Health Affairs November 5, 2019
Kushal T. Kadakia, Shivani A. Shah, Barak D. Richman

If you live in Graham County, North Carolina, there’s a good chance that one of your neighbors went to the hospital last year—not necessarily for a surgery or an emergency, but rather because the emergency department (ED) is their primary care physician.

We first encountered this rural county when we began our research on North Carolina’s Medicaid program. In this era of rising health care expenditures, our first objective was to determine which counties had the costliest Medicaid beneficiaries. To our surprise, urban centers such as Raleigh and Charlotte were far down on the list. Instead, Graham, a county on the state’s mountainous western border, rose to the top.

What causes a county to become the state’s costliest...

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