In the rural North Carolina town of Washington, Gwendolyn Gilbert witnessed a community transform after healthcare became more accessible. She described the positive momentum as a “domino effect” in a community that desperately needed it. 

“When you have a healthy community, you have fewer people visiting the emergency department because they can get those issues caught earlier and get their medications and get support before they become these big issues,” Gilbert said. “When it’s healthy, you have fewer incidents of law enforcement and less transportation to hospitals, and more focus can be on those who need those services more.”

And as folks got healthier and stayed out of crisis, the whole town began saving money — fewer emergency transports, fewer acute care visits, and more time and resources freed up for the people who need deeper support.

The change in Washington came with Medicaid expansion, which allowed more individuals to become eligible for health insurance coverage. As the chief behavioral health officer at Agape Health Services, a Certified Community Behavioral Health Clinic (CCBHC) with multiple locations and a mobile clinic, Gilbert saw previously uninsured patients enroll in coverage. 

She watched them get their own prescriptions. And she saw them seek out treatment for chronic illnesses, including substance use disorder, which has ravaged surrounding Beaufort County.

“They were so excited to get care and have options,” Gilbert said. “We gave them hope.”

Because it is a CCBHC, Agape Health Services offers a sliding fee scale and is required to treat any patient regardless of their ability to pay. Gilbert said Agape’s patient population is about an even split between insured and uninsured. Those who are insured, by an overwhelming margin, are enrolled in either Medicaid or Medicare.

“Medicaid expansion meant for us that more of our uninsured patients could get insured,” she said. “We were able to get people in on their own to get their own healthcare. We saw some very sick patients with advanced stages of disease, so they’re having more problems, more acuity, and more gaps in care. But Medicaid allowed us to refer them out to specialists and not worry how they’ll get there because it included transportation.”

Beaufort County can be described as geographically “disconnected” just due to the lay of the land. A particularly impoverished area known as Aurora had raised alarm. Transportation, and funds for it, are scarce in the area. Overdose deaths there, and across the county, have climbed in recent years.

A 2022 report revealed the severity of the crisis. A county with just 44,000 people had seen a 650% increase in opioid overdose deaths since 2015. The formation of the Beaufort County Behavioral Health Task Force, which manages millions of dollars of opioid settlement funds the county received from national pharmaceutical lawsuits, created a social safety net.

The work Gilbert does through Agape is just one example of what that safety net can do. Agape’s mobile unit, called Hope on Wheels, began after Medicaid expansion and offers behavioral health in addition to medication-assisted treatment (MAT) for opioid use disorder. Most importantly, it brings care to the county’s rural communities. 

Once in those communities, Gilbert asked those living there how Agape could help and then began providing individuals with information and training on Narcan, a medication used to reverse an opioid overdose.

And soon, Agape started seeing people come in for their own suboxone prescriptions. Suboxone is a medication used to treat opioid use disorder. The medication contains buprenorphine and naloxone, which work together to manage cravings and withdrawal symptoms.

“When they came in for suboxone, we were doing Medicaid applications on site,” she said. “We saw more people come in for substance use and their own medications, and we didn’t see a lot of diversions. You’re going to have people divert anything. If someone is diverting or selling suboxone, they’re buying it because they need it. But we could get them their own prescription. We’d say, ‘Hey, you’re paying $35 for 1 dose and I can get you a month for $4.’” 

As a result, the clinic saw a wave of patients coming in for their own suboxone medications. Agape had to bring on two additional clinicians to manage the load. But with new restrictions on Medicaid certification on the horizon, and requirements to recertify more frequently, Gilbert predicts a regression in the communities that have made so much progress.

Recent funding cuts to Medicaid, a result of the budget and tax bill championed by the Trump administration, has Gilbert concerned. It has the potential to wipe out the progress the county has made in the wake of the COVID-19 pandemic, which is when opioid overdose deaths peaked across the county.

For its part, Agape is dedicating the focus of new staff members exclusively to helping community members recertify for Medicaid coverage.

“We’re not talking about the healthiest of communities. They’re afraid of systems and afraid of being judged. We still deal with stigma,” she said, worrying out loud about the repercussions of Medicaid cuts. “They’re going to lose it and go back to the streets.”

Despite those challenges, Gilbert said the task force gives her hope, because collectively they’re committed to helping individuals anyway they can. Healthier individuals lead to healthier, safer, more prosperous communities. And the community leaders assembled on the task force understand that, she said.

That collaborative spirit is one of the community’s greatest assets, the kind of invisible capital that keeps rural places moving forward even when policy moves backward.

“We recognize there are things going on in communities that will have to continue with or without dollars. We’re very good at just making it happen and making it work. We’re very close knit and we’re going to make it work. And lean on each other and support each other. No one is going to slip through the cracks on any of our watches,” she said. “We’re not driven by dollars. If I was, I wouldn’t even be in Eastern North Carolina. My passion is community health. It’s not about numbers, it’s about people.”