By Rose Hoban & Taylor Knopf
In today’s political climate, it can be a dangerous thing to try to predict the future. But each NC Health News reporter looked at what trends and stories they’ll likely be following in 2018. Today, we take a look at federal and state policies that could change the health care landscape.
How will health care in NC be affected by Congress’ actions?
Just before decamping for home from Washington, D.C., Congress left a big bill under President Donald Trump’s Christmas tree in the form of a massive tax cut.
But the jury’s still out as to whether Congress was naughty or nice to North Carolinians.
Lawmakers eliminated the medical expense deduction in the House version of the bill, which would have dinged people with large medical bills. In the final bill, however, Congress retained the medical expense deduction and actually lowered the threshold at which people could start to take the deduction from 10 percent of adjusted gross income to 7.5 percent for the 2017 and 2018 tax years. In 2019, the deduction readjusts so that people will only be able to deduct expenses exceeding 10 percent of their income.
However, the final bill repealed the individual mandate to purchase health insurance which was included in the Affordable Care Act. This comes even as enrollment for insurance purchased on the online health marketplace remained strong, with almost 519,000 North Carolinians signing up for coverage.
But with removal of the mandate, along with moves by the Trump administration to weaken the law, it is uncertain what will happen to the rate of uninsured North Carolinians, which is at a low of 10.4 percent. Before passage of the ACA, the rate of uninsurance in North Carolina had reached almost 20 percent in 2009.
This past year, Blue Cross and Blue Shield of North Carolina announced that its premium increases for 2018 would have been lower if President Trump had kept cost sharing reduction payments to insurers which had helped offset the costs of copays and deductibles for low income customers.
Medicaid “transformation” in NC picks up speed
In late 2015, after years of wrangling, lawmakers in the North Carolina General Assembly voted to transform the state’s Medicaid program. Lawmakers chose to convert Medicaid from a traditional fee-for-service program to one run by large managed care companies that get paid a per-patient monthly fee in exchange for supplying all of a patient’s care.
At the time, legislators set an aggressive timeline for the state to submit an application to the federal Centers for Medicare and Medicaid Services for a waiver to the way North Carolina currently pays for Medicaid. Since the federal government pays for two-thirds of the program, regulators in Washington have significant input into how the program plays out in individual states.
North Carolina officials submitted an initial waiver application to CMS in June 2016. Since then, the application has undergone some tweaking from the new administration of Gov. Roy Cooper and his DHHS Sec. Mandy Cohen, who helped run CMS during the Obama administration.
State Medicaid head Dave Richard said the finalized application should go to federal regulators in February, in order to “go live” with the managed care program in mid-2019.
“We intend to issue a request for proposal for the health plans, those people who will bid on three statewide plans and on the regional provider-led entities in the spring of this year, with the goal of being able to award those bids in the fall,” Richard said.
He admitted this represented an “aggressive” timeline, and also said DHHS was “comfortable” with it, but Richard left some wiggle room.
“We’ll always say that if there’s something that happens in this process that changes the direction of the things as we’re going through them we would want to make sure [Medicaid managed care] goes live successfully,” he said.
Not included in the application: Expanding Medicaid to cover some half-million uninsured North Carolinians, mostly low-income workers, who could be eligible for the program under guidelines set up by the Affordable Care Act.
Some Republican lawmakers in the state House of Representatives have expressed willingness to expand the program, and Rep. David Lewis, the second most powerful member of the House, will convene a committee on access to healthcare in rural North Carolina. An agenda has not been set for the first meeting of the committee on Jan. 8.
More changes in store for mental health system
In the wake of revelations about extravagant salaries, perquisites and severance plans for executives at Cardinal Innovations, one of the North Carolina’s state funded mental health management companies, calls for changes to North Carolina’s mental health system are starting to mount.
Initially included in plans to transform Medicaid to managed care were plans to keep in place North Carolina’s system of mental health agencies which are state-funded but run like managed care companies. But lawmakers and Cooper administration officials have expressed increasing openness to allowing responsibilities handled by the state’s mental health agencies (known as LME-MCOs) to be assumed by the commercial managed care companies expected to bid on Medicaid as a whole.
This would allow for better “integration” of physical health with mental health care, said Dave Richard, the state’s Medicaid head.
“For those individuals who have mild mental health and substance use needs, we’re proposing that those individuals would receive services through what we’re calling “standard plans,” which are what everybody has been talking about, that go live in 2019,” Richard said.
For people with more severe, chronic and life-long mental health, intellectual or developmental disabilities, Richard said the thinking is to create “tailored“ plans to care for those people.
“We believe this builds on the work the LME-MCOs have done, but integrates care by sort of having a partnership between commercial health plans and the LME-MCOs,” he said.
“We think there’s movement toward the General Assembly agreeing to that, but there’s a lot more work that needs to be done in terms of exactly how that works.”
For their part, the LME-MCOs seem to be responding to the handwriting on the wall. As of Jan. 1, the North Carolina Council of Community Programs, which until now has been the umbrella organization for the LME-MCOs, is changing its name, its mission statement and its board of directors position itself to represent all the new players who will be involved in mental health services once Medicaid transforms.
“It’s a recognition that things have been changing with the LME-MCOs,” said Mary Hooper, head of the council. “In fact, it’s a recognition of the larger environmental changes that have been occurring now for five, six, seven years.”
Telemedicine could expand rural access to care
About 40 percent of North Carolinians live in one of the state’s 80 rural counties, many of which lack ready access to health care. With rural hospitals and medical centers struggling, telemedicine can help digitally connect patients with health providers elsewhere.
The use of telemedicine is growing across the United States, especially as a way to improve rural access to health care. And with more insurance companies, including Medicaid in many states, reimbursing for telemedicine visits, it’s gaining traction.
However, many gaps remain in North Carolina state policy about virtual medical visits.
Legislators at the General Assembly passed a bill earlier this year that directs the state Department of Health and Human Services to study and recommend a telemedicine policy for North Carolina. Every state has different definitions, standards, limitations, safeguards and payment methods for telemedicine, which DHHS should consider in making its recommendations.
And though digital communication can happen anywhere, a provider in North Carolina currently cannot see a patient via telemedicine who is located in Virginia. Doctors can only practice in the state they are licensed, but this is one area that could see some change.
Some advocates think telemedicine will greatly improve access to specialists in particular. However, many of those specialty providers living in more urban settings are already at capacity.
In addition to policy, North Carolina’s connectivity and broadband must be strengthened in rural areas to adequately provide digital care to those patients. There are still many parts of North Carolina where it’s difficult or impossible to find a cell phone signal, much less broadband.
Will policy changes affect the opioid epidemic?
Opioid abuse and addiction will continue to be a hot topic going into 2018.
On average, four North Carolinians die every day due to opioid overdoses. Life expectancy in the United States declined for the second year in a row during 2016, according to the Centers for Disease Control and Prevention. This is the first time mortality has dropped for two years in a row since the early 1960s. Much of that decline was driven by fatal opioid overdoses.
President Trump has declared a state of emergency due to the opioid epidemic. This means some federal resources are being freed up for addiction prevention and treatment.
And attorneys general across the U.S., including North Carolina’s, are investigating opioid drug manufacturers, claiming they may have broken the law while marketing prescription pain pills over the last decade. N.C. Attorney General Josh Stein’s office is also fighting the increasing spread of synthetic opioids coming from overseas.
North Carolina leaders have come up with a multi-pronged plan to attack the problem that includes more addiction recovery services and eliminating the over-prescribing of opioids.
In 2018, we will see if efforts so far will have an impact, or if the death toll will continue to rise.
I am “new” to this site. In your coverage of future trends in health care in NC, do you consider the growing support in NC for “Medicare for All.” There are now three  organizations in NC that advocate for this type of health care. These are linked to a national organization: Physicians for A National Health Care Program [PNHP], and be found on the pnhp.org website.
I would consider a future “trend,” worthy of your consideration.
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