NC Medicaid Reform Advisory Team (2016-2017)

What is the best path forward for Medicaid in North Carolina? The question of how our society can provide quality health care at a sustainable cost is one of the most important policy issues of the 21st century and touches all Americans across the education, income and demographic spectrum.

Medicaid covers more than two million North Carolina residents with diverse health needs. It accounts for roughly 30% of total state spending. At the same time, 13% of North Carolinians remain uninsured, and even among the insured, significant health disparities persist across income, geography, education and race. The Affordable Care Act offers states additional federal dollars if states agree to expand their Medicaid programs to all nonelderly adults with income below 133% of the federal poverty level. North Carolina opted against Medicaid expansion. Advocates for expansion argue that an additional 300,000–500,000 low-income adults would gain access to health insurance, with the federal government picking up most of the tab for three years. Opponents cite the growing state financial obligations after those three years, plus the burden of federal mandates that must be followed when accepting federal Medicaid expansion funds.

This Bass Connections project team drew on Duke’s expertise in public policy, law, medicine and business under the umbrella of the Duke-Margolis Center for Health Policy to craft a Medicaid reform proposal to fit the constraints and demands of North Carolina politics, especially in light of the revised political landscape resulting from the 2016 elections. Team members analyzed Medicaid reform proposals from the McCrory Administration (Section 1115 Waiver), Cooper Administration (Berger vs. Burwell) and the General Assembly (House Bill 662). A Section 1115 Waiver allows a state to use federal Medicaid funds in ways that are not otherwise allowed under federal rules, as long as the waiver meets the objectives of the Medicaid program. Previous waivers have expanded Medicaid to those who were otherwise not covered by the program, provided services typically not covered by Medicaid or piloted innovative service delivery systems. The McCrory Administration submitted an NC 1115 Waiver in June 2016, which proposed to shift from the fee-for-service model of primary care management to a managed care system financed on a capitated basis.

On April 25, 2017, the team submitted its report to North Carolina’s policymakers and citizens and hosted a presentation and discussion in Raleigh. The report assesses the Medicaid landscape in and offers recommendations to policymakers concerning the potential impact of federal block grants on North Carolina Medicaid; the construction of Medicaid Managed Care markets; opportunities and risks associated with instituting consumer-driven financial incentives in Medicaid; targeted “hotspotting” strategies to address the needs and escalating costs of Medicaid’s high-utilizers and dual-eligibles; and benefits of pursuing telemedicine and related reforms to reimbursement, regulation and Graduate Medical Education programs that could fuel telemedicine solutions to improve access and delivery.

Also on April 25, the North Carolina Department of Health and Human Services requested public comments regarding a Section 1115 waiver and statewide Medicaid reform. The team submitted a public comment synthesizing recommendations contained in its report.

Four undergraduate team members received a grant to take this work further through a project called Reforming North Carolina Medicaid. They took a “hot-spotter approach” to health policy, identifying the counties with the highest health expenditures and greatest Medicaid burden as well as conducting interviews with officials, providers and patients to understand the challenges of current payment and delivery structures.


Fall 2016 – Spring 2017

Team Outputs

Hot-Spotting North Carolina’s Medicaid Transformation (by Kushal Kadakia, Shivani Shah, Barak Richman), Health Affairs

Reforming North Carolina Medicaid: A County Level Analysis of Challenges and Opportunities (poster by Kushal Kadakia, Shivani Shah, Jackie Lin, Aakash Jain), presented at Bass Connections Showcase, April 18, 2018

Public comment regarding the North Carolina Department of Health and Human Services (DHHS) Proposed Program Design for Medicaid Managed Care, September 9, 2017

North Carolina Medicaid Reform Advisory Team (poster by Brandon Yan, Brooke Bekoff, Graeme Peterson, Haley Hedrick, Jackie Lin, Kushal Kadakia, Leah Yao, Riley Herrmann, Shivani Shah, Sonia Hernandez, Deanna Befus, Madhulika Vulimiri, Patrick O’Shea, Shanna Rifkin, Trey Sinyard)

NC Medicaid Reform: A Bipartisan Path Forward (Report)

North Carolina Medicaid Reform: A Bipartisan Path Forward (Event, April 25, 2017)

Public comment submitted to North Carolina Department of Health and Human Services on Medicaid and NC Health Choice Request (Deanna Befus, Patrick O’Shea, Shanna Rifkin, Trey Sinyard, Madhulika Vulimiri, Brooke Bekoff, Haley Hedrick, Sonia Hernandez, Riley Herrmann, Kushal Kadakia, Jackie Lin, Graeme Peterson, Shivani Shah, Brandon Yan, Leah Yao, Barak D. Richman, Allison Rice, Donald Taylor, Susan Kline, Leigh Ann Simmons, Hilary Campbell, Amanda McMillan)

Bass Connections Follow-on Student Research Grant (Aakash Jain, Kushal Kadakia, Jackie Lin, Shivani Shah)


Bass Connections: NC Medicaid Reform Team


Kushal Kadakia (2019)

Trey Sinyard

Faculty Perspectives: Barak Richman

Kushal Kadakia (2017)

Madhulika Vulimiri, MPP Student

Healthcare is a Human Right (Kushal Kadakia)

This Team in the News

Bass Connections: An Academic Journey With Lasting Effect

In Her Own Words: A State Health Official On How Bass Connections Shaped Her Career

Rhodes Scholar Shares Insights into Project-based Education at Duke

Class of 2019: Eight Students Who Changed Duke...And Themselves

Duke Law Faculty and Students Showcase Range of Expertise through Bass Connections Projects

Seniors Kushal Kadakia, Claire Wang and Ariel Kantor Win Rhodes scholarship

Episode 1.13 — Kushal Kadakia ’19

Sanford Student Wins Rhodes Scholarship

For Rhodes Scholars, Duke’s Interdisciplinary Institutes and Initiatives Played Vital Role

Three Duke Seniors Named Rhodes Scholars

Two Duke Students Selected As Truman Scholars

Top Student Scholars: Independent Studies of Neutrinos, Medicaid Policy and African Feminism

Duke's Madhu Vulimiri Talks Medicaid on WUNC

The Integrated Approach To Health That Could Save Our System Millions

NC Medicaid Team Member Selected as Margolis Scholar in Health Policy and Management

Two MPP Students Named Margolis Scholars as Part of First Student Cohort

Margolis Scholars in Health Policy and Management Welcomes First Student Cohort

Student Laurels and Honors for 2017

Students Present Their Research and Learn from Each Other at the Bass Connections Showcase

PhD Student Befus Presents at Bass Connections Program on Medicaid Reform

Bass Connections NC Medicaid Reform Team Presents in Raleigh

Student Research Shared, Awards Announced at Bass Connections Showcase

Twelve Students Receive Grants to Take Their Bass Connections Research Further

Reflections on Mentoring from Bass Connections Graduate Students

Students Craft NC Medicaid Reform Proposal

Duke-Margolis Center for Health Policy Director Explains Mission of Center, Future of Health Care Policy

NC Medicaid Reform Advisory Team Kickoff

Trump Administration Brings Opportunities, Risks for NC Medicaid Program

This project team was originally part of the Education & Human Development theme of Bass Connections, which ended in 2022. 

Team Leaders

  • Barak Richman, Duke Law
  • Donald Taylor, Sanford School of Public Policy

/graduate Team Members

  • Madhulika Vulimiri, Masters of Public Policy
  • Trey Sinyard, Medicine MD Fourth Year, Business Administration-MBA
  • Shanna Rifkin, Juris Doctor
  • Patrick O'Shea, Business Administration-MBA, Health Sector Management
  • Deanna Befus, Nursing-PHD

/undergraduate Team Members

  • Kushal Kadakia, Public Policy Studies (AB)
  • Leah Yao, Psychology (BS)
  • Brandon Yan, Public Policy Studies (AB)
  • Shivani Shah, Biology (BS), Public Policy Studies (AB2)
  • Graeme Peterson, Public Policy Studies (AB)
  • Jackie Lin, Biology (BS)
  • Aakash Jain, Economics (BS), Biology (BS2)
  • Riley Herrmann, Public Policy Studies (AB)
  • Sonia Hernandez, Economics (BS)
  • Haley Hedrick, Psychology (AB)

/yfaculty/staff Team Members

  • Susan Kline, School of Medicine-Pediatrics
  • Amanda McMillan, School of Medicine-Duke Clinical Research Institute
  • Allison Rice, Duke Law
  • Leigh Ann Simmons, Department of Human Ecology, UC Davis
  • Hilary Campbell, Margolis Center for Health Policy

/zcommunity Team Members

  • Lincoln Community Health Center
  • Community Care of North Carolina
  • N.C. Community Health Center Association
  • National Health Law Program
  • North Carolina Justice Center
  • Cone Health Foundation
  • Brooke Bekoff, UNC-Chapel Hill