Five years ago, North Carolina launched an innovative experiment: could providing essential services like nutritious food, stable housing, and transportation to medical appointments help vulnerable Medicaid recipients stay healthier and reduce expensive hospital visits?
For Krista Shalda, a single mother navigating the complex medical needs of her two boys, this meant a weekly delivery of fresh produce. These provisions were vital, making it easier to maintain the specialized diet that significantly reduced her 15-year-old son’s emergency room visits.
Kellie Prince, facing homelessness after spinal surgery, found refuge in a motel room for several weeks, preventing her family from having to sleep in their car outside the hospital.
And for Debra Hensley, a 60-year-old who is partially blind and physically disabled, the Medicaid-funded Healthy Opportunities Pilot (HOP) program covered a new roof and essential electrical work, allowing her to remain in the aging trailer she shares with her teenage grandson.
“It’s not an exaggeration to say that HOP saved my life,” Ms. Hensley stated, pointing to ceiling holes where rainwater once poured into her living room.
By most accounts, this $650 million Medicaid initiative in North Carolina was a resounding success, even garnering bipartisan support within the state’s Republican-led General Assembly.
An analysis by the UNC School of Medicine revealed that the program saved $1,000 annually for each of the 13,000 Medicaid recipients in the pilot, which served three rural areas of the state.
Despite its success, the HOP program is now being discontinued, becoming an early casualty of Medicaid cuts approved by Congress in July. State Republican leaders, facing impending reductions in federal healthcare spending under President Trump’s recent legislation (which extends tax cuts and slashes social safety net programs), opted not to renew the funding.
State lawmakers have until September 30th to reverse this decision and secure another five years of funding for the pilot. However, many organizations involved have already ceased services, and some have completely shut down.
“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, an Asheville-based nonprofit that helped manage the program 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 analysts warn will significantly diminish benefits for the state’s three million Medicaid recipients.
The cancellation of the pilot program has been particularly disheartening for residents of Asheville and its surrounding mountainous counties, a region still grappling with the devastating floods caused by Hurricane Helene almost exactly a year ago.
Many locals feel abandoned by the Federal Emergency Management Agency (FEMA), which announced in May that it would no longer share the costs of recovery efforts with the state.
In recent years, the area has become a draw for affluent retirees and remote workers, attracted by the beauty of the Blue Ridge Mountains and Asheville’s vibrant arts scene. Yet, in a state with a $7.25 minimum wage, the soaring housing prices have made the region increasingly out of reach for low-wage workers.
State Senator Ralph Hise, whose district benefited from the pilot, and several other Republican leaders in the General Assembly did not respond to requests for an interview.
However, some have publicly expressed doubts about the program’s effectiveness.
“It’s not clear from our side that any folks are really benefiting from that program anyway,” House Speaker Destin Hall stated in June.
North Carolina’s decision offers a somber preview of the sweeping changes ahead for American healthcare, with over $900 million in projected Medicaid cuts expected over the next decade. According to the Congressional Budget Office, nearly eight million people are anticipated to lose Medicaid coverage by 2034.
After their suburban Asheville home was ravaged by floodwaters during Helene, Ms. Shalda and her two sons, both autistic, endured months in shelters and motels. 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, expressing her dismay at the program’s termination.
Dr. Seth A. Berkowitz, a primary care physician at the UNC School of Medicine, who has been evaluating the HOP program for the federal Centers for Medicare & Medicaid Services, affirmed its success in aiding families in crisis. “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.
While initial spending on participants increased for prescribed services—such as mold removal to alleviate a child’s asthma—Dr. Berkowitz observed that costs ultimately decreased over time.
“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 emphasized.
Beyond individual benefits, the pilot program also stimulated the local economy, channeling significant funding through social service organizations, food banks, and farms across the region.
Many farmers, who had already planted their spring crops, were caught off guard by the program’s sudden shutdown. “For us, the timing is terrible,” said Nicole DelCogliano, who cultivates 30 varieties of organic vegetables along the South Toe River in Yancey County.
The HOP revenue had been crucial in helping Ms. DelCogliano’s family recover after Helene inflicted $250,000 in damage to their farm. “And personally speaking, it was especially gratifying to know our food was going to people who really needed it,” she added.
Much of the farm’s harvest was distributed through a network of community markets operating in low-income neighborhoods around Asheville. These markets, run by the nonprofit Bounty & Soul, function much like traditional farmers’ markets, but with one key difference: shoppers receive farm-fresh produce without cost.
Paula Sellars, director of Bounty & Soul, reported that these community markets now serve 26,000 people monthly, a figure that has doubled since Hurricane Helene.
While the markets will continue, the termination of the HOP program means 260 Medicaid recipients with severe health conditions will no longer receive the weekly boxes of fruits, vegetables, and eggs that Bounty & Soul provided. “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 godsend.
Her eldest son, Alex, 15, is a tall, gentle boy, wise beyond his years, who was born with hydrocephalus, a condition involving fluid buildup in the brain. Over time, he has endured numerous hospitalizations and surgeries, making him particularly vulnerable to convulsive seizures and kidney stones.
When Alex’s doctor prescribed a strict, two-page diet rich in fresh vegetables, dairy, and meat to lessen these episodes, Ms. Shalda was overcome with frustration. Such a diet was almost impossible to afford on the $700 in food stamps her family received each month.
The HOP food boxes, meticulously tailored to her family’s specific dietary needs, provided two dozen eggs, cheese, bread, and a wide variety of seasonal produce. Ms. Shalda was so delighted she would eagerly share photos of her full refrigerator with friends. Over time, Alex’s hospital visits for seizures and kidney stones began to decrease.
“And it’s been such a relief to watch him run around crunching on carrots and peppers instead of eating junk food,” she said.
However, since the food deliveries ceased in July, Ms. Shalda has been forced to rely more on frozen and canned vegetables. Her boys visibly recoiled at the mention. “The frozen carrots tasted like mush,” Alex complained.
Recently, the familiar pain from his chronic kidney stone condition has started to resurface.
Ms. Shalda dreads what the future holds, as federal cuts to Medicaid and food stamps are set to take effect.
“I feel overwhelmed just thinking about the future,” she admitted.
Ms. Prince, who is raising three grandchildren, shares this profound anxiety. Since the weekly food boxes stopped, she’s been visiting local food pantries, but few offer fresh produce, and most 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 in shelters and motels, her husband secured a $20-an-hour job with the Asheville Housing Authority, enabling the family to rent a two-bedroom apartment in nearby Black Mountain. However, his income subsequently made the family ineligible for their $173 in monthly food stamps, and Ms. Prince also lost $798 in federal disability payments.
Ms. Prince, 55, is a cheerful and seemingly tireless woman, but she has been unable to work since a car accident left her with numerous health issues years ago. In July, she received a breast cancer diagnosis and underwent a double mastectomy.
On a recent afternoon, Ms. Prince recounted the challenges of raising three grandchildren under the age of eight on a limited income while managing surgical complications, including swelling, constant pain, and a series of blood clots that concerned her doctor.
“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 said, her youngest grandchild, Klover, wiggling in her arms.
In many respects, the Prince family embodies the very purpose of the HOP program. It helped them escape homelessness, and the food boxes provided the foundation for healthy meals.
Conversely, the loss of this support vividly illustrates how the relentless stress of poverty can severely impact health. “I’m not one to complain, but it’s been hell,” she confided in a quiet moment, her grandchildren out of earshot.
Just a few days later, Ms. Prince was rushed to the emergency room after the right side of her body went numb and she lost the ability to speak. Doctors diagnosed her with a series of small strokes.
After five days in the hospital, she was sent home with strict instructions: eat well, rest, and avoid stress.