By Will Atwater, Anne Blythe Rachel Crumpler, Clarissa Donnelly-DeRoven, Thomas Goldsmith, Rose Hoban and Taylor Knopf
Will North Carolina legalize medical marijuana?
Our most read stories of the year dove into the status of medical marijuana in the state. North Carolina remains one of just 13 states that has yet to legalize any cannabis products for medical use, though that could change soon. The NC Compassionate Care Act, first introduced in the North Carolina Senate in April 2021, would make medical marijuana accessible for a small subset of people with chronic illnesses, such as cancer, HIV/AIDS, and post traumatic stress disorder.
On June 6, the bill passed the senate and moved over to the state House of Representatives. Two days later, it was referred to the house committee on Rules, Calendar, and Operations, a committee where, often, bills are sent to die. Sure enough, the bill hasn’t gone anywhere since.
North Carolinians of all political stripes overwhelmingly support legalization of both medical and recreational marijuana. A poll from SurveyUSA and WRAL found 72 percent of voters supported legalizing medical marijuana, and 57 percent supported recreational legalization.
Because so many people who use medical marijuana do so to alleviate pain, researchers across the country have investigated whether medical marijuana could be used as a substitute for opiates. Two studies from 2015, one in the Journal of Health Economics and the other in JAMA Internal Medicine, found that states with legal medical marijuana saw lower rates of opioid addiction and overdose deaths than the states where it remained illegal.
Year three of the coronavirus pandemic
North Carolina started the year in an Omicron rage. On New Year’s Eve, the state Department of Health and Human Services reported a daily case count record of 19,174 new cases of the novel coronavirus, with new infections being driven by new variants to COVID-19.
Record numbers of hospitalizations followed within weeks and the health care system groaned under the strain.
A workforce shortage further complicated scenarios at hospitals struggling to keep up with the influx of patients.
The highest average case count in North Carolina of 235,688 occurred during the week of Jan. 15, 2022, according to the tracker created by DHHS.
The Omicron variant proved to be a survivor, morphing into sub-variants that have continued to menace as 2022 comes to a close.
The past year has shown how remarkable advances in vaccine technology have led to revised vaccines and boosters such as the bivalent booster that protects against Omicron. Though vaccines and antibodies from COVID infections have helped North Carolinians and others return to some pre-pandemic activities — travel, sporting events, concerts, larger gatherings, in-person school and on-site work in office and retail jobs, COVID still can throw curves.
People have learned to isolate and mask when infected and manage risks that not only protect them from severe illness but help prevent huge surges in cases and deaths.
In just three years, scientists and researchers have developed treatments such as Paxlovid and monoclonal antibodies that can be taken within days of infection to ward off severe illness, but as the virus continues to mutate, some of those treatments have become less effective or completely ineffective.
Vaccines have been developed for young children. The percentage of children younger than 4 who have received vaccines is only about 4 percent, but nearly all of the 65-and-older population has had two doses COVID-19 vaccine, according to the DHHS COVID dashboard.
Fifth-nine percent of North Carolinians who completed the initial series of vaccination have also received a booster, but only 19 percent have gotten the bivalent booster that specifically targets Omicron, according to the dashboard.
With the wider availability of home tests, the 3.316 million cases in North Carolina might be an underestimate since many home-test results are not captured in the data.
COVID-19 has created societal changes that are likely to last beyond the pandemic. Working from home is a trend many companies are likely to embrace more, and masking up against respiratory illnesses during winter months might become more common in heavily traveled indoor facilities.
Kody Kinsley, the DHHS secretary who stepped into the job after former secretary Mandy Cohen resigned in 2021, hopes to persuade lawmakers to better fund and add to the public health infrastructures built during the pandemic as North Carolina evolves into recovery and reformation modes.
In the short term, Kinsley has used DHHS funds to create a temporary telehealth program with StarMed through which COVID-infected people without insurance or a primary care doctor can have a free appointment and receive prescriptions for oral antivirals.
“More than 1 million people in North Carolina don’t have health insurance, which has made accessing care for COVID-19, as with other diseases, very challenging,” KInsley said in the announcement. “This program provides a temporary bridge to care for many in rural and historically marginalized communities, but we still need long-term investments to close the coverage gap.”
— Anne Blythe
Medicaid’s changes after a year
In July, North Carolina’s Medicaid transformation turned one year old. At the start of the transition, providers spoke of significant administrative burdens and patients shared their confusion when they were registered with one of the state’s contracted managed care companies. About a year in, things seem about the same, though — luckily — with fewer disruptions to care than expected.
While the technical parts of the state’s Medicaid switch are important to follow, we’ve also been watching North Carolina’s unique pilot project, the Healthy Opportunities Program, which theorizes that by using Medicaid dollars to help people access basic, non-medical services such as housing and healthy food, the state can save money on medical care in the long run.
This summer, we published a three–part series on the program and hosted our monthly Health Care Half Hour with some of the people making the program happen. I think each story is worth a read, but to summarize: the pilot holds a ton of potential, but faces a lot of barriers.
There are issues with the referral process and with increased paperwork for the housing providers. As of September, the state hadn’t yet figured out how to make the domestic violence portion of the program feasible, given the serious privacy concerns involved in supporting people through that experience.
But, for the people who have received services through the program, the impact has been massive. One example: after receiving free produce and whole grains through the program, Mary K, who has diabetes, saw her A1C (a measure of average blood sugar over three months) decrease from 10.8 to 7.6. In the months before, Mary had suffered one health problem after another, so the impact of getting some good news could not be overstated.
Mental health system in crisis
The pandemic put pressure on every part of the societal safety net and the mental health system nearly buckled under its weight. With the help of a grant from the Fund for Investigative Journalism, I spent this year documenting the droves of patients who showed up at emergency departments across the state seeking psychiatric care.
The data we uncovered showed rising mental health-related emergency room visits, more involuntary commitments and longer wait times for psychiatric hospital beds. Health experts explained that these are symptoms of much larger problems within the state’s mental health system which have persisted for over a decade as community treatment resources waned. As more patients find themselves in crisis, the system in place to help them is leaving some more traumatized than when they first sought care.
I wrote the story of an 11-year-old girl at risk for suicide who was sent to a privately run hospital against her parents wishes’ where she was allegedly sexually assaulted. Police records show law enforcement regularly visits this particular hospital in response to calls with reports of sexual assault or rape. Many – including some lawmakers – have called for reform in response to the story.
Health leaders at the center of these issues have ideas for how to fix them, but they would require some significant financial investment in the state’s mental health system.
— Taylor Knopf
Fallout from the Dobbs decision
On June 24, the U.S. Supreme Court overturned Roe v. Wade, the 1973 landmark ruling that made access to abortion a federal right in the United States. The Dobbs decision dismantled that legal protection, handing abortion regulation to individual states.
In the weeks that followed, many states — particularly in the South — took action to either ban or severely restrict abortion, significantly changing the abortion landscape. Abortion remains legal in North Carolina but access diminished after a federal judge reinstated a 20-week ban on Aug. 17, cutting the time frame during which women can access the procedure. The Republican-led state legislature did not try to enact further restrictions on abortion because Democratic Gov. Roy Cooper said he would use his veto power to block any such efforts.
The state’s 14 abortion clinics have stayed busy, accommodating an influx of out-of-state patients. The Carolina Abortion Fund has worked to help patients sort out logistics and payment for the procedure.
Physicians voiced concerns about how abortion restrictions could negatively affect pregnancy care. They’re concerned maternal mortality will increase at a time when the United States already has some of the worst maternal health outcomes of any developed nation. They expressed concern about how medical providers will be able to accommodate the additional pregnancies bound to occur and they also talked about their concerns about how the next generation of physicians will be trained.
In response to reduced access to abortion, an increased number of women are seeking long-lasting birth control options and even long-term fixes for pregnancy prevention such as tubal ligation, a procedure to close a woman’s fallopian tubes permanently. Some women have also noticed how abortion regulations complicate access to drugs for other conditions like cancer and rheumatoid arthritis.
How will NC spend millions in opioid settlement funds?
Over the next nearly two decades, North Carolina will receive hundreds of millions of dollars from the multi-state opioid settlement with several drug manufacturers and distributors. The first of those payments arrived in the state this summer. The big questions are how will the state spend the money and will it actually be used for the purposes laid out in the settlement agreement?
Most of the money will be sent to North Carolina’s county governments to help people and communities impacted by the overdose crisis. The NC Attorney General’s Office and the state health department created very specific guidelines for how each county can use its share of the money. We documented the growing tension around what interventions and treatments should be funded, some of which are backed by more scientific evidence for treating opioid addiction than others.
We also partnered with Kaiser Health News on a deep-dive into an example of one such controversial addiction treatment program. Durham-based TROSA has received millions from the state General Assembly over the years despite its questionable work program and refusal to allow some of the most effective medications for opioid use disorder.
We’ll be watching how communities begin to spend their shares of the money this coming year.
— Taylor Knopf
Hospital financing becomes a bigger issue
This past year saw more hospital consolidation in North Carolina, with Charlotte-based Atrium Health partnering with Winston-Salem-based Wake Forest Baptist Medical Center to create a huge system that could change the shape of how care is delivered in the western Piedmont of the state.
Atrium finished up the year with another megamerger, this time with Midwest-based Advocate Aurora Health.
The state’s larger hospitals saw record revenues during the pandemic, thanks to federal money for COVID relief but smaller hospitals continue to struggle financially. That reality drove hospitals’ efforts to push the General Assembly to expand the state’s Medicaid program even as the bill coming out of the state Senate could significantly change the landscape of hospital competition.
Meanwhile, the state’s rural hospitals continue to struggle, even after seeking the shelter of consolidation with larger systems.
Critics of hospital consolidation continue to call out issues with the Mission Health system, which was bought by hospital behemoth HCA in 2019, and the system has seen an exodus of some physicians and has been the subject of nursing unionization efforts.
– Rose Hoban
The pros and cons of new dental sedation rules
A North Carolina widow launched a widely followed debate about dental sedation rules after her husband, a cardiologist from New Hanover County, died.
Hemant “Henry” Patel died in August 2020 in New Hanover Regional Medical Center days after he went to an oral surgeon for what was described as a routine dental implant procedure.
During the procedure, Patel’s heart rate and oxygen saturation levels dropped to dangerously low levels while he was sedated.
Mark Austin, the former oral surgeon who put Patel under anesthesia before and during the implant procedure on July 30, 2020, consented to permanently surrender his dental license and agreed to participate in a program for health care workers with substance use problems.
Patel’s death was described as an outlier among Austin’s peers in the North Carolina oral surgery field.
That did not sit well with Shital Patel, the widow of the highly-regarded cardiologist. She strove to require an anesthesiologist or registered nurse anesthetist to be present during any surgeries in which a patient is deeply sedated.
The North Carolina State Board of Dental Examiners considered changing the rules but met opposition from oral surgeons. They argued that requiring the additional staff would make procedures cost-prohibitive for many and create disparities in rural and underserved communities.
In the late fall, the board decided not to adopt sweeping changes but put in more steps for review and oversight.
— Anne Blythe
Climate change gains attention across the health care system
This year while reporting on environmental health issues, we noticed an emerging trend: health care providers are seeking to develop skills needed to address the impact of climate change on patient health. We first reported on the trend in a story published in April.
Medical students and professors at the medical school at UNC-Chapel Hill discussed the need to incorporate courses on how extreme weather, due to climate change, can impact human health. UNC is the only of North Carolina’s five medical schools incorporating climate change topics into its curriculum.
UNC is at the forefront of a growing trend: medical schools across the country are starting to respond to this need and are beginning to introduce climate-change-related courses into the curriculum offered, including schools in conservative states such as Texas.
Not only are medical school students seeking to address climate change issues in their training, but clinicians are also responding to this need.
On Dec. 6, 2022, Americares, an organization that, among other things, supports clinics that provide services to low-wealth, uninsured and underinsured individuals teamed up with the Harvard T.H. Chan School of Public Health and developed the Climate Resilience for Frontline Clinics toolkit.
The toolkit is a resource for health care providers, patients and administrators who work in “frontline clinics.” The Community Care Clinic of Dare located in Nags Head, N.C. is one of the pilot clinics that participated in developing the toolkit. Located on the coast, Dare County residents have experienced several extreme weather events, such as hurricanes and Nor’easters, in recent years. On some parts of the barrier islands, some houses are washing away, resulting in miles of debris strewn along beaches.
The toolkit provides a checklist of things for clinic administrators to do, for instance, to prepare a building for an extreme weather event. This may include making sure that there are generators available in case the facility loses power. The toolkit also offers tips health care providers can share with patients regarding how to keep themselves and medications, such as insulin, cool in the case of a heatwave.
— Will Atwater
Medicaid expansion – so close, yet still so far
It felt like watching hell freezing over or a pig taking flight. That’s what it was like to see North Carolina Senate leader Phil Berger (R-Eden) get up on the floor of his chamber in June to support expanding the state’s Medicaid program to cover hundreds of thousands of low-income adult workers.
Berger had resisted implementing this policy for a decade, since early 2013, when the Affordable Care Act made it possible for states to add many low-income workers onto their Medicaid rolls with the feds paying 90 percent of the tab. Usually, the federal government matches North Carolina’s Medicaid expenditures with a two-for-one match, but the law sought to tempt states to expand with this nine-out-of-10 dollar match.
As of the middle of 2022, 39 states and the District of Columbia had accepted the expansion (South Dakota voters approved expansion in November), North Carolina remains one of 11 states – mostly in the South – to continue saying “no.’”
What changed the minds of Berger and other Republicans? For one thing, many Republicans and conservatives in rural areas of the state have come to realize that lack of health insurance for many workers is a drag on local economic development. Several leaders from the western part of the state, including a member of the state Senate, spent the better part of a year advocating for embracing the policy and pointing out that expansion would be a net-positive on the state’s annual budget. And the federal government added a sweetener of about $1.7 billion to flow into state coffers, no strings attached.
Many applauded the Senate’s move, but two key players – physicians and hospitals – found plenty to dislike. The Senate’s bill included several long-sought policies in addition to expansion: reworking the state’s laws governing hospital competition and expanding the independence and role of advanced practice nurses.
The Senate sent its bill over to the House of Representatives Speaker Tim Moore (R-Kings Mountain) said he didn’t feel comfortable with the controversial provisions and the two chamber leaders waited for the other to blink for the rest of the year. Despite hospitals making some concessions, the bill died when lawmakers allowed the clock to run out on the legislative year.
Many advocates find themselves – once again – hoping that the coming year will be “the” year that expansion finally happens.
— Rose Hoban
NC seniors had plenty to choose from in 2022
Whether wiser with age, or perhaps losing their sharpest edges with passing years, older North Carolinians faced a stack of crucial choices in 2022.
Among the decisions with the greatest potential on daily lives concerned which type of Medicare health insurance coverage to pick and, often with input from relatives or guardians, which long-term care facility to care for them through periods of frailty.
State officials said people older than 65, plus some with disabilities, had more than 150 Medicare Advantage plans offered to them across the state. These are the plans run by private insurance companies that are given federal funds to provide health care, as opposed to original Medicare’s practice of paying providers on a fee-for-service basis. Medicare Advantage as a whole continued to increase its share of beneficiaries, even though studies showed it cost the nation more without producing clearly superior results.
In the long-term care sphere, North Carolinians found the state populated by more than three dozen nursing homes owned by a controversial out-of-state hedge fund that faced litigation claiming the company had deliberately reduced staffing to increase profits, placing residents in jeopardy. The company, broadly identified by the names of owners, Simcha Hyman and Naftali Zanziper, denied the claims.
In another development, the University of North Carolina’s COVID Recovery Clinic spent the year working with patients experiencing devastating after-effects of COVID-19. It’s a growing area of research that examines both the set of symptoms that constitute long COVID and potential definitive treatments.
— Thomas Goldsmith