North Carolina once championed a groundbreaking initiative, the Healthy Opportunities Pilot (HOP), designed to keep vulnerable Medicaid recipients healthy by addressing their fundamental needs: nutritious food, stable housing, and access to medical transportation. This ambitious five-year experiment aimed to reduce costly hospital visits by tackling the root causes of poor health.
For individuals like Krista Shalda, a single mother navigating the complex medical needs of her two sons, the program was a game-changer. She received a weekly delivery of fresh produce, making it possible to adhere to a specialized diet that significantly cut down her 15-year-old son’s emergency room visits. Similarly, Kellie Prince, facing homelessness after spinal surgery, found refuge in a motel room provided by HOP, preventing her family from sleeping in their car outside the hospital.
Debra Hensley, a 60-year-old who is partially blind and physically disabled, also experienced the direct impact of HOP. The program funded a new roof and essential electrical repairs for her aging trailer, allowing her to stay in her home with her teenage grandson. “It’s not an exaggeration to say that HOP saved my life,” Ms. Hensley shared, pointing to the ceiling where rainwater once streamed into her living room.
By all accounts, this $650 million Medicaid experiment in North Carolina was a resounding success, earning rare bipartisan support from the state’s Republican-led General Assembly. An independent analysis by the UNC School of Medicine confirmed its effectiveness, reporting an annual saving of $1,000 for each of the 13,000 Medicaid recipients across three rural regions.
However, this vital program is now being shut down, becoming an early casualty of wider Medicaid cuts approved by Congress in July. State Republican leaders cited anticipated reductions in federal healthcare spending under President Trump’s legislation – a bill that extends tax cuts while drastically slashing social safety net programs – as their reason for declining to renew HOP’s funding.
Despite a looming September 30 deadline for state lawmakers to reconsider and extend the pilot for another five years, many participating organizations have already ceased operations, with some closing their doors permanently. “There’s a lot of heartache and disappointment to watch the demise of something that was stabilizing the community and helping people get back on their feet,” lamented Laurie Stradley, CEO of Impact Health, a nonprofit instrumental in administering HOP in western North Carolina. “We’re going to see ripple effects for years to come.”
These cuts are part of a larger $320 million reduction in Medicaid spending by the North Carolina Legislature, which healthcare experts warn will severely diminish benefits for the state’s three million Medicaid recipients.
The decision to cancel the pilot hits particularly hard in Asheville and its surrounding counties. This mountainous area is still reeling from the devastating floods caused by Hurricane Helene just one year prior. Many residents feel abandoned, especially after the Federal Emergency Management Agency (FEMA) announced in May it would no longer share the full cost of recovery efforts with the state.
The region, famed for the beauty of the Blue Ridge Mountains and Asheville’s vibrant arts scene, has become a magnet for affluent retirees and remote workers. Yet, with a state minimum wage of just $7.25, the skyrocketing housing costs have made life increasingly unaffordable for low-wage earners.
Repeated attempts to contact State Senator Ralph Hise, whose district benefited from the pilot, and other Republican leaders in the General Assembly for comment were unsuccessful. Public statements from some officials, like House Speaker Destin Hall, have cast doubt on HOP’s effectiveness. “It’s not clear from our side that any folks are really benefiting from that program anyway,” Hall stated in June.
North Carolina’s move serves as a stark precursor to the monumental shifts expected in American healthcare. Over the next decade, federal Medicaid cuts are projected to exceed $900 million, potentially leading to nearly eight million people losing their Medicaid coverage by 2034, according to the Congressional Budget Office.
For Ms. Shalda, the aftermath of Hurricane Helene meant months in shelters and motels with her two sons, both autistic, after their suburban Asheville home was ravaged by floodwaters. Since November, they’ve been living in a donated recreational vehicle next to their damaged house. “North Carolina legislators seem to think we’re just a bunch of hillbillies and don’t deserve a helping hand,” Ms. Shalda remarked, reflecting on the program’s termination.
Dr. Seth A. Berkowitz, a primary care physician from the UNC School of Medicine, who evaluated HOP for the federal Centers for Medicare & Medicaid Services, confirmed its success in stabilizing families during crises. “We’re talking about ‘a straw that broke the camel’s back’ situation, where a family is barely holding it together and then someone loses a job, or their only car breaks down,” he explained.
Dr. Berkowitz’s research indicated that while initial spending per participant rose due to prescribed services—such as mold removal for a child’s asthma—the overall trend showed a decline in long-term costs. “If you spend resources to get people through a rough patch, that translates down the line to better health and lower health care spending,” he concluded.
Beyond individual health benefits, the pilot also stimulated the local economy by channeling significant funding through social service organizations, food banks, and farms throughout the region. Many farmers, like Nicole DelCogliano, who cultivates 30 types of organic vegetables along the South Toe River in Yancey County, had already planted their spring crops when news of the program’s closure broke. “For us, the timing is terrible,” she said.
The HOP funding was crucial for DelCogliano’s Green Toe Ground farm, helping them recover from $250,000 in damage incurred during Hurricane Helene. “And personally speaking, it was especially gratifying to know our food was going to people who really needed it,” Ms. DelCogliano added.
Much of their farm’s bounty was distributed through a network of a dozen community markets in and around Asheville, operated by the nonprofit Bounty & Soul. These markets function much like traditional farmers’ markets, but with one crucial difference: fresh produce is offered to shoppers at no cost. Paula Sellars, deputy director of Bounty & Soul, noted that these markets now serve 26,000 people monthly, a figure that has doubled since Hurricane Helene.
While the community markets will continue their vital work, the cessation of the HOP program means 260 Medicaid recipients with severe health challenges will no longer receive their weekly boxes of fruits, vegetables, and eggs from Bounty & Soul. “With all its micronutrients, fresh produce is the foundation of good health,” Ms. Sellars emphasized. “Rather than chasing disease, supporting people’s well-being is actually the smart economic choice, and the humane choice.”
For Ms. Shalda, this fresh produce was a lifesaver. Her eldest son, Alex, 15, born with hydrocephalus, has a history of hospitalizations, surgeries, convulsive seizures, and kidney stones. When his doctor prescribed a strict, two-page diet rich in fresh vegetables, dairy, and meat, Ms. Shalda felt overwhelmed, knowing these items were beyond her family’s $700 monthly food stamp budget.
The custom-tailored HOP food boxes—packed with eggs, cheese, bread, and various seasonal produce—brought immense relief. Ms. Shalda was so delighted, she’d send photos of her fully stocked refrigerator to friends. Over time, Alex’s seizures and kidney stones, which had frequently sent him to the hospital, became less common. “And it’s been such a relief to watch him run around crunching on carrots and peppers instead of eating junk food,” she beamed.
However, since the food deliveries stopped in July, Ms. Shalda has resorted to serving more frozen and canned vegetables. Her sons’ reactions were immediate. “The frozen carrots tasted like mush,” Alex commented. Tragically, the pain from his chronic kidney stone condition has recently resurfaced.
Ms. Shalda is deeply concerned about the future, especially with the impending federal cuts to Medicaid and food stamps. “I feel overwhelmed just thinking about the future,” she admitted.
Ms. Prince, who now cares for three grandchildren, shares this profound anxiety. Without the weekly food boxes, she navigates local food pantries, which rarely offer fresh produce and limit visits to once every two weeks. “The kids really used to look forward to the strawberries, bananas and eggs,” she recalled. “Have you seen the price of eggs lately?”
After 11 months enduring shelters and motels, her husband secured a $20-an-hour job with the Asheville Housing Authority, enabling them to rent a two-bedroom apartment in Black Mountain. Yet, this progress came at a cost: his income disqualified the family from their $173 in monthly food stamps, and Ms. Prince lost her $798 federal disability payments.
Despite her cheerful demeanor, 55-year-old Ms. Prince has been unable to work since a car accident left her with numerous health issues. In July, a breast cancer diagnosis led to a double mastectomy, and she now grapples with surgical complications, including swelling, constant pain, and alarming blood clots. “It’s hard to recover properly when you can’t get any sleep and you’re worried all the time about feeding your family,” she explained, as her youngest grandchild, Klover, squirmed in her arms.
The Prince family’s journey perfectly illustrates the rationale behind the HOP program: it pulled them out of homelessness and provided the foundation for healthy eating. Conversely, the abrupt withdrawal of this support starkly highlights how the relentless stress of poverty severely undermines health. “I’m not one to complain, but it’s been hell,” she confided, her voice hushed, with her grandchildren just out of earshot.
A few days later, Ms. Prince was rushed to the emergency room, experiencing numbness on her right side and an inability to speak. Doctors diagnosed a series of small strokes. After five days in the hospital, she was sent home with stringent instructions: eat well, rest, and above all, avoid stress – a cruel irony for someone living in her circumstances.