When they unveiled their plans, the room was crammed with hundreds of people —a stunning turnout for their home in rural Appalachia. 

Juanita Colvard knew many of these people lost someone. Her own best friend died of breast cancer in her 50s. Another woman watched her father and two brothers die of kidney failure. And most blamed the health care drought for those losses.   

All were there to hear Graham County’s plan to bring health care back to their home. Led by Colvard and a team of county employees, the county bought CT and mammogram machines. Graham County now owns government-restricted medical machines, opening care to residents but also launching a new government intervention in North Carolina. 

The moment was possible only because a slew of unlikely events. An economic disaster freed nearly $1 million in funding when Stanley Furniture closed and paid its debt to the county. The Golden LEAF Foundation agreed to redirect these state funds into medical equipment. People wrote hundreds of letters, battering the state until it gave them a rare Certificate of Need permission. Nearly five years of work went into these two machines.  

“We realized that if we just sat back and waited for health care to come to us, it just wouldn’t happen,” said Rebecca Garland, Graham County manager. “We have to do something different.” 

Nestled deep in the Appalachian Mountains, Graham County is known for the Dragon — a famous, deadly pass popularized by motorcycle riders. The Nantahala National Forest engulfs the county. Some 8,500 people live there, an hour from the nearest hospital, hours away from specialists, in a medical hotspot for Medicaid spending.  

North Carolina pours money into Graham County, without results.  

Graham County ties for third place for the highest spending per enrollee. Medicaid spends 1.5 times more, or $2,000, per person, but the money has left health outcomes untouched. The county is a paradox that reveals a “fundamental flaw” in the program responsible for the state’s most vulnerable residents, says an Annals of Health Law paper. 

Residents describe their health care as “disaster control.” Only four physicians live inside the county, and the shortage is more severe than the numbers. Some residents boycott the local Tallulah Clinic, while the Snowbird Clinic serves only the Eastern Band of Cherokee Indians. 

Residents hail the county’s three ambulances like Uber. More than 70% of calls aren’t emergencies. Some callers want to be driven to hospitals for basic primary care; other “frequent fliers” simply use paramedics for quick checkups, says Larry Hembree, Graham County emergency services director. 

“Their primary care is the emergency care. It’s been that way ever since I can remember,” Garland said. “But you can’t not try. You have to try to make them better and give the people some hope.” 

But without preventative care, medical problems spiral into disasters. 

“Most of the women, the first [prenatal] visit they have is when they deliver. They can’t afford to take off work all day,” said Beth Booth, Graham County health director. “The sheer medical cost of what is wrong with that woman … is staggering.” 

Medicaid has failed Graham County, analysts say.  

“Medicaid dollars still found their way to these counties, but in such inefficient ways,” said Barak Richman, Duke University professor. “It’s a little surprising that such an incredibly inefficient use of funds would not prompt policy makers to change things on the ground.” 

A county buying medical machines is unheard of in North Carolina, but that’s how Colvard and the others hope to rescue health care in their hometown.  

David Castor, the doctor whose urgent care will rent the machines, hopes to catch appendicitis, cancer, and other problems early. Alone, he couldn’t afford the $284,215 Mammogram machine and the $404,527 CT machine — not to mention the regulatory fees.  

“It was really needed in the area. I’ve seen people who haven’t seen a doctor in their entire lives,” Castor said. “It’s going to make an incredible difference. It’s really going to change these people’s lives.” 

Patients also will dodge facility fees — a hospital overhead charge that can drive the cost of scans into the thousands. Both patients and taxpayers will pay a mere $400 to $800 for scans. Castor will send 25% of each payment back to the county, as well as providing charity care. 

Their pricing is so competitive a Raleigh doctor with similar prices lured patients from other states to his clinic. 

“Imagine people actually coming into the county for health care instead of out,” Booth said. “They’ve been told no, that they aren’t good enough, for so long that it’s the accepted culture. But there’s no reason why we can’t provide better health care than anyone else.” 

That could be problematic, says John Locke Foundation senior fellow Joe Coletti. 

“Now the county is competing with private providers,” Coletti said. “The problem is that when you start doing this it opens the door to all sorts of things.” 

Policy problems 

Politicians and bureaucrats alike have tried to bully rural health care into some semblance of vitality for decades. 

The rural-urban divide has become a yawning gulf. Rural Americans earn $9,242 less than their urban counterparts on average. Unintentional injury deaths are a whopping 50% higher in rural areas. And they’re more likely to die of cancer, stroke, and heart disease, according to the Centers for Disease Control and Prevention and the American Academy of Family Physicians. 

This year’s General Assembly poured $20 million into a rural hospital loan program, and lawmakers revisited Medicaid expansion, telehealth, and nurse practitioners, as well as making the perennial stab at CON law repeal.  

Medicaid transformation was also crafted with rural health care in mind. The reform will give private insurers a block sum to manage enrollees’ health, and whatever the insurers dont spend, they will keep. In theory, this will spur insurers to invest in preventative care for areas like Graham County.  

“Food, transportation, access to housing — those are some of the things we were trying to address with Medicaid transformation,” said Maggie Sauer, Office of Rural Health director. “Medicaid transformation could have an enormous effect on their health, not just their health care.” 

But none of that can happen unless patients can see providers. Sauer is delighted Graham County bought imaging machines. Coletti isn’t so convinced. He worries about allowing the government to compete with private businesses, especially with government-restricted medical equipment. 

The county’s machines are an argument for reform, says Coletti.  

“This is another example of everything wrong in our health care system,” Coletti said. “Look at all the wasted effort. Instead of making the decision itself, the county had to rally its citizens to write letters to the [state]. Regulations have left the county with nothing but bad alternatives.” 

“On the ground there, it might seem like the best option,” said John Locke Foundation analyst Jordan Roberts. “It sets a troubling precedent for future government involvement.”