The fight for better health (and health care) in rural North Carolina

By Sarah Nagem

Newly released health rankings paint a grim picture of North Carolina’s rural Border Belt counties compared to the rest of the state: Residents here are more likely to smoke, be obese, have diabetes, experience frequent mental health issues and die prematurely. 

Teen girls are more likely to get pregnant, and babies are more likely to have a low birthweight. Adults are more likely to lack health insurance, and the ratio of doctors, dentists and mental health providers is far below the statewide rate. 

Children are more likely to live in poverty and in single-parent homes. A smaller percentage of people earn high school diplomas, violent crime rates exceed state figures, and people don’t get as much sleep. 

Counties covered by the Border Belt Independent – Bladen, Columbus, Robeson and Scotland – are typically considered among the least healthy in North Carolina in the annual County Health Rankings. Not much has changed for the 2022 figures. 

Robeson County came in last for health outcomes – “how long people live and how healthy people feel while alive” – among North Carolina’s 100 counties. Scotland County was No. 98, Columbus County was No. 91, and Bladen County was No. 85. 

The rankings, produced by the University of Wisconsin Population Health Institute, are widely considered a valuable snapshot of the health and well-being of communities across the country.

This year’s data comes as North Carolina lawmakers could take on an issue that some say would help improve health, particularly in poorer, more-rural counties: Medicaid expansion. 

“Rural North Carolinians are disproportionately uninsured compared to their urban and suburban counterparts,” said Brandy Bynum Dawson, senior director of policy and advocacy at the NC Rural Center, which advocates for the state’s 78 rural counties. 

North Carolina is one of only 12 states that has not expanded Medicaid, a federal and state program that provides health care benefits for poor residents. 

Estimates show that about 500,000 more people in North Carolina would qualify for Medicaid under an expansion, which would require approval from the Republican-led General Assembly. N.C. Gov. Roy Cooper, like many Democrats, has said for years that he wants to expand the program. 

Some local advocates, health leaders and medical providers say Medicaid expansion could help improve access, which in turn could lead to a greater emphasis on preventative care and reduce the burden on hospitals’ emergency departments. 

Some say the issue is especially important in rural counties, which were already fighting an uphill battle with the opioid epidemic when COVID-19 ravaged local communities.

“In rural North Carolina, access to care is a problem,” said Dr. Joseph Bell, a pediatrician at Children’s Health Pembroke, noting the cost burden for many families in poor counties. “People have to weigh out health care versus getting groceries and buying gas.” 

Now, some Republican lawmakers from the Border Belt counties say they too are warming to the idea of Medicaid expansion.  

“Based on the information we have now, I would vote in favor of it,” said N.C. Sen. Danny Britt, a Lumberton Republican who represents Robeson and Columbus counties. 

The Columbus Regional Healthcare System previously put up an overflow tent to deal with a new surge of COVID patients.
Photo by Les High

Shift in thinking

N.C. Rep. Charles Graham, a Robeson County Democrat and member of the Lumbee Native American tribe, recently released a public letter in support of Medicaid expansion. 

Graham, who serves on the joint legislative committee on access to healthcare and Medicaid expansion and is now running for Congress, said the committee has “heard of the success both Democrat- and Republican-led states have had in expanding healthcare access.” 

He noted out-of-state politicians such as former Ohio Gov. John Kasich, a Republican, who visited North Carolina to speak about the benefits of expanding coverage. 

An additional 13,747 people would qualify for Medicaid in Robeson County under an expansion, Graham said, citing a 2019 report by the Cone Health Foundation. (See the chart below for figures in other local counties.)

Beyond health care coverage, Graham, like many advocates for Medicaid expansion, touted the potential economic impact. The NC Rural Center has said expansion would create 83,000 jobs in North Carolina and generate $168 million in tax revenue by 2025. 

“Meaningful expansions in our economy are necessary, especially as so many people are hurting,” Graham said.

With Graham leaving the N.C. House, District 47 will soon have new representation – and could flip to the GOP. Robeson County voters have historically picked Democratic candidates, but that has changed in recent years. President Donald Trump won more than 58% of the vote in Robeson in 2020. 

Graham, a conservative Democrat, won 52% of the vote in 2020, beating his Republican opponent by five points – a far cry from his 18-point victory two years before

The two Republicans vying in the May 17 primary election for a chance at the seat – Mickey Biggs and Jarrod Lowery – did not return requests for comment on Sunday.  

Britt, the first Republican to win state Senate District 13, said his changing stance on Medicaid expansion is about money. 

Initially, Britt said, estimates showed that the expansion would cost North Carolina $500 million over three years. But now there’s a promise of more than $1 billion from the federal government to states that have not yet expanded Medicaid.  

“The facts now are different than what the facts were two years ago,” said Britt, who also serves on the state’s Medicaid expansion committee. 

Last year, Britt was a primary sponsor on a bill that allows parents to keep their Medicaid coverage if they lose custody of their children but seek treatment for substance misuse or mental health disorders. 

Britt said he hopes Medicaid expansion would make it easier for residents to get basic health care and treatment for behavioral disorders. He noted, however, that nobody is turned away from emergency care, regardless of their health insurance status. 

State Rep. William Brisson, a Republican who represents Bladen and Sampson counties, said he “does not have a problem” with expanding Medicaid, according to his spokesperson. But Brisson said he was unsure how far the discussion would go during the legislature’s short session this year.  

Brisson faces no challengers this year, so he will serve another term in office. 

The growing support for Medicaid expansion includes that of Phil Berger, the state’s top Republican senator. Berger, who represents Caswell, Rockingham, Stokes and Surry counties, said last year that expansion is bad policy but said it “would be appropriate” for the legislature to move forward with the plan. 

'A right, not a privilege'

Medicaid expansion wouldn’t solve all of the health concerns in rural North Carolina, advocates say. But Bell, the Robeson County pediatrician, said it’s a step in the right direction. 

“Health care should be a right, not a privilege,” he said. “But unfortunately, in poor counties people typically have poor health care status.” 

In Robeson County, 32% of adults say they are in poor or fair health, compared to 18% statewide, according to the County Health Rankings. The figure is 28% in Scotland County and 26% in Bladen and Columbus counties. 

People in the four-county region also reported more mentally unhealthy days in a 30-day span: 5.7 in Robeson, compared to 4.4 statewide. 

The rankings used data from 2019 to calculate those figures, which could now be higher as a result of the coronavirus pandemic. Experts say there has been a rise in the number of people seeking mental health treatment during COVID.  

Residents in Robeson County live, on average, six years less than people statewide, the rankings show. All four Border Belt counties have a lower average life expectancy. 

Some issues, such as smoking, eating unhealthy foods and not exercising, are often handed down through generations. 

“When you’ve got children in middle school that are already using vaping products, then we know that’s an issue,” said Terri Duncan, director of Bladen County Health and Human Services. 

Bladen is working on outreach programs to help young people better understand the consequences of negative health decisions, which can lead to higher rates of cancer and diabetes, according to Duncan. 

“One thing we know,” she said, “is we have to reach children earlier.”

There are also systemic problems at play, said Bell, who is one of the roughly 60,000 members of the Lumbee tribe mostly living in southeastern North Carolina. 

“It’s some of both,” he said. “Obviously we have responsibility for our own health and the choices we make. … But then you have things that are out of our control. You take the Lumbee people – we have a higher risk of diabetes. Some of that is genetic.” 

Adverse childhood experiences, such as abuse and poverty, can also affect people’s health throughout their lives, Bell said. 

In Robeson County, 39% of children live in poverty, according to the county rankings. The number is even higher in Scotland County: 46%.  

Some people turn to drugs and alcohol to self-medicate, Bell said, noting that can be especially true for marginalized populations. 

Native American residents make up more than 35% of the population in Robeson County, while Black residents account for more than 20%. 

“You talk about historic trauma, people who have been oppressed – some of that is the reason for the cycle,” Bell said. 

In Bladen County, Duncan said, the top three health priorities are nutrition/exercise, mental health, and substance misuse, particularly alcohol and opioids. 

“There are very few people in this county who have not been affected by an opioid death,” Duncan said. “And while that is significant, alcohol is an even bigger problem in our county.” 

Bladen will soon launch a “mental health van” staffed with professionals who will travel to remote parts of the county, according to Duncan. 

“We’re trying to go to the people,” she said. “Health happens outside these four walls.” 

Nursing students at Bladen Community College study for an exam at the school's library. Experts say Bladen and surrounding counties need more nurses.
Photo by Sarah Nagem

Signs of progress

In Bladen and Columbus counties, there are signs of improvement when it comes to health. 

Columbus was ranked the least healthy county in the state from 2010 to 2015, according to The News Reporter in Whiteville. But it has climbed its way out of last place over the years and landed at No. 91 this year. 

“Anything upwards is better than anything downwards,” Columbus County Health Director Kim Smith told the newspaper. 

Duncan said she has been proud of the progress in Bladen County.

“Just for us to be moving from 95 to 85 in five years, to me that’s encouraging,” she said. 

Expanding Medicaid would likely help metrics continue to move in the right direction, according to Duncan. 

Advocates for Medicaid expansion say it’s important to remember that most uninsured adults have jobs. 

“They’re employed North Carolinians,” said Bynum Dawson with the NC Rural Center. “They’re in service industries. In particular, agriculture workers, construction workers, child care workers, cashiers, restaurant workers – kind of the essential front line of not just North Carolina, but rural North Carolina specifically.” 

In Robeson County, 19% of people under 65 are uninsured, the rankings show. The statewide figure is 13%. 

Other local counties also exceed the statewide rate: 17% in Columbus, 16% in Bladen and 14% in Scotland.

If more people gain access to health care, there's still the problem of having too few providers in the region.

Bladen County, for example, has one primary care physician per 4,670 residents, according to the rankings. That's more than three times the statewide rate.

Britt, the state senator, said he didn't know if Medicaid expansion would convince more doctors and nurses to move to the region, but it's possible.

“I think Medicaid expansion would lure more providers everywhere," he said.

Regardless of what happens with politics in Raleigh, Bell said he and other local health care workers will continue to preach their message in support of a healthy lifestyle. 

“It doesn’t discourage me,” Bell said of the health rankings. “It just means we have to work harder. We have to educate people better.” 

Follow Sarah Nagem on Twitter: @sarah_nagem

Dr. John Penrose, director of the Columbus Regional Healthcare System emergency room, talks about the impact of opioids in an earlier story.