NC health trends and policies to watch for in 2020

By North Carolina Health News staff

Our reporters explored some of the biggest topics in North Carolina’s health arena from Medicaid managed care to mental health in prisons, to the state’s opioid crisis. Here is a sampling of the topics they’ll be monitoring in the coming year:

Medicaid battles continue with a January mini session

2019 ended with a grumbled-about delay in transitioning the state to a managed care system for the bulk of the Medicaid program that provides health care for more than 2 million low-income children and their families, seniors and persons with disabilities.

The indefinite postponement from the February start date was a result of the ongoing impasse between the governor and legislative leaders over the state budget and the prospect of expanding Medicaid coverage to poor, childless adults – a policy measure that’s a key piece of the Affordable Care Act.

That means 2020 will bring a lot of changes on both fronts – including however Gov. Roy Cooper and state Republican leaders settle their differences over the state budget and Medicaid expansion, and how and when the transition to managed care will start up again.

These issues may get settled when the legislature returns to Raleigh for another “mini-session” in mid-January, or the impasse could continue. Given the unprecedented standoff between the Republicans and Democrats in the legislature and the governor, multiple legislative watchers say they have no idea what changes this short gathering could bring.

If legislators are able to come to an agreement with the Department of Health and Human Services and the governor over funding for the Medicaid transformation, 2020 should produce a new go-live date for the switch. Also, look for ongoing updates about how state health officials are hoping to streamline the switch to managed care. After the new year, it should be possible to calculate how much the delay will have cost providers, managed care companies and the public in money, time and energy.

Once the new system goes live, an estimated 1.6 million people will be turning to a brand-new way of getting health care – where they need to sign up with a particular managed care company and then use providers in those networks.

Whatever happens, no one expects things to go off without a hitch. Over here at N.C. Health News, we’ll have our eyes peeled on how the transition goes in 2020.

-Sarah Ovaska, Medicaid, children’s health

New efforts ahead for legislation to help NC’s vulnerable adults

As January’s short session of the General Assembly approaches, it’s time to try again for legislators pushing a series of bills to help older North Carolinians and those with disabilities.

The 2019 General Assembly proved frustrating for advocates and legislators who succeeded in placing priorities in either the House or Senate budgets, or both, only to see them languish as an overall document never passed. Renewed efforts to pass legislation could arise, although high-profile issues such as Medicaid and teacher pay are likely to dominate the session.

“The short session is for budget adjustment,” Rep. Cynthia Ball (D-Raleigh) said during a Christmas week phone interview. “I certainly intend to try to push any of the bills that I worked on.”

Along with Rep. William Brisson (R-Dublin) and Rep. Jean Farmer-Butterfield (D-Wilson), Ball sponsored House Bill 753, which would have increased the allowance provided to low-income residents of North Carolina assisted living centers whose tab is paid by Medicaid. Their stipend of $46 a month has to cover personal-care items, transportation, prescription and over-the-counter medications, clothes, snacks, cigarettes, and myriad other expenses.

House sponsors proposed that the amount be raised to $70 monthly. Senate Republicans produced a budget that would have hiked the amount first to $58 a month, then to $70 in 2019-2021.

Advocates said they plan to push for an increase in the personal needs allowance for residents of nursing homes as well as those in assisted living.

Additional House proposals would:

Provide about $1.8 million during a two-year period to hire more employees for county governments’ Adult Protective Services departments. Money from the federal government’s Social Services Block Grant would have aided counties’ state-mandated responsibility to protect adults from abuse and neglect. The Senate proposed spending $457,041 in each of two budget years for increasing APS workers.
Pay $2.9 million during the biennium for electronic systems to verify in-home personal-care visits by workers paid by Medicaid. The Senate proposed the same amount.
Provide $800,000 over two years for nutrition for people eligible for both Medicare and Medicaid. This was also proposed by the Senate.

It remains to be seen whether any of these proposals make it into any budget documents and onto Gov. Roy Cooper’s desk once the legislature returns for a mini-session in mid-January.

-Tommy Goldsmith, generations reporter

Communities contend with pollution in and out of court

Like other states, North Carolina continues to be plagued by “forever chemicals,” coal ash, hog waste and many other sources of environmental contamination.

Expect NC Health News to provide more in-depth coverage on these and other environmental health issues in the year ahead.

On Jan. 28, a federal appeals court will begin hearing arguments in three cases involving Smithfield Foods, the giant pork producer in Bladen County. Since 2018, Smithfield has lost five cases filed by nearly 500 neighbors of hog farms who say odors, pests and other nuisances have destroyed their way of life.

If Smithfield loses in the Fourth U.S. Circuit Court of Appeals, it could open the door for hundreds more lawsuits.

Near Smithfield lies the Chemours Fayetteville Works plant. Chemours has been found liable for contaminating drinking water with per- and polyfluorinated compounds — or PFAS — for an estimated 250,000 people.

Chemours is under a consent order to clean up the contamination, which includes private wells polluted by airborne contaminants.

Under the consent order, Chemours was required to begin operating a $100 million thermal oxidizer which started operating at the end of 2019. The oxidizer is expected to reduce 99 percent of PFAS leaving the plant from 2017 levels.

But hundreds of people still dealing with well contamination want public water lines to their homes. Look for their voices to grow louder in the year ahead.

Meanwhile, in the Wilmington area, the Cape Fear Public Utilities Authority has started construction on a $46 million granular activated carbon filtration system that is expected to remove 90 percent of PFAS from the region’s drinking water. The system is set to go online in 2022.

A new filtration system is also being considered for Pittsboro, the only municipality to draw its drinking water from the Haw River. Pittsboro has been plagued for years with high levels of PFAS and another industrial contaminant, a probable carcinogen called 1,4 dioxane.

In July, the state Department of Environmental Quality began requiring 25 municipalities to begin monthly sampling for PFAS and 1,4 dioxane at their sewer treatment plants. The hope is to identify which industries are contaminating the watershed and make them stop.

In April, the DEQ ordered Duke Energy to excavate all remaining coal ash impoundments in North Carolina. Duke Energy appealed the ruling, and in August a judge sided with the DEQ.

The ruling doesn’t fully settle the matter, however. Look for NC Health News to bring you the latest developments on that issue, along with PFAS, hog waste and other environmental health stories in 2020.

-Greg Barnes, environmental health reporter

A wider conversation on drug use

Like in other parts of the country, North Carolina has seen a surge in the use of drugs other than opioids in recent years. Though opioid deaths still make the bulk of fatal overdoses in the state, death from meth and other psychostimulants have increased from nine in 2009 to 267 in 2018. Cocaine overdoses in the state have likewise surged during that time, from 160 in 2009 to 723 fatal overdoses in 2018.

Up till now, the NC Department of Health and Human Services focused most of its surveillance on opioids, releasing monthly updates on deaths and hospitalizations. But an NCDHHS spokeswoman said in December that the department will begin releasing more frequent updates for psychostimulants and cocaine-related statistics. These updates will likely widen the conversation over drug use in the state. Updated statistics will help social service agencies and local municipalities solicit grant money for programs that focus on meth and cocaine use.

And as federal legislators work to allow states to use money earmarked for opioid misuse to address the rise of meth across the country, agencies may find that there’s more money to request.

-Liora Engel-Smith, rural health reporter

NC hygienists could play a larger role in health care access

It’s a pretty sure bet that in 2020, North Carolina will make progress toward offering people in underserved counties and regions more accessibility to oral health care.

A proposed change to the scope of practice rules that have long kept a tight lid on the tasks and procedures that dental hygienists are permitted to do without a dentist on-site could uncap the restrictions ever so slightly.

Hygienists in North Carolina have pressed for years to be able to clean teeth, check gum health, apply sealants and take x-rays without a dentist in close proximity.

The proposed rule change endorsed in 2019 by the N.C. Board of Dental Examiners would get some hygienists closer to that in a state with rules among the most limiting in the country.

Federal Trade Commission staff members weighed in favorably in a November letter to Bobby D. White, the state dental board’s chief executive officer, saying it could increase competition and open an avenue toward more oral health care coverage.

FTC staffers also suggested a tweak that would do away with an opt-out provision for dentists and open a path toward even more competition.

As written and endorsed by the board, the proposed changes would allow public health hygienists, or private practice ones deemed public health through fledgling public-private partnerships, to do screenings and cleanings in some public schools and elder-care and special-needs facilities even if a supervising dentist had not done an in-person, comprehensive exam of the patient.

Dentists taking part in the program also could supervise more than two hygienists, the limit under current law, and they could issue standing orders that give those public health hygienists a broader practice scope.

What troubled FTC commission staffers was a provision giving dentists the option to forgo the standing order and require a prior exam.

“We respectfully suggest that the Board consider whether giving dentists the choice of providing a written standing order or requiring a comprehensive oral examination is the best way to achieve the Board’s goals of improving access to care in underserved areas, or whether a less restrictive alternative might be equally effective,” Bilal Sayyed, FTC office of policy planning director, Bruce H. Kobayashi, FTC bureau of economics director, and Ian Conner, FTC bureau of competition deputy director, stated in the Nov. 15 letter to White.

To go into effect, the proposal still needs approval from a legislative review committee, but that could happen early in the year, advocates say.

-Anne Blythe, oral health reporter

NC prisons continue to weigh measures for officer safety and inmate mental health

The North Carolina prison system came under scrutiny and subsequent criticism in 2019 when an increased number of inmates with mental illness were placed in solitary confinement. The prison system moved backward in the treatment of inmates with mental illness after five corrections officers were killed on the job in 2017.

As security became a top priority, more inmates were held in long-term isolation for acting out. Prison officials stopped meeting regularly with mental health advocates who have warned that solitary confinement makes prisons less safe and causes symptoms of mental illness to worsen. The head of prison psychiatric care acknowledged the backward trend and said he anticipates that it will reverse.

State legislators held a special committee on prison safety and made several recommendations, including a call to reduce the use of solitary confinement. Lawmakers also recommended new hiring and salary incentives for prison workers to help fill staffing gaps. This coming year, we anticipate prison officials and lawmakers could work together to implement new safety changes in the form of additional funding for training or hiring incentives for prison employees. We’ll be following this closely.

Meanwhile, there’s been a positive shift toward more substance abuse treatment in county jails across the state. For a long time, few sheriffs and county commissioners were willing to take on responsibility for medication-assisted treatment (MAT) programs in jails for people with opioid addiction. But as opioid deaths rose to a level of national concern in recent years, these officials are increasingly willing to embrace alternatives.

Counties such as Durham, Rutherford and Buncombe recently implemented MAT programs in their jails and are paving the way for others. There are still many questions to work out as the treatment becomes more widespread, such as whether and where someone should enter treatment if they are charged in multiple counties, one with MAT services and the other without.

We will explore how these fledgling programs are working in 2020.

-Taylor Knopf, mental health reporter

Charlotte takes center stage with the 2020 RNC and more

The Republican National Convention, coming to Charlotte in August, may involve health care policy discussions and we’ll be there to cover them. We’ll talk to Mecklenburg County Public Health about the lessons they learned from the 2012 Democratic National Convention to prepare for such a large event.

We’ll also keep tabs on the Atrium and Wake Forest Baptist consolidation and continue covering nonprofits trying to help improve access to health care in the city.

In personal news, our Charlotte reporter, Yen Duong, will take a few months off for maternity leave, with her third child due at the beginning of March. We’re so excited for the continued growth of our NC Health News family!

–Yen Duong, Charlotte reporter

Hospital shifts in the year ahead

In 2019, some communities across the state lost necessary, but costly, services such as maternity care and mental health, and that trend is likely to continue to 2020.

It’s no secret that some rural hospitals across the state are struggling to stay afloat. A recent analysis by UNC Chapel Hill researchers found that four rural hospitals in the state were at high risk of financial distress, with an additional nine at a “mid-high” risk. And though financial distress is not necessarily an indication that a hospital will shutter, it isn’t a good sign either.

At least one hospital, Washington Regional Medical Center, will be starting 2020 in financial distress. In December, employees receive their paychecks late. In bankruptcy court later that month, a judge granted the hospital an extension on raising the necessary funds to pay its employees.

About three hours south of the Plymouth hospital, another facility will be exploring options for its future in 2020. New Hanover Regional Medical Center and its owner, New Hanover County, appointed an advisory group to study ideas such as outright sale, affiliation and other arrangements. The advisory group will create a request for proposals document and begin vetting the offers this year.