To work right, Medicaid expansion requires additional action

The North Carolina General Assembly’s recent expansion of Medicaid is a vital step to reducing the health inequities that produce a constellation of preventable harms.

But North Carolina is not prepared to reap the full benefit of expanding Medicaid. We cannot in good conscience improve the affordability of care and not address the lack of primary care health professionals necessary to deliver it. We must expand the healthcare workforce sufficiently enough to ensure care is available for all North Carolinians, including the newly covered.

We know there are two reasons people living in medically underserved communities are less likely to have a regular “healthcare home” and access to consistent care: they lack insurance to pay for it and there aren’t enough primary care providers to see them.

For example, 80 of North Carolina’s 100 counties don’t have enough primary care providers to properly care for residents, according to the North Carolina Rural Health Association’s 2022 NC Rural Health Snapshot. For individuals and families living in these areas, the ability to pay for healthcare is only part of the solution.

We can meet the increased demand for quality primary care in North Carolina with nurses, the largest, highly skilled and most trusted segment of the healthcare workforce leading healthcare transformation in North Carolina. If we re-imagine the role of nurses, our state can make significant progress in reducing health inequities and healthcare costs.

First, we must eliminate restrictive regulations on North Carolina’s Advanced Practice Nurses. These highly skilled clinicians are currently prevented from practicing at the full extent of their training and education – a major barrier for the provision of interprofessional and collaborative care in North Carlina. These restrictions remain in place even though when evaluated as a whole, the majority of available research suggests that there is no reduction in quality or safety of care delivered by APRNs compared to primary care MDs.

Second, we must deploy the state’s more than 150,000 registered nurses in new and innovative ways. For example, they can assess the acuity of illness and ensure care coordination, conduct routine health assessments and screening, and assist patients and their families with health education and chronic disease management. And they can do it across a range of settings including, schools, community organizations, mobile units, home visitation, and telehealth.

As a nurse, I know the power of this kind of support. People who have an ongoing relationship with a healthcare provider get care regularly and are less likely to experience disease progressions that require disruptive and expensive emergency care. This is good for them, for their families, and for the community.

The SAVE Act, introduced by a bipartisan group of legislators and currently in consideration at the General Assembly, removes the restrictions and increases access to routine and consistent care for the newly insured and other under-served people. And when the health of the state’s population improves, there are significant cost savings for the public health system, government agencies, and taxpayers.

Medicaid expansion will ease the economic burden on roughly 600,000 North Carolinians without health insurance and removes significant barriers to getting the health services they need and deserve. In the long term, this coverage reduces unnecessary healthcare expenditures stemming from untreated and poorly managed chronic health conditions. Thanks to Medicaid, more people benefit from health promotion and prevention, chronic disease management, and specialty services like sexual and reproductive health and mental health care.

But the expansion will also put additional strain on the already-stretched primary and specialty care workforce in rural areas and under-served urban communities. Reimaging the role of the nursing workforce and removing regulatory restrictions that limit how nurses can better respond to the health of North Carolinians is in the best interests of all.

Dr. Vincent Guilamo-Ramos is a nurse practitioner and dean of the Duke University School of Nursing. Photo: Duke University.