"I have held dying toddlers in my arms struggling to breathe, in Halifax County, one of the state's poorest counties, while waiting for air transport to Nash Regional Hospital.
"I have held the hands of dying people and wiped the tears from loved ones' eyes because the diagnosis came too late. And while doing this it never occurred to me to consider whether they were a Republican or a Democrat."
State Rep. Carla Cunningham, a first-term Mecklenburg County Democrat and palliative care nurse, spoke these words during the waning minutes of a futile debate last week over a bill that would prevent the expansion of Medicaid in North Carolina.
Cunningham laid out the consequences of closing access to health care to a half million North Carolinians, the result of the Legislature's overtly political refusal to expand the state's health care safety net. In their futile effort to rein in federal spending from their posts in Raleigh, conservative lawmakers have passed a bill with dire ramifications: people could postpone their health care or even die, because it's too expensive, too hard to get or both.
The rejection of Medicaid expansion and cuts in unemployment benefits and eligibility will hurt people everywhere, but especially in rural North Carolina where long-term unemployment and poor access to medical care are already chronic conditions.
Halifax County, where a quarter of the population lives in poverty, and its neighboring counties to the northeast have never recovered from the shutdown of paper mills in the 1980s and '90s. The small textile shops scattered among small towns throughout the area are gone, too.
On the other side of the state, mountain counties such as Graham are still reeling from a rapid exodus of manufacturing jobs. Unemployment in Graham County stands at 18.5 percent, the highest in the state.
There, and in similar areas of economic devastation, the consequences of the policy changes unfolding during the first few weeks of the legislative session are starting to sink in.
A state that once led the South in improving rural health care is turning its back on people in poverty, saying in effect that we can move forward while leaving behind more than a fifth of our citizens.
Shortly after Cunningham spoke, her Mecklenburg County colleague Rep. Beverly Earle offered this summation of the first fortnight of the General Assembly: "In two weeks you have put folks on the street. You have taken away their safety net and you've denied low income people health care."
According to a U.S. Department of Agriculture study released in December, poverty in North Carolina's rural counties averages 20 percent. The unemployment rate in the past two years has hovered around 12 percent—two percentage points higher than the state's urban areas.
Adam Searing, director of the North Carolina Health Access Coalition, said the Legislature's move to reduce unemployment benefits and kick the long-term unemployed off the rolls in July will push even more people in rural North Carolina into poverty, exacerbating a looming public health crisis.
The decision to reject the expansion of Medicaid under the Affordable Care Act, he said, will hit hardest in rural North Carolina, jeopardizing the network of rural health clinics and community hospitals built during the past few decades.
"They're the ones that have been there as the number of people in poverty has increased," Searing said. "They're the ones on the front lines seeing people without coverage."
The small health care centers rely on federal reimbursements to cover the costs of serving those uninsured and unable to pay. Under the Affordable Care Act, Searing said, those reimbursements are phased out. They were supposed to be replaced by another mandated expansion in Medicaid, but unlike previous expansions, this one, the result of political compromise, has been left up to the states. So far, 35 states, including those with conservative governors and legislatures like Florida and Arizona, have agreed to the expansion.
By rejecting the expansion and joining a minority of states including Texas, Mississippi and Alabama, Searing said, North Carolina is financially squeezing its rural hospitals so that cuts in services and access are all but inevitable.
"It's a kind of double hit if you're a really poor county," Searing said. There will be more patients without coverage seeking help in the emergency rooms in small community hospitals, while reimbursements for their care dries up, he added.
"[The hospitals] will end up laying people off or closing ERs," he said, and they will shift the burden for indigent care to larger regional hospitals.
Last week, GOP leaders seemed to be having some trouble settling on a reason to turn down the expansion, which would cost the state zero dollars in the first three years and 10 percent of the cost after 10 years.
The people of this state deserve more than platitudes about small government and arguments about Obamacare recycled from the last election. And the nearly 3 million rural residents of this state, many from places that voted heavily to keep the GOP in power in the Legislature, deserve to know why their elected leaders have decided that rural North Carolina, which used to rule the General Assembly, is taking the biggest hits.
This article appeared in print with the headline "Salt in the wound."