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Survey: N.C.’s Health Care System Ranks 40th in the U.S.


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By Rose Hoban

North Carolina has fallen behind in the quality of and access to its health care system, according to a new survey by the personal-finance website Wallet Hub.

One of the state’s leading health economists said it’s not surprising given some of the economics of North Carolina and the fact that its residents have some of the highest rates of obesity, diabetes and heart disease in the United States.

Mark Holmes

Health economist Mark Holmes. Photo courtesy of the UNC Gillings School of Global Public Health

Mark Holmes, who heads the Sheps Center for Health Service Research at UNC Chapel Hill said the first place to look is at resident’s health risk behaviors.

“We’re in the stroke belt, how do we compare in some of our behaviors,” Holmes said. “We know we are a little on the more obese side, our income is lower than the average state. All of these lead to generally less healthy people.”

The survey, which took into account cost, access and outcome, found North Carolina ranked 40th among states.

No coverage, no access

Even with high enrollment in the insurance marketplaces under the Affordable Care Act, North Carolina still has one of the highest rates of uninsured people in the country. Wallet Hub ranked North Carolina 44th in the country for access to care.

A recent report by the U.S. Census found North Carolina’s rate of uninsurance has dropped to 11.2 percent in 2015, the 11th highest in the country, down from 15.6 in 2013, just before the Affordable Care Act went into effect.

The U.S. average is 9.4 percent of residents who lack health insurance.

Source: WalletHub

Brandy Bynum, a policy analyst with Rural Forward NC, said the combination of lower rates of insurance and the lack of resources, particularly in rural counties, accounts for the state’s poor ranking on access. For example, physicians in North Carolina cluster in urban areas, leaving 84 counties below the state average number of physicians per capita.

Rural counties are “more likely to be impoverished, because of other social determinants, such as access to employment,” Bynum said. “That leads to higher poverty numbers.”

Sometimes the barriers to access in rural communities are banal.

“Just having the transportation to access a primary care provider on a routine basis is problematic in rural communities,“ Bynum said. “The geographical distances across a county, from one end to the other, just depending on where you live, it can be prohibitive. Those are social determinants that determine access to health beyond cost and affordability.”

Six of the top 10 states in the Wallet Hub study were places where lawmakers have decided to expand the Medicaid program. And without Medicaid expansion, many of the working poor who earn less than $16,000 have little access to insurance to help pay for care.

Cost

North Carolina is about in the middle of the pack when it came to cost of care, which Wallet Hub analysts calculated using the average costs for medical and dental visits, insurance premiums and out-of-pocket spending.

When asked whether the dominance of Blue Cross Blue Shield of North Carolina might increase costs in North Carolina, Holmes said that’s actually not the case.

“The fact that our health insurance market is more concentrated than typical, actually that would lead one to expect lower costs because an insurer might be able to drive down price through market power,” he said. He explained that dominant insurers can squeeze hospitals and providers for better deals in exchange for being in-network.

“Having less competition might not create the downward [price] pressure that we’d expect in a regular market, like in a grocery store,” he said.

Mark Hall from Wake Forest University said that because more people are uninsured and because the state has not expanded Medicaid, more people are paying out of pocket.

“There’s more uncompensated care that may feed back into the unit pricing,” he noted.

Without coverage, North Carolinians often seek medical help when conditions are at their worst and most expensive to treat rather than taking advantage of preventive medicine such as primary care checkups.

Some opponents of Medicaid expansion disputed the cost savings of expansion, pointing to studies that showed spikes in emergency room visits by the newly insured, but others — such as one UCLA survey — found that spike to be temporary.

Hall also said that increasing consolidation among providers could be driving up costs – bigger physician groups and bigger hospitals can push back against BCBSNC when the two sides negotiate prices.

“You’ve had these previously competing hospitals merge, in Asheville, Greensboro, Wilmington and in other areas of the state,” Hall said.

All of the factors studied – cost, access and quality – are interrelated, Holmes said. Cost and access play into the quality and outcomes of care.

“When you don’t have access sometimes that leads to more costs which will lead to poorer outcomes, which leads to higher costs,” he said.

That’s part of why North Carolina has some of the country’s worst outcomes on measures such as infant mortality, which recently ticked up for the first time in years, and the rate in rural areas of the state – especially for African-Americans – are higher than in the lowest ranking state in the country.

HPV Vaccination Rate Rises for Teens, Especially Boys


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By Michael Ollove

Stateline

The share of teenage boys getting the vaccine to prevent the cancer-causing human papillomavirus climbed significantly last year, according to a new report from the Centers for Disease Control and Prevention. The vaccination rate among girls rose as well, but not as steeply.

More than 1500 pharmacists in North Carolina have gone through the approval proces to give immunizations.

Photo courtesy U.S. Army Corps of Engineers Europe District, flickr creative commons

The CDC report says that 28.1 percent of boys between ages 13 and 17 completed the three-dose HPV vaccination cycle in 2015, compared to 21.6 percent the previous year. For girls, the percentage rose from 39.7 percent to 41.9 percent.

Nine years ago, the Advisory Committee on Immunization Practices, a group of doctors and public health experts that makes immunization recommendations to the federal government, said all teenage girls should get the HPV vaccination to prevent HPV-related cancers, pertussis and meningococcal disease.

In 2011, the committee recommended boys undergo the vaccination cycle as well.

But the vaccination rates remained stubbornly low, primarily, health officials said, because many doctors have not made HPV inoculation a priority for their patients.

Most state health departments have initiated outreach campaigns to educate pediatricians and primary care doctors with young patients about the benefits of the HPV vaccination.

Rhode Island had the highest HPV vaccination rates for girls (68 percent) and boys (58.1 percent) last year. Mississippi had the lowest rate among girls (24.4 percent) and Tennessee the lowest among boys (16 percent).

Lack Of Medicaid Expansion Hurts Rural Hospitals More Than Urban Facilities


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By Shefali Luthra
Kaiser Health News

It isn’t news that in rural parts of the country, people have a harder time accessing good health care. But new evidence suggests opposition to a key part of the 2010 health overhaul could be adding to the gap.

The finding comes from a study published Wednesday in the journal Health Affairs, which analyzes how the states’ decisions on implementing the federal health law’s expansion of Medicaid, a federal-state insurance program for low-income people, may be influencing rural hospitals’ financial stability. Nineteen states opted not to join the expansion.

Yadkin Valley Community Hospital in a Google streetview photo dated May, 2013. The facility now has a primary care practice operating on site, but the hospital facilities are not functioning.

Yadkin Valley Community Hospital in a Google streetview photo dated May, 2013. The facility now has a primary care practice operating on site, but the hospital facilities are not functioning.

Rural hospitals have long argued they were hurt by the lack of Medicaid expansion, which leaves many of their patients without insurance coverage and strains the hospitals’ ability to better serve the public. The study suggests they have a point.

Specifically, the researchers, from the University of North Carolina Chapel Hill, found that rural hospitals saw an improved chance of turning a profit if they were in a state that expanded Medicaid — while in city-based hospitals, there was no improvement to overall profitability. Across the board, hospitals earned more if they were in a state where more people had coverage and saw declines in the level of uncompensated care they gave.

To put it another way: All hospitals generally fared better under the larger Medicaid program, but there’s more at stake for rural hospitals when the state expands coverage.

The study looked at how expanding Medicaid affected hospital revenue, how many Medicaid patients they discharged, levels of uncompensated care the hospitals provided and how well the institutions did financially overall. It compared those effects in rural versus urban areas, across more than 14,000 annual cost reports from hospitals between January 2011 and December 2014, or a year after eligible states could have expanded their Medicaid programs.

In states expanding Medicaid, rural hospitals saw a greater increase in Medicaid revenue than urban hospitals did. City-based facilities save a higher percentage than rural hospitals with the reduction in uncompensated care, though that change “did not translate into improved operating margins for urban hospitals,” the study notes.

How much these differences matter, though, remains up in the air.

“There is a disparity in the impact of Medicaid expansion, and probably the [law] overall,” said Brystana Kaufman, a doctoral candidate at the university’s department of health policy and management and the study’s first author. “There needs to be more exploration into why we’re seeing this.”

One likely factor: Rural hospitals serve more low-income people — who weren’t eligible for insurance before, but who got covered after the health law took effect. And rural hospitals are historically more likely to operate at a loss than are urban ones. So the chance to see increased revenue is greater than in a city-based hospital.

That said, these are preliminary figures, looking at barely a year’s worth of evidence when it comes to the Medicaid expansion. But the effect merits further scrutiny, experts said.

It’s important because hospital finances matter for consumers, too. In rural communities, hospitals are often among the largest employers, and the main source of health care. Financial duress can affect what kind of services the facility offers.

“If you’re [a hospital] in a state that did expand Medicaid, obviously you’re going to be experiencing lower amounts of uninsured. Your bad debts and charity care have gone down,” said Brock Slabach, senior vice president at the National Rural Health Association. He was not involved in the study, although he is familiar with the research team’s work. “Has [that expense] gone to nothing? No. But it has helped.”

That’s especially true for rural hospitals, Kaufman said, because they have narrower profit margins than do urban ones. Any squeeze on the budget “is going to be more influential” and may limit a hospital’s offerings or quality.

Hospitals are “still really trying to anticipate and assess the shakeout from all the changes that are happening,” said Kristin Reiter, an associate professor at UNC-Chapel Hill’s Department of Health Policy and Management and another study author.

Meanwhile, rural hospitals are already facing financial strains, Slabach said. More than 70 have shut down since 2010. Still more are at risk of closure. Many endangered hospitals are in non-expansion states.

How Medicaid affects rural and urban hospitals could influence other debates, the study authors said. For instance, the health law also is expected to cut so-called disproportionate health spending payments – cash infusions that support hospitals that treat low-income people, often in rural areas.

Those cuts haven’t taken effect yet, but the researchers suggest, the paper could make a case for indefinitely postponing them.

“The hospitals rely on that funding to address uncompensated care,” Kaufman said. In rural states that declined the expansion, uncompensated medical treatment poses a significant financial hurdle for hospitals.

But others cautioned against drawing hard conclusions yet. It’s unclear how meaningful the rural-urban difference will be, especially over time, said Doug Staiger, a professor of economics at Dartmouth who has researched rural health access but was not involved with this study.

“I’d be really cautious interpreting,” he said.

Plus, Slabach added, researchers must examine how the findings actually affect consumers.

And, it’s possible the effects seen here aren’t just thanks to Medicaid, said Mark Holmes, an associate professor at UNC and director of the university’s North Carolina Rural Health Research and Policy Analysis Program. Expansion states may have taken other steps meant to help hospitals and consumers. If so, it’s worth figuring out what those are.

“Medicaid expansion is not a random event. That’s very important to consider here,” said Holmes, another author of the study. “These are states that have decided to do it. There could be other elements” at play.

Number Of Uninsured Falls Again In 2015


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By Julie Rovner

Kaiser Health News

The federal health overhaul may still be experiencing implementation problems. But new federal data show it is achieving its main goal — to increase the number of Americans with health insurance coverage.

screen shot of obamacare online portal

The next open enrollment period to purchase insurance starts November 1. Photo credit: Rose Hoban

According to the annual report on health insurance coverage from the Census Bureau, the uninsured rate dropped to 9.1 percent, down from 10.4 percent in 2014. The number of Americans without insurance also dropped, to 29 million from 33 million the year before.

In North Carolina, the rate of uninsurance fell from 15.6 percent in 2013 to 11.2 percent in 2015. About 1.1 million North Carolinians continue to lack health insurance.The Census numbers are considered the gold standard for tracking who has insurance and who does not, because its survey samples are so large. It does change methodology from time to time, however (most recently in 2013), so years-long comparisons are not necessarily accurate.

Still, between 2013 and 2015, the first two full years the health law was in effect, the uninsured rate dropped by more than 4 percentage points. The total number of uninsured fell by 12.8 million. Meanwhile, the percentage of Americans with insurance for at least some part of the year climbed to 90.9 percent, by far the highest in recent memory.

“I don’t remember it ever being in the 90s before,” said Paul Fronstin of the Employee Benefit Research Institute, who has been tracking insurance statistics since the early 1990s.

sign on the side of a building reading "Insurance"

Photo credit: Rose Hoban

The Obama administration was quick to take credit for the insurance improvements. “The cumulative coverage gains since 2013 have put the uninsured rate at its lowest level ever,” said members of the White House Council of Economic Advisers in a statement.

The 2015 report shows insurance gains across all income levels, ages and types of employment, although some groups did better than others. Young adults — specifically 26-year-olds — remain the most likely to lack coverage. Although the Affordable Care Act guaranteed that young adults could stay on their parents’ plans longer than in the past, that protection ends when they turn 26.

Among states, those that took the health law’s option to expand the Medicaid program for the poor saw greater gains in coverage than those that did not. “The overall decrease in the uninsured rate of 2.4 percentage points in expansion states, compared with 2.1 percentage points in no-expansion states,” said the report. The state with the highest percentage of uninsured residents remained Texas at 17.1 percent; the state with the fewest uninsured remained Massachusetts with an uninsurance rate of 2.8 percent.

The single largest source of health insurance remains plans provided by employers. An estimated 177.5 million Americans had employment-based coverage in 2015, which was up more than 3 million from 2013.

Disabled and Want to Vote? New Website Makes the Process Clearer


As many as three million more ballots nationwide could be cast in every election if people with disabilities voted at the same rate as the general population.

That’s the word from Disability Rights North Carolina, which this week launched a drive to help people with disabilities overcome the problems they sometimes encounter in North Carolina’s polling places. These can include obstacles for people whose physical mobility and/or visual abilities are limited.

NC Health News file photo

Photo credit: Rose Hoban

Leaders of the nonprofit group say a new website, www.accessthevotenc.org, should simplify matters.

The website guides potential voters through issues such as eligibility, registering, and voting in person, from home, or from a residential facility, Matthew Herr, policy analyst for Disability Rights, said in a news release.

Mark Ezzell, a Raleigh lawyer who uses a wheelchair, said in an interview that he worked on a similar effort, Accessvote, in 2000, along with the American Association for People with Disabilities.

“I do think progress has been made, I’m not sure that there’s been enough,” said Ezell who is also a member of the Wake County Board of Elections. “I think it’s always going to be helpful to have that stuff codified in one spot.”

The website will make for easier for people with disabilities to report problems they encounter in a polling place, including physical barriers or any effort to restrict their right to vote because of incorrect perceptions about their intellectual abilities.

www.accessthevotenc.org has all the information you need to exercise your right to vote.

Ezzell noted that the overturning of the voter ID law in North Carolina removed one barrier, because many people with disabilities don’t have and can’t easily obtain the types of identification the statute specified.

[If the voter ID bill had stood, lawmakers had approved a bill allowing people with developmental disabilities to get a free ID card if they presented a letter from a medical provider affirming their disability.]

HouseAd2016As another part of the effort to encourage voting, a campaign called “I Have a Disability, and I Vote!” will run through the end of October. Disability Rights is asking people with disabilities to send in their pictures, names and a sentence or two about why voting is important to them.

Disability Rights NC will publish the entries on its Facebook page until election day. Submissions should be sent to voting@disabilityrightsnc.org or posted on Facebook or Twitter using #accessthevotenc.

If your voting rights have been violated you can call:

•Your county board of elections.
•The State Board of Elections at 919-733-7173.
•Election Protection at 1-866-OUR-VOTE (1-866-687-8683) .
•Disability Rights NC at 877-235-4210 (888-268-5535 TTY).

Source: Accessthevotenc.org

Need a Ramp in NC? Here are Some Resources to Check Out


Since publishing a story on a ramp-building program in 2012, North Carolina Health News has received multiple inquiries about how to get a ramp built. So, we talked to several physical therapists for ideas and resources.

Getting a ramp built cheaply, or for free:

Inquire with your local Boy Scout Troop. There’s almost always an Eagle Scout looking for a project.

Baptist Men’s Association – located in most counties. Statewide information number: (800) 395-5102 ext. 5599

Local high schools – kids need service projects, they also need projects for shop classes. Call your local principal.

Your church.

If you can afford to build or buy your own ramp:

The materials can be costly: For every 1 inch of rise, you need a foot of run. That means, for one 6-inch step, you need 6 feet of ramp. So, space can be an issue.

Ramp leading to the first of a flight of steps.

Creating a ramp that’s the correct height and at the correct angle can be more complicated than you think! Photo credit: Richard Elzey, Flickr Creative Commons

If you’re a renter you may have to pay full cost of construction and installation AND pay the cost of removing it when you leave.

Who’ll build it for you?

Go to Lowe’s or Home Depot and ask around in the wood section. All the local construction guys hang out there and the people who work there may just know someone.

Am-ramp is a company you can rent or purchase a ramp from, but according to the physical therapists we spoke to, they can be pricey.

Craigslist – some people have used ramps and no longer need them.

Local “durable medical equipment” companies. Put those words into Google with your town’s name, they may have a 6’-10’ pre-fabricated ramps for sale.

People With Obamacare Plans Filled More Prescriptions, But Had Lower Costs


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By Shefali Luthra

Kaiser Health News

The 2010 health law was meant to expand insurance coverage so that Americans could get medical care they would otherwise go without — and not spend a fortune doing so. Though it’s still early, new evidence suggests this scenario is playing out.

Research published online by Health Affairs last week examines what happened when people got insurance through the law — either with a private plan purchased via the online marketplaces or through Medicaid, the state-federal program for low-income people. The study specifically focuses on how many medical prescriptions they filled.

hand with pills

People who got insurance through the health law were significantly more likely to get prescription medications than they were before. Photo credit Okko Pyykkö, flickr creative commons

The researchers analyzed data from more than 6.7 million people who filled prescriptions in January 2012 and followed their patterns of medication use and out-of-pocket spending through December 2014. One third of those people had no health insurance before the Obamacare coverage took effect in January 2014. It tracked how people’s insurance status changed, compared how many prescriptions they filled after the switch and tracked how consumers’ out-of-pocket costs were affected.

The takeaway: People who got insurance through the health law were significantly more likely to get prescription medications than they were before. And when they did, they typically ended up spending less of their own money for those drugs.

“People who gain coverage filled more prescriptions and spent a lot less out of pocket. It speaks to the potential health benefits from gaining coverage,” said Andrew Mulcahy, the study’s lead author and a health policy researcher at the RAND Corp., a non-profit think tank based in California. “It speaks to the barriers to getting care when you don’t have insurance.”

That said, those gains aren’t uniform: Lower-income people were far more likely to benefit. Specifically, people who went from being uninsured to enrolling in Medicaid filled 13.3 more prescriptions on average. They also spent 58 percent less out of pocket for those drugs. Those who got private insurance, by comparison, filled four more prescriptions on average and spent 29 percent less out of pocket.

The idea, Mulcahy said, is that those who now qualify for Medicaid are more likely to go without health care if money is an obstacle. They are also more likely to have health conditions that require prescription drugs.

“Paying cash for your prescriptions is a barrier to your care. It’s more of a barrier for people who are low-income,” he said.

The findings help illuminate the law’s effectiveness, especially in terms of improving access to medication, said Jonathan Kolstad, an assistant professor of economic analysis and policy at the University of California, Berkeley. But it’s important to note that it only looks at a select group: people who were willing and able to buy at least some drugs before 2014, even if they had no insurance and had to pay the full costs themselves. That suggests they might need the drugs more, or be more motivated to manage their health — a quality that possibly guides their ability to select an appropriate health plan and then use it.

“If you have people who have such a strong demand for health care service … that’s a group we’re intrinsically interested in from a policy perspective,” said Kolstad, who wasn’t involved with the Health Affairs study but has researched how people navigate and use health insurance. “It’s not representative. But it’s a piece in the broader puzzle.”

There’s also the question of what prescriptions are necessary — whether, for instance, people are getting vital care they previously couldn’t afford, or if they are now buying drugs they don’t need because they don’t see the costs.

That remains open, Mulcahy said. But there are clues. Here, for instance, the researchers looked at people with chronic illnesses: diabetes, breast cancer, depression, asthma and high cholesterol. Those people saw a similar proportional increase in prescriptions filled and probably do need the medication.

“If you have diabetes or one of these other conditions, there’s a pretty compelling argument that you should be on some kind of treatment,” he said.

And, importantly, the growth in prescriptions can be used as a proxy to answer other questions, Mulcahy said, such as if people who get health insurance then use it to get medical care. After all, filling a prescription means the patient also visited at least one doctor. From that vantage, he said, the results are promising.

“These people are more than getting coverage,” he said. “They’re using coverage to get care.”

But getting care isn’t the same as getting healthier. Though the researchers found people were more likely to get drugs, Kolstad noted, the research doesn’t have enough evidence in it to figure out long term outcomes.  For instance, are these newly insured people being compliant with their medications? And are the drugs helping them manage their conditions and improve their wellbeing? Or are they having unintended side effects that could later be damaging?

And there’s the sampling issue, which the authors note as a limitation on their study. Because the people surveyed here were already getting prescriptions — even when it posed a greater financial hardship — they could have, for instance, been more likely to seek out a doctor than the average consumer.

Previous research, for instance, has suggested getting insurance means people are more likely to see a doctor. But there’s no proof they’ll do other things that might matter, such as eating healthier, exercising or quitting smoking. Other experts have suggested more time is necessary to understand how expanding health care coverage could actually improve health and lead to system-wide cost savings.

As more data becomes available, researchers can tackle those questions, Mulcahy said. But the findings underscore a meaningful growth.

“If the goal of the coverage expansion was to reduce the financial burden of being insured, this is direct evidence of that happening. If the goal was to improve health, we’re one step short of that,” he said. “But the signs align. We have some direct evidence it’s offering financial benefits. And there are signs it’s helping on the health side.”

This story originally appeared in Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Wilkes Regional Medical Center to Affiliate with Wake Forest Baptist


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By Thomas Goldsmith

Wake Forest Baptist Health is taking on a 30-year lease of Wilkes Regional Medical Center in North Wilkesboro, following negotiations among county commissioners, the town, the hospital operating corporation and the Winston-Salem based hospital system.

The parties signed a non-binding letter of intent toward a long-term lease of Wilkes Regional Medical Center during an August town board meeting.

The 130-bed Wilkes Regional Medical Center was founded in 1952.

The 130-bed Wilkes Regional Medical Center was founded in 1952. Photo credit: Wikimedia Creative Commons

The process is expected to last several months, but under the proposed lease, Wake Forest Baptist would invest $238 million to support the hospital, town and patients during the first lease term.

“We announced our intentions to move forward with Wake Forest Baptist back in April,” Debbie Ferguson, a North Wilkesboro town commissioner, said in statement. “The time spent during these more than three months on reaching this agreement reassures us we have the best partner to navigate Wilkes Regional Medical Center through the growing health care needs of the North Wilkesboro community.”

The projected deal continues a trend in which smaller, community-based hospitals in North Carolina affiliate with larger hospital systems as insurance against health care and compensation trends which can be perilous for independent hospitals in largely rural areas.

The agreement stipulates that Wake Forest Baptist will move Wilkes Regional Medical Center and Wilkes Physician Network, an affiliate, onto its electronic medical record system as soon as possible.

“The transition period we are entering is a key step in the evolution of our partnership with Wake Forest Baptist,” said Eric Cramer, board chairman of the operating corporation of Wilkes Regional Medical Center.

The transition should not disrupt the operations of the hospital, physicians network or the care or safety of patients, principals said. Carolinas HealthCare System, which has managed the hospital since 2007, will continue to support the hospital’s operation during the transition, said Cramer, describing Carolinas HealthCare System as “a great partner.”

The letter outlines several months of due diligence and information technology changeover, with Wake Forest Baptist supplying advanced IT tools.

“We see a great opportunity to grow clinical programs and continue effective recruitment and engagement of physicians that will ensure excellent care for Wilkes County citizens and benefit the Wilkes region,” Wake Forest Baptist CEO John D. McConnell said.

Wake Forest Baptist expects the deal to close on July 1, 2017.

In a May 2015 public notice, the North Wilkesboro Board of Commissioners sent out a request for proposals from companies interested in leasing the hospital. Parties notified included Carolinas HealthCare System, Duke LifePoint, Mission Health, Novant Health, RegionalCare Hospital Partners and Wake Forest.

The current management company, Carolinas HealthCare, did not submit a proposal.

This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina.

Coal Ash & Water: Timeline of a Controversy


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By Catherine Clabby & Rose Hoban

++ February 2014: Storm water pipe breaks under a 27-acre coal ash pond, spilling 38,000 tons of coal ash into the Dan River and sending a plume downstream in the direction of municipal water intake.

The pipe that spilled coal ash into the Dan River, Feb. 2014. Photo courtesy Catawba Riverkeeper

The pipe that spilled coal ash into the Dan River. Photo courtesy Catawba Riverkeeper

++ August 2014: North Carolina General Assembly passes Coal Ash Management Act (CAMA). It requires Duke Energy to shut down coal ash waste dumps on 14 properties and a survey of drinking wells near the waste.

++ February 2015: Department of Health and Human Services attorney Chris Hoke briefs division of public health officials on CAMA’s requirements for assessing risk from potential coal ash contaminants in well water.  Since no state or federal standards exist for unsafe levels of hexavalent chromium, they develop new ones, based on latest research. (Source: Rudo deposition, page 75)

++ As directed by CAMA, state health and environmental officials use state groundwater regulations to assess health risk levels in well water near coal ash plants. That involves a formula establishing the level above which hexavalent chromium poses a one-in-a-million risk of causing cancer. (Source: Davies deposition, page 82).

++ Two DEQ toxicologists calculate the level, which is .07 parts per billion. DHHS toxicologists, including Ken Rudo, review and agree with level. (Source: Megan Davies resignation letter.)

Excerpt from Megan Davies' resignation letter where she outlines the procedures followed to determine minimum levels of chromium 6 and vanadium in drinking water wells neighboring Duke Energy coal ash dumps.

Excerpt from Megan Davies’ resignation letter where she outlines the procedures followed to determine minimum levels of chromium 6 and vanadium in drinking water wells neighboring Duke Energy coal ash dumps.

++ Mina Shehee, an environmental program manager at DHHS, has the Agency for Toxic Substances and Disease Registry at the Centers for Disease Control and Prevention confirm that North Carolina level uses the correct “cancer slope” calculation. (Source: page 53, Shehee deposition)

++ DHHS leaders, including then-DHHS Secretary Aldona Wos, review and approve the approach used to set levels for hexavalent chromium. (Source: Davies resignation letter.) North Carolina joins California in having the lowest health levels for metal in the country.

Tom Reeder candid headshot

DEQ Undersecretary Tom Reeder. Photo credit: Coastal Review Online

++ March 2015: DEQ Assistant Secretary Tom Reeder wants DHHS to add language in do-not-drink advisory letters for owners of wells near coal ash waste with levels of hexavalent chromium above the new screening level. Language stresses that the contamination don’t exceed federal standards for public drinking water supplies. (Source: Rudo deposition, page 37)

++ March 2015: Rudo summoned to the governor’s mansion for a meeting with press secretary Josh Ellis to discuss the wording of the letters sent originally to warn well owners of contaminants. He says McCrory called Ellis during the meeting. (Source: Rudo deposition, page 42)

++ March 2015: Rudo refuses to have his name included on state health risk evaluation letters due to the added language, which does not note that, currently, no federal standards exist for hexavalent chromium in public drinking water. (Source: Rudo deposition, page 3)

After the Senate Health Care Committee meeting Tuesday, State Health Director Randall Williams makes a point to lobbyist John Del Giorno, who represents the pharmaceutical industry.

State Health Director Randall Williams after a meeting at the North Carolina General Assembly. Photo credit: Rose Hoban

++ July 2015: Randall Williams takes over as state health director; state epidemiologist Megan Davies briefs him on process used to reach new health screening level for hexavalent chromium. (Source: Davies resignation letter)

++ Williams meets with staff members of Senate Pro Tem and Assembly Speaker who tell him letters advising people not to drink well water have alarmed people in ways disproportionate to the risks. (Source: Williams deposition, page 24)

++ January 2016: Williams grows concerned that people who live far from coal ash are needlessly worrying that levels of hexavalent chromium and a second metal, vanadium, in public drinking water supplies pose dangers. He alerts staff that the do-not-drink recommendations are disproportionate and unwarranted. (Source: Williams deposition, page 68)

++ March 2016: Letter signed by Reeder and Williams sent to well owners who were previously advised not to drink water due to elevated levels of hexavalent chromium or vanadium. The new letter says: “We updated our recommendation after extensive study of how other cities, states and the federal government manage the elements … we have now concluded that water out of your well is as safe as the majority of public water systems in the country.”

++ April 2016: Reeder speaks at public appearance at UNC Institute for the Environment saying letters rescinding do-not-drink advisories came after DHHS decided to revise its health risk evaluations and make them consistent with federal rules.

Well owner Deborah Graham holds up a photograph of the coal ash pit that’s several hundred yards from her home in Salisbury while at a press conference at the General Assembly in Raleigh. Photo credit: Rose Hoban

Well owner Deborah Graham holds up a photograph of the coal ash pit that’s several hundred yards from her home in Salisbury while at a May press conference at the General Assembly in Raleigh. Photo credit: Rose Hoban

++ May 2016: In her sworn deposition, Davies reveals discord among health officials saying that she opposed the letter rescinding the do-not-drink advisories because the language saying well water with elevated hexavalent chromium or vanadium compared to cities did not match data she saw from Raleigh and Charlotte. (Source: Davies deposition, page 58)

++ August 1, 2016: Rudo’s deposition released, the news that Gov. McCrory participated by phone in meeting discussing language in the letters causes a stir.

++ August 2, 2016: In a hastily called, late-evening press conference McCrory Chief of Staff Thomas Stith accuses Rudo of perjury, insisting the governor did not participate in the meeting. Rudo stands by his statement.

++ August 9, 2016: Reeder and Williams issue a letter to media outlets criticizing Rudo for “questionable and inconsistent scientific conclusions.”

++ August 10, 2016: Megan Davies resigns “Upon reading the open editorial yesterday evening, I can only conclude that the Department’s leadership is fully aware that this document misinforms the public. I cannot work for a Department and Administration that deliberately misleads the public.”

Excerpt from Davies' resignation letter.

Excerpt from Davies’ resignation letter.

Resignation Fuels Suspicion

At protests in Raleigh on Thursday, critics of the state’s response to possible coal ash risks to well water praised Megan Davies and Ken Rudo, while calling for Williams’ and Reeder’s resignations. Photo credit: Catherine Clabby

Few Young Doctors Are Training To Care For U.S. Elderly


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By Kara Lofton

West Virginia Public Broadcasting

At Edgewood Summit retirement community in Charleston, W.Va., 93-year-old Mary Mullens is waxing eloquent about her geriatrician, Dr. Todd Goldberg.

“He’s sure got a lot to do,” she said, “and does it so well.”

According to the Kaiser Family Foundation, North Carolina spent close to $1.2 billion on nursing homes for elderly Medicaid recipients in 2013.

According to the Kaiser Family Foundation, North Carolina spent close to $1.2 billion on nursing homes for elderly Medicaid recipients in 2013. Image courtesy Derrick Tyson, flickr creative commons

West Virginia has the third oldest population in the nation, right behind Maine and Florida. But Goldberg is one of only 36 geriatricians in the state.

“With the growing elderly population across America and West Virginia, obviously we need healthcare providers,” Goldberg said.

That includes geriatricians — physicians who specialize in the treatment of adults age 65 and older — as well as nurses, physical therapists and psychologists who know how to care for this population.

“The current workforce is inadequately trained and inadequately prepared to deal with what’s been called the silver tsunami — a tidal wave of elderly people — increasing in the population in West Virginia, across America and across the world really,” Goldberg said.

The deficit of properly trained physicians is expected to get worse. By 2030, one in five Americans will be eligible for Medicare, the government health insurance for those 65 and older.

Goldberg also teaches at the Charleston division of West Virginia University and runs one of the state’s four geriatric fellowship programs for medical residents. Geriatric fellowships are required for any physician wanting to enter the field.

Last year, 11 out of North Carolina’s potential 16 geriatrician residency positions were filled.For the past three years, no physicians have entered the fellowship program at WVU-Charleston. In fact, no students have enrolled in any of the four geriatric fellowship programs in West Virginia in the past three years.

“This is not just our local program, or in West Virginia,” said Goldberg. “This is a national problem.”

The United States has 130 geriatric fellowship programs, with 383 positions. In 2016, only 192 of them were filled. With that kind of competition, Goldberg laments, why would a resident apply to a West Virginia School, when they could get into a program like Yale or Harvard?

Adding to the problem, the average medical student graduates with $183,000 in debt, and every year of added education pushes that debt higher.

Dr. Shirley Neitch, head of the geriatrics department at Marshall University Medical School in Huntington, W.Va., says students express interest in geriatrics almost every year. But, “they fear their debt,” she said, “and they think that they need to get into something without the fellowship year where they can start getting paid for their work.”

This trend troubles many people, including Todd Plumley, whose mother, Gladys, has dementia and lives in West Virginia.

“It’s kind of scary that [older patients] don’t have the care that they really need to help them through these times, and help them prolong their life and give them a better life,” Plumley said.

There are no geriatricians in the family’s hometown of Hamlin, so Plumley drives his mother almost 45 minutes to another town, Huntington, to see one. He says seeing this specialist has helped stabilize his mother’s symptoms.

“Right now, if we didn’t have the knowledge and resource,” he said, “I believe my mother would have progressed a lot further along, quicker.”

Plumley is in his 50s. He worries that if he needs the care of a geriatrician as he gets older, driving even 45 minutes may not be an option.

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