Lessons From Community on NC Medicaid Expansion Enrollment

As of May 3, 2024, North Carolina has enrolled 447,498 residents into Medicaid since expansion began in December.

This massive progress in improving access to care has been fueled by volunteers, community-based organizations and backbone agencies leading effective outreach and enrollment efforts in communities across our state.  

The returns on Medicaid enrollment totals are encouraging. The NCDHHS Medicaid Expansion Dashboard shows that Robeson County, a rural southeastern community that has historically experienced health outcomes that rank among the lowest in our state and nationally, has enrolled 14.9 percent of its adult population. However, neighboring rural counties experiencing similarly poor health outcomes are enrolling at rates significantly lower. While 75 percent of urban residents have enrolled, only 25 percent of eligible rural adults have signed up. High rates of enrollment among any community is a positive change, but if outreach efforts fail to engage communities that are traditionally excluded and marginalized, existing health disparities could worsen. 

To learn more, we connected with grassroots organizations and regional coalitions directly engaging underserved populations. Key early lessons from insights shared by Care Share Health Alliance, Peletah Ministries, and El Refugio, emerged: 

  1. Targeted messaging about Medicaid to specific audiences is critical to ensure equitable enrollment. 
  2. Relationships in communities damaged by institutional harm must be repaired, so trust can be built.   
  3. Active outreach that centers the needs and lived experiences of excluded groups increases engagement. 
  4. Be prepared to listen to community voices.

Invest in robust, targeted messaging to center equity. 

Investing in a communications and outreach plan that centers the needs, concerns and lived experiences of all impacted communities is critical. This requires governing agencies to be aware of and in-tune with presuppositions, biases, concerns, and fears experienced by groups that are often least represented. It’s also important to consider how diverse audiences access and consume information.  

Hollis Smith, the Medicaid expansion outreach and education coordinator for Care Share Health Alliance, said, “While the state has promoted messaging about Medicaid expansion, misinformation and disinformation remain prevalent and require more targeted efforts.” 

The most prevalent myths Smith identified include: residents with a criminal record are ineligible to enroll; eligibility is tied to the asset thresholds associated with other public benefits; Medicaid is a form of Medicare; immigrant communities are at risk of public charge; and that Medicaid is for employed parents of young children. Unfortunately, many of these falsehoods dwell both in community and in local Medicaid agencies, particularly, in rural areas where access to reliable information sources is at a premium. Smith noted that stigmas around government-provided benefits stem from long-standing and destructive social narratives about people who use them.  

“In many rural communities, being enrolled in government programs carries perceptions that prevent eligible, working-class North Carolinians from signing up,” said Smith.  

Care Share Health Alliance has been a backbone supporter of expansion by providing grassroots organizations and other stakeholders with resources to support Medicaid expansion outreach through virtual and in-person trainings across NC. These trainings, cosponsored by Care Share and the North Carolina Community Health Center Association, have been offered in collaboration with policy experts and community-based organizations with lived experience on how to meet residents where they are.  

Their collaboration also includes the NC Navigator Consortium, a highly trained network of nonprofit organizations offering enrollment assistance in all 100 counties. Free in person and virtual appointments can be scheduled online at ncnavigator.net or by phone at 1-855-733-3711. Partnership with navigators on the ground in diverse communities has helped identify harmful misinformation and supported the collaborative’s ongoing effort to engage individuals and families where enrollment rates remain lowest. Older individuals with low technology literacy, Black residents, and men in general were identified as key target audiences. 

Relationships damaged by institutional harm must be repaired. Pursue authentic partnership with local organizations that have built trust. 

Peletah Ministries, a faith-based organization located in New Bern, NC, works regionally to connect residents with Medicaid enrollment and healthcare resources. It leads by forging partnerships to provide solutions to pressing community health issues.  

Earlier this year, Peletah hosted its sixth annual Eastern North Carolina Regional Church & Community Resiliency Collaborative at St. Peter AMEZ Church. This day-long collaborative saw community members, clinicians, service organizations, advocates, and enrollment navigators participate in open conversations directly connected to their lived experiences. As Peletah’s executive director Dr. Dawn Baldwin Gibson reminded the audience, “the wisdom was in the room!”  

Institutional mistrust emerged as a core theme. Many residents offered vulnerable contributions reflecting wounds inflicted by previous experiences within the health care system. Whether it was an anecdote about a loved one who experienced a poorer health outcome or the sharing of a firsthand experience, there was a collective need for repair and healing. Conversation was led around building community advocacy groups and care teams for residents in the health care system, so people aren’t forced to individually hold providers accountable. Attendees of the Resiliency Collaborative also learned more about how they can be advocates for themselves or a loved one receiving long-term care.  

The institutional skepticism that exists in many disinvested communities is often a direct product of negative systemic interactions. Peletah, like many grassroots organizations, faces the daunting task of asking its community to engage with systems that have damaged relationships and allowed them to become increasingly tenuous over time.  

Local and state agencies must partner with and support organizations, like Peletah, that have built momentum and established deep community ties as a part of the trust-building process to ensure access to Medicaid is equitable. 

Creative enrollment outreach that centers traditionally excluded populations can improve enrollment rates across the board. 

The need for institutions to build trust in partnership with local organizations is underscored by El Refugio’s success in leading Medicaid expansion outreach. El Refugio provides language and citizenship classes, family enrichment activities, legal information, and resource connections to Latinx residents. Executive Director Yanira Vanegas Scott shared that a local health department infant mortality program hosted at its facility was a bridge that built institutional trust at the local level. Creativity has also helped El Refugio enroll residents in Medicaid while building a culture of health awareness among a community that has been underserved.  

Last December, El Refugio hosted a free holiday dinner with Santa Claus and invited the NC Navigator Consortium to present and answer specific questions about Medicaid expansion and enrollment. 

“Oftentimes, the political culture and dearth of unbiased news access in rural communities has a major influence on how underrepresented communities seek care,” said Vanegas. “Many residents we serve work long hours past when many local agencies close, and parents with young children have to provide care at home. By hosting an event that was family friendly and in a safe space, community members could ask direct questions to trusted information sources. Individuals were then able to enroll and be exposed to available services.” 

Across the state, some of the major wins of Medicaid enrollment outreach have come in the form of community block parties, baby showers, and other collaborative events that engage populations by creatively meeting people where they are. This degree of detailed consideration, if applied universally, could boost enrollment rates, and similarly shift how residents in our state value and seek health resources.  

Don’t invest in a bullhorn, without first purchasing a headset. Be prepared to listen.  

Communication needs to happen in circles rather than through chains. Strong feedback loops that center the voices of communities, especially those who stand to benefit most from any public health initiative, is another essential component. Seeking sporadic feedback from those most impacted or inviting community voice only in the waning stages of the process perpetuates power imbalances and aggravates systemically inflicted wounds. When organizations listen to residents, they hear some people’s concerns around Medicaid revolve around provider shortages, transportation access, and overall accessibility.  

Statewide organizations and individuals who hold power must listen to community questions and issues and create space to make connections to local groups on the ground. Grassroots organizations only have so much capacity to run the feedback up the chain, and the timeconsuming work can take them away from the on-the-ground work they’re established to do. 

Listening to those most impacted by inequities and to those who will benefit from Medicaid is critical to ensuring equitable access to care. In Medicaid enrollment and health care in general, connecting authentically with the people programs aim to serve is crucial to success and to a thriving, equitable state.