Investment in Proven Strategies is Critical for NC Rural Health Transformation Program

North Carolina’s Healthy Opportunities Pilot (HOP) is the nation’s leading Medicaid approach for containing costs while improving beneficiaries’ health. HOP focuses on improving rural access to health-related social needs (HRSN) such as nutritious food, safe housing, and healthy relationships – the building blocks of health that account for up to 80 percent of health outcomes. Sustained investment in HOP’s proven results over the past three years will be critical for North Carolina’s rural health transformation

HOP community care networks make North Carolina RHTP ready.

North Carolina has invested significant resources in operationalizing rural community care hubs under HOP. With sustained investment, HOP’s established infrastructure and service alignment will accelerate the implementation of the Rural Health Transformation Program (RHTP) and multiply its impacts across rural regions of the state.

1.1M

HRSN services successfully delivered in NC to date¹

40K

NC Medicaid members improved their health through HOP¹

90%

of HOP services targeted food insecurity, an identified NC RHTP priority^2,3

HOP improves rural health outcomes and reduces healthcare costs.

An independent evaluation has demonstrated that HOP participation improves health outcomes for Medicaid members who have traditionally depended on costly emergency medical care. These findings enabled the state to secure a second Medicaid waiver to build on HOP’s success, which aligns with federal rural health transformation goals.⁴

23%

reduction in hospitalizations for HRSN program participants⁵

264

fewer ED visits per 1,000 beneficiaries per year^6,7

$1,020

saved per beneficiary per year^6,7

“I wouldn’t be where I am today without the Healthy Opportunities Pilot. It gave me exactly what I needed: fair access to healthy food, meaningful work, and a real chance to build a better life.”

—Christina S., former HOP participant

HRSN interventions increase the capacity of rural health systems.

Community-based care improves health and reduces strain on overburdened rural hospitals. This integrated approach allows primary care providers to focus on what they do best – delivering high-quality medical care. Investments in HRSN services yield results.

27%

increase in hospitalizations is associated with food insecurity^8,9

83%

reduction in ED visits after HRSN interventions^10,11

53%

reduction in pediatric hospitalizations after environmental asthma triggers were addressed^10,11

HOP increases participation in the rural labor force.

Preventing and stabilizing chronic diseases and meeting the basic needs of the workforce increases labor force participation now and for future generations. HOP is an investment in rural workforce development, retention, and resilience.

10M+

lost school days/year are attributed to unmanaged childhood asthma¹²

22%

more likely to lose a job as a result of housing insecurity¹³

2x more

lost work days for those with diabetes who are food insecure¹⁴

HOP is an investment in rural economic development and disaster resilience.

In Western North Carolina, HOP created multi-sector job opportunities, supported local farms and industry, and increased household spending. HOP also served as an effective rapid-response system for communities reeling from Hurricane Helene.¹⁵

$114M

total business generated in WNC through HOP¹⁶

$50M

invested in WNC food economy through HOP¹⁶

400+

WNC farms and food businesses participated in HOP¹⁶

“HOP helps us stabilize cash flow year-round. Our team has taken pride in knowing the work they do helps families, grandparents, and neighbors eat better, live better, and stay out of the hospital.”

– Darnell Farms, Swain County

Works Cited

North Carolina Department of Health and Human Services, Healthy Opportunities Pilots at Work, NCDHHS, 1 Oct. 2025, https://www.ncdhhs.gov/about/department-initiatives/healthy-opportunities/healthy-opportunities-pilots/healthy-opportunities-pilots-work.
Amanda Van Vleet, “Reflecting on Nearly Two Years of North Carolina’s Healthy Opportunities Pilots,” North Carolina Medical Journal, vol. 85, no. 2, Mar. 2024, pp. 92–95, https://doi.org/10.18043/001c.94844.
North Carolina Department of Health and Human Services, “Rural Health Transformation Program,” NCDHHS, https://www.ncdhhs.gov/divisions/office-rural-health/rural-health-transformation-program.
North Carolina Department of Health and Human Services, North Carolina Medicaid and NC Health Choice: Draft Section 1115 Waiver Application, 1 Mar. 2016, https://www.ncdhhs.gov/draft-section-1115-waiver-2016-03-01/open.
Kurt Hager et al., “Medicaid Nutrition Supports Associated with Reductions in Hospitalizations and ED Visits in Massachusetts, 2020–23,” Health Affairs, vol. 44, no. 4, Apr. 2025, pp. 413–21, https://doi.org/10.1377/hlthaff.2024.01409.
S. A. Berkowitz et al., “Medicaid Spending and Health-Related Social Needs in the North Carolina Healthy Opportunities Pilots Program,” Journal of the American Medical Association, 2025, https://jamanetwork.com/journals/jama/fullarticle/2830892.
North Carolina Department of Health and Human Services, Healthy Opportunities Pilots Interim Evaluation Report, 16 July 2024,
https://www.ncdhhs.gov/healthy-opportunities-pilots.
Hilary K. Seligman et al., “Exhaustion of Food Budgets at Month’s End and Hospital Admissions for Hypoglycemia,” Health Affairs, vol. 33, no. 1, 2014, pp. 116–123, PubMed Central, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4215698/.
Sanjay Basu, Seth A. Berkowitz, and Hilary K. Seligman, “The Monthly Cycle of Hypoglycemia: An Observational Claims-Based Study of Emergency Room Visits, Hospital Admissions, and Costs in a Commercially Insured Population,” Medical Care, vol. 55, no. 7, 2017, pp. 639–645, PubMed Central, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5695234/.
Evans, Geoffrey, et al. “Effectiveness of Community Health Worker Intervention at Dayton Children’s Hospital at Decreasing Emergency Department Visits and Hospitalization Rates for Pediatric Asthma Patients.” Journal of Primary Care & Community Health, vol. 16, 2025, p. 21501319251358571, SAGE Journals, https://doi.org/10.1177/21501319251358571
Bryant‑Stephens, Tyra, Cizely Kurian, Rong Guo, and Hauqing Zhao. “Impact of a Household Environmental Intervention Delivered by Lay Health Workers on Asthma Symptom Control in Urban, Disadvantaged Children with Asthma.” American Journal of Public Health, vol. 99, suppl. 3, Nov. 2009, pp. S657–S665, American Public Health Association, https://doi.org/10.2105/AJPH.2009.165423
Joy Hsu et al., “Asthma-Related School Absenteeism, Morbidity, and Modifiable Factors,” American Journal of Preventive Medicine, vol. 51, no. 1, 2016, pp. 23–32, https://doi.org/10.1016/j.amepre.2015.12.012.
Matthew Desmond and Carl Gershenson, “Housing and Employment Insecurity among the Working Poor,” Social Problems, vol. 63, no. 1, Feb. 2016, pp. 46–67, https://doi.org/10.1093/socpro/spv025.
Jennifer M. Weinstein, Amanda R. Kahkoska, and Seth A. Berkowitz, “Food Insecurity, Missed Workdays, and Hospitalizations among Working-Age US Adults with Diabetes,” Health Affairs, vol. 41, no. 7, 2022, pp. 1045–1052, https://doi.org/10.1377/hlthaff.2021.01744.
Dogwood Health Trust, “Impact Health – When a Network Forms a Safety Net (Hurricane Helene Grantee Spotlight),” Dogwood Health Trust, https://dogwoodhealthtrust.org/partner-profile/impact-health/.
Impact Health, Economic IMPLAN Report, July 2025, https://impacthealth.org/wp-content/uploads/2025/07/Economic-IMPLAN-Report.pdf.

View the full list of works cited and works consulted or download the PDF.

Disclaimer
This content was developed by the WNC Health Policy Initiative Social Determinants of Health Workgroup in consultation with people and organizations with connections to the health of people of Western North Carolina. Findings, conclusions, or recommendations are those of the contributors and do not necessarily reflect the view of the WNC Health Policy Initiative or its host institutions of the University of North Carolina Asheville (UNCA), Mountain Area Health Education Center (MAHEC), or funders.

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