By admin 
America’s health care affordability crisis is no longer a looming threat; it is a present-day catastrophe that transcends partisan boundaries, bankrupting families, straining state budgets, and overwhelming emergency rooms from the hollows of rural Appalachia to the high-rises of downtown Seattle. For decades, the United States has spent more per capita on health care than any other developed nation, yet it continues to lag behind in life expectancy, chronic disease management, and maternal health outcomes. The disconnect lies in a fundamental misunderstanding of what actually produces health. While clinical care is vital, it accounts for only about 20 percent of health outcomes. The remaining 80 percent is driven by social, economic, and environmental factors—the conditions in which people are born, grow, live, work, and age.
In the purple state of North Carolina, a revolutionary experiment has provided a roadmap for bridging this gap. Known as the Healthy Opportunities Pilots (HOP), this initiative represents the nation’s first comprehensive program to test the impact of using Medicaid funds to pay for targeted, evidence-based social services. The results of this multi-year endeavor, recently validated by rigorous independent research, offer a compelling case for a paradigm shift in American domestic policy. By addressing the "root causes" of illness—such as food insecurity, housing instability, and lack of transportation—North Carolina has demonstrated that it is possible to improve human lives while simultaneously reducing the staggering costs that threaten the sustainability of the Medicaid program.
The premise of the Healthy Opportunities Pilots is elegantly straightforward: what if Medicaid could help pay for a box of healthy produce, the remediation of asthma-triggering mold in a home, or a reliable van ride to a specialist’s appointment? For too long, the traditional medical model has been reactive, waiting for a patient to spiral into a crisis before intervention occurs. This approach is not only inhumane but fiscally irresponsible. An emergency room visit for a diabetic patient in ketoacidosis costs thousands of dollars; a consistent supply of healthy, medically tailored meals costs a fraction of that. A hospitalization for a child with a severe asthma attack is exponentially more expensive than fixing the leaky roof or removing the old carpeting that caused the flare-up.
The origins of this program date back to 2018, at the start of Governor Roy Cooper’s administration. Navigating a complex political landscape, state health officials worked in tandem with the first Trump administration’s Centers for Medicare and Medicaid Services (CMS) and North Carolina’s Republican-controlled General Assembly. This cross-aisle collaboration was essential. It required a shared recognition that the status quo was failing both patients and taxpayers. To secure a Section 1115 demonstration waiver from the federal government, North Carolina had to prove it could design a system that was both innovative and accountable.
Building the infrastructure for HOP was a monumental task. It was not enough to simply authorize the spending; the state had to create an entirely new ecosystem for delivery. This involved designing novel contracting mechanisms that allowed traditional Medicaid managed care organizations to partner with local non-profit community-based organizations—groups like food banks, domestic violence shelters, and housing agencies that had never before operated within the rigorous regulatory environment of Medicaid. To facilitate this, the state launched NCCARE360, the first statewide technology platform that allows health care providers and social service agencies to send and receive secure electronic referrals, ensuring that no patient falls through the cracks. Thousands of frontline workers were trained, many in rural communities where skepticism of government programs often runs deep.
The recently completed evaluation by the University of North Carolina (UNC) Sheps Center for Health Services Research provides the data that proponents of "whole-person care" have long sought. Covering more than 31,000 enrollees from the program’s launch in 2022 through late 2024, the study’s findings are transformative. The headline figure is a net saving of $164 per person per month. Crucially, this figure is calculated after accounting for the cost of every social service delivered and every dollar of administrative overhead. While these savings were not instantaneous—building the necessary habits and environmental changes takes time—they grew consistently over the measurement period, reaching levels of statistical and fiscal significance that are rare in social policy evaluations.
These savings were achieved by fundamentally shifting the site of care from high-cost clinical settings to the community. Participants in the HOP program experienced significantly fewer emergency department visits and hospital admissions. Instead, they had more frequent contact with outpatient providers, suggesting that by meeting their basic needs, the program empowered them to engage more effectively with preventive primary care. Furthermore, the program led to measurable reductions in food insecurity and housing instability. Perhaps most tellingly, nearly 90 percent of participants reported that the program improved their health and the health of their children, a testament to the human impact behind the data points.
When viewed at scale, the implications of a $164 per member per month saving are staggering. For a state like North Carolina, which serves millions of Medicaid beneficiaries, this translates into billions of dollars in potential savings for both state and federal budgets. In an era of fiscal constraint, where Medicaid often represents the largest or second-largest line item in state budgets, such efficiencies are not merely a "rounding error"; they are a lifeline for the program’s long-term viability.
The political success of the Healthy Opportunities Pilots is as noteworthy as its clinical success. North Carolina is a microcosm of the nation’s political divisions, yet the program survived and thrived across two very different federal administrations and a deeply divided state government. The key to this durability was a relentless focus on fiscal stewardship and community-led solutions. Conservative legislators were drawn to the program’s emphasis on eliminating waste and the use of private-sector non-profits to deliver services. Progressive leaders focused on equity and the moral imperative of addressing the social determinants of health. By framing the program as a "test"—a rigorous, time-bound evaluation with clear endpoints rather than a permanent entitlement—proponents built the credibility necessary to sustain bipartisan support.
However, the journey was not without its hurdles. In 2025, during a period of intense budget impasse in the North Carolina General Assembly, the program was temporarily paused as part of broader fiscal negotiations. This pause served as a stress test for the program’s advocates. Armed with the preliminary data from the UNC Sheps Center, a coalition of health care providers, business leaders, and community advocates successfully lobbied for its reinstatement. In July 2026, the legislature voted not only to continue the program but to begin scaling it, recognizing that the "drivers of health" are also the drivers of state savings.
The North Carolina experience offers urgent lessons for the rest of the country. Currently, states that wish to innovate in this space must navigate a grueling and idiosyncratic waiver process with CMS, often spending years in negotiation for programs that may only last a few years. Congress should act to codify pathways that allow states to integrate evidence-based social services into their Medicaid programs as a standard option, rather than an exception. This would provide the regulatory certainty needed for states to make long-term investments in social infrastructure.
In the interim, the executive branch has the power to act. CMS can expand its guidance to provide states with broader "in lieu of" services (ILOS) authority, allowing Medicaid plans to offer social interventions as cost-effective substitutes for traditional medical care. Additionally, the federal government should encourage the use of rural health transformation funds to help smaller, under-resourced communities build the technical and organizational capacity required to participate in these programs.
The Healthy Opportunities Pilots program has proven that pragmatism can indeed triumph over partisanship. It has shown that when we stop treating health as something that only happens inside the four walls of a doctor’s office, we can unlock better outcomes and lower costs. The era of debating whether social factors matter is over; the data is in. The challenge now is one of will and implementation. As the nation looks for ways to heal a fractured health care system, it should look to the lessons of North Carolina. By investing in the basic needs of our most vulnerable citizens, we are not just performing an act of charity; we are making a strategic investment in the economic and physical health of the entire country. The experiment has been run, the results are clear, and the time to replicate what works is now. Health care affordability will not be solved by rhetoric, but by the quiet, hard work of building durable coalitions around ideas that have been proven to work in the real world. North Carolina has shown the way; it is time for the rest of the nation to follow.
