By Anne Blythe, Clarissa Donnelly-DeRoven, Thomas Goldsmith, Rose Hoban, Taylor Knopf and Elizabeth Thompson

As 2021 comes to a close, we took time to look back on the stories and topics that resonated with North Carolina Health News readers over the past 12 months.

It’s not surprising that during our second year in the not-so-novel coronavirus pandemic many of you turned to us for coverage about COVID-19.

But health care is more than the pandemic and we doubled down this year on coverage of issues that you found important, as evidenced by heavy readership of our top ten topics. 

Enjoy the trip back in time, as the North Carolina Health News team looks ahead to 2022 with hopes that you will return to the site to find in-depth reporting on the health care topics, problems and policies of importance in your world and ours.

COVID coverage – vaccines, surges and new variants

This past year has provided peaks and valleys in the fight against COVID-19.

At the start of the year, the Pfizer, Moderna and Johnson & Johnson vaccines offered hope that an end to the pandemic could come in 2021.

Vaccine providers saw long lines in January, February, March and even early April as adults anxious to protect themselves and others from the virus jockeyed to get a shot at the limited supplies.

Even as vaccines provided promises of protection, the 2020 winter holidays and family gatherings created a surge in cases that put North Carolina in such a danger zone in January that many hospitals were canceling elective surgeries so staff and resources could be shifted to provide for COVID patients.

As the surge dissipated and vaccine supplies increased and became more readily available, demand for shots waned. North Carolina saw large pockets of the population either refusing to or reluctant to get vaccinated against COVID-19, frustrating public health leaders and others hoping to put the pandemic in the rearview mirror. 

In the spring, Gov. Roy Cooper started easing restrictions on businesses such as aquariums, barbershops, retail businesses and more. Bars, restaurants, sports and entertainment venues were allowed to open at 50 percent capacity with masks and social distancing restrictions.

By May, the governor did away with most mask requirements, crowd restrictions and social distancing measures while also encouraging unvaccinated North Carolinians to get a shot.

With federal aid, Cooper tried to build interest in vaccines through a lottery program with million-dollar prizes and college money. While North Carolina saw an uptick in vaccine takers, many still resisted. Differences have persisted with a wide variation in county vaccination rates, from only 38 percent of people in Gates County to the state’s highest rate, 74 percent, in Orange County.

By summer, the fierce Delta variant moved swiftly through the unvaccinated population, creating a surge of cases in the late summer that caused health care systems and their weary workers to groan as extremely ill patients filled intensive care units and COVID ward beds in record numbers. David Wohl, an infectious disease specialist at UNC Health, joined North Carolina Health News for a Health Care Half Hour in mid-August and did a question and answer session with founder and editor Rose Hoban to better explain the Delta variant.

This month, the governor and public health officials began sounding the alarm about the Omicron variant and the possibility of as many as 10,000 new COVID cases per day. 

— Anne Blythe

2. Medical marijuana legalization gets closer

Some advocates and lawmakers were hoping that 2021 would be the year for some sort of marijuana legalization in North Carolina.

While one bill that would have made medical marijuana legal for one set of diseases, the NC Compassionate Care Act, got the backing of some powerful state Republicans, North Carolina Health News reported. However, it did not pass by the end of the legislative year in December.

That doesn’t mean you can’t get your hands on the psychoactive tetrahydrocannabinol (THC) in North Carolina. The Eastern Band of Cherokee Indians approved growing, selling and using medical marijuana on tribal lands in early August.

Even before then, Delta 8-THC had been available to people 21 and older throughout the state, North Carolina Health News reported. Delta 8-THC has a similar chemical structure to Delta 9-THC, except it is derived from hemp plants, not marijuana. 

Delta 8-THC falls into a legal gray area. Congress passed the 2018 Farm Bill that legalized hemp sale in every state and declassified cannabis from the Controlled Substances Act. It allowed companies to sell products derived from CBD that contain less than 0.3 percent THC. 

A legal fight in Texas has challenged whether the psychoactive substance is actually legal in the state; the Texas health department insists Delta 8-THC is a controlled substance.

In the meantime, marijuana will soon be available in Virginia, North Carolina’s northern neighbor.

– Elizabeth Thompson

3. Demise of Cardinal Innovations

Over the years, NC Health News has spilled plenty of pixels on Cardinal Innovations, the mental health provider organization (called LME/MCOs) based in the southern Piedmont and managing the mental health care for hundreds of thousands across the state.

But Cardinal’s history of financial missteps, controversy, poor oversight of the care of foster children and increasing frustration with denial of services from county commissioners led to those commissioners voting to switch managed care organizations for their constituents’ mental health needs. 

A story written by former Triangle Business Journal reporter Seth Gulledge (who is now attending law school) detailing the slow demise of Cardinal garnered heavy readership. 

The irony of Cardinal’s crash is that it was announced in June, weeks before the state’s Medicaid system transitioned to a similar model of care, where patient care is paid for using a set monthly payment, rather than paying for each patient encounter, test and hospital admission as they happened. As of Dec. 31, Cardinal will cease to exist and the care management for all the organization’s service recipients will transfer to other LME/MCOs. 

“If it was a question of greed, then yes, I think we have solved that,” Duke psychiatry professor Marvin Swartz said. “But if it’s a more systematic, operations problem, I don’t know if we have solved that. I don’t know if we have adequate oversight of network adequacy, or that the quality measures that were put in place are going to be adequate.”

In case you missed the story, which ran in July, you can read it here: The demise of Cardinal Innovations: How a state-mandated mental health organization failed in slow motion.

– Rose Hoban

4. Opioid overdose crisis deepens amid the pandemic

The United States saw a record-breaking number of drug overdose deaths in 2021 as fentanyl — an opioid that’s much stronger than heroin or morphine — became even more prolific in the street drug supply. Nationally, the Centers for Disease Control and Prevention found that fentanyl and similar synthetic opioids were involved in 64 percent of the more than 100,000 overdose deaths from May 2020 to April 2021. The rate of death from overdose went up by 27 percent nationwide.

North Carolina had a similar uptick in the number of opioid deaths, with 37 percent more overdose deaths between May 2020 and April 2021 than the year before.

NC Health News documented this tragic trend with a couple of dozen stories this year, including how the opioid crisis has worsened in North Carolina, to the racial disparities among those who get treatment, and how the overdose crisis has played out in carceral settings. State lawmakers allocated funds across the state to address addiction issues in the community and in jails. 

Thank you for writing about this absolutely critical issue that has a direct impact on the lives of not only our direct care workers, but our most vulnerable citizens in the state who benefit from their care and service.

a state regulator

One story that caught readers by surprise was about state lawmakers giving one of the largest state grants for substance use treatment to a new church ministry in Robeson County. There’s no evidence on the church’s website to suggest it has experience in treating addiction disorders. Meanwhile, substance use experts argued that, at a time where a record-breaking number of people are dying of drug overdoses, state money should be directed to clinics and organizations with a track record of providing evidence-based addiction treatment, including medication-assisted treatment (MAT) for opioid use disorder. 

Our readers also remained interested in our 2019 series about innovative solutions in Europe for treating opioid use disorders and reducing drug overdose deaths, with the stories remaining in the ranks of most-read stories of 2021. The series explored solutions such as no-barrier access to an array of medication-assisted treatments, including oral morphine and heroin. 

Europeans have also documented the success of supervised injection sites, an idea that’s grown in popularity in recent years. In fact, New York City opened the nation’s first supervised drug injection sites last month, a place where people can safely use drugs with new, sterile supplies and be monitored by health professionals who can reverse a possible drug overdose. European countries found that these sites save lives, reduce drug-related infections and decrease drug supply litter (such as used syringes) in the streets.

– Taylor Knopf

5. Water quality issues created increased concern 

While North Carolina spent much of 2021 fighting the new coronavirus that showed its adaptability and formidability, residents in eastern North Carolina who live along and near the Cape Fear River Basin continued a years-long battle against the formidable PFAS, or per- and polyfluoroalkyl substances, polluting their water.

The Wilmington Star-News reported in 2017 that the DuPont spinoff company, Chemours, had been releasing  a chemical called GenX into the Cape Fear River from its Fayetteville Works plant for years.

That same year, the state Department of Environmental Quality took legal action against the manufacturing company that led to a long timeline of action and inaction. That activity came to a head this fall when the state DEQ negotiated a consent order between Cape Fear River Watch and their agency this October.

In the same month, the U.S. Environmental Protection Agency revealed its nationwide PFAS Strategic Roadmap to address contamination in North Carolina and elsewhere over the next three years.

Michael Regan, the former NC DEQ secretary tapped by President Joe Biden to lead EPA, is familiar with the complaints and steps taken in North Carolina.

Greg Gisler, senior attorney and head of the Southern Environmental Law Center Clean Water Program, described the consent order as one that would stop nearly 99 percent of the PFAS pollution that contaminated water supplies for as many as 300,000 people.

… called to say that the sister of a patient struggling with mental health issues contacted him after finding our Health Care Half Hour video and IVC stories. He was able to help and give her resources. The patient reached out recently via a letter and said the help he was able to give them “saved her life.” He said he never would have connected with them if it wasn’t for our stories and HCHH. He said he wanted us to know that these stories are quite possibly life saving.

Bob Ward, Mecklenburg County public defender in a conversation with one of our reporters

“EPA’s Roadmap pairs a plan for the future with the tools it currently has to stop ongoing contamination as the agency develops new standards,” Gisler said in a statement. “This roadmap, when fully implemented, could change the landscape in our efforts to protect communities from PFAS pollution.

“While the roads to standards identified by EPA are necessarily long; the route to stopping ongoing pollution of our streams and rivers can and should be short.”

While the parties were on the path to such an agreement, North Carolina Health News reported on wells in the Bayfield neighborhood on the outskirts of Fayetteville nearly 18 miles from the Chemours plant contaminated with PFAS. 

Our readers showed great interest in an N.C. State University research study released this summer revealing the presence of  PFAS in the blood of 31 dogs tested in the Cumberland County Gray’s Creek rural community near the Chemours plant.

In another long-running water contamination event, former members of the military and their family members petitioned federal officials to create a medical registry that scientists would use to help uncover additional diseases that can be tied to the contaminated water and qualify more people for compensation.

In addition to chemicals polluting waterways, state environmental workers and members of the N.C. Wildlife Resources Commission sounded an alarm in April about invasive zebra mussels found in moss balls sold in North Carolina pet stories.

The tiny mollusks, not much bigger than a fingernail, can wreak havoc in lakes and other waterways. They attach themselves to water intake infrastructure and filter out algae that native species need to survive.

Michigan and other states have spent billions of dollars to clean up the problems caused by the invasive species. 

– Anne Blythe

6. Strides seen for NC’s older population in state budget

At Iredell Adult Day Services members range from age 101 to age 10, the latter a person with autism. It’s the only adult day care center in Statesville.

“It was born out of a ministry to help those living alone, unable to afford in-home care, and to keep them home longer before moving to a nursing facility,” The Rev. Thomas Corbell, board president, told the Statesville News & Record.

The financial calculus for such adult day centers changed in 2021 when the General Assembly lifted a cap on the fees they could charge and voted to let local officials set the rate. 

That action was one of several that raised the profile and viability of North Carolina’s agencies helping older people — whether tax-supported divisions, nonprofit entities or privately owned businesses. Legislative action should lift both the number of people affected and the quality of services, said Heather Burkhardt, executive director of the North Carolina Coalition on Aging.  

“Many of these have a direct impact on individuals’ quality of life while improving access to services,” Burkhardt said via email.

I really appreciate your reporting, and your whole group’s reporting, all very unbiased and fair.

Fallin McCoy, quoted in March, 2021 in her response to our story

In addition to the change in reimbursement to adult-day services, state legislators voted to increase the long-stagnant personal needs allowance supplied to residents of the state’s adult care homes or assisted living centers. The basic amount to meet needs such as toiletries, transportation and entertainment for residents rose from $46 to $70 monthly. 

County commissioners will have a bigger pie of block grant money to divide when they consider worthy recipients such as local Meals on Wheels programs, senior centers and home-based services. And employers seeking direct care workers will have bonuses and wage increases to lure and retain people who had learned they could earn as much in fast-food jobs.

Legislators also inserted a budget provision that mandates an annual report on the treatment of veterans in the state nursing homes devoted to their care, as well as other reexaminations of veterans services. NC Health News has given extensive coverage to the privately managed nursing homes since more than three dozen veterans died there during the pandemic. 

– Thomas Goldsmith

7. Medicaid transformation finally goes live

On July 1, N.C.’s Medicaid program flipped the switch, starting the transition from a system run by the state to one managed by five different managed care organizations, or MCOs. AmeriHealth, Carolina Complete, Healthy Blue, UnitedHealthcare, and WellCare are now administering the program, rather than the state Department of Health and Human Services. Before the switch, which was years in the making, North Carolina was the largest state in the country without a significant presence of managed care companies within its Medicaid system. 

Carolina Complete Health, a partnership between the N.C. Medical Society, the N.C. Community Health Center Association, health insurance giant Centene and other N.C. providers, announced a massive investment in Charlotte back in 2020. Centene planned to build an east coast regional headquarters, estimated to bring in 6,000 jobs with average salaries coming in around $100,000.

Over the last year, the company has added 1,200 North Carolina residents to its list of employees, a spokesperson wrote in an email. Centene broke ground on the site in August 2020 and anticipates it will be done with the entire project by 2024, at which point it still plans to employ up to 6,000 employees. The company did not respond to questions inquiring if the average salary is still expected to be $100,000 and whether in the wake of the pandemic, all of those employees would still be reporting to work at an office.

The Medicaid transformation plan dates back to 2015 when the Republican-led state legislature ordered the state to scrap its traditional fee-for-service system and switch to one where the managed care organizations receive a per-person fee. The goal, they said, was to save the state money and incentivize the MCOs to improve a patient’s health. The transition was delayed from its original 2019 implementation date by a tug-of-war over the state budget between Gov. Roy Cooper and the state legislature. Later, the COVID-19 pandemic further delayed the switch.

The transition hasn’t been without bumps. Three months in, we spoke with Medicaid providers who said the added administrative burdens of the new system were limiting their ability to spend time with patients. They worried the added processing time might mean they’d need to limit the number of Medicaid patients they took on in the future. 

By mid-December, the North Carolina Medicaid Ombudsman said they’d received 9,000 calls from individuals on Medicaid about issues they’d experienced during the transition to managed care. They said they’ve helped resolve 6,807 of these issues.  

 – Clarissa Donnelly- DeRoven

8. Tracking the rise of involuntary commitments for mental health patients 

When someone experiences a mental health crisis in North Carolina, they are often met by police officers. The patient is handcuffed, taken to a hospital and strip searched. Then the doors are locked and medication is forced on them under an involuntary commitment order. 

People leave traumatized and can be reluctant to seek psychiatric help in the future, some report increased thoughts of suicide after these experiences with the mental health system. Others end up committed in psychiatric hospitals over and over with little progress towards wellness. 

This is the crisis state of North Carolina’s behavioral health system, which relies heavily on law enforcement, emergency rooms and involuntary commitments. 

Thank you for opening the eyes of individuals who can possibly make changes that will make these women’s life safer, healthier, better. I appreciate your efforts. These women matter. They are someone’s wife, daughter, aunt, grandmother and friend.

Sandy, a reader who has a relative incarcerated at the NC Correctional Institute for Women in response to a story about COVID testing in NC prisons

We reported a 91 percent increase in North Carolina’s use of involuntary commitment (IVC) petitions over a decade — from 2009 to 2018 — far outpacing the state’s population growth. Meanwhile, the state was not tracking or reporting IVC publicly. With the help of dedicated mental health advocates, we published this data which has sparked a conversation among state leaders and proposed legislative changes. 

We’ve also reported on solutions to this problem that stem from people with their own histories of mental health diagnosis, hospitalizations, homelessness and incarceration. 

– Taylor Knopf

9. Cone Health and Sentara Healthcare call it off

In August 2020, Greensboro-based Cone Health announced it would be merging with Norfolk, VA-based Sentara Healthcare, making it the latest of the state’s hospital systems giving in to the “urge to merge.” 

Cone is the smallest of the state’s major hospital systems, ranking No. 6 among North Carolina health systems with about $2.2 billion in annual revenue and 13,000 employees. While that seems large, compared to some of the behemoths such as Duke and Atrium, both looking to expand into the Greensboro market, Cone has been under pressure. 

The health care environment these days is not friendly to hospital systems of modest size that face rising costs, increased local competition, stingier payouts from insurers, and heightened pressure from their customer base for the latest and best technology.

Long-time Greensboro reporter Taft Wireback wrote several stories about the proposed merger for NC Health News, including a deep dive into the public comments made by people from both North Carolina and Virginia. 

But what was originally presented as a “marriage made in heaven” unraveled, and the merger was called off in June 2021. Both parties remained mum as to why and Wireback could find few people willing to speak either on- or off-the-record as to what transpired behind closed doors. 

In announcing the merger’s abandonment on June 2, Cone and Sentara leaders spoke vaguely of realizing late in their discussions that the two health systems had “different cultures.”

UNC health economist Mark Holmes predicted that hospital system consolidation would continue with Cone remaining a prime target.

Consolidations might happen because it’s likely to result in gains for patients and economies of scale, he said. Or they could be, “because my main competitor just connected with somebody else so now I’m the little guy in town.”

 – Rose Hoban

10. Medicaid expansion remains an elusive goal for advocates

North Carolina remained one of 12 states to not expand Medicaid, something made possible by the 2009 Affordable Care Act. Gov. Roy Cooper maintained that he wouldn’t sign a state budget that didn’t include expansion. Ultimately, he reversed course. 

Though outright expansion didn’t happen, some low-income people did see their health benefits grow. Pregnant people whose incomes are 196 percent of the federal poverty line or lower can now receive Medicaid coverage for up to a year after giving birth. Before the change, Medicaid coverage ended after 60 days postpartum, despite the fact that many post-pregnancy complications can occur for up to 12 months.

Like so many things North Carolina Health News does, Tommy’s article was well researched, comprehensive, and held up for public scrutiny an issue of importance to the state and to individual human beings. My thanks again for all that you and your team do…it truly makes a difference.

Tom Akins, head Leading Age, a statewide organization that advocates for seniors

Low-income parents who have children in foster care can also keep their coverage, something that was added to the state budget. Many parents with substance use disorder lose access to treatment when they lose their children to foster care. Advocates argue that expanding this benefit will improve the likelihood these parents can get treatment, and get their kids back. 

The state budget also created an 18-member joint legislative committee to study health care access and Medicaid expansion. Cooper referred to the compromise as “some progress,” but reiterated that he’d continue to fight for expansion. 

The newly created legislative committee is similar to another study commissioned by Cooper in 2020, which studied the various ways to expand coverage. That group concluded Medicaid expansion would be the most cost-effective program to increase health care coverage for N.C.’s low-income residents.

Those without coverage continued to be plagued by astronomical bills for emergency procedures, while many people — of all political stripes — continued to advocate for expansion. Six Republican county commissions in western North Carolina passed resolutions supporting expansion, and oncologists argued that expanding the program would help improve equity in cancer diagnosis and treatment. 

 – Clarissa Donnelly- DeRoven

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