The legislative session begins today and as lawmakers return to the General Assembly, a number of healthcare issues will be under consideration.

By Rose Hoban

As legislators return to Raleigh today to start the “long” legislative session this year, a number of healthcare topics are on the agenda for discussion.

Group homes

An early priority for many legislators will be resolving a funding problem that’s left operators of group homes for people with mental health disabilities scrambling for the funds to keep facilities running.

The problem emerged last year during work to fix an issue with the state’s Medicaid personal care services program. For many years, North Carolina’s Medicaid has paid for different levels of personal care services based on whether a recipient lived in an adult care or group  home, or at home with family (see box, below).

Through the fall, the issue became a political football, with legislators in the General Assembly claiming former governor Bev Perdue needed to find money to fix the problem. Perdue maintained that she didn’t have executive authority to fix the problem without the General Assembly in session.

Eventually, in December, Perdue found $1 million of unspent funds from a program for housing people with mental health problems and transferred the money to cover group homes until the end of January.

“The group home bill will move out of the house at least this week, we’ll keep that on track,” said Rep. Nelson Dollar (R-Cary) co-chair of the oversight committee on health and human services.

One of the other committee chairs, Justin Burr (R-Albemarle), said the bill number would be in the single digits.

Dollar said the fix would allow group homes to tap into a $39.7 million fund created in last year’s budget bill to help adult care homes deal with changes to personal care services.

Legislators have said it was a mistake when they removed a reference to group homes in the final language of the bill.

Alzheimer’s units

Similar to group homes, the changes legislators made to Medicaid rules to reimburse for personal care services has affected people with with dementia or Alzheimer’s disease living inside special care units run by some adult care homes.

Many operators of homes have complained the tighter rules are excluding some of the patients with dementia from getting the personal care.

Their complaint is that the new rules require the help for residents to be “hands on.”  In practical terms, it means a resident who needs help dressing needs to require someone to dress them or help them eat. But many dementia patients can be talked through those processes, and now many of them have been denied for personal care reimbursement.

Even when residents need the intensive, hands-on care, changes made by the legislature also limit the total number of hours a home can bill for. he previous maximum was 160 hours per month, but that’s been reduced to 80 hours per month at a slightly higher rate.

“The real problem here is the limitation on the hours,” said Tom Husvar, an operator of adult care homes with special care units in Raleigh, Fayetteville and Durham.

Husvar said under the new rules, his total reimbursement for a resident with Alzheimer’s has dropped more than 40 percent.

Medicaid officials have told adult care home owners to appeal decisions to the state’s office of administrative hearing, but the process is time-consuming and cumbersome.

“We’re looking at the special care unit problem,” said Rep. Nelson Dollar. He also said the state’s Medicaid program has submitted a plan to federal Medicaid officials to try to resolve the problem, but that could take months. In the meantime, there might be a fix that allows adult care home operators to take advantage of a $39 million fund to help adult care homes weather the changes in the system.

Dollar declined to say when he thought the work would be completed.

Expanding Medicaid

Last summer, the U.S. Supreme Court upheld President Obama’s Affordable Care Act, ruling that the law and it’s mandate for individuals to purchase insurance was constitutional. However, the justices ruled the expansion of state Medicaid programs included in the law was optional, leaving it up to individual states to decide whether or not to go forward with the expansion.

Currently, North Carolina has about 1.5 million uninsured residents. According to the North Carolina Institute of Medicine close to 600,000 low income people who are currently uninsured would be eligible for health care coverage; between 70,000-80,000 of those are people who are already eligible for Medicaid, but will newly identified because of simplified enrollment that’s required in the law.

The expansion will cost North Carolina about $850 million over the first six years of implementation, but will also bring in $15-16 billion of federal dollars to the state.

A recent analysis by the Urban Institute calculated that by expanding, North Carolina could end up saving state dollars, as the state  ends up paying less to subsidize hospitals that care of people who are uninsured.

Until now, North Carolina lawmakers have not made many statements about whether or not they intend to expand the Medicaid program. Others in the health care system have been circumspect in talking about expansion, but are slowly starting to speak out.

Last week, a coalition of dozens of advocacy groups signed onto a letter urging Governor Pat McCrory to expand the program, one of the signatories was the Duke University Medical System.

UNC Hospital head Bill Roper recently said the expansion would “mean a lot” for his safety net hospital.

Legislators have expressed concern about the price tag of the expansion, and also worried that the extensive federal subsidies to the program will disappear after the initial six year phase-in.

“If Medicaid is expanded, that will provide a means of care for lots and lots of North Carolinians,” Roper said. “The fact that down the road a little bit something bad might happen shouldn’t cause us to do something very good right now.”

Mental Health

At the end of the last session, the legislative oversight committee on health and human services submitted five recommendations for legislative action during the upcoming session – all of the recommendations were related to problems in the mental health system.

Suggestions included studying the shortages of psychiatric workers in the state, how well community hospitals providing mental health care are getting paid and exploring the possibility of building a fourth state psychiatric hospital to cover the south-central Piedmont.

“In the past decade… we’ve gone from 1,755 beds for the most severe mental health patients down to now 850 beds and we wonder why we haven’t been able to solve problems in the mental health community and solve this crisis,” said Rep. Burr. “I think we’ve discovered in part that they deinstitutionalized people and didn’t put community support in place and in turn, decreased the number of state beds while our population increased by over a million and a half.”

But Vicki Smith, head of Disability Rights North Carolina, decried suggestions to build a new psychiatric hospital.

“It’s our understanding that the state can’t staff the available beds at the psychiatric hospitals the do have,” Smith said. “We’re also hearing that at Broughton they don’t have the capitol to build the information technology, to buy furniture for that hospital.”

“I’d also say that to rush into building a new facility would be ill-advised because we need to focus on building infrastructure to serve people in the communities where they live.”

The state association of county commissioners has also made adequate funding of the mental health system one of it’s legislative priorities for the upcoming session.

Other topics legislators have said will come under consideration during the upcoming session include:

• Looking at creating a North Carolina run health benefits exchange to comply with President Obama’s Affordable Care Act.
• Considering changes to the rules governing licensure of hospitals.
• Launching the state’s Medicaid Management Information System
• Enhancing the Controlled Substances Reporting System, the database allowing doctors and pharmacists to track people using large amounts of prescription painkillers.
• Funding for children’s health initiatives.

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