North Carolina legislators say they’ve been at work already, cranking out proposals and draft legislation to address a number of health care issues.
By Rose Hoban
North Carolina’s lawmakers returned to Raleigh on Wednesday to be sworn in, take photos with family, meet and then return home for the next two weeks.
Even as they packed boxes of files to move to another office and showed around grandchildren, legislators involved with health and human services took a few moments to talk about their priorities for this session.
Medicaid was top of mind for anyone who works on health care issues, with the most questions surrounding changes in the coming year.
“There are so many moving wheels right now,” said Rep. Greg Murphy (R-Greenville), a urological surgeon who sits on the Joint Legislative Oversight Committee on Health and Human Services.
When asked about the prospect of expanding the state’s Medicaid program, a move allowed under the Affordable Care Act, he said, “As a physician, I take care of people and I want everyone to have access to care because I want everyone to lead healthy lives. So that’s really my first thought. But in general, Medicaid expansion is one piece of the Affordable Care Act and the new incoming federal president has said as part of his agenda that he wants to repeal the ACA.”
Murphy said there were some good things about Obamacare, such as the ability for children to stay on their parents’ insurance plans until they’re 26 years old.
He also said that pre-existing conditions should be covered.
“It’s through no fault of people’s own, the bodies into which they’re born and some of the difficulties that they face,” he said.
But Murphy complained about some of the burdens put on his practice by the ACA and bemoaned the increased costs to states.
He and other Republican lawmakers also complained about Gov. Roy Cooper’s gambit to ask the federal government to allow North Carolina to expand.
“Just as the legislature couldn’t go out on its own, willy-nilly and do something without the other branches involvement, nor can the governor go out and just do expansion something or do something that is contrary to the statutes,” said House Speaker Tim Moore (R-Kings Mountain).
“I suspect that straightening that out will be our first actions if there’s anything we need to do prior to coming in,” said Ralph Hise (R-Spruce Pine), who is a co-chair of the HHS oversight committee.
Hise also said the state’s Medicaid system needs adjustments to ensure that it’s consistent with any new federal policies. Mostly, though, he said he wanted to see the steady progress on North Carolina’s Medicaid reform plan that will replace the current fee-for-service system with managed care. Beyond that, he was noncommittal.
“We have no idea what the federal government is going to do with the Affordable Care Act, what they are going to do with Medicaid policy,” he said.
He did say he wants to reintroduce legislation to move the Medicaid program away from the Department of Health and Human Services and create an independent board to run the program.
That idea met with stiff opposition in the House a few years ago during discussions on Medicaid reform, but Hise said he believes that opposition has softened.
“A lot of the circumstances that led House members to oppose that have changed,” he said, and nodded when asked if that was a reference to the fact that DHHS is now run by a Democratic appointee.
Mental health priorities
Once they got done shrugging their shoulders about larger forces at work in the country, lawmakers quickly moved on to their desire to improve North Carolina’s mental health system.
“I’d like to see the behavioral health urgent care and facility-based crisis (centers) continue to roll out, make sure that we’re meeting people where their needs are,” said Rep. Susan Martin (R-Wilson) as she walked between legislative buildings with husband and children in tow.
“There’s an emphasis on the work we did in the [Governor’s Task Force on Mental Health and Substance Use] in the system to make sure we have better, earlier interventions and screenings and getting people services earlier,” she said.
She and other Republicans noted that hospital emergency departments are jammed with behavioral health patients, many of whom sit, on average, more than 90 hours to get a bed in a psychiatric hospital.
Murphy called emergency department wait times a “massive problem.”
“Local hospitals, emergency departments and jails have become recycling… for folks who should be treated in mental facilities,” he said.
Winston-Salem Republican Donny Lambeth linked some of the issues in the mental health system with limitations placed on health care providers by the state’s certificate of need laws. Those laws and rules dictate how many and what kinds of facilities health care businesses can create.
“We don’t need certificate of need for psychiatric and mental health services. Let’s mark it up and see if there are others who are interested in coming in,” he said. “We don’t have enough mental health beds, we don’t have enough substance abuse programs, let’s open it up and see if the free market will work in that case.”
Certificate of need reform has been a hot topic for the past few years at the General Assembly, with many lawmakers looking to revise the laws, while hospitals have strenuously resisted most changes.
Lambeth laughed when this reporter suggested that, for hospitals, mention of CON reform is like kryptonite to Superman.
“I guess the good news is I’m a former hospital person,” said Lambeth, who, earlier in his career was the head of Baptist Hospital in Winston-Salem. “I do… talk to hospital providers about it and of course, in a perfect world, they’d rather leave it like it is, but that’s not realistic.”
He did say that hospitals would probably like some of the changes he’d like to see, such as raising the cap for when hospitals need to report expensive equipment purchases, such as MRI machines. Currently, no reporting to the state is necessary if a hospital replaces a big piece of equipment that costs less than $2 million. Once over that limit, hospitals have to file a lot of paperwork.
“I’m in between complete repeal and minor tweaking,” Lambeth said.
Hise also said he’s interested in CON reform, but didn’t elaborate.
Drugs and providers
The steady drumbeat of deaths from opiate overdose was also a cause for concern with most lawmakers. In the past year, more than 1,200 people in North Carolina overdosed on opiates such as heroin and prescription drugs, with heroin claiming more lives as the pills become harder to get.
“Law enforcement is starting to tell me that we are seeing a shift from prescription drugs being replaced by heroin,” Hise said. “Two years ago they would tell you that they saw nothing but prescription drugs… at least in western North Carolina.”
Hise said he’d like to see more integration of the computerized controlled substances reporting system into the state’s health information exchange system. The CSRS tracks how many opiate prescriptions a person might receive, allowing for pharmacists and doctors to see if a patient has been shopping for prescriptions. The health information exchange is the nascent system linking medical records among hospitals.
Murphy, the doctor, said he’s working with the state pharmacy, medical and dental boards to create the ability to e-prescribe narcotics because, currently, paper prescriptions are too easy to forge.
He also said providers need education about the risks of writing prescriptions for too many pills at once. But there’s a balance.
“[Patients] don’t need that many pills,” he said. “On the other side of the coin you have patients who don’t take a narcotic at all, but when they get home, they need one and now because you cannot e-scribe it, they have to physically come to the office.
“I have a lot of patients who are two and sometimes three hours away,” he said.
Lambeth also said he’d like to see more talk of revising licensure rules for nurse practitioners, nurse-midwives and physician assistants.
He pointed to something that Speaker Moore talked about with reporters on Wednesday, a “rural-urban divide” in resources and economic development that’s getting attention from lawmakers.
Lambeth said that allowing advanced practice nurses, such as psychiatric nurse practitioners, more leeway in their practice could relieve some of the health care access shortages in rural areas. And he said he’s been talking to Murphy about widening the scope of practice, something doctors such as Murphy have traditionally resisted.
“Rural North Carolina is a priority and I think we need to figure out what to do, because living without adequate health care is a problem in many of those places,” Lambeth said.