By Greg Barnes, Sarah Ovaska-Few & Rose Hoban
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Environmental health issues will continue to make headlines
At N.C. Health News, environmental health reporting promises to start the New Year where it left off in 2018.
GenX, the environmental story that dominated the headlines last year, will be back in the news by early January, when the state Department of Environmental Quality ends a public comment period and, at some point, decides whether to enter a consent order with the Chemours Fayetteville Works plant.
DEQ, Chemours and the Cape Fear River Watch agreed to a draft of the consent order on Nov. 21. The public comment period has been extended until Jan. 7 amid objections to the plan by some neighbors.
The order would require Chemours to dramatically reduce air emissions of GenX, provide permanent drinking water to people with contaminated wells, and pay a $12 million civil penalty.
Climate Change
Last month, the North Carolina Climate Change Interagency Council met for the first time to begin the task of carrying out Gov. Roy Cooper’s executive order that calls for reducing greenhouse gas emissions 40 percent from 2005 levels by 2025.
The council, made up of Cooper’s cabinet secretaries or their representatives and headed by DEQ Secretary Michael Regan, will draft a North Carolina Clean Energy Plan to encourage the use of renewable energy. Among the council’s targets are to increase the number of zero-emission vehicles from 9,000 to at least 80,000 and to reduce energy consumption in state-owned buildings by 40 percent.
Most scientists concur that climate change is starting to have dramatic effects on the Earth, everything from rising sea levels to forest fires and storms bringing major flooding.
Hog farm lawsuits
Murphy-Brown, the hog-production arm of Smithfield Foods, is expected to be back in court this year, fighting more lawsuits from neighbors of contract farms who say the industrial-scale operations create offensive odors, fumes, clouds of bacteria and toxic waste.
More than 500 people have joined 26 lawsuits that have been filed under the state’s nuisance laws. Last year, neighbors won all four of the lawsuits that were heard in U.S. District Court. Combined, the lawsuits led to about a half-billion dollars in damages, but those numbers were reduced to a fraction of that because of a state law capping the amounts awarded.
In late October, Smithfield announced that it will cover 90 percent of hog waste lagoons on finishing farms in North Carolina, Missouri and Utah and add anaerobic digesters, a move the company expects will create renewable natural energy from methane and reduce its greenhouse gas emissions by 25 percent by 2025. Together, Smithfield and Dominion Energy will spend $250 million on the project, which now includes farms in Virginia.
Lead in schools’ drinking water
Another issue likely to make news in 2019 is the presence of lead in drinking water at public schools in the state. The Charlotte-Mecklenburg and Guilford County school districts recently conducted tests for lead, which was used in the plumbing of older drinking fountains and faucets in schools statewide.
Lead in public water systems’ plumbing was banned when Congress passed the Safe Drinking Water Act Amendments in 1986. But older systems abound in schools throughout North Carolina.
In 2017, Charlotte-Mecklenburg voluntarily tested more than 1,600 water fountains and fixtures at 58 of its 176 schools. It found unsafe lead levels at 27 schools. This year, a test of a drinking fountain at the system’s Garinger High School’s cafeteria found lead at levels almost 44 times higher than what is considered safe.  The U.S. Environmental Protection Agency’s action limit for lead is 15 parts per billion.
Tests this year on water fountains at schools in Guilford County found three with unsafe lead levels. Those fountains and others in the district suspected of having lead in the plumbing are being replaced.
In 2017, state lawmakers introduced a bill in the House that would require public schools and child care centers to test drinking water for the presence of lead.
The bill, which stalled in committee, points to an evaluation of public water system data in the federal Safe Drinking Water Information System database. That data, collected between 2012 and 2015, show 79 water systems in North Carolina were found to test higher than the EPA’s action level for lead. The systems were in 44 of the state’s 100 counties.
- Greg Barnes: Environmental Health
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A new head for UNC Health Care
There’s someone new at the helm of UNC Health Care, one of the state’s largest healthcare providers and one of the nation’s top teaching hospitals. Bill Roper, UNC Health Care’s CEO since 2004, is forgoing his planned retirement to take over as the interim president of the entire UNC system this January.
Sliding into Roper’s place as the CEO of UNC Health Care system is Dr. A. Wesley Burks, a pediatric allergy and immunology researcher known for his groundbreaking work in peanut allergy treatments.
Burks is no stranger to the UNC system, having been the executive dean of UNC’s School of Medicine in Chapel Hill. He arrived in 2011 as physician-in-chief of the N.C. Children’s Hospital on Chapel Hill’s campus and served as the chair for UNC’s pediatric department before becoming the medical school’s dean in 2015.
As CEO of the UNC Health Care system, Burks will be in charge of a massive organization that employs more than 31,500 people and took in nearly $5 billion in revenue, according to 2017 statistics.
Watch to see if Burks follows the path of his predecessor by continuing to expand UNC’s reach across the state. The nonprofit system now counts more than a dozen hospitals under its umbrella.
Medicaid transformation
2019 will be a big year for North Carolina’s health care landscape, with arguably one of the biggest changes to the state in decades taking place with the move to managed care for the state’s $14 billion Medicaid program. At the state legislature’s behest, North Carolina is handing off Medicaid — the federally mandated but state-managed health care system for poor seniors, children, and disabled persons – to managed care companies and networks to run day-to-day operations.
Under managed care, at least four statewide companies or provider-led groups will be paid a yet-to-be determined per-person rate to manage all of a patient’s health care needs. (Currently, the N.C. Department of Health and Human Services uses a fee-for-service model, where the state uses a mix of federal and state dollars to cut a check for every flu shot, operation and doctor appointment.)
[sponsor]As it’s been in other states, the switch is more than certain to be bumpy, given the sheer logistics needed to move a massive system serving 2.1 million people, one in every five North Carolinians, to a whole new way of accessing care.
Most of Medicaid’s patients – 1.6 million of them– will switch to the new system by November while a half-million Medicaid patients who have significant medical or behavioral health issues will move to specialized, tailored plans in 2020.
Pay attention in February, when DHSS will announce which managed care companies or provider groups will get contracts with the state. (Click here to find out who is in the running.) And then this spring and summer, providers of all sizes, from single practitioner offices to large hospital systems, will be negotiating rates of their own with the managed care companies. Meanwhile, patients will start hearing about the transition in detail this summer and will be faced with choices of which provider group to sign up with.
Other things still in the unknown pile: How much the state will pay these new contractors for each patient’s care and how exactly it plans on ensuring the managed care companies are doing their jobs and not providing substandard care.
North Carolina is also being watched by a national audience to see how an ambitious pilot plan will use Medicaid dollars to address  social determinants of health – the housing, transportation, employment and family violence issues – that can undermine a person’s well-being.
Medicaid expansion, finally?
Whether or not North Carolina will join other states in expanding its Medicaid program to low-income adults remains one of the biggest policy debates in the state.
The question is largely a political one, with the Republican-led state legislature thus far committed to its opposition of what was a key piece of then-President Barack Obama’s Affordable Care Act. But pressure to expand Medicaid is mounting from medical providers and hospital administrators, who struggle with the costs of treating an estimated 339,000 uninsured adults in the state.
A group of House Republicans is also hopeful 2019 could be more favorable to their compromise expansion proposal, a program called Carolina Cares that would include work requirements and financial buy-in from most users.
Gov. Roy Cooper, a Democrat, has made clear his desire to see Medicaid expanded. He could also use it as a bargaining tool in state budget debates now that Democrats have enough seats in the state legislature to break a long-standing Republican supermajority.
Nationally, several typically conservative states are warming up to the idea of Medicaid expansion, with midterm elections decisions by voters in Utah, Nebraska and Idaho to extend Medicaid coverage to their low-income residents.
Will North Carolina follow? 2019 will be the year we find out.
- Sarah Ovaska-Few: Medicaid, Generations Beat (children)
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Health policy at the legislature
It’s been close to a decade since Republicans at the General Assembly have had to seriously consider input from their Democratic colleagues because the Republicans have had enough votes in both chambers to override gubernatorial vetoes.
But voters sent more Democrats to Raleigh in November, meaning there will no longer be a veto-proof majority in either chamber. This could lead to one of two outcomes: more compromise, where Democrats find themselves participating more in policymaking, or legislative gridlock, where Republican leadership prevents anything that has had Democratic input from going to the floor.
Either strategy bears risk for Republican leaders and there’s no indication yet as to how they’ll proceed. But health policy questions will loom large in 2019 either way.
As noted above, Medicaid expansion will be one of the first big topics to come up during the coming legislative session.
In the past, leadership has been reluctant to bring legislation to the floor unless the bill passes the so-called “Hastert Rule,” namely, that a majority of the majority will vote yes. Several Republican House leaders in the health care space have expressed confidence they can get the votes this year, and there’s little doubt Democrats will enthusiastically support any effort.
The Senate side, however, has always been the chamber that’s been more reluctant to alter Medicaid, and there’s a good chance that in order to sign onto passage of Carolina Cares, Senate health care leadership will ask for a big priority in return.
It’s no secret that Sen. Ralph Hise has long wanted to significantly alter the state’s certificate of need laws, the set of statutes determining how much hospitals and other health care providers can build in a given area. Hise, who represents a rural constituency, has expressed concern about the viability of his local hospitals and has said he believes that changing certificate of need laws will increase competition.
But hospitals will fight changing certificate of need, and they’re a powerful constituency.
Hospitals will also likely resist another one of Hise’s priorities, namely making changes to the scope of practice for providers such as nurse practitioners, nurse-midwives and physician assistants in order to allow them to practice more independently. Hise has said publicly in the past that he believes loosening scope of practice for these providers will allow for better access in rural areas, and the research bears him out in that belief.
In the past, most physicians’ organizations have opposed this move, but advocates privately express optimism around this issue in the coming legislative session.
- Rose Hoban (Legislative reporter, Editor)
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