By Taylor Knopf, Rachel Crumpler, Jennifer Fernandez, Rose Hoban, Jaymie Baxley and Ashley Fredde
When patients feel mistreated, it’s become difficult to find recourse in the courts. A law passed in 2009 makes it challenging — if not impossible — for patients to sue providers for malpractice.
Sometimes their only recourse is to reach out to the media.
That’s often driven coverage of North Carolina’s troubled mental health system, where NC Health News has been chronicling problems with private psychiatric hospitals in the state.
Reporter Taylor Knopf has painstakingly chronicled some of these issues for years, spending sometimes months gathering testimonies from patients, and more recently, from staff members who find themselves troubled by what they encounter at work.
Our most-read mental health stories in 2025 were on Knopf’s investigation into serious safety violations at Holly Hill Hospital in Raleigh and a report by Disability Rights NC on the flawed involuntary commitment process that often funnels vulnerable children and adults to places like Holly Hill against their will.
Holly Hill Hospital, a for-profit psychiatric facility owned by national behavioral health giant Universal Health Services, has been repeatedly cited by state and federal regulators for safety violations, including patient escapes, alleged physical and sexual assaults, missing treatment plans, medication errors, unsanitary conditions and poor documentation. The hospital has been placed under immediate jeopardy — the most severe regulatory sanction — multiple times over the past five years.
Mental health experts say repeated deficiencies like these are often tied to staffing shortages and inadequate training. State health leaders said there are ongoing conversations with their counterparts in the federal government about ways to hold repeat offenders accountable.
Despite its troublesome track record, Holly Hill recently expanded to serve more patients. A partnership launched last year with the Raleigh Police Department encourages officers to transport people experiencing mental distress directly to Holly Hill instead of to hospital emergency departments for initial evaluation.
This year Holly Hill opened new adult units to serve patients with less severe needs and a “Patriot Support Program” for veterans and active-duty service members.
Patients are frequently admitted to psychiatric hospitals under involuntary commitment, a legal tool that mandates treatment for someone determined to be a danger to themselves or others. The patient temporarily loses some of their rights to make decisions about their health care, including where they will go for treatment. Disability Rights NC found in a report published in May that the use of involuntary commitment petitions has increased, leaving people detained for days, even weeks, in chaotic emergency departments without timely access to treatment or legal counsel. Meanwhile, gaps in community-based mental health services have made involuntary commitment a default response to a crisis, increasing trauma and costs while failing to ensure meaningful care. The report also outlined numerous solutions and policy recommendations.
State lawmakers have been forced to re-examine North Carolina’s involuntary commitment law, as well as other problems within the mental health system, since September when they passed Iryna’s Law, which makes changes to the involuntary commitment process. Because they passed the law so quickly with little input from experts, House lawmakers are now meeting monthly to study the current involuntary commitment process and make administrative and policy recommendations to improve it.
Missed our other top stories of 2025? Here’s a quick recap: You clicked on stories about hog poop, hospital executive salaries and changes in the state’s health care policies that had both positive and negative outcomes.
Frustrated by defendants languishing in their jails, three sheriffs bring mental health treatment behind bars
Issues with mental health treatment have increasingly extended into national and state carceral settings, which in many cases have become de facto mental health facilities, as an increasing number of people are entering jails with mental health needs that exceed what jails are equipped to handle.
Some of these criminal defendants are deemed “incapable of proceeding,” meaning they are so mentally impaired that they cannot understand court proceedings or assist an attorney in their defense.
That designation often results in a monthslong wait in jail for a bed in a state-run psychiatric hospital to become available so they can then begin receiving “capacity restoration” services aimed at helping them get well enough to go to court. During that time in limbo, defendants frequently deteriorate, and jail staff struggle to manage people with serious psychiatric needs.
As the number of people ruled incapable of proceeding has swelled in recent years, state health officials have sought alternatives to hospital-based treatment. The state Department of Health and Human Services has allocated just over $9 million to launch and support three jail-based and three community-based capacity restoration pilot programs, aiming to reduce wait times and costs.
Mecklenburg County Sheriff Garry McFadden, frustrated by detainees languishing in jail while waiting for scarce state psychiatric hospital beds, launched the state’s first jail-based capacity restoration program in December 2022. Mecklenburg expanded its program this year, adding beds for people deemed incapable to proceed who are from other counties. Sheriffs in Pitt and Wake counties launched their own programs in 2025, citing similar concerns about detainees’ deteriorating mental health.
Early results have been promising. The average time to restore capacity in the jail-based programs is about 50 days, compared with more than 140 days when receiving the same services at a state psychiatric hospital. Jail-based treatment also costs far less — roughly $400 per day, compared with about $1,200 per day in a hospital.
State officials say expanding capacity restoration beyond hospitals could ease pressure on the state’s limited psychiatric beds. In November 2025, 35 percent of patients treated at North Carolina’s three state psychiatric hospitals were deemed incapable to proceed, with many more on a wait list. Serving more of these patients elsewhere could free beds for people from the community who are in crisis. They end up waiting weeks or even months in emergency rooms for a spot at one of the state hospitals.
Federal food aid cuts affect NC residents
About 1.4 million North Carolinians rely on the federal Supplemental Nutrition Assistance Program to put food on the table, totaling about $230 million to $250 million each month. Nonetheless, this year, President Donald Trump’s administration began cutting federally funded food programs.
By late March, funding was rolled back for two initiatives that had been expanded under former President Joe Biden. The Local Food Purchase Assistance Cooperative Agreement program, which helped food banks buy from local farmers, lost $500 million, and another $500 million was cut from the Emergency Food Assistance Program, which provides food directly to food banks.
North Carolina food banks braced for the cuts.
Chatham Outreach Assistance, or CORA, calculated it would lose $313,788.
“There’s no amount of fundraising that we can do that’s going to make up for the funds we’ve lost,” CORA executive director Melissa Driver Beard told NC Health News in June. “At some point we can’t accommodate everything.”
Nourish Up, the food pantry network that helps more than 200,000 food insecure people in the Mecklenburg County area, said cuts to the Emergency Food Assistance Program would mean a million dollar loss for them.
In July, Congress passed a budget for the current fiscal year, eliminating SNAP-Ed, a more than 30-year-old nutrition education program. North Carolina received $11 million annually for SNAP-Ed, which supported community gardens, nutrition education and other local initiatives. Separately, the U.S. Department of Agriculture eliminated the $660 million Local Food for Schools Cooperative Agreement program, which helped schools buy food from local farms.
Advocates say these programs are critical, as research shows that poor nutrition and food insecurity are linked to heart disease, diabetes, obesity and mental health challenges.
In November, North Carolina families received another jolt. SNAP benefits were temporarily halted during a record 43-day federal shutdown. The delay also impacted the estimated 85,000 college students in North Carolina who receive the federal food aid. After legal challenges and confusion over payments, Congress passed a bill restoring full SNAP funding through September 2026, insulating the payments in case of another shutdown.
Looking ahead to 2026, the federal budget also significantly reduces federal reimbursement to states for administering SNAP. For North Carolina, at least $475 million in program costs and an additional $65 million in administrative expenses are shifted to the state starting in October 2026.
As a result, state leaders must decide in 2026 whether to cover the gap, reduce enrollment or withdraw from the program altogether. The mini-budget the General Assembly passed in July was limited in scope and did not address SNAP cuts.
States are also required to expand work requirements for able-bodied adults without dependents, though state officials note that 80 percent of North Carolina SNAP recipients already work.
Food aid in NC by the numbers
In North Carolina, federal food benefits help 1.4 million people, including:
- 580,000+ children
- 159,000 adults over 65
- 46,000+ veterans
- 85,000 college students
Source: NC DHHS, Student Basic Needs Coalition
Need help? Search for locations near you that provide food assistance.
State employees face higher health insurance premiums
Just days into his tenure in early 2025, newly elected Republican State Treasurer Brad Briner warned that a financial reckoning would likely drive up premiums for the 750,000 members of the health plan for state employees and their dependents in 2026.
Briner cited looming budget deficits that had come to public attention in 2024 under the administration of former Republican treasurer Dale Folwell. The deficits would total some $500 million for the 2026 plan year and a projected gap of $800 million to $900 million for plan year 2027 unless something changed.
“If we make structural changes to the program that save us $500 million this year … the gap gets a little smaller, but you still have a material gap that you need to deal with,” Briner told NC Health News in February.
One of the changes on the table was to raise premiums for members, most of whom had not seen a premium hike in nearly eight years.
That immediately raised hackles for state employees dealing with other plan changes, the result of the State Health Plan changing administrators from Blue Cross Blue Shield of North Carolina, which held the contract for close to four decades, to national insurance giant Aetna.
Amanda Thompson, president of the Charlotte-Mecklenburg Association of Educators, told NC Health News that many teachers were caught off guard by higher copays because they were told that little would change under the transition to Aetna.
“They’re paying more for infusions, for appointments,” she said. “That’s unfortunate because our paychecks already aren’t rising with the cost of inflation.”
One of the main reasons for the plan’s deficit was former treasurer Folwell’s signature project, the Clear Pricing Plan, intended to reward providers for being transparent about prices. An analysis done by NC Health News found that the Clear Pricing Plan, which lacked an enforcement mechanism, drained the State Health Plans coffers by as much as $150 million a year over at least three years. Combined with a lack of increase in premiums, the State Health Plan lost almost $800 million in reserves between 2019 and 2025.
Higher premiums became a reality once the plan’s board voted to increase premiums, in August.
“This didn’t have to be this bad, but we play the hand we’re dealt,” Briner said in a YouTube video posted after the August vote.
Plan administrators created a tiered increase, where the lowest-paid state employees — those earning less than $50,000 — will see increases that could be as little as $10 extra per month for the basic plan and $16 more for the premium plan. Employees earning $90,000 or more will see premium increases of at least $55 extra per month for the lower tier plan and $110 more each month for the more comprehensive plan.
Open enrollment took place in October. Plan administrators reported at the final trustees’ meeting in November that more than 146,000 people signed up for the higher priced plans, despite the greater monthly premium increases.
“Given what we had heard about the premium increases, I had assumed that number would be significantly lower,” Friedman said.
Medicaid’s year in the crosshairs
North Carolina’s more than 3 million Medicaid beneficiaries spent much of 2025 bracing for impact amid uncertainty about the program’s future.
Throughout the year, enrollees faced a stream of threats to their coverage. It was a stark contrast from 2024, when nearly 693,000 newly eligible residents joined the rolls as part of the state’s hard-fought expansion of Medicaid in late 2023.
But expansion seemed consigned to a bleaker under the current administration in Washington.
Soon after Trump’s second inauguration, there were concerns that the federal government, which pays 90 percent of the cost of insuring expansion beneficiaries, would make disruptive cuts to the program to offset trillions of dollars worth of expiring tax breaks that Trump had vowed to extend.
In February, the Republican-controlled U.S. House of Representatives advanced a spending plan that Jay Ludlam, head of the state’s Medicaid program, warned could force North Carolina to end expansion, stripping coverage overnight from more than a half-million residents who only recently became eligible for it. The following month saw an outpouring of protests and appeals to federal lawmakers, with Democratic Gov. Josh Stein urging members of the state’s congressional delegation “not to vote for any budget that includes cuts to Medicaid.”
Ultimately, U.S. Sen. Thom Tillis was the only Republican from North Carolina to vote against the federal budget bill that Trump signed into law in July — a defection that drew ire from the president and led Tillis to announce he would not seek reelection in 2026.
His concerns were rooted in two controversial aspects of the law, which includes a provision that limits North Carolina’s ability to impose taxes on health care providers, a key funding mechanism that generates more than a quarter of all non-federal dollars used to support Medicaid in the state. It also includes a mandate requiring “able-bodied” Medicaid beneficiaries to prove they are working, volunteering or attending school for at least 80 hours a month.
The law does not provide states with funding to implement the work requirement. In fact, the lower tax cap means North Carolina will have less money overall to develop the complex new system needed to check beneficiaries’ employment status.
Ludlam told NC Health News that the combination of the reduced tax cap and work requirement is likely to trip a financial “trigger” law that the N.C. General Assembly tied to its 2023 passage of expansion. Under this provision, expansion will be discontinued if the state is forced to shoulder any of the measure’s costs.
“We use provider taxes to help pay for the administrative costs of expansion,” Ludlam explained. “We are not permitted under local statute to pay for those costs using state general funds. Therefore, there’s only one way to really get it, and that is through these provider taxes.”
While expansion remains in place for now, its future depends on the General Assembly’s willingness to either modify or repeal the trigger.
North Carolina’s Healthy Opportunities Pilot, a first-in-the-nation program that used Medicaid dollars to address non-medical health needs in rural areas, shut down in July after its funding was cut by the General Assembly. The demise of the program, which provided beneficiaries with food, rides to doctor’s appointments and other services, came just months after Devdutta Sangvai, head of the N.C. Department of Health and Human Services, expressed interest in expanding it.
In October, lawmakers’ failure to pass a biennial budget fully funding the state’s Medicaid rebase, an annual accounting of enrollment numbers and care costs, led NC DHHS to reduce Medicaid reimbursement rates for health care providers. The rate cuts, some of which were as steep as 10 percent, prompted protests and lawsuits from patients, who alleged the move jeopardized their access to care.
Stein reversed the cuts earlier this month, but he said lawmakers must still fully fund the rebase to prevent worse disruptions down the road.
State budget stalemate
What began as a summer budget delay has now dragged into a new year, with North Carolina lawmakers still unable to agree on a state spending plan — leaving critical services funded at last year’s levels and long-promised state employee raises on hold.
Instead of passing a comprehensive spending plan for the upcoming biennium on July 1, lawmakers adopted a bare-bones “mini-budget” that avoided an outright shutdown but left key priorities underfunded. Millions of dollars intended for health and human services were trimmed, and community programs faced uncertainty. That’s beyond the fight over the overall Medicaid budget that played out between the legislature and Gov. Stein’s administration.
“It doesn’t get much more bare bones in our HHS world than this,” Karen McLeod, who runs Benchmarks, an advocacy organization focused on child and family service providers, said in July.
While Gov. Josh Stein and the NC DHHS relented on the cuts to Medicaid, without a budget agencies are stuck operating on old funding levels, and salaries for teachers, law enforcement and state employees are stagnant. North Carolina is the only state in the U.S. without a full budget as a deadlock driven by disputes between the leaders of the Republican-controlled chambers drags on over funds earmarked for a new state children’s hospital, and over the size and timing of tax cuts.
The stalemate has drawn sharp criticism from the General Assembly’s Democratic colleagues, who held a public hearing in late November to highlight the real-world consequences of the legislature’s ongoing failure to pass a state budget.
Administrators of food pantries testified to the growing difficulty of meeting the rising need amid uncertainty of whether additional funding will be allocated in the upcoming budget. Lawmakers also heard from teachers who expressed frustration at increased health care premiums while long-promised raises have yet to appear.
“An approved budget is not a nice to have, it’s a necessity,” said Mary Jane Bowman, a fourth grade teacher at Stories Creek Elementary School. “Educators who were expecting raises, raises that help them keep up with the rising cost of living, were left without that increase. This uncertainty makes it difficult for teachers to plan for their families, their homes and their futures.
“Health care costs have increased dramatically for educators and staff across our district. For teachers with six or more years of experience, premiums have doubled, and in many cases they are paying more for less coverage.”
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