“The Program That Worked — Until Politics Killed It: How North Carolina’s Healthy Opportunities Pilot Proved ‘Food Is Medicine’”

The end of North Carolina’s groundbreaking Medicaid experiment reveals how ideology and short-term politics can derail long-term health reform — even when the data proves it saves lives and money.

In the quiet mountains of western North Carolina, the Healthy Opportunities Pilot (HOP) was rewriting the playbook for public health. It wasn’t a new drug or a billion-dollar hospital expansion that was changing lives — it was boxes of fresh produce, safe housing repairs, and reliable transportation.

HOP began as an ambitious experiment under a $650 million federal waiver first approved by the Trump administration: could food, housing, and community support be prescribed like medicine — and paid for with Medicaid dollars?

For 38,000 participants, the answer appeared to be yes. Patients saw fewer emergency-room visits, chronic illnesses reversed, and, according to researchers at UNC-Chapel Hill, HOP saved an average of $1,020 per person annually in healthcare costs. For Rebecca Smith, a recovering addict from Graham County, the program didn’t just treat her diabetes — it helped her rebuild her life.

“I was snacking on grapes instead of chips,” she said. “After a few months, I wasn’t diabetic anymore.”

Food as Medicine — and Politics as Poison

HOP represented the kind of preventive healthcare reform that the “Make America Healthy Again” (MAHA) movement has championed under Health and Human Services Secretary Robert F. Kennedy Jr. and adviser Calley Means. The initiative’s success seemed to prove the central MAHA thesis: that America’s chronic-disease crisis stems from what people eat, not just what they can afford.

But by mid-2025, despite bipartisan praise and documented savings, the Republican-controlled North Carolina legislature killed the program. Gov. Josh Stein had requested $87.7 million to sustain HOP through 2027 — but appropriations leaders refused, claiming the program “cost more than it saved.”

Their math, Medicaid officials said, was wrong. HOP’s long-term cost reductions would not appear until after the current election cycle — an inconvenient truth in a statehouse where policy is measured in months, not years.

“This is not a straight math problem,” said Jay Ludlam, deputy secretary for NC Medicaid. “The cost will be higher because we’re not doing the program.”

The Ripple Effects of a Shutdown

The end of HOP wasn’t just a policy defeat — it was an economic one. A University of Kentucky report found that every dollar spent on the program generated $1.53 in economic activity and supported nearly 900 local jobs across western North Carolina. Farmers, nonprofits, and families all benefited.

Then, Hurricane Helene struck. As federal aid lagged, HOP became a lifeline for displaced families — distributing $2.7 million in food, rent, and relief. When the program vanished in June, those same families lost not only meals but medical stability.

Corey Graywood, a mother of two asthmatic children, says her family’s grocery bill has doubled since HOP ended. “We were finally getting ahead,” she said. “Now, we’re sliding backward.”

Washington’s Retreat from Innovation

At the federal level, enthusiasm for “food-as-medicine” waivers is fading. In March 2025, the Centers for Medicare & Medicaid Services quietly removed guidance encouraging states to fund social-determinant programs like HOP. The new MAHA Commission strategy mentions only vague “MAHA boxes” to distribute farmer-grown food — with no clear funding or delivery plan.

Policy veterans like Brandon Lipps, a former USDA official, say this signals a crossroads: “There’s broad agreement that Americans’ health is failing,” he said. “But no agreement on how to fix it.”

A Lesson in Political Patience

Programs like HOP challenge both fiscal orthodoxy and political impatience. They demand upfront investment with returns measured in healthier lives and stronger communities — not quarterly balance sheets.

“It’s absolutely a real challenge to match the political cycle,” Ludlam admitted. “It’s been a painful lesson.”

As of press time, North Carolina’s legislature has yet to restore the funding. The story of HOP — like the lives it transformed — remains suspended between proof and politics, progress and paralysis.

For now, Rebecca Smith is doing what she can: staying sober, working two jobs, and remembering the program that made it possible. “It showed me what healthy really looked like,” she said. “I just wish they could see what we’re losing.”

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-- By Michele Robinson

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