A decade after the Affordable Care Act promised sweeping healthcare reform, millions are still choosing between groceries and doctor’s visits—even with insurance in hand. The problem is not simply a lack of insurance, but the illusion that coverage automatically equates to care. In North Carolina, this disconnect is vividly reflected in the oral histories of individuals who navigate a healthcare system that may include them on paper, yet excludes them in practice. As our group project on healthcare disparities in North Carolina reveals, structural barriers like financial strain, geographic isolation, and racial discrimination persist even for the insured. The voices captured in the Southern Oral History Program (SOHP) archive reveal a recurring theme: access is conditional, delayed, or inadequate, regardless of coverage status.
Despite the Affordable Care Act’s expansion of insurance coverage, structural barriers such as high out-of-pocket costs, narrow provider networks, and safety net limitations continue to prevent North Carolinians from accessing timely and adequate healthcare. These limitations expose a fundamental truth: insurance coverage alone does not equate to actual care.
1. Insured but Impoverished: When Coverage Still Means Cost
At the heart of this contradiction is the issue of underinsurance—coverage that offers the illusion of protection but imposes cost barriers so steep that patients delay or forgo care entirely. High-deductible health plans, marketed for their low premiums, have become increasingly common, particularly in employer-sponsored markets. However, these plans often leave individuals with high out-of-pocket costs, rendering routine visits and necessary prescriptions unaffordable.
Tammy Blackman, an insured x-ray technician, captures this dilemma with painful clarity: “The affordability for patients. Like, my daughter that is at the urologist… her first kidney stone was two days before her new health insurance went into effect. Had to have ER visits, CT, then you have the radiology interpretation fee. I mean, it was like $10,000 for that stuff,” (Blackman, [36:35]). Though covered by insurance, Blackman’s family faced overwhelming medical costs due to timing and billing structures—exposing how coverage alone does not guarantee affordable care. Her story underscores how even those who appear to be protected by the ACA’s safety net face a healthcare landscape defined more by economic calculation than clinical need. According to Bailey et al. (2017), patients must navigate confusing billing systems, opaque benefits information, and pre-authorization requirements for even routine care. Rather than facilitating access, insurance in these cases operates as a barrier cloaked in bureaucracy.
2. Coverage with Caveats: How Narrow Networks and Red Tape Restrict Access
Even when costs are manageable, insurance networks often impose structural limits that restrict patients’ ability to receive care. Many plans, especially Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs), require enrollees to see in-network providers to avoid substantial out-of-pocket expenses. These limitations prioritize cost-containment for insurers but severely limit patient autonomy. Someone may have mental health benefits on paper, but if no local providers accept their plan, that coverage is meaningless. As Collins et al. (2019) report, nearly 40% of underinsured Americans delay or avoid care due to cost—but availability is just as critical.
Patients frequently discover network restrictions only after receiving care, when surprise bills arrive in the mail. Referral requirements, shifting networks, and poor communication from insurers all complicate access. As North Carolina physician George Gould observes, the reality is stark: “People who don’t have insurance don’t necessarily get to see the best people, and their healthcare can be delayed or absent,” (Gould, [26:54]). Even for the insured, quality and timeliness vary drastically. Those with comprehensive plans might access a specialist within weeks, while others wait months or settle for urgent care. The result is a system where insurance offers partial, uneven coverage—one that often breaks down when people need it most.
The impact of narrow networks and administrative hurdles is especially evident in preventive care—services meant to catch health issues early but often delayed or skipped due to systemic barriers. Patients may find the nearest in-network provider hours away or face long wait times and confusing pre-authorization rules. These obstacles undermine insurance’s promise of proactive care, pushing patients toward costly emergency interventions instead. As Carlin et al. (2016) note, provider shortages, administrative complexity, and poor care coordination significantly reduce the use of preventive services, such as cancer screenings, especially among underserved populations. In practice, the very structures designed to expand access often end up obstructing it.
3. The Shortcomings of Safety Nets
For North Carolinians who fall outside of employer-sponsored plans or marketplace options, Medicaid and sliding-scale clinics are essential lifelines. Yet these safety nets are riddled with limitations that compromise their effectiveness. Clinics are often understaffed and overwhelmed, leading to long wait times, limited availability, and an overreliance on short-term fixes rather than preventive care. While these clinics are essential in theory, they are often underfunded, overstretched, and unable to provide the full continuum of care patients require. This structural inadequacy reflects broader systemic neglect, where safety nets are expected to fill in for systemic gaps without the resources or reach to do so effectively.
Medicaid, while a critical resource for low-income individuals, presents its own challenges. According to the Centers for Medicare & Medicaid Services (2025), outdated and redundant requirements significantly delay access and reduce equity. Many who qualify never enroll due to the program’s complexity or fear of jeopardizing immigration status under public charge laws. Even for those who do enroll, finding care can be a struggle, as many providers do not accept Medicaid due to its low reimbursement rates. Kenneth Cook, a Medicare recipient and Consumer Advisory Board member for the Positive Life department, captures the uncertainty many face as their coverage shifts: anticipating the loss of his Medicaid benefits at age 65, he says, “I just have to wait and see… It’s kind of like, would you want to know the day you’re going to die?” (Cook, [49:34]). His words, though laced with humor, reflect a deeper anxiety about losing access to medications and affordable care. This fragility reveals a two-tiered system in which safety nets function as stopgaps rather than comprehensive solutions. As Cook and others remind us, safety nets are crucial, but they cannot substitute for a comprehensive and accessible healthcare infrastructure.
4. Reimagining Access to Care
The voices captured in the Southern Oral History Program archive complicate the narrative that expanding insurance coverage alone is enough to address healthcare disparities. Together, the stories of Tammy Blackman, George Gould, and Kenneth Cook reveal how structural barriers persist at every point along the path from being “covered” to actually receiving care. Their experiences reflect the full spectrum of how the U.S. healthcare system fails not just the uninsured, but also the insured, the underinsured, and those relying on public options.
True reform demands more than enrollment figures or legislative milestones. It requires reimagining access as a process shaped by affordability, availability, and trust. Ultimately, the SOHP narratives make one thing clear: healthcare justice cannot be measured by who has insurance on paper, but by who can use it in practice. To be covered is not necessarily to be cared for. Reimagining access means designing a system where those two terms finally mean the same thing.
References:
Bailey, Sarah R., et al. “Receipt of Diabetes Preventive Services Differs by Insurance Status at Visit.” American Journal of Preventive Medicine, vol. 52, no. 6, 2017, pp. 735–739.
Blackman, Tammy. Interview with Maddy Kameny. 25 June 2018 (Y-0010). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Carlin, Caroline C., Brian Dowd, and Lacey Higuera. “The Impact of Narrow Provider Networks on Patterns of Care.” Journal of Patient-Centered Research and Reviews, vol. 3, no. 3, 2016, pp. 208–214. Advocate Aurora Health Institutional Repository, https://institutionalrepository.aah.org/jpcrr/vol3/iss3/95/.
Centers for Medicare & Medicaid Services. Optimizing Care Delivery: A Framework for Improving the Health Care Experience. 2025, https://www.cms.gov.
Collins, Sara R., Herman K. Bhupal, and Michelle M. Doty. “Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, but More Underinsured.” The Commonwealth Fund, 7 Feb. 2019, https://www.commonwealthfund.org/publications/issue-briefs/2019/feb/health-insurance-coverage-eight-years-after-aca.
Cook, Kenneth. Interview with Madelaine Katz. 23 July 2019 (Y-0093). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Gould, George. Interview with Joanna Ramirez. 26 June 2018 (Y-0026). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
HealthCare.gov. “Health Insurance Plan & Network Types: HMOs, PPOs, and More.” HealthCare.gov, https://www.healthcare.gov/choose-a-plan/plans-types/.
Syed, Sameer T., Ben S. Gerber, and Lisa K. Sharp. “Traveling Towards Disease: Transportation Barriers to Health Care Access.” Journal of Community Health, vol. 38, no. 5, 2013, pp. 976–993.