North Carolina, Medicaid, and the Cost of Putting Politics Before People

North Carolina has never had a simple relationship with Medicaid.

From fee-for-service to the transformation of Medicaid Managed Care. Behavioral health plans. Foster care health plans. Merged health plans. A decade-long delay of Medicaid expansion. A budget impasse almost every single year over the state funding required just to keep the program running.

With that history as the backdrop, it is no wonder that beneficiaries struggle to understand what they are actually entitled to. The system was never designed to be easy to navigate. And for many of the people who depend on it most, the complexity alone is a barrier to care.

Now layer on what is happening nationally.

Unprecedented cuts to the social safety net. A wave of layoffs hitting working families. A health insurance marketplace whose future remains uncertain. A political moment where ideology is moving faster than impact assessments and the people absorbing the consequences are the same people who were already holding on by the thinnest thread.

Here is the truth about Medicaid that gets lost in the political noise: this program serves a majority of women, children, and people with disabilities. The population that, regardless of where you stand politically, we should all agree deserves to be protected.

When political ideology takes precedent over people’s lives, we all pay the price. Every single one of us.

The Entire Ecosystem Is at Risk

This moment is not just a Medicaid crisis. It is a healthcare ecosystem crisis.

The DSS offices already stretched beyond capacity, historically underfunded and understaffed, now asked to absorb more. The hospital systems balancing budget sheets against the complex web of reimbursement models required to keep their doors open. The managed care organizations/insurance companies who, if we are honest, profit most from this ecosystem and have the greatest responsibility to show up differently right now. And the nonprofits who have always done extraordinary work with extraordinarily little, now being asked to do even more with even less.

Every layer of this system is feeling the pressure simultaneously. And when every layer is under strain at the same time, the people caught in the middle are the beneficiaries who have nowhere else to turn.

This Is Not a Doom and Gloom Story

The future does not have to be as bleak as the current moment suggests. But only if we make a deliberate choice to lead with humanity first and capitalism second.

That means corporations and philanthropy cannot pull back right now. The instinct to protect budgets in uncertain times is understandable. It is also dangerous when the organizations filling critical gaps in community health depend on that funding to survive.

That means managed care organizations have to look beyond the bottom line and ask whether the benefits they are contracted to provide are actually reaching the people who need them. That means all of us, individually and institutionally, have to sit with an uncomfortable question: what kind of future are we building, and who gets left out of it?

We are living in a moment that will define the health of communities for a generation. The decisions being made right now in budget meetings, in legislative chambers, and in boardrooms will ripple forward in ways we cannot fully anticipate.

The cost of inaction is not abstract. It shows up in maternal mortality rates. In children without consistent healthcare. In families navigating a system designed to be confusing on purpose.

At Future Forward Impact, we believe health equity is not just a program. It is a choice. One that has to be made every day, at every level of this ecosystem. I spent years inside a Medicaid managed care organization watching benefits go unused because the system made access too hard. I built Future Forward Impact because I believed we could do better.

What made you decide to do something about it in your corner of this ecosystem? I’d love to hear your story below.

The storm is here. How we respond to it is still up to us.