By Jaymie Baxley
When Christina Schnabel’s son began having gastrointestinal problems a few years ago, his doctor didn’t prescribe medication. Instead, he prescribed a food box.
Schnabel, a single mother living in public housing in Henderson County, enrolled in North Carolina’s Healthy Opportunities Pilot after that visit. Through local food bank Caja Solidaria, she received boxes of healthy food — and her son’s symptoms cleared up.
What followed changed her family’s life. She took a job at Caja Solidaria. She got off Medicaid. She bought a house on her own.
“It was the Healthy Opportunities Pilot and Caja that has allowed this to happen for my family,” she said in an interview for The Root of Good Health, a new documentary about HOP produced by Beacon Media NC.
Advocates point to stories like Schnabel’s as evidence of what the program achieved — and what was lost when the state legislature halted funding for the pilot.
Nearly a year after North Carolina shuttered HOP, a first-in-the-nation program that used Medicaid dollars to address nonmedical health needs, the organizations that oversaw the initiative are still working to revive parts of it.
HOP launched in 2022 across three largely rural regions of the state. It provided Medicaid beneficiaries with services tied to the so-called social determinants of health — things like boxes of fresh food, removal of mold from houses and rides to doctors appointments.
While studies showed the program saved the state about $1,000 a year on participants’ health care costs and had a positive effect on local economies, state lawmakers declined to designate the money needed to keep it going.
Though services ground to a halt last June after funding dried up, the regional organizations that ran the program remained active. Now, two of those organizations have been selected to coordinate similar services using North Carolina’s share of a $50 billion federal funding pool aimed at improving health outcomes in rural communities.
On May 1, Impact Health, the entity that oversaw HOP in an 18-county stretch of western North Carolina, and Access East, which oversaw nine northeastern counties, were named as two of the five network leads for the state’s Rural Health Transformation Program. The N.C. Department of Health and Human Services was awarded $213 million by the federal government in January to set up the program.
NC DHHS, which hopes to receive $1 billion split into annual payments for the program over the next five years, said the money will be used to strengthen care delivery and expand access to services in rural communities, with a focus on many of the same food, housing and transportation gaps that HOP was designed to address.
Impact Health and Access East are among the five agencies selected to lead what the state is calling the ROOTS Hub. Short for Rural Organizations Orchestrating Transformation for Sustainability, the hub is designed to carry out the goals of the Rural Health Transformation Program across the state’s six Medicaid regions.
“Our selected NC ROOTS Hub Leads will bring together voices from across the state to deliver coordinated, impactful services that foster better outcomes and address the unique challenges our rural communities face,” Debra Farrington, deputy secretary of NC DHHS, said in a news release.
Laurie Stradley, CEO of Asheville-based Impact Health, said her organization applied to become a hub lead because it “learned so much about convening, collaboration and coordination” through HOP. At the same time, she noted that federal restrictions prevent the Rural Health Transformation Program from replacing the direct service funding that HOP had provided.
Under the terms of the federal award, ROOTS Hub funding is structured strictly as an infrastructure investment — it can be used to build care coordination systems, conduct needs assessments and support workforce development. The money cannot be used to pay directly for services like food boxes, transportation or housing repairs.
That means the hub must rely on separately funded programs in order to deliver on the services the Rural Health Transformation Program is designed to support.
“It’s really important to ground ourselves in the ROOTS Hub [being] about rural health — not about Medicaid,” Stradley said Friday during a meeting organized by the Mountain Area Health Education Center in Asheville. “I think we often conflate ‘poverty,’ ‘need’ and ‘rural’ as sort of one piece all tied up together, but there are some things about accessing rural health care that are difficult, no matter what your income status is.”
She offered a simple example: a flat tire. In a rural area without reliable transportation options, any disruption, regardless of a patient’s income, can mean missing a doctor’s appointment.
The same holds for what she described as the broader threat posed by federal Medicaid cuts. If reduced Medicaid reimbursements cause rural hospitals, emergency rooms or physician practices to close, even well-insured patients will feel the consequences.
“It does not matter what your income status is,” Stradley said. “You could have all the money in the world and if there is no obstetrician within three hours of you, you are primed for more child and maternal health risk.”
Building a new model
As Impact Health and Access East pursue the ROOTS Hub work, the state’s other organization that led a HOP network is trying to build a model that doesn’t depend on budget decisions or federal awards.
Community Care of the Lower Cape Fear, which oversaw HOP across six counties in the southeastern corner of the state, has used a planning grant from the New Hanover Community Endowment to develop a blueprint for a local “social care network” that draws on the HOP model but is designed to be payer-agnostic and insurance-independent.
“What we wanted to do is put together a social care network that would be a regional and community approach,” Sarah Ridout, the organization’s director of community programs, said in a recent interview with NC Health News. “This is not to move on from HOP, but to do something in parallel.”
Where HOP was funded through a single Medicaid waiver, the new network would allow a range of entities — hospital systems, health plans, local governments, philanthropies and researchers — to connect with vetted community-based organizations and pay for services according to their own goals.
A health plan, for example, might contract with the network to bundle food and education services around diabetes management for its members. A local government might use it to connect uninsured residents to resources that can help them navigate finding and obtaining care.
Ridout said the network would also retain HOP’s focus on housing, transportation and nutrition, while leaving room to expand into areas like workforce development.
“We’re open to also expanding to other services that would contribute to the health of an individual,” she said, “and then obviously the overall health and impact on the community.”
The model is also designed to address one of HOP’s persistent operational headaches: the administrative burden on the often-small community organizations that provided services to beneficiaries.
Under HOP, those organizations had to invoice and reconcile payments from as many as six managed care organizations at once. The new network would centralize some back-office functions, freeing up those organizations to focus on delivering services.
“We’re already talking to some interested entities [about] plugging into this,” Ridout said. “It’s very exciting that there’s already some interest.”
Ripple effects
While the debate over HOP’s future continues, advocates say the evidence of what the program achieved — and what was lost when it stopped — is growing clearer.
Stradley said HOP served more than 40,000 North Carolinians across its three regions and delivered more than 1.1 million services in its little over three years of operation. Participants, she said, showed improved health outcomes and reduced reliance on expensive forms of care like emergency room visits, hospitalizations and unplanned procedures.
The program also had a large economic impact. Stradley said HOP generated an estimated $86 million in reimbursement income flowing to partner organizations in western North Carolina alone. It also supported approximately 1,100 full-time jobs, with $138 million in total estimated business activity.
Statewide, the program generated an estimated $384 million in total business activity and supported close to 3,000 rural jobs. For every HOP dollar spent across the state, an additional 55 cents in economic activity was generated, according to an economic analysis led by Impact Health.
When the services ceased, organizations like Caja Solidaria — the Henderson County food bank where Schnabel works — felt the blow directly. At its peak, Caja Solidaria was serving 450 families and investing $2.5 million annually into the local economy by purchasing from local farmers. When HOP ended, Schnabel said, the organization had to lay off seven people.
The fight for funding
Despite the new federal program and the local innovations underway, the agencies that oversaw HOP still wish that state lawmakers would restore its funding.
Ridout argued that the state needs a program like HOP to make the Rural Health Transformation Program work.
“If these ROOTS Hubs are created and there aren’t programs that can plug into this where those resources are available, it’s going to be challenging for the state to meet the goals and objectives approved by CMS,” she said, referring to the federal Centers for Medicare and Medicaid Services.
(Community Care of the Lower Cape Fear applied to be the ROOTS Hub lead for one of the two regions that Trillium Health Resources was selected to oversee.)
At Friday’s meeting, state Sen. Ralph Hise, a Republican who represents several counties in western North Carolina, raised the question of whether a HOP restart might work best if it began in one region before expanding to others.
“If we can restart Healthy Opportunities, at least in this region, and we start going through expansions of the program, does it make sense, maybe even this time, to consolidate the restart to the region, and expand it out by regions?” he asked.
Stradley said she agreed with that approach. Because Impact Health has maintained its network of community partners over the past year — aided by private partnerships with organizations like Dogwood Health Trust and UnitedHealthcare — it could begin delivering services almost immediately while helping the other two regions, which largely dissolved their networks when funding ran out, rebuild from scratch.
“Because of our public-private partnerships in western North Carolina, we’ve been able to keep our network and our hub intact, and that wasn’t possible in the other two regions,” she said. “So they pretty much will have to start over.
“We’re ready to go day 1.”
KEEP UP WITH THE LATEST
Republish our articles for free, online or in print, under a Creative Commons license.
