Fifty years ago this week Medicaid and Medicare were signed into law. These two programs provide children, seniors, people living with disabilities and working families with access to the health care they need. To celebrate 50 years of these two programs, each day this week one of our partners will share a story about their work to ensure more people can access Medicaid. We’ll also be reflecting on the two programs and what’s ahead. 

After the murder of nine African-Americans in a Charleston, South Carolina, church last month, Rev. William Barber, the President of the North Carolina NAACP and leader of the “Moral Mondays” movement, said, the best way to honor the legacy of Reverend Clementa Pinckney and the other victims, was to overturn voting rights restrictions and expand Medicaid eligibility. As we approach the 50th anniversary of Medicaid, Barber’s comments are of particular importance. Health care in North Carolina, and the country more generally, continues to be seen as a privilege not a right. But without health coverage, North Carolinians are more likely to see their health compromised, impacting both their quality of life and their mortality. Health care access, like low wages, is a measure of the inequality that is rending the fabric of our communities.

Rev. Barber draws attention to Medicaid because North Carolina is one of 21 states—11 in the Southern region of the U.S.– that have refused federal funds allocated by the Affordable Care Act to provide health coverage to all adults living in households with incomes below 138 percent of the poverty level. Currently, Medicaid coverage in the state is restricted to extremely poor parents (household income below 40 percent of the federal poverty level or $667/mo. for a three-person family), pregnant women, and children. Nonelderly, nondisabled adults without dependent children are ineligible regardless of income.  About 500,000 North Carolinians could benefit from expanded Medicaid coverage, according to the North Carolina Justice Center. Of these, 300,000 have no other coverage option.

A recent paper from the Paraprofessional Healthcare Institute (PHI), “Too Sick to Care: Direct-Care Workers, Medicaid Expansion, and the Coverage Gap,” indicates that of North Carolinians who are affected by the Medicaid coverage gap nearly 10 percent are direct-care workers—the home health aides, personal care aides, and nursing assistants who provide support to the state’s elders and people living with disabilities. About 45,000 direct-care workers live in households with incomes below 138 percent of the poverty level. Moreover, 29,000 of these workers live in households with incomes below 100 percent of FPL. These workers fall in the “coverage gap”: they have no new options for health coverage under the Affordable Care Act, because they are ineligible for federal tax credits that make buying insurance on the state marketplace more affordable.

Direct-care workers provide 80 percent of the paid hands-on care for elders and people living with disabilities. As the recent profile in the Raleigh News and Observer documented, this is strenuous, emotionally difficult work that is essential to the dignity and health of North Carolinians who need assistance with personal care and other tasks that many of us take for granted. It seems particularly ironic that these care providers are forced to go without care themselves.

Medicaid coverage is especially important to North Carolina’s direct-care workers because fewer than one in two has access to an employer-sponsored health plan. In some cases, employers—whose primary revenue often comes from providing Medicaid funded long-term services and supports—don’t have the resources to offer affordable coverage; in other cases, erratic and part-time hours, which are typical for home care aides in particular, make workers ineligible for coverage. 

North Carolina, like much of the country, has an aging population. An additional 22,000 direct-care workers are needed by 2022 to meet the state’s eldercare needs. But finding and keeping workers is becoming increasingly difficult. It’s not surprising: wages are low, injury rates are high, and employer-sponsored health coverage is uncommon. The result is that one in two workers leave the field annually. Anyone who needs care or manages care for a family member knows viscerally what this means: a parade of ever-changing aides who lack experience and who don’t stay long enough to build the quality relationships upon which good care is built. It is tough on the family, and even tougher on those who depend on the care provided.

Closing the coverage gap in North Carolina is an opportunity to address multiple issues, from the economic and racial inequality Reverend Barber seeks to address to providing quality long-term care services. The latter has been on the agenda of North Carolina aging services for nearly a decade. The NC NOVA program awards long-term care providers for investing in training, mentoring, and other workplace innovations that improve the quality of direct-care jobs and, as a result, the quality of care. The state should take the next step and ensure that all direct-care workers have access to affordable health coverage—a healthier, more stable workforce is absolutely essential to meeting the needs of North Carolina’s elders and people living with disabilities.

Jodi M. Sturgeon, President, PHI
Thomas R. Konrad, Ph.D. 

Jodi M. Sturgeon is the president of PHI, a national nonprofit that fosters dignity, respect, and independence– for all who receive long-term care, and all who provide it. PHI is the nation’s leading authority on the direct-care workforce. This week, PHI released “Too Sick to Care: Direct-Care Workers, Medicaid Expansion, and the Coverage Gap,” which examines how the direct-care workforce is affected by state decisions not to expand Medicaid eligibility.

Thomas R. Konrad holds a Ph.D. in sociology and recently retired from the University of North Carolina at Chapel Hill, where he conducted healthcare workforce and workplace research for over 40 years, while at the Cecil G. Sheps Center and the North Carolina Institute on Aging. Dr. Konrad developed and evaluated training programs for direct care workers in various long term care settings and has conducted numerous studies of the impact of health care workforce development and workplace redesign on care outcomes with support from federal, state and foundation sources.