By Clarissa Donnelly-DeRoven

This is the first story in a series examining how NC Medicaid’s Healthy Opportunities Pilot is going

Since April 2020, 52-year-old Mary K has fought off one health problem after another: First, it was the rare flesh-eating bacterial infection necrotizing fasciitis and then infection with MRSA, an antibiotic-resistant strain of staph. Then came a case of pneumonia. Finally, a cut on the bottom of her toe progressed into a bacterial bone infection, which later required the amputation of her big toe and eventually her entire leg below the knee. 

Throughout, the Hendersonville resident was bedridden and unable to work. She lost her ability to drive and started missing payments on her house. 

Also, she was uninsured, which, of course, made everything worse.

On top of her hospitalizations, Mary K already struggled with a handful of chronic conditions: diabetes, obesity, anxiety. Keeping these under control without reliable health coverage was a Herculean task. She’d get her insulin from a free clinic in Hendersonville, for example, but skipped regular exams and blood work when the overworked physicians there couldn’t fit her in.

After Mary K’s below-the-knee amputation, she applied for Medicaid. In the time it took her application to process, she started receiving tens of thousands of dollars worth of bills from her hospital stays. There was no way she could pay any of them. 

After a few months though, her Medicaid application was approved and she enrolled in the joint state-federal insurance program that provides coverage for low-income people. She learned her coverage would be retroactive, so the program would pay back medical debt she’d incurred while uninsured but eligible for coverage. 

Being on Medicaid enabled her to get a primary care doctor and regularly see an endocrinologist to monitor her diabetes. Also, with the program’s full-cost coverage of her insulin and other medications, she’d no longer need to rely on free clinics. 

But health insurance alone couldn’t solve all the medical-based problems she had to contend with. She’d lost her job, and without a right foot, she could no longer drive. In a small town like Hendersonville without reliable public transportation or cabs, that meant she had to rely on friends and family to take her everywhere.

One day Mary K was speaking with her case manager at WellCare, the company that manages her Medicaid plan. She told the woman she’d been getting most of her food from pantries, but she could only get there when she had a ride. Once there, the food bank workers usually only offered shelf stable goods, such as peanut butter, pasta or beans, foods that didn’t help her keep her diabetes or weight under control. 

During the conversation, her care manager determined Mary K qualified for a program North Carolina’s Medicaid office has been experimenting with since March: the Healthy Opportunities Pilot

Food as medicine

The pilot, abbreviated as HOP, currently operates in the western mountains, the Lower Cape Fear region, and much of the northeastern part of the state. Underlying the program is the idea that the state could lower the cost it pays for the medical care of the low-income patients in the program if it covers non-medical services — such as fresh produce — which have been shown to be good preventative care. 

Different community organizations in the regions signed up to provide these services to Medicaid patients. Food programs began offering their services in March, and in May organizations that offer various types of housing and transportation support joined the pilot program. 

Domestic violence agencies were supposed to join the HOP program in June, but that portion of the pilot continues to face delays.

baskets of fruits and vegetables — okra, peppers, zucchini, peaches, green beans, habaneros — sit on a table
Each week, Sonya Jones and other volunteers with Caja Solidaria pack food boxes for participants — both those through Medicaid, and those not enrolled in the program. Credit: Clarissa Donnelly-DeRoven Credit: Clarissa Donnelly-DeRoven

Mary K’s care manager connected her with an organization in her town called Caja Solidaria, the “solidarity food box” in English. Since 2020 the mutual aid organization has sourced produce from different farmers and built and delivered food boxes to low-income people around Henderson and Transylvania counties. 

Starting in March of this year, the organization was one of hundreds of community groups to join the HOP experiment. They’re doing what they’ve always done, but now Medicaid pays them for it. 

Five months into the program, Caja’s co-founder Sonya Jones says it’s going well. 

“We have 47 referrals,” she said. “We have really strong relationships with health care providers, so people know to talk about it. And then also our participants are talking with each other — they’re calling and saying, ‘call and figure out how to get on this program.’”

In addition to getting plenty of clients, Jones and others who work with the food programs say they have access to enough food to feed everyone. An added benefit: they’re mostly being paid on time.

“We’re trying to buy what we can from local farms and farmers,” Jones said. “We’re really trying to think in the long term about how to build and maintain wealth in this community.”

The program has also quickly proven its worth in the lives of people such as Mary K. Access to better quality calories has had a measurable impact on her ability to manage her diabetes.

“I was able to lower my A1C from 10.8 to 7.6,” she said. The hemoglobin A1C test measures average blood sugar over about three months. While still in the range of diabetes, Mary K’s decline was significant. 

“Even my doctor said, ‘Well, what did you do?’ And I said, ‘Well, I think that finally having the right mix of insulin, but I said I’m also trying to eat healthier,’” she said. ”The vegetables have certainly been a big part of that.”

Counteracting isolation

The Healthy Opportunities Pilot has also helped Mary K emotionally. Living in a small town without the ability to drive, she gets lonely. Each week she’ll go to church, Bible study and physical therapy, but that’s it. So, she looks forward to Jones’s visits on Friday afternoon — it’s a chance to chat and connect, and get some vegetables. Mary K has also found herself experimenting more in the kitchen, using borrowed cookbooks or other recipe suggestions to make something tasty out of some of the unfamiliar produce.

Also, because she expressed interest, Jones’s partner Dennis Lanigan brought Mary K some seeds, so she could start her own vegetable garden.

“They brought me some tomato plants. I planted some green bean seeds and they have sprouted up. I’ve already got them going up on a trellis,” she said. “I figure once I start harvesting them and they start coming in, I’ll share them with my church family. I won’t keep them all.”

Success hasn’t been as straightforward for the rest of the Healthy Opportunities Pilot. For example, many organizations describe the referral process as painfully clunky. Others describe how the scarcity of any housing  — let alone affordable housing — negatively impacts their ability to show the value of their support. And finally, organizations are struggling to participate simply because many people on Medicaid don’t even know the pilot exists. 

While nearly everyone involved in the program believes it’s bursting with potential, many of those same people worry that unless some fundamental aspects of the program change, it’ll be unlikely to reach all its goals. Healthy Opportunities could end up unable to prove that the state can, in the words of former state health department secretary Mandy Cohen, “buy health” rather than “buy health care.” 

Though that’s certainly what the program has done for Mary K.

Next: For a program bursting with potential, there sure are lots of bumps

Correction: a previous version of this story referred to Dennis Lanigan as Sonya Jones’s husband. He is her partner.

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Clarissa Donnelly-DeRoven covers rural health and Medicaid. She previously worked at the Asheville Citizen Times where she reported on the police, courts, and other aspects of the criminal justice system....