CDC: Pregnant Women Continue to Light Up
By Rose Hoban
New data from the Centers for Disease Control and Prevention show almost 10 percent of North Carolina women smoked while they were pregnant.
Smoking during pregnancy is one of the prime risk factors for infant death. The new data for 2014 show 9.8 percent of pregnant women in North Carolina smoked during pregnancy and 13.3 percent were smoking in the three months prior to becoming pregnant.
In many counties, however, more than 20 percent of pregnant women continued smoking, and in mountain counties Graham and Allegheny more than 30 percent of babies were born to women who smoked, according to 2014 state data.
North Carolina has one of the worst infant mortality rates in the country, with 7.1 infant deaths per 1,000 live births, compared to a national average of about 6.0 deaths per 1,000.
The state has struggled to improve outcomes for newborns. But the rate has remained stubbornly high, as have the rates of low birth-weight babies, which is a risk factor for infant death.
Smoking during pregnancy has been shown to contribute to both low birth weight and infant death, as well as to preterm birth.
Across the U.S., Native Americans had the highest pregnancy smoking rates, at 18 percent, followed by whites (12.2), blacks (6.8) and Latinos (2.0). Nationwide, young women between the ages of 20 and 24 were most likely to continue puffing while pregnant.
For years, North Carolina saw a decreasing rates of cigarette smoking for teens. Then in 2012, the General Assembly all but eliminated funding for teen tobacco-cessation programs. The legislature also eliminated state funding for You Quit, Two Quit, a program aimed at helping pregnant women stop smoking.
“If you’re smoking while pregnant, the baby is smoking as well, and that program is not funded,” Vitaglione said. “We’re hoping that the General Assembly will take a good look at this and realize that it’s money saved, and to put a special emphasis on the prenatal period.”
Rates have inched up for teens since 2012, but have skyrocketed in the past three years for teens using e-cigarettes. A growing body of data exists on the effects of e-cigarette use on fetal development; nicotine from the devices is able to cross the placenta. Research has shown nicotine impairs neurological development and constricts blood vessels, among other effects.
North Carolina rates are in the middle of the pack for the U.S.: The state with the highest rate is West Virginia, where 27.1 percent of pregnant women were smokers, while only 1.8 percent of California women lit up during pregnancy.
North Carolina has one of the lowest excise taxes for cigarettes in the nation, at 45 cents per pack, despite decades of research showing that increasing cigarette taxes decreases the rate of smoking.
“We know for every 10 percent that we increase the tax, we’re able to reduce the overall smoking rates by 4 percent, and it’s higher for children than for adults,” said Christine Weason, a lobbyist for the American Cancer Society.
A Voter’s Guide To The Health Law
By Julie Rovner
Nearly six years after its enactment, the Affordable Care Act remains a hot-button issue in the presidential race — in both parties.
“Our health care is a horror show,” said GOP candidate Donald Trump at the Republican debate in South Carolina Dec 15. Texas Sen. Ted Cruz, winner of the Iowa caucuses, said at the debate in Des Moines Jan. 28 that the health law has been “a disaster. It is the biggest job-killer in our country.”
Democrats largely support the law, but even they can’t agree on how to fix its problems. Hillary Clinton said at the Jan. 25 town hall on CNN that she wants to “build on the ACA. Get costs down, but improve it, get to 100 percent coverage.”
Clinton’s rival for the nomination, Vermont Sen. Bernie Sanders, acknowledged that “the Affordable Care Act has done a lot of good things,” but added that “the United States today is the only major country on earth that doesn’t guarantee health care to all people as a right.” Sanders is pushing a government-run “Medicare for All” plan instead.
In some cases candidates are bending the truth. But in general, both praise and criticisms of the law are accurate. That’s because the health law is so big and sweeping that it has had effects both positive and negative.
Here is a brief guide to some things the health law has — and has not — accomplished since it was signed by President Barack Obama in 2010.
CLAIM: The law has increased the number of people with health insurance coverage.
This is true, no matter what measure you use. The official Census Bureau and polling firm Gallup both found substantial drops in the percentage of people without health insurance after the majority of the law’s coverage expansions took effect in 2014.
COUNTER-CLAIM: There are still millions of Americans who don’t have insurance.
This is also true. Even though approximately 90 percent of Americans now have insurance, that remaining 10 percent amounts to more than 30 million people.
Millions aren’t eligible for coverage under the law because they’re not in the U.S. legally. Another 3 million are in the so-called “Medicaid gap,” meaning they would be eligible for Medicaid under the ACA except their states opted not to accept the expansion after the Supreme Court effectively ruled the expansion optional.
Still others are eligible to purchase coverage on a health insurance exchange but either can’t afford it, don’t think the insurance available offers a good value or don’t know they are legally required to obtain it. An estimated 7.5 million Americans paid a fine to the IRS for failing to get covered in 2014; millions more were exempt from the requirement and didn’t have coverage.
In recognition of the fact that enrollment has been smaller than expected, the Congressional Budget Office recently lowered its projections for those who will buy insurance under the law from 21 million to 13 million in 2016.
CLAIM: The ACA has fixed the dysfunctional individual insurance market.
Prior to the passage of the health law, millions of people who did not have work-based or government coverage were shut out of buying their own insurance because they had been sick or because the coverage offered did not cover the services they needed.
The law aimed to address the problems in the individual market in several ways, including requiring insurers to sell to those with preexisting conditions at the same price as healthier people; standardizing the benefits package; and limiting the size of deductibles. Tax credits were made available in order to help people afford coverage. And the law created insurance exchanges intended to help consumers compare, choose, sign up and pay for health insurance.
How well these changes succeeded in stabilizing the market is not yet clear. What is clear is that more people are now insured through the market.
COUNTER-CLAIM: The ACA has made the individual market worse.
All is not well in the reformed individual market.
Even with help paying premiums, many moderate-income Americans are finding that their deductibles and copayments are so high they cannot afford to use their insurance.
In other cases, individuals can get insurance they can afford to use, but it does not include their regular doctors and hospitals. In fact, plans that do offer coverage outside of the insurer’s network are becoming harder to find and more expensive.
That change affected Cruz, who initially claimed his private insurance had been cancelled. In fact, his insurer had stopped offering his broad-choice plan and automatically transferred him to a narrow-network product.
CLAIM: The ACA has improved the Medicare program.
While most of the law was aimed at those without insurance, lawmakers also took the opportunity to beef up some benefits for the 55 million Americans in the Medicare program.
Medicare enrollees got new coverage for preventive services and annual checkups, and those with high prescription drug expenses got help to fill the “doughnut hole” gap left by the 2003 Medicare drug program.
Over the longer term, the law created several payment experiments intended to improve the quality of care Medicare patients receive and lower costs. These include efforts to prevent patients from going back to the hospital after they’ve been discharged.
COUNTER-CLAIM: The ACA has not saved money for Medicare.
The rate of increase in Medicare spending has slowed since the health law was passed in 2010. But it’s not clear how much of that can be attributed to the law, aside from some provisions that actually cut payments to hospitals and other health providers.
And some of the most highly anticipated projects, including “accountable care organizations” that are paid bonuses for keeping Medicare patients healthy and lowering spending, have not so far shown very good results.
CLAIM: The ACA has killed jobs.
One of Republicans’ favorite talking points — that the health law would depress employment, particularly full-time employment — has turned out not to be the case.
An analysis in 2015 by the Urban Institute found that the health law “had virtually no adverse effect on labor force participation; employment; the probability of part-time work; and hours worked per week by nonelderly adults.”
While there would be fewer people in the workforce due to the law, the Congressional Budget Office found in 2014 that “almost entirely” stems from voluntary actions by workers who could quit because they no longer depended on their jobs for insurance — now they could buy it on their own.
CLAIM: The ACA has slowed overall health spending.
The White House trumpeted the fact that health spending grew at its slowest rates ever between 2010 and 2013. But health policy analysts are still engaged in a lively debate about how much of the slowdown was attributable to the recession, to the health law and to other changes in the health care system.
Meanwhile, the rate of spending has begun to accelerate again, jumping from a 2.9 percent increase in 2013 to 5.3 percent in 2014. That has occurred as millions more Americans gained access to health care through the law.
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.
What Are States Doing About Medicaid Expansion?
By Christine Vestal
Louisiana this month became the first state in the Deep South to make the politically charged decision to expand Medicaid health insurance to low-income adults under the Affordable Care Act.
At least one other state – South Dakota – is expected to extend Medicaid coverage this year. But in the lead up to the November presidential election, supporters of the ACA aren’t holding out much hope that more states will join in extending Medicaid coverage to more people, although the governors of Alabama, Virginia and Wyoming say they want to, as do key legislators in Maine and Nebraska.
Meanwhile, newly elected Republican Gov. Matt Bevin in Kentucky and Republican lawmakers in Arkansas are threatening to roll back or modify their states’ existing expansion programs.
After a new president is elected, the situation could change and more states could join in expanding coverage, predicted Joan Alker, executive director of Georgetown University’s Center for Children and Families, which advocates for greater health care coverage for the poor.
Ever since the Supreme Court’s 2012 decision making Medicaid expansion a state option, the issue has been more political than practical. Many Republican governors and lawmakers have rejected the deal, fearing they would lose their jobs if they were seen cooperating with President Barack Obama on a law most conservatives abhor.
With Obama out of office, that could change.
“The ideological opposition to the president will have to start fading when he’s out of office,” Alker said. “At that point, the facts and the evidence will start to matter more.”
Matt Salo, executive director of the National Association of Medicaid Directors, agrees. If a Democrat is elected president, the new administration could be expected to continue the Obama administration’s approach of approving proposals from Republican-governed states to shape expanded Medicaid programs to fit their individual state needs and politics.
Even greater flexibility could come if a Republican is elected president, Salo said. In that case, the GOP-led states that have so far shunned expansion would likely seek authority to revamp their programs more radically than the Obama administration has allowed.
Until then, Salo said, “Governors are probably thinking, ‘Maybe I’ll just keep my powder dry.’”
Congress voted 60 times on repealing the ACA before successfully passing legislation earlier this month to undermine the law and phase out Medicaid expansion. Obama vetoed it.
Would a newly elected Republican president instead sign it and eliminate health coverage now extended to millions more poor people? Most analysts doubt it and predict expansion will endure, even if other parts of the ACA are changed.
Hard to take back
So far, 31 states and the District of Columbia have taken the federal government up on its offer to fund all but a fraction of the cost of providing health care to about 8 million low-income adults not previously eligible for the federal-state program. Of them, 10 states were run by Republican governors at the time of expansion.
Defunding or eliminating Medicaid expansion would mean taking away billions of federal dollars from the states and their ability to provide health care for their residents. It also would mean canceling health coverage for millions of people, many of whom could be sick and in need of immediate care. That’s not something any administration is likely to do, Salo said.
For similar reasons, it will be difficult for Arkansas and Kentucky to roll back their Medicaid coverage. Kentucky’s Bevin promised during his fall campaign to dismantle the state’s Medicaid expansion, which is among the nation’s most successful at reducing the uninsured rate and cutting state health care costs.
But in December, Bevin changed his mind and announced he would not eliminate the expansion, but instead transform the way Medicaid is delivered. Without providing details, Bevin said a new system would be in place by the beginning of 2017.
In Arkansas, Republican Gov. Asa Hutchinson, who was elected in 2014, has supported the state’s expansion, but said he was willing to make changes to the program to satisfy critics in the GOP-dominated legislature. Because of Arkansas’ unique requirement that at least 75 percent of lawmakers must approve any appropriation and its conservative legislative majority, the future of the state’s Medicaid expansion has been shaky from the start.
Under the Medicaid expansion, the federal government pays the full price of covering newly eligible adults with incomes up to 138 percent of the federal poverty level ($16,242) through 2016 and then gradually lowers its share to 90 percent in 2020 and beyond.
Opponents of expansion in the states say they fear the 10 percent share states will have to pay will burden their budgets over the long run and force them to neglect other priorities. They also argue the federal government can’t afford higher Medicaid costs and could eventually renege on its promise to pay 90 percent of the bill.
To entice more states to expand, President Obama asked Congress in his 2017 budget proposal this month to allow states to get a full three years of 100 percent federal funding if they take up the option this year or next. The Republican-controlled Congress is not expected to approve the proposal.
In general, the Obama administration has been lenient in approving state requests to modify traditional Medicaid rules. Six states – Arkansas, Iowa, Indiana, Michigan, Montana and New Hampshire – have expanded their Medicaid programs under so-called waivers to federal rules.
The states have sought approval for a combination of changes that would allow Medicaid enrollees to purchase private policies on a state exchange, while requiring them to pay small co-payments and premiums, engage in healthy behavior, seek employment and, in Indiana’s case, contribute to a health savings account. The federal government has approved most requests, but has drawn a line at allowing states to cancel a Medicaid enrollee’s policy for failure to meet any of the requirements.
Some Republican-led states want to go further. Salo predicted that Texas, for example, might ask a Republican president’s administration for permission to operate an expanded Medicaid program much like a block grant, in which the federal government provides the money and the state sets most of the rules.
The issue won’t go away
Whether to expand coverage has been a contentious point between not only Democratic governors and Republican-led legislatures but between GOP governors and Republican legislatures. And some governors have sidestepped legislators to do it.
After replacing Republican Bobby Jindal this month as governor of Louisiana, Democrat John Bel Edwards signed an executive order extending Medicaid to nearly 300,000 poor residents effective July 1. So far, the Republican-led legislature has not pushed back.
Governors in four other states – Alaska, Kentucky, Ohio and West Virginia – have approved Medicaid expansion without legislative consent. In Ohio, it was Republican Gov. John Kasich, a presidential candidate.
In South Dakota, second-term Republican Gov. Dennis Daugaard is asking the GOP legislature to approve extending Medicaid to as many as 55,000 poor residents, including Native Americans. His proposal, which is contingent on federal approval, would for the first time allow Medicaid coverage for Indian health services both on and off the reservation.
In Virginia, Democratic Gov. Terry McAuliffe is seeking expansion. So is Republican Gov. Matt Mead in Wyoming. But their Republican legislatures have rejected it before and are likely to again. Alabama Republican Gov. Robert Bentley has declared support for expansion but is not expected to push the GOP-dominated legislature to approve it this year.
Republican governors Gary Herbert of Utah and Bill Haslam of Tennessee pushed for it last year but ran into opposition from their Republican legislatures, an obstacle that remains this year.
In some states, the opposition shoe is on the other foot. In Nebraska, a bipartisan bill was introduced last week that would expand Medicaid using the so-called “private option” pioneered by Arkansas, in which newly eligible beneficiaries would receive private insurance on the exchange rather than under the existing Medicaid plan. So far, Republican Gov. Pete Ricketts has opposed expansion.
In Maine, two Republican senators – Roger Katz and Tom Saviello – have sponsored a bill to extend Medicaid. But Republican Gov. Paul LePage, who already has vetoed five attempts to enact Medicaid expansion, vowed to do it again.
Facts and evidence
Research shows that major fiscal and health benefits have accrued to states that have expanded Medicaid, and, contrary to claims from opponents, job losses have not occurred. Hospitals also reported fewer un-reimbursed expenses.
A study published in the journal Health Affairs this month concluded that more patients got care for chronic illnesses and fewer residents said they skipped medications or had problems paying medical bills in states that expanded, compared to nearby non-expansion states.
More than 6 million more people would become eligible to receive coverage under the health law’s Medicaid expansion if all remaining states opt in to the program, according to an analysis by Families USA, which advocates for expansion. But states like Florida and Texas, with the highest uninsured rates and the most to gain, continue to reject federal funding.
Historically, health care has been a bipartisan issue, George Mason University professor of health economics Len Nichols said. And it could be again.
“Once Obama is gone, it’s not ‘Obamacare’ anymore,” Nichols said. “It’s American law.” At that point, he said, it will be hard for any state to reject a deal that is “good for their budget, good for their economy and good for the health of their residents.”
Appalachian Community Health Centers to Open After Delays
By Margaret Williams
This story first appeared in Carolina Public Press and is published by N.C. Health News through a content-sharing agreement.
Initially scheduled to open in Asheville last fall, Western North Carolina’s newest community health center has seen substantial delays, but the facility’s director says he expects it to open Feb. 8.
Appalachian Mountain Community Health Centers, awarded a $704,167 federal grant last May, had been scheduled for a September 2015 opening.
“Delays on our end [came from] trying to nail down contracts [and] doing this the right way,” director Nic Apostoleris told Carolina Public Press in October when the center was only a few weeks behind.
That same month, representatives of the U.S. Health Resources and Services Administration, which oversees such health centers, visited Asheville and “provided training and technical assistance,” Apostoleris said.
Some regional leaders of other health centers saw the visit as a sign that HRSA was investigating the new organization or at least scrutinizing its progress more closely, in part because of its close ties with a major hospital, Mission Health, and the Mountain Area Health Education Center, as Carolina Public Press reported Oct. 19.
After a two-year process, Appalachian Mountain had been awarded status as a federally qualified health center – independent nonprofit organizations that provide care to “medically underserved populations/areas or special medically underserved populations comprised of migrant and seasonal farmworkers, the homeless or residents of public housing,” according to HRSA guidelines.
“Since approval [in May], we’ve been working to iron out the details,” Apostoleris said, responding to the criticism. Some of the 16 sites listed in Appalachian Mountain’s federal application were dropped from its plans, he said. Others were still being negotiated.
“What we all want is to do this the exact right way,” Apostoleris said.
As the new year arrived, none of Appalachian Mountain’s proposed sites had been opened.
Asked about the nature of the fall 2015 visit to Asheville and the reason for the delay, HRSA spokesperson Elizabeth Senerchia said the agency “utilizes a variety of methods to monitor health-center program grantees throughout the year to support continued compliance with program requirements.”
The agency can’t comment on progress at a specific health center, she said.
“We also work to identify areas where technical assistance might be beneficial (and work) with grantees to resolve identified issues while also focusing on continuity of service so that people in the communities the health centers serve can continue to receive high quality primary care.”
A few weeks into 2016, Apostoleris reported, “Now it’s coming, and it’s real. We’re opening on Feb. 8.”
He also said, “It’s been a difficult birth process.”
Appalachian Mountain will launch services at 7 McDowell St., a location selected and prepared with cooperation with MAHEC and the Asheville Buncombe Community Christian Ministry, he explained. The new access point, or NAP, will be named after Dr. Dale Fell, a former chief medical officer at Mission Health, MAHEC board member and longtime healthcare advocate in the region.
Despite other delays along the way, “we’re getting it right,” Apostoleris said. “We’re ready to go.”
He emphasized the regional need for affordable care, Appalachian Mountain’s independence as a health organization and the community-based mission of aiding the underserved. He’s assembled “a good clinical team” for the Dale Fell Health Center, he said, and he’s close to announcing satellite locations in the region.
Jeff Heck, director of MAHEC, helped establish Appalachian Mountain. MAHEC is continuing its collaboration with the new organization, he said.
Mission spokesperson Susan Dunlap said the hospital isn’t aware of “any change of status [for] Appalachian Mountain Community Health Centers.” Nor is there “any change regarding Mission Health’s involvement with the new health center.”
Appalachian Mountain will help “expand access to critically needed services in Western North Carolina,” she said.
Apostoleris, the former interim chief operating officer of a community health center in Massachusetts, had served as board president for the National Health Care for the Homeless Council. He’s used his experience to “rework” Appalachian Mountain’s model “and align the details with what community health centers are supposed to do,” he said.
The Dale Fell clinic will complement other local organizations that help the homeless, and new access points across the region will help those who need affordable care, Apostoleris said.
“We’ve made a lot of progress [on Dale Fell and satellite locations]. This is a starting line.”
Researchers Focus on Groundwater
by Mark Hibbs
The increasing demand on drinking-water resources is one of the major issues facing those who live and work in eastern North Carolina, according to a U.S. government report.
State officials estimate the New Hanover County population, now more 216,000, will increase by more than 38 percent by 2030 and by 100,000 people in the next 25 years. That’s not including the seasonal tourist population, which swells during the warmer months. Add in industrial development, and the potential for problems grows. Then there are the other growing communities in the larger Cape Fear region, many of which depend on the same groundwater or surface-water resources.
Groundwater and surface-water resources are related but problems below ground aren’t as easy to spot and until recently little research has been done.
A 2012 report by the U.S. Geological Survey showed that because of long-term over-pumping, groundwater levels in the Peedee, Black Creek and Upper Cape Fear aquifers of the state’s central coastal plain in counties to the north of New Hanover have declined substantially over the past 30 years. The survey, which was done in cooperation with Cape Fear Public Utility Authority, was the first scientific study of its kind in more than 40 years.
“It was a good partnership; they have expertise and know-how,” said Mike Richardson, the authority’s water-resource manager. “Naturally, we want to see what the current and the future is. We can’t prepare unless we know the things that are going to affect us.
“This was an opportunity to learn more about the current groundwater situation and the impacts of saltwater as it continues to encroach into these aquifers.”
Kristen McSwain is a USGS hydrologist who worked on the study. She said the report provides merely snapshot comparisons of data from 1964 and 2012, but big changes have occurred over the years.
“There’s been explosive growth in the area and groundwater is a resource that’s heavily used,” McSwain said. “[The study] was basically to look at groundwater quantity and quality in comparison from the ‘60s to today; but with only two data sets, it’s hard to draw conclusions. This is not a long-term statistical study.”
McSwain said the specific reasons for the declines in groundwater quantity can’t be readily identified based on the results of her work. “All I can say is they declined. I can’t say why and I can’t say when. What it indicates is a need for increased monitoring,” she said.
Groundwater chemistry showed similar changes in the comparison, including indications of saltwater intrusion into the freshwater aquifers. “But again, it shows that monitoring is needed. I don’t know when it happened,” McSwain said.
A national water census
Research is continuing at the state and federal levels. The scope for these studies goes far beyond just groundwater, and also beyond New Hanover County’s borders.
New Hanover County’s drinking-water supply comes from a combination of surface water and groundwater. Wilmington relies mainly on the Cape Fear River as its drinking-water supply, and so do many other communities.
The Cape Fear River basin, the state’s largest river basin, extends from near Greensboro and High Point to the Wilmington area. The area includes all or part of 27 counties. More than 21 percent of the state’s population lives in the more than 9,000-square-mile basin area.
A state law passed in 2015 authorized the N.C. Department of Environmental Quality to study all uses of ground and surface water in the Cape Fear River Basin, including public water systems, industrial facilities and agricultural operations.
The study is supposed to identify potential conflicts among the various users and offer recommendations for developing and enhancing coordination in order to avoid or minimize those conflicts. An interim report is expected this year, with the final report due in 2017.
A separate but related study is underway at the federal level. The USGS Coastal Carolinas Water Availability Study is a step toward assembling a national water census. Chad Wagner, USGS associate director for investigations at the N.C. office of the South Atlantic Water Science Center in Raleigh, is heading up the work, which began in October
The study is different from the state’s work in that it’s a three-year project due for completion in late 2018 or early 2019, and it’s wider in scope, including coastal basins in southeastern North Carolina and northeastern South Carolina. But there is collaboration.
“We’ve definitely been in communication with the state and we let them know what we’re doing,” Wagner said.
The goal is to use the results to develop and refine water-use estimates for agriculture, public supply and industrial sectors. The water-use data will be site specific to allow tracking of water from its source to the ultimate users and its disposal, both within and beyond the study area.
For surface water, models will be used to evaluate potential changes in water availability and salinity in response to various water uses and climate-change scenarios. Ecology, including fish and plant life, will also be examined in terms of responses to changes in flow.
Groundwater-flow models of water-supply aquifers will be used to simulate the effects of various usage scenarios and gauge the problem of saltwater intrusion from pumping.
The coastal region was selected for study because of current and projected population increases and the effects on fresh and saltwater ecosystems. The recent history of frequent coastal storms and droughts here was also a factor.
The area is also deemed a groundwater capacity-use area, or an area where demands on water resources have reached a point where coordination and regulation may be needed to avoid threatening or impairing those resources. The region is also considered vulnerable to sea-level rise, land-use changes and climate change, in terms of effects on aquifer water levels and saltwater intrusion.
New Hanover County is working toward completing a comprehensive planning document for future growth with goals for preserving and protecting water quality and supply. The plan recommends establishing a groundwater- and aquifer-protection ordinance.
“There’s an increased awareness of the protection of our drinking-water supply,” said Chris O’Keefe, New Hanover County’s planning director.
Dylan McDonnell , a long-range planner with New Hanover County’s planning department, said the county expects to have the planning document completed by early spring. The effort, which began more than a year ago, includes input from a 12-member advisory committee made up of local residents and approval by the county planning board and board of commissioners.
The advisory committee raised the issue of water resources, McDonnell said.
“There was not a concern as far as quantity,” he said of the county’s water supply. “We just want to make sure we have sustainable sources for the future and to make sure we’re not degrading them to the point where we can’t use those sources.
“We weren’t singling out certain industries or looking at industry in general. We were looking at creation of our land-use map, an overall, general vision that the county has for the future.”
The plan is also not a zoning ordinance, McDonnell said. “That’s the next component after we finish with the comprehensive plan: revising our zoning ordinance, which was written in 1969.”
Meanwhile, officials in charge of the county’s public water system are putting in place new technology also meant to ensure there’s enough water for future demand. This includes a new process of pumping treated water back down into the aquifer for storage until it’s needed. The process, known as aquifer storage and recovery, or ASR, is set to become operational this year at a plant near Wrightsville Beach in the Cape Fear Public Utility Authority’s system.
The system is expected to provide cost-effective, seasonal storage of treated water, said Mike Richardson, water-resource manager with the authority. Part of the cost savings is having no physical tank to maintain.
The ASR system may also allow the water-treatment plant to operate more efficiently during lower-demand periods while being available to meet the need during periods of peak demand. The system can also provide an emergency supply and could slow or reverse the effects of saltwater intrusion in the aquifer.
Economics and race
There are more than 6,000 regulated public-water systems in the state, according to the N.C. Department of Environmental Quality. About 75 percent of the state’s population lives in areas served by community water systems, and many others and visitors to the state are served by other types of public water systems.
Homeowners in communities without access to public water rely on domestic wells. North Carolina has the fourth-highest number of private well users in the country. The high rate of dependence upon wells and septic systems is partly because of the rural nature of the state with its many unincorporated communities.
Economics and race are also factors.
A study in 2015 by the UNC Gillings School of Global Public Health found that 26 percent of North Carolinians rely on private wells, as compared with 14 percent nationally, and 49 percent use septic systems, compared with 24 percent nationwide.
Septic-system failures can lead to contamination of well water, and the high density of septic systems in rural communities is a public health risk associated with increased incidences of bacterial and viral diarrheal diseases, according to the report by Julia Marie Naman, a 2014 Gillings School alumna, and Jacqueline MacDonald Gibson, associate professor of environmental sciences and engineering at the school.
“Unequal access to water and sewer services can have considerable health effects,” they write, “and disproportionately burdens the politically vulnerable.”
Naman conducted interviews during 2013 with 25 elected officials, health officials, utility providers and community members in New Hanover, Hoke and Transylvania counties. She found that economics was the primary factor determining whether access was granted to municipal services. Improved public health was described as a minor reason.
Problems with septic systems tend to be under-reported, according to the study, because local health departments rely mainly on homeowners or their neighbors to report failed systems, and repairs can be costly.
The Gillings research team has also found statistical evidence that race plays a factor in who does and does not have access to municipal water services in North Carolina. This lack of access also increases people’s health risks.
The research concluded that better understanding the health costs and benefits of water and sewer extension and considering these factors in the local decision-making process may help address disparities in access to municipal services.
The Death-Rate Divergence: Urban vs. Rural
By Shawn Poynter and Tim Marema
Rural America’s above-average mortality rate ought to be getting more attention than it is, according to a former federal health official who will be part of a presentation this week on rural life expectancy.
“Several million people dying too soon is as important as a terrorist attack, but it’s not on the candidate debates or the evening news,” said Wayne Myers, who was head of the federal Office of Rural Health Policy during the Clinton administration.
From 2005 to 2009, the rural mortality rate was 13 percent higher than the mortality rate for urban residents, according to a policy brief from the National Advisory Committee on Rural Health and Human Services. Until 1990, both urban and rural death rates were improving at about the same pace (see graph above). But since then, rural America has not been keeping pace with improvement in urban areas. Over the past quarter century, the gap has widened.
That’s bad news for the country as a whole, not just rural areas, according to Myers. The same trends may be affecting metropolitan areas but be harder to spot, he said.
“In a large complex city, you may have all sorts of trends in different demographic groups headed in different directions and cancelling each other out: trends in prosperity, security, access to medical care, drug use. You can see effects sooner on smaller, more homogenous rural populations. We need some smart statisticians willing to work on smaller populations to sort this out.”
Myers is one of the participants in a Thursday, Jan. 28, webinar that will review the National Advisory Committee’s findings. (The webinar is free and open to anyone who is interested. Registration information.)
“I hope the webinar will get some more people wanting to know why too many rural people are dying young,” Myers said. “I think that is really important. Eventually I’d like to see a group convened to sort out what is scientifically known about (1) the impact of social and economic change on people’s health, and (2) what actually works to improve the health of groups of people.”
There are many reasons the rural and urban mortality rates have diverged, according to the National Advisory Committee on Rural Health and Human Services. Rural America is “older, poorer, and sicker than urban America,” they write. Other factors include a rising rate of accidental “poisoning” (which is a polite way to say “drug overdose”), poverty, unintentional injuries (car and ATV wrecks, gun accidents, etc.) and proximity to emergency health services and lack of reliable transportation to get to medical attention. These factors have converged to make rural life expectancy a full two years short of urban life expectancy (see Figure 2).
The brief notes that “social circumstances and behavior” are major factors in premature rural deaths, contributing in more than half of rural deaths.
“When discussing mortality and life expectancy – inextricably linked to population and individual health – it is also necessary to examine aspects outside of health care that both lead to poor health and can be used to improve it,” the brief states. “This includes factors in households, schools, places of employment, transportation, and physical environments.”
The brief was presented to Department of Health & Human Services Sec. Sylvia Mathews Burwell. Among policy suggestions were support for more research and increased funding for rural medical personnel and programs.
Poll Shows Support for Expanded Medicaid Program
By Rose Hoban
Voters of every stripe believe the state should expand the Medicaid program to include those who are currently too poor to have insurance. That’s according to results of a survey from Public Policy Polling released on Tuesday.
In a survey of more than 2,000 registered voters, clear majorities of men, women, Democrats, Republicans and Independents said they supported the legislature and Gov. Pat McCrory fixing “the coverage gap by creating a special North Carolina plan in partnership with the Federal government.”
North Carolina is among those states that haven’t expanded Medicaid, and between 360,000 and 500,000 North Carolinians are today too poor to afford private insurance or to receive federal subsidies to help buy insurance but make too much money to qualify for Medicaid.
Thirty-one states and the District of Columbia have chosen to expand the program, which will be paid for in whole by the federal government until 2017. After that, the federal government will pick up about 90 percent of the tab.
The poll asked whether North Carolina should make a plan to fix the health insurance coverage gap; 84 percent of Democrats and 62 percent each of Republicans and unaffiliated voters answered yes. The poll also found majority support for expansion among all age groups and all races.
Because of the large number of participants in the poll, the margin of error is only +/- 2.2 percent.
“This poll shows that there is widespread, bipartisan support for closing the health insurance coverage gap,” said Michelle Hughes, executive director of NC Child, in a press release.
NC Child is a statewide advocacy group that commissioned the poll.
“We hope this sends a clear message to Governor McCrory and state legislators that all North Carolina voters will support an effort to expand health insurance coverage,” Hughes said. “This data should give comfort to conservative candidates who haven’t been sure what their constituents think on this issue.”
In 2013, the General Assembly pushed through a bill, which McCrory signed, restricting decisions about whether or not to expand Medicaid to the legislature alone.
Senate leader Phil Berger (R-Eden) could not be reached for comment about the poll. In a response to a request for comment, Berger’s chief of staff, Jim Blaine, called Public Policy Polling “highly partisan Democrat Party political hacks.”
A Fordham University study found PPP to be the most accurate of the nation’s polling organizations during the 2012 elections, despite the organization’s Democratic affiliation.
“We don’t respond to their propaganda,” Blaine wrote in an email.
Insured parents = insured kids
About 95 percent of North Carolina children are insured, thanks largely to the State Children’s Health Insurance Program, which covers children in families earning up to 211 percent of the federal poverty level ($50,324 for a family of four).
When asked why his organization commissioned the poll if so many children are already insured, NC Child spokesman Rob Thompson responded that there are still about 100,000 North Carolina kids who aren’t covered.
“That’s enough to fill up a big football stadium,” he said. “About two-thirds of those kids are eligible for health insurance, they’re just not enrolled.”
Thompson said evidence from the SCHIP program indicates that when parents get insurance, they often learn that their children are eligible.
“It creates this welcome-mat effect,” he said. “When the parents come in and get their own insurance, the children get insured as well. So we think it’s a good strategy for getting that tough remaining 5 percent.”
Thompson also said insuring adults could help bring down North Carolina’s stubbornly high infant-mortality rate, one of the highest in the country.
He said getting women more healthy even before they conceive is important to positive pregnancy outcomes.
Government Agencies Point Fingers Over Coal Ash Delays
By Kirk Ross
With a March primary and an early start to the session, the N.C. General Assembly’s environmental oversight committees have begun prepping legislation for this year’s short session, including a potential revision to a coal ash bill passed two years ago.
The legislature’s Environmental Review Commission devoted much of last week’s meeting to coal ash. Tom Reeder, an assistant secretary for the N.C. Department of Environmental Quality, gave commission members an assessment of the effects overseeing coal ash cleanup will have on his agency and leveled a blistering attack on the federal Environmental Protection Agency for its role in draining coal ash ponds in the state.
Reeder said DEQ is stretched “to the breaking point” to keep up with a timetable mandated in a bill the legislature passed in 2014 that requires the cleanup of the 32 ponds at 14 Duke Energy power plants.
He also sharply criticized EPA officials in Atlanta for not moving faster on proposed changes to federal permits for wastewater discharge that would allow decanting and dewatering to begin at most of the ponds. Those are the first steps in the cleanup process.
DEQ in December approved an updated discharge permit for ponds at Duke Energy’s L.V. Sutton power plant in New Hanover County, one of four high-priority sites where excavation and removal of coal ash has already started. The permit allows the plant to begin drawing down water in the ponds at the rate of one foot a week.
Reeder expressed frustration in getting the water out of the remaining ponds, charging that the EPA took more than 15 months to approve decanting at the sites and is currently holding up approval on permit modifications that would allow dewatering at 13 sites.
Decanting is the removal of the surface water in the pond, while dewatering is the final step in removing the rest of the water ahead of excavation.
“Until we get the water out of those ponds, we’re going to continue to have groundwater contamination, we’re going to continue to have threats from this water to dams and surface water,” Reeder said. “The key thing is we’ve got to make those ponds dry.”
Legislators shared his frustration. “We may not know what steps 25 and 30 are, but we certainly know what steps one and two are, and that is decanting and dewatering,” said Rep. Jimmy Dixon (R-Duplin).
During questioning by commission members, Reeder said DEQ Sec. Donald van der Vaart is considering what Dixon termed “unilateral action” to move forward with the revised pollution-discharge permits and start dewatering the ponds without EPA approval.
In a response to a request from for details on the move, Crystal Feldman, DEQ deputy secretary for public affairs, said EPA approval of the discharge permits is a courtesy and not a requirement.
“When given a permit to review, EPA may offer comments, object to or remain silent on the permit. DEQ may issue the permits if EPA does not object. As a courtesy, in recent years DEQ has waited for explicit EPA approval before issuing coal-ash permits despite it not being required by law,” Feldman wrote in an email. “Assistant Secretary Reeder noted that we may no longer provide that courtesy.”
Feldman said the department has yet to decide how to proceed on the permits.
“The EPA is struggling with how to handle these types of permits because they are the first of their kind in the nation, which has caused long delays in the permitting process,” Feldman wrote. “If DEQ is faced with a choice between protecting the environment or the federal bureaucracy, protecting the environment will win every time.”
EPA officials in Atlanta said they are moving forward on permits that would allow dewatering following procedures set out in a memorandum of understanding with the state. DEQ has forwarded to EPA two proposed final permits that include dewatering, explained Davina Marraccini, an agency spokeswoman.
EPA completed its review of the first permit and has asked for a 90-day delay, which ends on Feb. 10, on the other. Such a delay is authorized by law, she said, and is included in a memo that the state signed.
Legislators at the meeting said the timetable in the cleanup bill could be adjusted this session.
Chromium standards debated
Also during the ERC meeting, commission members looked into an interagency debate between DEQ and state public health officials over setting threshold levels of contaminants for a well-testing program near coal ash sites.
The focus was on do-not-drink notices sent by the state Department of Health and Human Services based on testing around the 14 coal ash sites. In all, more than 476 private drinking-water wells near the sites were tested. Of that total, 424 well owners, about 89 percent, were issued do-not-drink notices by the department, with 369 of those notices triggered by levels of hexavalent chromium and vanadium that exceeded the standard used by health officials.
Reeder told legislators that the standards for hexavalent chromium was set far lower than federal drinking-water standards for public water systems. Nearly every public water system in the state would get a similar notice if the standard was applied, he said.
Legislators also questioned the notices, saying they alarmed residents and forced them to switch water sources unnecessarily.
Rep. Rick Catlin (R-New Hanover) said the notices have had a negative effect that in many cases outweighed the risk. He said future do-not-drink notices shouldn’t go out unless there is clearer evidence.
“Wait until we have that information to tell them to quit drinking their water, because we are impacting them kind of unfairly [compared] to the way we’re impacting everybody else,” Catlin said.
State Health Director Randall Williams stressed that the risk evaluations were recommendations to residents and not regulations. He said the chromium standard used was based on public health standards for risk of cancer due to lifetime exposure at the levels of the well tested.
“We’d rather error on the side of caution,” Williams said.
The department, he said, is waiting for new data and will re-evaluate its risk assessments, including looking at background levels for the areas tested.
“We’re in the midst of evolving science,” he said, adding that there has yet to be a standard set for hexavalent chromium and it is treated differently by different government agencies.
DEQ and DHHS have been charged with preparing a study for the ERC on how to set proper levels for hexavalent chromium and vanadium, two known coal ash constituents that carry a high risk to public health. Few states have regulations on either. The study is due by April 1.
Grady McCallie, policy analyst with the N.C. Conservation Network, said although it focuses on just two constituents, the outcome of the study could have a significant effect on how the state determines the extent and amount of groundwater contamination.
“The underlying issue is an important one and broader than just hexavalent chromium,” McCallie said in a recent interview. “How do you handle substances that change over time and those that are naturally occurring in some wells and not in others?”
DEQ officials have repeatedly pointed to naturally occurring levels of various toxic coal ash constituents, such as arsenic, as a challenge in determining whether high levels in groundwater can be directly attributable to coal ash basins.
N.C. Obamacare Signups Strong as Deadline Looms
By Rose Hoban
With less than two weeks to go before the end of the enrollment period for marketplace insurance on Jan. 31, North Carolina enrollment in plans remains strong.
That’s despite well-publicized glitches in processing applications and payments at Blue Cross and Blue Shield of North Carolina.
According to the federal Centers for Medicare and Medicaid Services, 569,694 people in North Carolina have selected a marketplace plan. Already that’s more people who have enrolled for insurance than the total in the state who enrolled last year.
Of that number, 88 percent have qualified for financial assistance.
As of early January, the largest percentage (42 percent) of enrollees from North Carolina fell into the income bracket between 100 and 150 percent of the federal poverty level ($24,250-$36,375 for a family of four). That trend holds true for states that have not expanded the Medicaid program, as allowed for under the Affordable Care Act.
In states which have expanded the Medicaid program, fewer enrollees come from that income level.
This week, Gov. Pat McCrory said he’s still not ready to support expansion of the program unless federal officials allow North Carolina to add a work requirement to eligibility.
“When you’re talking about expanding Medicaid, you’re really talking about expanding Obamacare,” McCrory said. “We still don’t know the real impact of Obamacare. We’re seeing premiums go up, seeing companies dropping insurance; we’re seeing individuals and young people not signing up for insurance.”
Federal officials estimate that more than a million of North Carolina’s 10 million people are eligible to buy insurance on the marketplace, with expected enrollment somewhere over 600,000.
Another 32,708 people who attempted to enroll in insurance were determined to have incomes low enough to be eligible for North Carolina’s Medicaid program.
Old and new
1-855-733-3711 is a statewide hotline to find in-person help for signing up.“We are seeing so many people enrolling,” said Lovemore Masakadza, the North Carolina spokesman for Enroll America, a not-for-profit organization that’s coordinating sign-ups for the exchanges in 11 states. “It’s a mix of new and old people who need to re-enroll.”
In 2014, North Carolina had one of the highest rates of eligible enrollees signing up for insurance on the marketplace. But Masakadza said his organization this year was doing special outreach to Latinos and African-Americans.
“We’ve seen that we have a lot of uninsured Latinos and African-Americans, so we’ve been collaborating with community groups and organizations to reach out to those people.”
An update released by federal officials in the beginning of January showed 70 percent of enrollees in North Carolina were white, 6 percent Latino and 16 percent African-American. But Masakadza pointed out that those figures only include people who self-reported their race or ethnicity, less than half of the total enrollees.
“We’ve been able to reach out to some people we weren’t able to reach out to in the previous enrollment period,” he said.
Rural residents make up about a quarter (26 percent) of North Carolina’s enrollees; rural folks are another target group.
The same federal report showed close to half (45 percent) of the people who were still enrolled in marketplace plans in November 2015 decided to switch their plans, while another 27 percent of people enrolled last year were automatically re-enrolled in the same plan as last year.
About 37 percent of North Carolina enrollees are under the age of 34, an important figure because younger people cost less to insure and their premiums help make up for lower-cost plans being offered to older adults under 65 years old.
Some states, such as Utah, have had as many as 55 percent of their enrollees under the age of 34.
With only 11 days remaining, Masakadza said his organization is reaching out to people they met earlier in the open-enrollment period, encouraging them to sit down with in-person assisters to fill out their forms.
“We want to make sure people don’t wait until the bitter end,” he said. “So many people wait until the deadline; that tends to motivate some people.”
But this year has an additional motivation for enrollees. The tax penalty for not being covered rises to $695 or 2.5 percent of yearly income, whichever is greater, once the deadline passes on Jan. 31.
“Once some people find out the insurance covers things like prevention and pharmaceuticals, and screenings are covered, they’re more likely to check out their options,” Masakadza said.
State, Local Officials Push Manufacturers to Pay for Drug Disposal
As more people use drug drop-off services at local law enforcement agencies and events such as Operation Medicine Drop, the price tag is starting to grow.
By Sarah Breitenbach
Each month, Monty Scheele, a pharmacist in Lincoln, Nebr., sends a big box of unused medications to be incinerated.
He collects the drugs at his three pharmacies from customers who may be cleaning out their medicine cabinets or abandoning a prescription after an adverse reaction. His effort is part of a program using state funds to keep medications from polluting water supplies and out of the hands of people who might misuse them.
But drug disposal is expensive – the Nebraska program spends $10 per pound to ship and destroy medication – and some states and municipalities want drug companies to pick up the tab.
Six municipalities in California require drugmakers to pay for take-backs. Nine states – California, Florida, Maine, Maryland, Minnesota, New York, Oregon, Pennsylvania and Washington – have considered similar measures. Another such proposal is in front of the Massachusetts legislature.
Proponents say these laws, which are similar to programs that require manufacturers to pay for electronics recycling, would make it easier for patients to dispose of prescriptions. But drugmakers oppose the local mandates and warn that disposal costs could be passed on to patients through higher drug prices.
Alameda County in California was the first jurisdiction to pass a law requiring manufacturers to pay for take-backs, in 2012, though the industry was quick to file suit, arguing it violated the interstate commerce clause of the U.S. Constitution. The Alameda law was upheld this year when the U.S. Supreme Court refused to hear the industry’s appeal.
That law initially applied to “non-controlled substances,” including antibiotics and over-the-counter drugs, because until last year only law enforcement could accept more strictly controlled substances like oxycodone, morphine and Valium. But last year, the Drug Enforcement Administration issued new rules allowing DEA-registered pharmacies, drugmakers, hospitals and narcotics treatment centers to take back controlled substances, though pharmacies across the country appear reluctant to get involved.
Heidi Sanborn, director of the California Product Stewardship Council – a network of local governments, nongovernmental organizations and businesses that want producers to be responsible for the proper disposal of their products – helped pass the Alameda law. She points to other countries, like Canada and Mexico, which have had drug take-back programs for years.
“People [in the industry] are making this out to be super complicated and really hard, but the truth is that we can put a man on the moon, don’t tell me we can’t figure out how to collect pills,” Sanborn said.
It was the industry’s opposition to a California-wide version of the Alameda law that led advocates to focus on passing county-level measures instead, she added.
Drugmakers would rather lead their own take-back programs than comply with local or state mandates, said Priscilla VanderVeer of the Pharmaceutical Research and Manufacturers of America, a plaintiff in the Alameda case.
Because drugmakers sell across the country, meeting the customized disposal requirements of local programs is complicated, VanderVeer said. There are also more effective ways to get rid of the medicines, she said, like at-home disposal or returning unwanted drugs using special envelopes with carbon lining.
“That’s just a financial and logistical nightmare for something that’s not necessarily going to be effective, or secure or environmentally helpful,” she said.
Public health crisis
Take-back advocates want to get unused opioid painkillers and other highly addictive medications out of circulation so they cannot be abused or sold to recreational users.
Scheele, the Nebraska pharmacist, has begun to use secure lockboxes where customers can return their controlled medications under the new DEA rules. He said he was apprehensive about adding a lockbox, on top of his existing efforts, because it would bring excess amounts of highly desired drugs to his pharmacies. But the security of the metal boxes, which are bolted to the floor and the wall, has diminished that concern.
“I’m really glad to see this stuff get out of the community,” he said, noting that he would continue to use the lockboxes even if the funding for Nebraska’s program disappeared.
About 110 Americans die each day from a drug overdose. More than half of those deaths are attributed to opioids, including painkillers. And 70 percent of people who misuse painkillers report getting the drugs from a friend or a relative.
Marcia Mueting, with the Nebraska Pharmacists Association, said it makes sense for patients to return unused medications to pharmacies because they have relationships with their pharmacists, who can inquire about why a patient did not finish a medication and potentially identify adverse reactions.
“At the point when you decide that I no longer want this medication in my home, you should be able to take it somewhere,” she said.
More than half of Nebraska’s 500 pharmacies are doing take-backs. The program began in Lincoln and Lancaster County in 2012 and went statewide earlier this year. Since 2012, more than 14,800 pounds of drugs have been taken back.
Many participating pharmacies are small and independently owned. Some larger pharmacy chains have rules that prevent them from collecting the drugs, Mueting said.
VanderVeer argued that take-back programs are not a panacea and patients won’t be willing to make frequent trips to a pharmacy with their medications. The industry would rather focus on educating consumers about at-home disposal, she said.
“It’s sort of like recycling: the easier you make it for people, the more likely they are to comply,” VanderVeer said.
The U.S. Food and Drug Administration advises that some medications can be flushed down toilets or sinks, but that others should be removed from their original containers and mixed with undesirable substances like used coffee grounds or cat litter (to deter people from using them) and then sealed in a plastic bag before being thrown away.
Sealing and disposing of medications in the trash is supposed to be safe, but studies have found that even treated liquid waste from landfills still contains contaminants, and that drugs in water supplies are affecting fish.
It is unclear just how much groundwater contamination comes from flushed drugs versus human waste, said Cindy Kreifels, an executive at the Groundwater Foundation, a Nebraska nonprofit.
“Obviously, we need to get the pharmaceuticals out of all water bodies,” she said, and take-back programs are important because the first step in cleaning up groundwater is getting people not to flush their medications.
Kreifels said there had not been any studies of contamination in Nebraska’s water since the take-backs began in 2012.
Stateline is a nonpartisan, nonprofit news service of the Pew Charitable Trusts that provides daily reporting and analysis on trends in state policy.