Improving Health Care for the Low-Income Uninsured

In North Carolina and South Carolina, more than one in five nonelderly adults are uninsured. To improve access to more comprehensive health care services, The Duke Endowment is part of a public/private partnership working to integrate health providers serving the uninsured into community-based, collaborative networks.


Between North Carolina and South Carolina, more than 1 million low-income adults lack health insurance coverage.

What's more, in recent years North Carolina and South Carolina experienced larger increases in the number of uninsured people, and larger decreases in employer-based insurance coverage than most of the country.

In the Carolinas, a majority of uninsured people are full-time workers or in a family with full-time workers. In a statewide survey in North Carolina, more than half of the uninsured said they could not afford insurance coverage because of cost.

Impact on Health and Beyond

In the Carolinas and elsewhere, studies show that lack of insurance has a negative impact on health—which, in turn, adversely affect worker productivity and school performance. Even families who have health insurance coverage are affected by the growing number of uninsured. In South Carolina, for example, 20 percent of people without coverage rely on hospital emergency rooms for general or routine health care. Patients face longer waits as a result, and resources designed for emergency care are diverted.

Although good safety net providers exist—including community health centers, free clinics and medication assistance programs—they can't meet all the health care needs of the uninsured in a coordinated way.


James B. Duke, the founder of The Duke Endowment, was committed to removing barriers to quality health care. In his 1924 Indenture of Trust, he established a program designed to help provide hospital care for patients who weren't able to pay for it. In his words, his Endowment would pay a sum "not exceeding One Dollar" for each "free bed per day for each and every day that said free bed may have been occupied during the period covered by such payment free of charge by patients unable to pay as the amount available for this purpose hereunder will pay on a pro rata basis."

In later years, the Endowment called this its Free Days of Care program, which allowed all eligible hospitals to apply for an assistance award. The Endowment reviewed and slightly modified the program in 1970, and again in 1992 and 2002.

Adopting a Comprehensive Approach

In 2006, the Trustees elected to redesign the program to make it more comprehensive.

Endowment staff began meeting with health care leaders in North Carolina and South Carolina and with other major funders. The groups focused on establishing collaborative networks for low-income, uninsured people in North Carolina and South Carolina. Instead of reacting to patient needs when patients are already sick, this model would integrate health services on the front end. Helping low-income, uninsured patients have access to primary care and preventative care would help them stay healthier in the long run.

In June 2007, an initial grant from The Duke Endowment went to the North Carolina Healthcare Association and South Carolina Hospital Association to establish statewide partnerships to oversee the development of resources for these collaborative networks.

The partnership in North Carolina includes the N.C. Institute of Medicine, the N.C. Healthcare Association, the N.C. Department of Public Health, the N.C. Association of Free Clinics, the N.C. Medical Society, and the N.C. Community Health Center Association.

In South Carolina, partners include the S.C. Hospital Association, Welvista, the S.C. Office of Rural Health, the Primary Care Association, the Department of Health and Human Services, the United Way Association of S.C. and the Free Clinic Association.

In June 2008, Endowment Trustees approved an initial $2.1 million grant to the South Carolina Hospital Association and an initial $1.8 million grant to the North Carolina Hospital Association to expand provider capacity and develop integrated networks in nine S.C. counties and 12 N.C. counties. The Endowment now supports collaborative networks in 78 counties – 46 in North Carolina and 32 in South Carolina -- providing an estimated $460 million in primary care services annually.

Participating Sites



Area of Work

  • Access to health care

Program Area

  • Health Care

Grantmaking Status

Areas of Work

  • Prevention and early intervention for at-risk children

    To equip children and families with skills to ensure that children reach developmental milestones to lead successful lives.

  • Out-of-home care for youth

    To drive child welfare systems toward greater accountability for child well-being.

  • Quality and safety of health care

    Improving the quality and safety of health care delivery

  • Access to health care

    Improving health by increasing access to comprehensive care

  • Prevention

    Expanding programs to promote health and prevent disease

  • Academic excellence

    Enhancing academic excellence through program and campus development

  • Educational access and success

    Increasing educational access and supporting a learning environment that promotes achievement

  • Campus and community engagement

    Promoting a culture of service, collaboration and engagement among schools and communities

  • Rural church development

    Building the infrastructure and capacity of United Methodist churches to enhance ministry and mission

  • Clergy leadership

    Strengthening United Methodist churches by improving the quality and effectiveness of church leadership

  • Congregational outreach

    Engaging United Methodist congregations in programs that serve their communities