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Officials Eye Water Quality As Floods Recede


By Kirk Ross

Coastal Review Online

Floodwaters are starting to recede upstream along the Tar, Pamlico, Cape Fear and Neuse rivers, but an increasingly contaminated flow of freshwater is headed downriver, eastward to the coast.

The short-term prospects don’t look good for those ready for their first taste of local oysters this season.

Throughout the river basins, sounds and tidal areas of Eastern North Carolina researchers, environmental advocates and an array of state agencies are gearing up testing to get an idea of what effects the floodwaters are likely to have.

The template for anticipating Matthew’s continuing effects has been 1999’s Hurricane Floyd. And like the aftermath of that disaster, much of the concern right now is what happens to Pamlico Sound, the nation’s second largest estuary.

Ben Peierls, a researcher with the University of North Carolina’s Institute of Marine Sciences in Morehead City, said teams from the institute began sampling the Neuse River on Monday, looking for a range of effects.

He said researchers will be sampling for dissolved oxygen chlorophyll and measuring the amount of organic matter in the river. For now, he said, the sheer amount of moving water will probably reduce some of the possible effects.

Hog-waste lagoons near the overflowing Neuse River near Goldsboro are a concern for riverkeepers. Photo: Rick Dove, Waterkeeper Alliance Inc.

Hog-waste lagoons near the overflowing Neuse River near Goldsboro are a concern for riverkeepers. Photo: Rick Dove, Waterkeeper Alliance Inc.

“With Matthew, as in Floyd, there’s a lot of water coming down. It probably contains a good amount of nutrients as it washes through the watershed, but at the same time you can get a dilution effect,” Peierls said. “The more you wash out, the less that’s in there, so the concentrations aren’t always as extreme as they might be. But you’re still bringing a lot of water and a lot of particulate matter with that water.”

With heavy water flow, he said, the effects of additional nitrogen, which could lead to algae blooms, might not be as great. “If you have a lot of water moving through the system there’s not time for biomass to accumulate.”

How the surge of freshwater flowing down the Neuse will influence the estuary is also a focus, Peierls said. A major concern is stratification, in which a top layer of freshwater reduces the amount of dissolved oxygen in the saltier waters below. That can put stress on fish and potentially lead to fish kills.

“If the freshwater becomes more of a lens on top, and we get salty water underneath and the temperatures are high enough, that generally is a recipe for oxygen decline,” Peierls said.

Flying the rivers, planning for tests

Cape Fear Watch Riverkeeper Kemp Burdette is part of a group of North Carolina riverkeepers who have spent more time reviewing the effects of Hurricane Matthew from the air than from the water.

Riverkeepers and environmental advocates took to the skies shortly after Matthew cleared the coast, keeping an eye on hog waste lagoons and other potential sources of significant contamination.

In an interview Tuesday, Burdette said that although he hasn’t seen any breaches, there were several waste lagoons in the Black River and Northeast Cape Fear River watersheds that were surrounded by floodwaters.

“I saw lots of lagoons that were totally surrounded by water and there appeared to be just inches between the tops of the berms and the floodwaters,” he said.

Inundated lagoons have been spotted by riverkeepers in the Tar, Neuse and Cape Fear river basins. State agriculture officials estimated late last week that at least 11 waste lagoons had been flooded.

Burdette said the flights he’s made over southeastern North Carolina revealed just how widespread the flooding was, as well as the effects. He said that in addition to seeing flooded barns and fields, it was easy to spot petroleum slicks atop the water.

The sheen of an unknown substance flows from an inundated barn. Photo: U.S. Coast Guard

The sheen of an unknown substance flows from an inundated barn. Photo: U.S. Coast Guard

“When I was flying, the landscape was so flooded,” he said. “You could see something flowing into the water out of barns or from other sites, but you couldn’t get an idea of what it was or how much.”

Plans for testing for contaminants and the effects of Matthew have started, Burdette said, but for now the waters are too high to get an accurate sample.

“We’ve been waiting for the water to get down to a point where it is reasonable to start testing,” Burdette said. “It’s just everywhere right now.”

Another major concern is the disposal of massive numbers of livestock that died in the flooding. According to early estimates by the state, more than 2 million chickens and turkeys and several thousand hogs have been killed so far.

Oyster harvest delayed

Oyster season opened as announced on Oct. 15, but the harvest is halted at nearly every spot on the North Carolina coast.

That would have been certain given just the heavy rains the storm dumped on the coast and more than 100 miles inland, but with the prospect of a lot of nutrients flowing downstream, the state is stepping up testing as it reviews when it’s safe to reopen the oyster beds.

Shannon Jenkins, Shellfish Sanitation and Water Quality section chief for the North Carolina Division of Marine Fisheries, said four water-testing teams are working along the coast to determine whether beds can be opened.

Jenkins said some portions of Pamlico, Core, Back and Bogue sounds are open, but the most productive areas are not.

“Effectively, most productive oyster areas are closed due to the rainfall and coastal flooding,” he said.

Most were closed early because of the amount of rainfall, which in some areas reached 15 inches in less than a day.

Jenkins said given the stretch of dry weather, he expected areas to begin to open up soon. Harvesting areas where water tends to move faster, such as near inlets and in faster flowing rivers, are likely to be first to open, he said.

“Some water bodies and watersheds are quicker to return to normal,” Jenkins said. As an example, he said, a faster-moving river, such as the New River, is likely to return to satisfactory status sooner than the slower-flowing Newport River.

Crews began sampling in Brunswick County on Monday and were working Down East beds in Carteret County on Tuesday.

Jenkins said if the weather holds he expects most areas to be open by the start of the mechanical harvest period in mid-November.

This story originally appeared Coastal Review Online and is shared through a content-sharing agreement with N.C. Health News.

Two New NC Counties Take on Paid Parental Leave


Durham adopts the policy, Wake considers adding six to eight weeks of paid leave for county employees.

By Thomas Goldsmith

Parents who work for Wake County government would be eligible for six weeks of paid parental leave under a policy presented Monday to the Wake County Board of Commissioners.

Following Durham County’s move earlier this month to offer employees 12 weeks of leave and Greensboro’s vote in August to offer six weeks, Wake becomes the third local government in North Carolina to move toward paying parents who take leave following the birth of a child.

Wake County Board of Commissioners members Betty Lou Ward, left, Jessica Holmes, in background, and Sig Hutchinson consider a proposed new county policy on paid parental leave. Holmes was the driving force behind the action. Photo credit: Thomas Goldsmith

Wake County Board of Commissioners members Betty Lou Ward, left, Jessica Holmes, in background, and Sig Hutchinson consider a proposed new county policy on paid parental leave. Holmes was the driving force behind the action. Photo credit: Thomas Goldsmith

Research published in 2011 found reduced infant mortality in families with paid maternal leave, and research by the Institute for Women’s Policy Research has found better breastfeeding rates in mothers on leave, higher vaccination rates in families where leave is an option and fewer illnesses in the babies of moms on paid leave.

The trend toward paid leave for new mothers and fathers is a national one, given President Barack Obama’s direction to federal agencies in February to allow workers six weeks of paid leave to look after a new child or ailing family member.

Wake County benefits manager Ashley Lategan rolled out the idea for Wake commissioners during a work session, with a vote likely to take place Nov. 7. Members had questions about the details, which included a provision that gives parents eight weeks of paid leave when a child is born with complications or via Caesarean procedure.

“I think this is great,” said board member Sig Hutchinson. “I do like the six weeks, with eight for the Caesarian. Should we be progressive and forward thinking and just go with eight weeks?”

That question was not resolved in the work session. Members learned that the policy would also cover employees who adopt children, welcome a foster child, or take on guardianship for someone.

Said outgoing board member Caroline Sullivan: “We’ve got to have it.”

Johnna Rogers, deputy Wake County manager, said the program, designed to start Jan. 1 if approved, would not create a shortfall in the budget, because the affected workers’ salaries are already included in planning. Lategan said the program was a good choice because it serves as a means for recruiting, promotes employee retention, and adds to current benefits.

BF_babyfeedingAccording to the county’s projections, Wake would pay about $275,000 to workers on paid parental leave per year.

“It’s really no additional budgetary impact, because we had to cover when people were out,” Rogers said.

The work usually done by workers on paid parental leave could be absorbed by other workers or carried out by workers on overtime, officials said.

Another study by the Institute for Women’s Policy Research report also said that the policy has real benefits to municipal employers as well as employees. The think tank report was sponsored by the U.S. Department of Labor Women’s Bureau.

“Research shows that paid leave increases the likelihood that workers will return to work after childbirth, improves employee morale, has no or positive effects on workplace productivity, reduces costs to employers through improved employee retention, and improves family incomes,” the 2014 report said.

Durham County commissioners acknowledged the policy at an Oct. 4 work session. It was described as a “policy to provide for approved time off with pay for the birth of an employee’s own child or the placement of a child with the employee in connection with adoption, foster care or in loco parentis.”

“I think the paid parental leave is a very important step for our county to take,” Durham County Commissioner Ellen W. Reckow said. “It will in fact make us family-friendly.”

Reckhow cited studies that have shown that paid parental leave leads to better productivity and more loyalty to an organization.

Paid parental leave: What is it?
A presentation to Wake County Commissioners on Monday defined paid parental leave as:
“The period of time in which an employee may receive paid leave for parental care of a newborn, a child placed for adoption, foster care, or guardianship within one year of the qualifying life event.
“Such leave would be in addition to any annual leave, sick leave or other leave provided by Wake County.”
More information:
National Partnership for Women and Families


Increase in Youth Suicide Prompts Some States to Act


By MIchael Ollove


When J.D. Goates was 17 and newly graduated from high school, he decided that he had had enough.

J.D. Goates, a senior at Brigham Young University, tried to take his life at 17. The decadelong rise in youth suicide in the U.S. has been particularly steep in Utah, which has launched several suicide prevention efforts aimed at young people.

J.D. Goates, a senior at Brigham Young University, tried to take his life at 17. The decadelong rise in youth suicide in the U.S. has been particularly steep in Utah, which has launched several suicide prevention efforts aimed at young people. Photo credit: J.D. Coates

His thoughts of suicide, which had begun when he was eight, had become stronger. He was ashamed of being bisexual, especially because his Mormon church told him that homosexuality was abhorrent. His classmates and even his teachers in northern Utah heaped scorn on people like him. When he came out to people he thought were his friends, he was crushed by the hostility of some of them. With both his parents away on business trips, he tried to take his life.

“I thought, ‘If I’m going through this hell now is there a greater reason for all of this?’ ” Goates said. “And I came to the decision that there wasn’t.”

Goates’ suicide attempt failed, and now he is a 23-year-old senior at Brigham Young University. But many young people in Utah and across the country haven’t survived.

Between 2006 and 2014, the suicide rate among Americans 19 and under rose from 2.18 to 2.75 per 100,000 people. At least 36 states have experienced an increase, but the problem is especially dire in Utah, where the suicide rate rose from 2.87 to 6.83 during that period.

Among the possible causes cited by suicide experts is a decline in the use of psychiatric medicines and the rise of cyberbullying. Whatever the reasons, a number of states, over the last five years, have adopted measures to try to reverse the trend.

In Texas, for example, a 2015 law requires the state health department to identify and publicize the best practices used in all states for suicide prevention. All public school teachers, counselors and principals in the state must receive training in how to recognize and address signs of suicide risk in students, and schools must notify parents if there’s a concern their child might be at risk for suicide.

New York established an office to coordinate all state suicide prevention activities. The state also provides extensive training for teachers and staff, as well as student peer groups, in how to identify children who seem to be in distress and direct them to adults who can connect them to mental health services. This month, Wyoming established a statewide crisis text line for residents considering taking their own lives, especially teens.

Dr. Gregory Hudnall, a former high school principal in Utah, has more than 20 years of experience in suicide prevention. He provides training for staff and students. Here he speaks to students at Pender High School.

Dr. Gregory Hudnall, a former high school principal in Utah, has more than 20 years of experience in suicide prevention. He provides training for staff and students. Here he speaks to students at Pender High School. Photo credit: Andrew Rhew

And most states now deploy suicide response teams to schools where a student has committed suicide. Research has shown that publicity surrounding a suicide can prompt others, particularly young people, to take their own lives.

“You have to do everything to prevent contagion,” said Greg Hudnall, who created a program that trains Utah students to recognize classmates who seem isolated or depressed and direct them to help or tip off counselors or teachers.

It’s one of several steps Utah has taken since 2012 to try to stem the tragedies, including mandatory suicide prevention training for teachers and parents and similar outreach to pediatricians, coaches and others who interact with young people.

“For Utah, more has happened on the suicide prevention front in the last three years than in the 20 years before that,” said Doug Gray, a psychiatrist at the University of Utah who has studied suicide for more than two decades.

While the numbers continue to rise, Gray and others believe the prevention efforts are making a difference. But some suicide experts and advocates for children believe certain factors in Utah forestall more effective youth suicide prevention efforts.

The state has few restrictions on gun ownership, which suicide experts link to higher rates of suicide, and it has resisted expanding Medicaid eligibility, which critics say would make mental health services more available to those at risk for suicide. Utah also restricts discussion of homosexuality in the classrooms, which gay rights advocates argue further stigmatizes gay students, who are already more vulnerable to suicidal impulses.

Looking for Answers

Youth suicide declined in the 1990s, which many suicide researchers attribute to the growing use of antidepressants. But that trend came to an abrupt end in the mid-2000s, when the youth suicide rate began its upward trajectory.

Suicide rates are much higher among older Americans than they are among teens: For every 100,000 people, in 2014, there were 19.4 suicides among 40- to 59-year-olds, compared to 2.75 among those 19 and younger.

Some suicide experts, like Gray, associate the rise with the U.S. Food and Drug Administration’s warnings, starting in 2003, that the use of antidepressants may increase the risk of suicide in teens and adolescents.

The warning, Gray said, persuaded many pediatricians and family practitioners to stop prescribing the drugs to their young patients with depression. Some studies have linked higher rates of teen suicide to the decreased prescribing of antidepressants.

There may be other factors at work in Utah. Studies have found higher suicide rates in areas with low population, where people are more likely to be depressed and mental health services may be less accessible. Utah public schools are barred by law from “advocating homosexuality,” which, critics say, discourages any candid conversation on the subject.

Those “laws exacerbate the stigma that LGBTQ students experience,” said Troy Williams, executive director of Utah Equality, a gay rights organization.

The state does not track suicides by sexual orientation. Like all states, Utah periodically asks students whether they have considered suicide or made attempts, as well as if they take drugs, use alcohol, smoke cigarettes or are sexually active. Starting next year, those surveys will include questions about sexual orientation.

Some child and gay rights advocates say the Mormon church, which dominates the state’s culture, and its doctrinal objection to homosexuality, cause deep distress to young gay people, like Goates, who see themselves as outcasts who will fail to live up to the ideals of their church of marrying and having large families.

“The church is essentially telling gay youngsters, you are outsiders and will always be outsiders,” said Terry Haven, deputy director of Voices for Utah Children, a child advocacy nonprofit. “Of course there will be consequences from that message.”

A spokeswoman for the church, Kristen Howey, declined to address the question of whether the church’s views on homosexuality contribute to the greater suicide risk among LGBTQ youth. But she called suicide “tragic, no matter the explanation or circumstances.”

“We are concerned about the physical, emotional and mental challenges our members face, and the church is actively pursuing ways to help, including online resources and local leader training,” Howey said. “We invite youth, parents, friends and church leaders to take action to become informed on this subject, and we encourage communities to continue to partner on prevention and intervention.”

Prevention Efforts

But the Mormon church has not become less tolerant of homosexuality in recent years and none of the other explanations account for the steep increase in youth suicides in Utah since 2006. State officials admit they are confounded.

The best guess, state officials say, is an increase in cyberbullying and increased computer screen time, which some suicide experts hypothesize is either a symptom of increased isolation or a cause of it.

Andrea Hood, the state health department’s suicide coordinator, said police officers stop investigating once they determine the cause of death was suicide, without delving into the psychological factors behind it.

To fill that gap, Republican state Rep. Steve Eliason said he would propose creating a position in the state medical examiner’s office to perform what he called “psychological autopsies” on suicide victims.

A suicide by a middle school student near his home spurred Eliason to champion most of the youth suicide prevention legislation in Utah in the last half decade. Some of the measures — like having a statewide suicide prevention office to disseminate information on best practices — were imported from other states. Others originated in Utah and have drawn interest elsewhere.

This year Utah passed legislation requiring all teachers and licensed school staff to take a suicide prevention course as part of their recertification. High schools are required to offer parents training on suicide prevention. And every high school and middle school was given $500 to create suicide prevention programs, which 130 used to create Hudnall’s “Hope Squads.”

Hudnall, a former Provo school administrator, said that he has done or will do training to put the student program into schools in numerous other states, including Alaska, Colorado, North Carolina Oklahoma, Texas and Wyoming.

The Utah Legislature also created positions for three full-time suicide prevention coordinators, one each in the departments of Education and of Health and Human Services, and a third in the state’s Division of Substance Abuse and Mental Health.

Earlier this year, the state also started to roll out a smartphone app that enables students to send text messages about bullying, threats and violence they have witnessed, to text with a counselor and to be directed to help. Eliason said that by mid-September this school year, the app had recorded 3,000 student contacts and led to interventions in the cases of six children who seemed to be close to attempting suicide. He said that other states have contacted him about obtaining the app.

Eliason is also planning to introduce legislation to establish a new three-digit emergency telephone line, manned by mental health crisis counselors, for anyone on the verge of a suicide attempt.

As much as Utah has done, Eliason acknowledges it is not enough. The state spends about $600,000 a year on its suicide prevention efforts. “It’s an extremely small down payment on a problem that needs to have a much larger appropriation,” he said.

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


The lack of access to care around the state drags down North Carolina’s rating.

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.


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


By Michael Ollove


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


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


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,, 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. 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 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).


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


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.

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