Introduction

Strong healthy adults raise strong and healthy chil­dren. Among the estimated 600,000 people who will gain access to health insurance coverage through expanded Medicaid eligibility in North Carolina,¹ many are parents or serve in other roles supporting and caring for children. Some are barely beyond childhood themselves, still growing, maturing, and finding their way as young adults. Some are women soon to become pregnant. Some serve in care and support roles for children outside the home and others work in jobs providing care and education for children. Expanding access to health insurance coverage for these groups has the potential to astronomically improve their health and well-being and that of the children who depend on them.

Who Gains Coverage?

Medicaid eligibility in North Carolina is complicated and changes with age and circumstance. Children under age six qualify for Medicaid with a higher household income than older children or adult enrollees.² As children grow older, the eligibility threshold goes down, shifting many of them off the Medicaid rolls, though they still qualify with a higher family income than adult enrollees do. Income eligibility changes when an individual becomes pregnant, and since 2022 North Carolina has continued that coverage for one year after delivery.³ Currently, Medicaid health coverage for non-pregnant or non-child-caregiving adults is limited to those with a disability.

Medicaid expansion will change that. Once North Carolina’s new law is enacted, while young children and pregnant women will maintain their current income eligibil­ity, everyone else aged 6 to 64 with a household income less than 138% of the Federal Poverty Level (FPL) will be eligible for Medicaid insurance. Young adults with low earnings who previously lost Medicaid coverage at age 19 will now have access to continued coverage. This change will help to allevi­ate some of the gaps in coverage leading to inconsistencies in health care access for children, young adults, and those who care for them.¹

Maternal and Infant Health Outcomes

Medicaid coverage will improve maternal and infant health outcomes and reduce health disparities. During the COVID-19 pandemic, the United States experienced a rise in the rate of preventable maternal deaths.⁴ Wang and colleagues report that North Carolina mothers experi­ence higher maternal mortality than the national rate and describe the racial disparities found in their study: “In North Carolina, where just 22% of the population is Black, 43% of the state’s 202 pregnancy-related deaths between 2020 and 2022 were Black women”.⁴

In North Carolina, more than 1 in 6 women of childbear­ing age lack health insurance.⁵ In an analysis of states that have expanded Medicaid previously, Searing and Ross demonstrate that access to insurance improves health out­comes, including, “increasing access to preventive care, reducing adverse health outcomes before, during and after pregnancies, and reducing maternal mortality rates”.⁵ These and other studies show that expanded access not only improved overall health outcomes for women and children but also helped to decrease the health disparities across race.⁶

Health insurance does not equal access to health care. As maternity care units have closed across North Carolina in recent years, especially in rural areas, many women struggle to find accessible care.⁷ While the upcoming increase in insurance coverage may not bring back closed delivery sites, it likely will help to prevent future closures as rural hospitals care for more people with Medicaid as a payment source. Many hospitals and health care providers also recognize that the health professions workforce shortage is impeding their ability to adequately serve patient needs. This short­age was exacerbated during the pandemic and continues to challenge providers and patients alike. As more individuals are enrolled in Medicaid through expanded coverage, it is essential to examine and address the myriad reasons for this workforce shortage to ensure that newly enrolled beneficia­ries can reach the care they need.

Insured Parents and Caregivers Grow and Develop Healthier Children

When parents and caregivers have access to health insurance, they experience healthier outcomes.⁸ This translates to health and well-being for children while they are young and as they grow. The benefits of health insur­ance are intergenerational. Parents who get the physical and emotional support they need are better able to offer similar support for their children. Families with insurance are less likely to face financial pressures that lead to stress and poorer health outcomes.⁹ McGinty and colleagues report that Medicaid expansion “has reduced the risk fac­tors for child neglect and physical abuse, including parental financial insecurity, substance use, and untreated mental ill­ness,” and demonstrated a 17% decrease in reports of child neglect in Medicaid expansion states versus states that did not expand.⁹

Decreasing social stress in families can decrease chil­dren’s exposure to adverse traumatic events. Felitti dem­onstrated a graded response between exposure to adverse childhood events and myriad health outcomes in adults, including early initiation of smoking; cancer; diabetes; heart, lung, and liver disease; and depression.¹⁰ Expanding Medicaid will help to stabilize families economically and socially. Based on Felitti’s findings, the benefits to our next generation’s health and well-being will likely be profound for individuals and cost-saving for society.

Many young children spend many hours each day in the care of adults who are not their parents or guardians, thus, the health status of early childhood educators and caregivers also can affect children’s health and well-being. Children’s brains begin developing before they are born and continue to form millions of connections every single day in the early years of life. A large body of research demon­strates that a child’s experiences influence this develop­ment for better and worse. As stated by the Harvard Center on the Developing Child, “Child development—particularly from birth to five years—is a foundation for a prosper­ous and sustainable society”.¹¹ Ensuring children have healthy and supported caregivers is critical to their future. Early childhood education professionals show up for our children but earn low wages in jobs without benefits and often lack health coverage.¹² These circumstances do not support teachers’ optimal capacity to foster and develop our children.

“Because of such low pay and high cost of health benefits, other teachers and myself are in constant stress over how to afford basic necessities. This stress is so great it carries over onto our care for the children daily.”
— Early Childhood Lead Teacher¹³

Expanded Medicaid eligibility will provide affordable health insurance for these teachers and is a first step in reforms needed to support this workforce and ultimately the children they serve.

Young Adults Fare Better With Medicaid Expansion

Young adults aged 19–25 experienced the highest unin­sured rates prior to the passage of the Affordable Care Act (ACA) in 2010, at approximately 30%.¹⁴ The ACA allowed young adults the option to remain on their parent/ guardian’s plan until age 26. For states that did not expand Medicaid, many young adults over age 26 still cannot afford coverage. Often, they are working entry-level jobs, starting new businesses, or pursuing their education. Lack of insur­ance is especially challenging for the one in six in this age group living with a chronic health condition or those who experience a medical emergency.¹⁴

A study by Gangopadhyaya and Johnston compared insured rates for young adults in states that expanded Medicaid early after the ACA passed with those that did not. They found a 20% decline in uninsured rate in the early expansion states versus a 10% decline in non-expansion states.¹⁵ For households with income below 200% FPL this difference was double, with the greatest benefit to Black and Hispanic young adults. The authors noted upward trends in the likelihood of young adults to have a primary care provider, attend preventive care visits, and receive a flu shot, and a decline in reporting that they delayed needed care because of cost.¹⁵ As our North Carolina young peo­ple transition to adulthood, access to health care is critical to establishing regular health maintenance, early identification of and intervention for issues—especially mental health— and fostering good health habits.

Healthy Opportunities

As part of Medicaid Transformation, the North Carolina Healthy Opportunities Pilots program adds the delivery of non-medical interventions that have been shown to improve health to services paid for by Medicaid.¹⁶ With Medicaid expansion, this program will bring needed social support to more people in our state. Many families with children and others insured through Medicaid who qualify and live in one of three pilot areas will be able to access services, such as healthy food, transportation, and support for a healthy and safe living environment as well as services for victims of domestic violence or toxic stress. These services can be life-changing and health-producing, and now will be accessible to more North Carolinians.

Conclusion

We often focus on the health benefits of having health insurance for the individual who is insured. Since chil­dren—and even young adults—are dependent on the care, nurturing, and guidance of the adults around them, access to health insurance and the resulting progress in health sta­tus translates to better health and well-being outcomes. Based on the experiences of states that expanded access to Medicaid coverage previously, once Medicaid expansion is implemented, North Carolina can expect to see signifi­cant improvements in maternal and child health outcomes, access to care for young adults, and reduced financial stress on parents and caregivers of young children.

Disclosure of interests

The authors report no conflicts of interest.