New data from NC Child, a Raleigh-based children’s health research group, shows that although 85% of Buncombe County mothers received prenatal care in 2017 — nearly 20 percentage points higher than the North Carolina average — the percentages of Buncombe babies born pre-term or with a low birth weight remain comparable to those across the state.
NC Child Deputy Director Rob Thompson claims that the lack of movement on those benchmarks is due in part to the connection between children’s health and whether parents have access to health care. According to 2017 data from the U.S. Census Bureau, 13.5% of Buncombe County residents were uninsured, close to the state figure of 12.6%.
“We’ve got too many uninsured parents in our state, and when parents are uninsured, kids suffer as a result. It has a negative impact on a parent’s ability to be a good parent,” Thompson says. “I know that if I’m not healthy, I don’t have the same level of attention and engagement that I do when I am healthy — and for parents suffering from chronic conditions, that’s even more pronounced.”
Thompson says that a central focus of this year’s NC Child legislative agenda, which uses research from the organization to promote public policy that benefits children’s health, is improving coverage rates for parents who fall into the insurance coverage gap.
“In our minds, the biggest priority for the state right now is closing this health insurance gap for parents,” Thompson says.
While Medicaid and the Children’s Health Insurance Program, both jointly funded by the state and federal government, ensure that around 97% of North Carolina’s children have access to health care, options for low-income adults remain limited.
“We have a very good insurance rate for children here in Buncombe County,” says Jackie Kiger, managing attorney at Pisgah Legal Services. “It’s really their parents who are often without the insurance, and that has an impact on that child in several ways.”
Kiger explains that the Affordable Care Act, which was signed into law by former President Barack Obama in 2010, required all states to expand Medicaid to address high rates of uninsured low-income adults. For North Carolina, this meant raising the income ceiling for adults to qualify for Medicaid from 40% to 133% of the federal poverty level, or about $17,236 per year for an individual. The law also provided subsidies for adults with incomes between 100-400% of the poverty level to purchase insurance through the Health Insurance Marketplace.
In 2012, however, the Supreme Court ruled that the Medicaid requirement was unconstitutional and left individual states to decide whether to expand the program; North Carolina is one of 14 states that have chosen not to expand Medicaid. While specific qualifiers are in place to grant insurance coverage to certain populations of low-income people, such as those with disabilities or women who are pregnant, the current law leaves as many as 500,000 adults statewide making between 40%-100% of the poverty level without government support for insurance.
“Right now in N.C., our Medicaid system is very specific. You have to be very low income and you have to fit into a certain type or category of person in order to qualify for coverage,” Kiger says. “If you are working a job making minimum wage, your employer doesn’t offer you coverage and you don’t make enough money to qualify for those ACA subsidies, then you’re left out of coverage.”
A solid start
Dr. Daniel Frayne, practicing family physician and president of Mountain Area Health Education Center, says that children’s health begins even before conception. Most low-income women become eligible for Medicaid when they become pregnant, but that coverage ends six weeks after delivery. This is important, Frayne says, because about 30% of birth outcomes are related to a woman’s health before conception.
“Mom’s health affects the child’s health. If we didn’t have prenatal care, of course we would have increased complications. But even if we’re doing the best in prenatal care, if we’re not addressing mom’s health before pregnancy, we’re not going to get the outcomes in children and the next generation that we want,” Frayne says.
Frayne explains that babies born to mothers who have untreated chronic illnesses, such as cardiovascular disease or diabetes, are at greater risk for developing the same illnesses. Levels of gene expression associated with certain diseases are influenced by a mother’s environment and have a greater impact on whether a child may develop a disease than other factors, such as diet.
“It really explains a lot of why we’re not getting the statistics and outcomes that we want, even though we’re doing great, high-class prenatal care,” Frayne says. “The more and more we learn about factors that determine future health, the more we understand that the environment in which babies grow determines health or illness later on in life.”
Asheville resident Jody Read says she lost her insurance coverage two years ago when she decided to start driving part time for Uber and Lyft. While her two teenage children have Medicaid, her increased income made her ineligible for the program but still unable to qualify for ACA subsidies.
“It’s an unbelievable situation to me. I’ve even looked at moving over the Virginia state line, because then I’m covered completely,” says Read. “It just seems really strange to me that I’m your average ordinary single-parent home, and there’s not a whole lot of options.”
Having quality medical insurance, especially Medicaid, is linked to financial and economic stability in addition to better health. In states that have expanded Medicaid, low-income adults are 25% less likely to miss rent or mortgage payments, according to Kiger.
“When you have good-quality healthcare coverage, there’s less medical debt, and less medical debt means that people aren’t at risk for bankruptcy. It means that they have the ability to have better credit scores; credit scores are linked to educational opportunities, employment opportunities, buying a vehicle, buying a home,” Kiger says. “Those are all factors that really come together.”
Read says that being the sole caretaker for her two children adds another layer to the stress and uncertainty that comes with not having health insurance.
“You know, it’s just kind of a Russian roulette with your health,” Read says. “It’s important that I stay alive to take care of these kids, and it seems that somewhere, somebody has to recognize that.”
Alternatives to Medicaid
In April, North Carolina Republicans introduced a bill that has gained bipartisan support — including sponsorship from local Reps. Chuck McGrady (R-Henderson) and Brian Turner (D-Buncombe) — that would expand Medicaid and help people who fall in the coverage gap. The bill, known as North Carolina Health Care for Working Families, has not yet been put up for a vote — and Kiger says now is the time for uninsured residents to speak out.
“We’re really encouraging folks to reach out to their lawmakers in both the House and the Senate to encourage them to put this bill up for a vote,” Kiger says. “It all ties back to a greater level of economic stability for kids here in Buncombe County.”
Meanwhile, local groups are working to ensure that parents and other adults who fall into the insurance gap in Buncombe County can access care. The Asheville-based Western Carolina Medical Society’s Project Access program provides free or low-cost health services to Buncombe and Madison County residents who do not qualify for ACA subsidies or Medicaid by providing access to a local network of more than 700 volunteer physicians.
“It’s not an insurance program, but it’s just a way to help the community to stabilize their health and help with preventative care,” says Mariela Solano, program director for WIN, an interpreter network affiliated with the nonprofit.
Solano says that primary care physicians can refer low-income patients into the program, where they have access to an extensive list of speciality services, ranging from acupuncture and dermatology to cardiovascular surgery and orthopedic care.
“People seem to think that this program is for the really poor or for those who just don’t want to work, but our greatest population that we actually serve are working class that have become sick and lost their jobs,” Solano says. “There’s so many people that would otherwise not have health care because they’re stuck in that gap.”
Frayne adds that MAHEC offers screening and preventative care to uninsured mothers during routine visits for children for up to two years after a child is born. He says the program, known as IMPLICIT, is just another way to take care of parents so they can care for their children.
“By doing that, we’re creating a strategy to mitigate our system that is not prioritizing women’s health,” Frayne says. “You can’t have healthy children without healthy parents. It just doesn’t work.”