‘A Win-Win-Win’ for N.C.’s Healthy Opportunities Pilot 

In a recent webinar, North Carolina health care leaders were jubilant. 

“We are changing lives,” said Dr. Betsey Tilson, state health director and chief medical officer at North Carolina’s Department of Health and Human Services. “This is a win-win-win.”

NCDHHS Secretary Kody Kinsley agreed: “The wall was hard to scale. That just underscores the power of this work.” 

“I’ve never seen a program this effective at getting health into rural communities,” said Blake Hart, executive director of Haywood Christian Ministry in Western North Carolina.  

The reason for the enthusiasm: North Carolina’s Healthy Opportunities Pilot, a $650 million health-promoting initiative designed and run by NCDHHS, in which Hart’s organization is a participant, had been evaluated and the findings were publicly presented on the webinar.  

The evidence was indisputable: the program is succeeding. 

The Assembly reported on the Healthy Opportunities Pilot (HOP) in 2022, shortly after it launched. At the time, the initiative was slow to get off the ground; potential beneficiaries were trickling in and participating organizations were still finding their way. It wasn’t clear then whether the pilot would achieve its aims of improving people’s health by strengthening the conditions in which they live. 

The concept that those conditions—access to food, housing, and transportation, in particular—have a greater effect on individuals’ health than medication or doctor visits is now widely accepted among health care researchers and practitioners. But North Carolina’s initiative is one of the most ambitious efforts in the country to apply those principles to residents enrolled in Medicaid, a public health insurance program for lower-income people.

Covering three parts of the state, 33 counties in total, the pilot is designed to work like a set of gears. In each region, a health-focused agency coordinates a slew of local, community-based nonprofits to provide direct services to eligible Medicaid members. 

The evaluation, an interim report by UNC’s Sheps Center that examined outcomes between March 2022 and October 2023, showed that even if HOP was still getting up to speed, the principles on which it stood were sound. More than 13,000 people were enrolled during that period, and the non-medical services they received resulted in fewer emergency department visits and hospitalizations. The program saved Medicaid $85 per person per month—a notable amount in a field in which costs invariably seem to rise. And significantly, the longer enrollees remained in the program, the more the findings improved. 

“What impresses me is this is a pretty robust evaluation. You don’t always get such clear quantification of the impact you’re having,” said Heather Howard, a professor of health policy at Princeton University who works with states on health reforms. “The N.C. Legislature and DHHS should be really proud of what they’ve achieved.”

The program exists because of a Medicaid waiver, which allows states to design and test innovative health-related projects; it’s set to expire this October but will likely be extended until June 2025. The evaluators recommended that HOP be renewed by the Centers for Medicare and Medicaid Services for five years and extended to the entire state. That would require approval from the N.C. General Assembly, which has provided roughly a third of the program’s funding.  

“It’s a good program, but I’m not sure about the appetite in the General Assembly,” said Rep. Larry Potts, a Republican who co-chairs the Joint Legislative Oversight Committee on Health and Human Services. The evaluation is a start, he added, but more evidence is needed to “prove that this program is actually cost effective, and effective in its treatment.”

On the ground, some nonprofit leaders and observers say HOP isn’t ready to go statewide. In Northeastern N.C., for example—one of the state’s poorest and most unhealthy regions—community-based organizations offering transportation and housing assistance remain scarce. The program’s many moving parts don’t always work well together. And in such a rural area, simply educating eligible people about it is a challenge. 

“I’m still very disappointed by the response to HOP in this area,” said Dawn Daly-Mack, a registered nurse living in northeastern N.C. who worked at a community health clinic in Halifax County and, later, spent a year enrolling people in the pilot; she now works on an unrelated NC Medicaid program.. “I don’t see where it’s being mentioned to patients in the clinics the way it could be.” 

But the number of enrollees across the state has more than doubled since the evaluation, giving it some momentum. And success stories definitely exist. Cornerstone Community Based Programs, a church-based nonprofit in Eastern N.C.’s Beaufort County that provides food, housing, and transportation assistance for HOP, has been party to a number of them. 

“We have had several unhoused individuals find housing and assisted them with first month’s rent and security deposit, and with food insecurity,” said Tameka Spruill, a Cornerstone program manager. The organization has also been able to repair the homes of several people who were living with black mold or water damage. 

In 2022, The Assembly spoke with Regina Goddard, a disabled Beaufort County resident who was saved from homelessness by HOP assistance with first and last months’ rent. 

Two years later, Goddard is still struggling in some major ways. Her hernias have continued to give her trouble, and she’s had more surgeries and extended hospitalizations. And her prior landlord sold the property, so she’s now in a new place that she considers temporary. 

But Goddard says her life would be even worse without HOP assistance. “They call me every Monday; they’re helping me look for a new place,” she said. “If it weren’t for them, I’d really be in a bind, I would.” 

Correction: This story initially included the wrong first name for Dr. Betsey Tilson. It has been corrected.

Amanda Abrams is a freelance journalist in Durham, N.C.