The lack of access to care around the state drags down North Carolina’s rating.

By Rose Hoban

North Carolina has fallen behind in the quality of and access to its health care system, according to a new survey by the personal-finance website Wallet Hub.

One of the state’s leading health economists said it’s not surprising given some of the economics of North Carolina and the fact that its residents have some of the highest rates of obesity, diabetes and heart disease in the United States.

Mark Holmes
Health economist Mark Holmes. Photo courtesy of the UNC Gillings School of Global Public Health

Mark Holmes, who heads the Sheps Center for Health Service Research at UNC Chapel Hill said the first place to look is at resident’s health risk behaviors.

“We’re in the stroke belt, how do we compare in some of our behaviors,” Holmes said. “We know we are a little on the more obese side, our income is lower than the average state. All of these lead to generally less healthy people.”

The survey, which took into account cost, access and outcome, found North Carolina ranked 40th among states.

No coverage, no access

Even with high enrollment in the insurance marketplaces under the Affordable Care Act, North Carolina still has one of the highest rates of uninsured people in the country. Wallet Hub ranked North Carolina 44th in the country for access to care.

A recent report by the U.S. Census found North Carolina’s rate of uninsurance has dropped to 11.2 percent in 2015, the 11th highest in the country, down from 15.6 in 2013, just before the Affordable Care Act went into effect.

The U.S. average is 9.4 percent of residents who lack health insurance.

Source: WalletHub

Brandy Bynum, a policy analyst with Rural Forward NC, said the combination of lower rates of insurance and the lack of resources, particularly in rural counties, accounts for the state’s poor ranking on access. For example, physicians in North Carolina cluster in urban areas, leaving 84 counties below the state average number of physicians per capita.

Rural counties are “more likely to be impoverished, because of other social determinants, such as access to employment,” Bynum said. “That leads to higher poverty numbers.”

Sometimes the barriers to access in rural communities are banal.

“Just having the transportation to access a primary care provider on a routine basis is problematic in rural communities,“ Bynum said. “The geographical distances across a county, from one end to the other, just depending on where you live, it can be prohibitive. Those are social determinants that determine access to health beyond cost and affordability.”

Six of the top 10 states in the Wallet Hub study were places where lawmakers have decided to expand the Medicaid program. And without Medicaid expansion, many of the working poor who earn less than $16,000 have little access to insurance to help pay for care.


North Carolina is about in the middle of the pack when it came to cost of care, which Wallet Hub analysts calculated using the average costs for medical and dental visits, insurance premiums and out-of-pocket spending.

When asked whether the dominance of Blue Cross Blue Shield of North Carolina might increase costs in North Carolina, Holmes said that’s actually not the case.

“The fact that our health insurance market is more concentrated than typical, actually that would lead one to expect lower costs because an insurer might be able to drive down price through market power,” he said. He explained that dominant insurers can squeeze hospitals and providers for better deals in exchange for being in-network.

“Having less competition might not create the downward [price] pressure that we’d expect in a regular market, like in a grocery store,” he said.

Mark Hall from Wake Forest University said that because more people are uninsured and because the state has not expanded Medicaid, more people are paying out of pocket.

“There’s more uncompensated care that may feed back into the unit pricing,” he noted.

Without coverage, North Carolinians often seek medical help when conditions are at their worst and most expensive to treat rather than taking advantage of preventive medicine such as primary care checkups.

Some opponents of Medicaid expansion disputed the cost savings of expansion, pointing to studies that showed spikes in emergency room visits by the newly insured, but others — such as one UCLA survey — found that spike to be temporary.

Hall also said that increasing consolidation among providers could be driving up costs – bigger physician groups and bigger hospitals can push back against BCBSNC when the two sides negotiate prices.

“You’ve had these previously competing hospitals merge, in Asheville, Greensboro, Wilmington and in other areas of the state,” Hall said.

All of the factors studied – cost, access and quality – are interrelated, Holmes said. Cost and access play into the quality and outcomes of care.

“When you don’t have access sometimes that leads to more costs which will lead to poorer outcomes, which leads to higher costs,” he said.

That’s part of why North Carolina has some of the country’s worst outcomes on measures such as infant mortality, which recently ticked up for the first time in years, and the rate in rural areas of the state – especially for African-Americans – are higher than in the lowest ranking state in the country.

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Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...

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