Skip to main content

By Maggie Hynek

The discussion of access to care within North Carolina and the nation as a whole would be incomplete without acknowledging the crucial role of health insurance. Health insurance dictates if patients can afford treatment for severe conditions such as cancer or if a parent can afford a primary care provider for their child. In a country without universal healthcare, the policies and caveats pertaining to insurance are complicated and extensive. Jonathan Oberlander even describes United States health insurance as a ‘nonsystem’ made up of “…patchwork insurance arrangements,” (Oberlander). Therefore, I will be primarily focusing on the personal impact insurance has on quality of care and access to care rather than the policies themselves.

To properly understand the impact insurance has on healthcare, we must understand the basic structure of the United States insurance network, as well as how it has developed over the years. The insurance system is composed of both public insurance and private insurance options. Private insurance is offered through private companies and while it tends to be more expensive, these programs provide more benefits than public insurance programs. Many people can access private insurance through their employer (Chan). Since the mechanisms of private insurance vary between companies and is not financially accessible for many North Carolinians, I will be focusing more on public insurance programs.

Public insurance is composed of the Medicare and Medicaid programs. Both are federal programs that provide coverage to various demographics and were signed into law in 1965 by then President Lyndon B. Johnson. Medicare provides coverage to citizens over the age of 65 or those with severe disabilities. Conversely, Medicaid is both a federal and state funded program that offers health insurance to low-income citizens (Medicare Interactive). Since 1965, many changes have been made concerning coverage and eligibility to allow more people access to affordable health insurance. The most recent change was in 2010, with the introduction of the Affordable Care Act. The ACA, dubbed ‘ObamaCare,’ aimed to expand coverage by making insurance more affordable and broadening the guidelines of Medicaid (Medicare Interactive).

While there are multiple options for health insurance in North Carolina, this does not mean all citizens have access to healthcare. According to the U.S. Census Bureau, 11.3 percent of North Carolina’s population was uninsured in 2020, an increase of nearly 70,000 people since 2018. The increase in uninsured rates is partially due to pandemic job loss and North Carolina’s failure to expand Medicaid under the ACA (Rockefeller Harris). High uninsured rates are also a result of the patchwork system described by Oberlander. The disconnect between public and private insurance creates an eligibility gap in North Carolina; a gray area that occurs when low-income families or individuals not eligible for Medicaid cannot afford private insurance. According to the Kaiser Family Foundation, there are 2.2 million people in the coverage gap across the 11 states that have not expanded Medicaid (Norris).

The importance of insurance in access to care cannot be understated. For patients with severe conditions, insurance may be the sole reason they can afford the care they need. Shannon McGowan, a long-term healthcare worker in Graham, North Carolina has seen such instances firsthand. “I’ve had patients just not do tests because they simply can’t afford to do so. They’re not getting medications because they simply can’t afford it…” (McGowan). This phenomenon is represented in statistics as well. People with health insurance have overall better health outcomes because they are more likely to utilize healthcare services, such as screening and preventative care (Institute of Medicine). Furthermore, uninsured persons receive a lower quality of care in general when compared to insured patients (Spencer et al). It is worth noting that North Carolina ranks 33rd in overall health and is experiencing “…stagnant or worsening population mortality rates and substantial health disparities,” as well as increased medical costs (McLellan). More North Carolinians are falling into unemployment and care is more expensive, yet no changes to healthcare policy has been made. Uninsured populations are being placed at risk now more than ever.

Christine Tabb, a Talent Management Coordinator at CommWell Health of Newton Grove, has worked within the healthcare system as a CNA. Prior to these jobs, she lived in Germany. In her interview with Joanna Ramirez for the Stories to Save Lives project, Tabb notes the differences between American health insurance and the universal health insurance in Germany.

When discussing health insurance policies in North Carolina, Tabb notes, “It’s all individually based, what people can afford, what they have. For me, I don’t understand why people fight universal healthcare… Shouldn’t matter how much income anybody has. Everybody should be able to have access to healthcare,” (Tabb).

In addition to income, various demographic and social factors can heavily impact someone’s chances of having insurance, such as race and location. Minorities, including Hispanic, black, and native communities, are less likely to have health insurance than their white counterparts (Artiga). The pre-existing obstacles that marginalized populations face when accessing care, such as stereotypes and lower quality of care, are exacerbated by lack of insurance (Commonwealth Fund). Similar disparities are found when comparing rural and urban communities. Rural populations tend to face barriers such as transportation and lack of funding for local hospitals (Sana, Pranathi, Pink). These issues are worsened by the 5.8 percent difference in insured rates between rural and urban communities in North Carolina (Holmes).

Considering the eligibility gap, job loss and socioeconomic-based disparities, a large portion of citizens in North Carolina are not receiving the care they need due to lack of insurance. It is undeniable that healthcare coverage has significantly improved, but the uninsured population is left with minimal treatment options and no financial assistance. In cases of emergency, these people are left to fend for themselves simply because of their financial status. Kesha Neely, a mother of two from Dunn, North Carolina also works at CommWell Health. Although her family was initially eligible for Medicaid while her husband was employed, once Kesha began working, they were at risk for losing coverage. Her primary concern was having insurance for her sons, “And then there was this period of, ‘So what are we going to do for insurance for them? We’re really now trying to get on our feet,’” (Neely).

Christine Tabb offers an additional perspective of a parent in need of public health insurance. After her daughter had a major stroke, Medicaid paid the nearly one-million dollar hospital bill from her daughter’s 15 week medical stay. Yet, Tabb still had to endure the frustrations of the reapplication and approval process every three months. Tabb had to act as a caregiver for her daughter since Medicaid regulations restricted their access to additional care, such as physical, speech or occupational therapy. Regarding her daughters discontinued coverage, Tabb states, “That was hard because she didn’t get the care she needed,” (Tabb).

Our healthcare system is elitist and without change, uninsured populations will continue to lack basic, essential care. Since our healthcare system is heavily interconnected with national politics, reform will be difficult and time consuming. North Carolina is beginning to implement various value-based care systems to improve quality and accessibility of care, proving that progress in healthcare is possible. While this is certainly a step in the right direction, we must also consider how different communities would benefit from expanding insurance.


“Affordable Care Act (Also Known as the Health Care Law).” Medicare Interactive, 1 Feb. 2022,

Artiga, Samantha, et al. “Health Coverage by Race and Ethnicity, 2010-2019.” KFF, 16 July 2021,

Chan, Anthony. “Differences between Private and Public Insurance in the United States.” Pacific Prime’s Blog, Pacific Prime’s Blog, 1 Apr. 2022,

“Differences between Medicare and Medicaid.” Medicare Interactive, 13 Jan. 2022,,have%20a%20very%20low%20income.

Holmes, Mark, and Thomas C Ricketts. “Rural-Urban Differences in the Rate of Health Insurance Coverage.” Http://,

Institute of Medicine (US) Committee on the Consequences of Uninsurance. Care Without Coverage: Too Little, Too Late. Washington (DC): National Academies Press (US); 2002. 3, Effects of Health Insurance on Health. Available from:

McGowan, Shannon. Interview with Isabell Moore. 3 August 2019 (Y-0113). Southern Oral History Program Collection (#4007), Southern History Collection, Wilson Library, University of North Carolina at Chapel Hill.

McClellan, M. B., Alexander, M., Japinga, M., & Saunders, R. S. (2019, February 7). North Carolina: The New Frontier for Health Care Transformation: Health Affairs Forefront. Health Affairs. Retrieved April 21, 2022, from

“Minority Americans Lag behind Whites on Nearly Every Measure of Health Care Quality.” Commonwealth Fund, 6 Mar. 2002,

Neely, Kesha. Interview with Madalaine Katz. 10 July 2019 (Y-0117). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.

Norris, Louise. “What Is the Medicaid ‘Coverage Gap’ and Who Does It Affect?”, 3 Mar. 2022,

Oberlander, Jonathan. “Unfinished Journey: The Struggle over Universal Health Insurance in the United States.” The New England Journal of Medicine. 16 Aug. 2012.

Rockefeller Harris, Logan, et al. “U.S. Census Bureau Releases Data on Health Insurance Coverage in N.C.” North Carolina Justice Center, 16 Sept. 2020,,lacked%20health%20insurance%20in%202019.

Sana, Pranathi, and George H Pink. Medicare Covers a Lower Percentage of Outpatient Costs in Hospitals Located in Rural Areas.

Spencer, Christine S et al. “The quality of care delivered to patients within the same hospital varies by insurance type.” Health affairs (Project Hope) vol. 32,10 (2013): 1731-9. doi:10.1377/hlthaff.2012.1400

Tabb, Christine. Interview with Joanna Ramirez. 27 June 2018 (Y-0053). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.

Comments are closed.