranchised, and many of them at the time, minority.”
Former President, Kate B. Reynolds Charitable Trust
Today, North Carolina is at a critical point in making health care accessible to every resident. Nearly 10 years after North Carolina rejected Medicaid expansion offered in the Affordable Care Act, the policy is back on the table and under consideration by lawmakers. If passed, expansion could provide health insurance for up to 600,000 people in our state.
Achieving equitable health outcomes means increasing access to affordable health insurance. Regardless of the outcome of Medicaid expansion, the Trust will remain focused on providing resources for uninsured residents and working for systemic change to help everyone in the state access health care.
“It’s a societal fantasy to think that philanthropy and charity care can fill a gap this big. When we decide as a state that we are not going to expand Medicaid, we are deciding as a state that we are going to let people die. If we don’t expand, we’ll continue to pay for it in higher insurance premiums, we will pay for it in hospitals closing, we will pay for it in poor health outcomes.”
Dr. Laura Gerald
President, Kate B. Reynolds Charitable Trust
The Trust’s initial approach to access in the 1940s was direct payments to hospitals for “charity care.” The concept of employer-sponsored health insurance (ESI) was just starting to take hold post-World War II. For most Americans, health insurance was still out of reach and if a person couldn’t afford to pay for their health care, another person or entity covered their bill. In these early years, a significant portion of the Trust’s funds went to these payments to hospitals.
“Before the rise of Medicaid, Medicare and health insurance, these payments from the Trust to the hospitals were significant.”
Director of Programs, Kate B. Reynolds Charitable Trust
North Carolina was one of the last states to adopt the Medicaid program in January of 1970. ESI was now widespread, and the addition of Medicaid boosted hospitals’ budgets, making payments for care more complex and less effective. Trustees (then the Trust Department of Wachovia) got court approval to stop making direct payments to hospitals. They felt there were more ways to have an impact on people’s health than recurring hospital payments.
Expanding Access to Health Care
In 1974, the Trust established the Program on Access to Health Care (PAHC). PAHC connected providers of health services to communities, monitored health needs, identified access problems, and developed solutions to those needs. The PAHC funded many initiatives like the Emergency Room Physician program, which extended doctor’s services into rural areas, and provided preventative and corrective dental care for children in specific public schools.
After the PAHC ended, the Trust continued to assist vulnerable populations through grants that aimed to make health care accessible, establishing the North Carolina Medical Society Community Practitioner Program, which deployed hundreds of physicians to rural areas to address issues missed by federal and state funds.
“The Trust was ahead of its time in addressing social drivers of health. I mean everything, from the aspect of access to dental to long-term care. The Trust really addressed people’s needs throughout the state.”
Former Health Improvement Advisory Council Member
In the late 80s, North Carolina had a growing number of residents who were uninsured, had low incomes, couldn’t afford private health insurance and were not eligible for Medicaid. With Medicaid, Medicare, and private insurance transforming access, Trust leaders determined they couldn’t make a significant impact without altering the grantmaking strategy to focus on changes in health insurance coverage and the remaining gaps of an inequitable system.
The Trust helped start Community Care of North Carolina (CCNC), which launched in 2001. CCNC works to improve health and quality of life by building better community-based health care delivery systems and supporting Medicaid and Medicare enrollees. During the program’s early development, the Trust provided six grants totaling more than $1.6 million.
“Health insurance was the only way to continue Mrs. Reynolds’ original vision. The Trust now works to ensure those not covered by private insurance have the resources to access Medicaid and Medicare.”
The passing of the Affordable Care Act (ACA) in 2010 expanded insurance options at all levels and dramatically decreased the uninsured rate in North Carolina. But the lack of Medicaid expansion left a gap in coverage for people who make too much money to qualify for the current Medicaid system and earn too little to afford private insurance. At the same time the state is changing the way Medicaid benefits are delivered to current recipients. These changes are meant to create more budget predictability for the state, but they also create greater potential for people to be denied services or fall through the cracks.
Medicaid is a joint state and federal program that pays for the care of approximately two million North Carolinians, or about 20 percent of the state’s population. Because our state has not expanded Medicaid, most Medicaid recipients in North Carolina are children, pregnant women, seniors, and people with disabilities. While advocating to close that coverage gap, the Trust focused on connecting uninsured people to health insurance through enrollment. To help individuals understand their health insurance options, the Trust convened Navigators to provide ACA enrollment education and support and supported a call system for people to receive additional assistance. The Trust has invested approximately $17 million since 2010 to help boost ACA enrollment and close the coverage gap in the state.
Today, North Carolina is moving toward a value-based care model. Value-based healthcare is a delivery model in which providers, including hospitals and physicians, are paid based on patient health outcomes.
The largest experiment implementing value-based care in North Carolina that most impacts communities with low incomes is the remaking of the state’s Medicaid program. Value-based care and Medicaid reform hold the promise to provide better care at lower costs. But a change of this size and scale also can reproduce or exacerbate the deficiencies and disparities of the current structure.
In 2020, in anticipation of implementation of Medicaid transformation, the Trust invested nearly $1.5 million in organizations focused on understanding the experiences of Medicaid enrollees and creating strong feedback loops. The Trust supported Care Share Health Alliance to host stakeholder convenings and the National Health Law Program, in partnership with the North Carolina Justice Center and Disability Rights North Carolina, to support consumers participating on advisory committees to the new Medicaid plans. Other organizations received funding to educate Medicaid enrollees on their rights under reform and provide legal representation for enrollment and service denial appeals.
In July 2021, Medicaid transformation went into effect in North Carolina resulting in about 1.7 million people in the state experiencing a change to their Medicaid insurance. Despite the state’s marketing push and outreach efforts, a quarter of people with Medicaid didn’t know about the transition last year, according to a study from an advocacy group. Data from the Medicaid Ombudsman’s office show that thousands are still confused about their insurance.
Amplifying Community Voices
The Trust is prioritizing feedback loops and working to amplify the voices of those affected by Medicaid transformation to hold the system accountable and to work to decrease health disparities. There is immense value in connecting community members with health care systems to provide information about what is really happening. The Trust is investing in several communities—including Mecklenburg, Durham, Robeson, and Rockingham counties—to build more significant connections between existing health systems and community-based organizations and promote how health systems can align with communities and drive local priorities. Representing the interests of low-income individuals and providing them with opportunities to ensure their voices are heard is critical to this work.
The Work Doesn’t Stop at Medicaid Expansion
The Trust believes that even if Medicaid expansion becomes a reality in North Carolina and Medicaid transformation is successful, more work is needed to improve health outcomes across the state. The Trust and its partners must continue to ensure enacted policies don’t create additional burdens and barriers. Grassroots efforts are essential in helping the uninsured access insurance coverage. Additionally, the Trust will continue to amplify the voices and experiences of people who have utilized Medicaid at critical points in their lives to showcase its value, diversity, and extensive reach.
“We must stay focused on what is happening—is health actually improving? If not, what resource can we provide to ensure health outcomes improve? We must continue working with the state around implementation and continue to center the voices and experiences of the people who have Medicaid. Ultimately, access to care is just a vehicle to improving your health.”
Dr. Laura Gerald