Even today, the biggest surprise among health exchanges sounds out of place among states with the highest enrollment, California, Florida, Texas, New York, and (drumroll) North Carolina.

Many state exchanges surprised for all the wrong reasons just ask Oregon, Nevada, or Maryland. Kentucky surprised back in October. The only Southern state running its own exchange and expanding Medicaid, Kentucky quickly established one of health reform's best-state-run exchanges.

But North Carolina appeared to be just another state staunchly opposed to the ACA. In the first month, just 1,662 people signed up. Once the feds fixed technical problems with healthcare.gov, North Carolina enrollment surged. By the end of 2013, it topped 100,000.

As of February, North Carolina exceeded 200,000 enrollees, more than all but two state-run exchanges.  The four states that have greater exchange enrollment all have at least twice the population of North Carolina.

On the surface, it seemed implausible. Few states have undergone the political upheaval of North Carolina in the past few years, with Republicans winning the governorship and both chambers of the state legislature for the first time since Reconstruction. The state rejected Medicaid expansion and defaulted to the federal government on exchange operations after previously planning a partnership exchange.

North Carolina's exchange market looked like one of the nation's least competitive another ominous sign for enrollment. Its exchange market has only two carriers, the state's dominant Blue Cross and Blue Shield of North Carolina and Aetna-owned Coventry Health Care. A third insurer, FirstCarolinaCare, withdrew before enrollment began. Because of Coventry's focus on larger metro areas, the North Carolina Blue plan is the only carrier in 61 of the state's 100 counties.

Then a funny thing happened people enrolled anyway, due in large part to advocacy groups and navigators assertively courting the state's uninsured.

Beneath the surface of ACA hostility, North Carolina had other forces at work. North Carolina's providers and its closely tied nonprofit sector gave it an infrastructure to base its exchange outreach efforts. Advocates didn't simply target uninsured populations in Charlotte, the Triangle or the Triad. Navigators went after the uninsured one-by-one in sparsely populated regions such as the state's western counties.

Legal Aid of North Carolina, one of the groups to receive navigator grants, built a statewide navigator appointment system to connect exchange customers with a navigator in their county. That made it easier for both navigators and exchange customers; only North Carolina has such a system.

The navigators coordination runs deep and even drafted law students, who were trained and certified as navigators and hosted exchange events around the state. Navigators did receive one break from the state; North Carolina lawmakers did not institute any of the additional licensing navigator measures enacted in other states. That could have added hours of continuing education, background checks, and restrictions on what navigators could discuss with exchange consumers.

Even with all this positive momentum, North Carolina still had issues. Nearly 319,000 residents fall into the Medicaid coverage gap, earning too much for Medicaid and not enough to qualify for exchange subsidies (Kaiser Family Foundation, accessed March 25, 2014). But few states can match its success in enrolling the exchange population.

Advocates in states with federal exchanges, little support in state government, and lagging enrollment could take a few lessons.

Access Health CT has made waves about setting up a consulting business to sell its exchange model to other states. Maybe North Carolina's navigators would consider selling their own enrollment model, considering how well it served the Tar Heel State in 2014.

Follow Bill Melville on Twitter @BillMelvilleDRG


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