Two former North Carolina health secretaries, Mandy Cohen and Kody Kinsley, delivered a verdict this week on the state's experiment with paying for social services through Medicaid: it worked, and the rest of the country should copy it. The Healthy Opportunities Pilots, known as HOP, spent Medicaid money on boxes of healthy food, housing repairs, and rides to appointments, and the state's multiyear evaluation found that Medicaid saved $164 per member per month after accounting for every service delivered and every dollar of overhead. Participants went to the emergency room and the hospital less often and saw outpatient providers more; nearly 90 percent said the program improved their health and their children's health. On the strength of those results, the two are asking Congress to bring the model nationwide, sparing other states the years of waiver fights North Carolina went through.
The results are real, and the request is understandable. But the essay leaves out the part of the story that matters most to anyone tempted to copy it: the program nearly died before its evidence arrived. The pilot's own history is a warning about the clock all such programs run on, and it bears directly on the expansion they propose.
The proof landed after the program had been stopped
HOP launched in March 2022, four years after the state began building its machinery: new contracts, community organizations new to Medicaid, a statewide technology platform, and thousands of rural frontline workers. The evaluation by the Sheps Center covered more than 31,000 enrollees from launch through late 2024 and found savings that grew steadily. An interim assessment with the Duke-Margolis Institute for Health Policy had found about $85 per member per month in the early years; the final figure, $164, appeared only at the end, once startup costs were absorbed. The savings became statistically significant only in the final measurement period, and that timing is the detail to worry about.
For most of the program's life, the evidence of success was a trend line heading the right way, not a proven result. While that trend line was still maturing, the program ran out of money: neither chamber's 2025 budget included funding for HOP, the legislature failed to pass a full budget, and state funding expired on July 1, 2025. The program suspended operations for nearly a year. The Sheps report that would justify it came out in March 2026, with the program already stopped, published into the silence of a program that no longer existed.
A budget ledger cannot see the visits that never happened
This is the structural problem with prevention, and it applies to everything HOP did. Food boxes, housing repairs, and rides are purchases. They show up on a ledger, line by line, month by month. What they buy is different: an emergency room visit that did not occur, a hospital admission that did not occur, a patient who stayed out of the intensive care unit. Averted events never appear on any budget. The $164 figure is a statistical estimate of money the state did not spend, produced by comparing enrollees against a control group. A legislator voting on next year's spending does not see $164 in savings; they see the cost of the services, with the savings living in a comparison nobody can point to.
Lawmakers who left HOP out of their budgets had a coherent fiscal case, and it deserves to be stated as its advocates would state it. The program had been financed with temporary Medicaid expansion money. Continuing it meant committing real state dollars, roughly $60 million a year, to services the state had never paid for before, with no obvious end to the commitment. From that side of the table, a pause looked like prudence: do not convert one-time federal funding into a permanent state obligation. Supporters had an equally strong counter: the state's own actuary, Mercer, independently validated that pilot savings were large enough to lower Medicaid capitation rates, meaning the program paid for itself. This analysis takes no position on that funding dispute, a real argument between two legitimate readings of the same situation. What is not debatable is the sequence: evidence matured after the money stopped.
The bipartisan story has a page missing
The essay presents HOP as proof that pragmatism can beat partisanship in a closely divided state, and the claim is partly true. A Democratic administration and a Republican-led legislature approved the pilot together in 2018. The revival in July 2026 was bipartisan as well: the state's first full budget in three years, drafted by the GOP-led General Assembly and signed by Democratic Governor Josh Stein, appropriated $25 million in nonrecurring funds to restart the program: $9 million in state money paired with $16 million in federal Medicaid funds.
The missing page is the gap between the applause and the appropriation. The governor had requested $87 million in recurring funding; senators on both sides put the program's true annual cost at $60 to $80 million. The revival money was roughly a third of that, and nonrecurring, a bridge rather than a restoration. The essay asks Congress to scale this model nationwide while the model's home state restarts it at a fraction of its own request, on money that will be fought for again next year. Bipartisanship revived the program; it did not fully fund it, and nothing in the national plan would protect a federal HOP from the annual budget clock that nearly killed the state version.
What the pause broke that the numbers cannot show
The year-long freeze cost more than time, and the evaluation cannot see most of the damage. It counts money saved and visits avoided, not the delivery system that was taken apart and now has to be rebuilt. The regional organizations that ran the program lost capacity during the freeze: food program drivers took other jobs, participating local farms scaled back, trained staff moved on. The assets built in the early years do not hold still while a budget fight resolves itself; they decay.
Even the essay's own closing request runs into this. It asks states to deploy rural health transformation funds toward social services, and North Carolina has such a program, backed by a $213 million award. But those funds, as local reporting documented, are restricted to infrastructure investment and cannot pay for food boxes or housing repairs. The money exists, the services do not, and the gap is exactly the kind of mismatch the headline figure does not advertise.
A pilot wears armor that a national program does not
This is the part of the story that does not travel. HOP survived its funding crisis in part because it was a pilot: a time-boxed test with defined endpoints and a rigorous evaluation, presented to both parties as an experiment rather than a finished product. That frame gave the program something no permanent entitlement has, a promise of a verdict. Lawmakers could hold off because a decision was coming: the report had a release date, the researchers were known, the endpoints set in advance. When the verdict landed, it was favorable enough to pull the program back from the dead.
Scale the model up and the armor disappears. A national program has no control group, no interim report to wait for, no defined endpoint. It is a line item competing every year against visible spending, judged by a ledger that records only what it costs, not the ICU stays it prevented. The essay's request, to codify a pathway so states do not fight for waivers one by one, would remove one obstacle and create another: a permanent program would have to survive every budget cycle with nothing but invisible counterfactuals in its favor. Codifying the pathway without the evaluation machinery and a multi-year funding design would scale the vulnerability rather than the success.
The real lesson in the $164 figure
So the honest reading of HOP is not quite the one the essay offers. The results are in, and they are good; the evaluation, the actuary's validation, and the bipartisan revival support the authors' basic claim. But the program's own history is the strongest available evidence of what happens to prevention programs in practice: the savings showed up last, the costs showed up first, and the program nearly died in between. The $164 is real, and it took years to become visible, on the far side of a funding pause that came within a year of becoming permanent.
The lesson for Washington is not simply that North Carolina proved social services can pay for themselves. It is that the proof arrives on a clock of years while budgets run on a clock of months, and a program whose evidence matures slowly can be dismantled before its verdict arrives. Scaling HOP means deciding in advance that state budgets will wait for savings that show up in the last measurement period, and that the delivery system will be protected while the evidence is forming. The harder question is what happens to prevention when it stops being a test and becomes a program, judged every year on spending that is visible and results that are not. Whatever one believes about who should pay for food boxes and housing repairs under Medicaid, no version of the argument is served by dismantling a working delivery system before the evidence arrives. The families who lost their food boxes and rides during the freeze are receiving a partial restoration this year, and the machinery that served them is being rebuilt from scratch, the true price of judging prevention on the wrong clock.
Primary sources
- The STAT First Opinion essay by Mandy Cohen and Kody Kinsley, both former North Carolina HHS secretaries, for the argument for national expansion, the description of HOP's origins, the framing of the program as a test with defined endpoints, and the claim of bipartisan support.
- The Sheps Center's evaluation of more than 31,000 enrollees, for the $164-per-member-per-month savings figure, the finding that savings grew over time and became statistically significant only in the final measurement period, the reductions in emergency and inpatient use, and the near-90 percent participant-reported health improvement, along with the interim Sheps-Duke-Margolis evaluation that found the $85 estimate, and Mercer's validation that pilot savings lowered capitation rates.
- The News & Observer's reporting on the July 2026 revival, for the $25 million nonrecurring appropriation, the $9 million state share, the $87 million request, and the $60 to $80 million cost estimates.
- North Carolina Health News reporting for the details of the suspension, the loss of drivers and farms, and the restrictions on rural transformation funds.