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NC health trends and policies to watch for in 2020

January 3, 2020 by Editor

NC health trends and policies to watch for in 2020 - North Carolina Health News

We asked our reporters to predict the biggest developments in health in the state this coming year. Today, we look ahead on Medicaid transformation, environmental policy, mental health and more.

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.

-Liora Engel-Smith, rural health reporter

The Appalachian Mountains near the Blue Ridge Parkway in North Carolina may benefit from the ARC's recovery ecosystem model. The area has a quickly growing outbreak of COVID-19

New dollars target opioid misuse, workforce revitalization in WNC

September 11, 2019 by Liora Engel-Smith

New dollars target opioid misuse, workforce revitalization in WNC - North Carolina Health News

Twenty-nine western North Carolina counties could benefit from a new Appalachian Regional Commission initiative that will invest in workforce training and treatment options for people with addiction.

By Liora Engel-Smith

Targeting some of the epicenters of the national opioid epidemic, the Appalachian Regional Commission announced a plan to revitalize the workforce in communities ravaged by addiction.

The agency, whose mandate is to promote economic prosperity in 420 counties in 13 states, including North Carolina, outlined a plan to bolster and link programs that support people struggling with substance use disorders to recovery and career-readiness skills. The federal-state partnership has also made it a priority to support initiatives that document and duplicate successful efforts across communities. The exact sum of money the agency will dedicate to these efforts in fiscal year 2020 isn’t yet finalized, pending congressional budget approval, an agency spokeswoman said this week.

The announcement comes on the heels of increased federal funding to combat the opioid crisis. Last month, the U.S. Department of Health and Human Services announced it was investing nearly $400 million in expanding and integrating opioid treatment in community health centers, which care for patients in rural or underserved areas, including the mountain region.

The Appalachian Regional Commission covers 29 counties in North Carolina

Alexander, Alleghany, Ashe, Avery, Buncombe, Burke, Caldwell, Cherokee, Clay, Davie, Forsyth, Graham, Haywood, Henderson, Jackson, McDowell, Macon, Madison, Mitchell, Polk, Rutherford, Stokes, Surry, Swain, Transylvania, Watauga, Wilkes, Yadkin, and Yancey

shows all Appalachian counties, with counties marked in red to show distressed. Most at-risk countis are clustered in Kentucky and West Virginia with a number of distressed and at risk in North Carolina — A map of economic conditions in Appalachia. All 420 counties depicted in the map could benefit from the Appalachian Regional Commission’s recovery ecosystem initiative. Map credit: Appalachian Regional Commission

Source: ARC

Like other parts of Appalachia, opioid addiction disproportionately affects the mostly rural western North Carolina region. In 2017, more than 500 people fatally overdosed there, according to data from the N.C. Department of Health and Human Services. These deaths account for roughly a fifth of all fatal overdoses in the state that year.

“It’s not hard to travel to western North Carolina and meet someone who is an employee or a business owner who says, ‘it’s really hard for me to keep employees because of this epidemic’ … or ‘if I do drug testing on the job and I find out someone has an addiction, I don’t know what to do with that information,’” said Kody Kinsley, deputy secretary for Behavioral Health and Intellectual and Developmental Disabilities at the state health department.

A man in a gray suit and red tie stands at a podium with two microphones in front of him. — Kody Kinsley, N.C. Department Health and Human Services deputy secretary, speaks at the opening of the renovated Broughton Hospital in Morganton last month. Photo credit: Liora Engel-Smith

Kinsley, who was part of the group that created the recovery ecosystem recommendations, said helping people with substance use disorders recover and return to the workforce has the potential to revitalize Appalachia by re-integrating people into their communities. Getting hired can also help people with substance use disorder, many of whom are uninsured, gain access to health insurance through their employers. And it can open up more avenues for support and treatment, he added.

“We’re taking the next leap forward, which is recognizing that you can’t have a thriving economy unless you have healthy workers to participate in that economy,” he said. “Health is so core to everything and this really takes an organization whose mandate is really centered on economic development, it’s them putting their hand up and saying ‘You know what? We need to engage in this because unless we have a healthy workforce, we can’t succeed.’”

‘Not just a job coach’

Across the region, those who help people in recovery with job-readiness skills applauded the emphasis on workforce development, saying that recovery has unique challenges that can make finding and retaining a job difficult.

In the early stages of recovery, balancing work demands with commitment to treatment can be difficult, said Philip Cooper, Up Skill Western North Carolina coordinator at A-B Tech Community College in Asheville. Outpatient drug treatment programs, he said, are a time commitment, sometimes requiring several hours-long meetings per week in addition to time dedicated to support groups. Finding a job that is flexible enough to allow clients to make the meetings can be challenging, he said. And many of the jobs that offer such flexibility don’t pay a living wage.

two African American men look at the camera. The man on the right has a t shirt on reading: — Philip Cooper (right) with Lionel Hightower. Cooper writes of Hightower: “He returned home in 2016. He has retained jobs, been a present father, and more importantly stayed engaged with his support system. He now works as a Tech at a local crisis center, where he is a role model for those in crisis.” Photo courtesy: Up Skill WNC Buncombe Facebook page

And if the client has a criminal record, he added, these challenges may be even greater because of stigma. Not every employer is willing to take a chance on people who have a record, particularly if the charges involve some form of violence.

But Cooper, who has helped roughly 100 participants since 2017, said that with the right support people can overcome these barriers. His job, he said, is to help clients with everything from obtaining a Social Security card — a necessity for the hiring process — to helping them navigate the stresses of working while also staying sober.

“I’m not just a job coach. I’m more like a recovery resource,” he said.

Cooper also works with employers, vouching for participants and advocating for them in the job-seeking process as needed. But, he said, while Buncombe County has considerable recovery resources, the region needs more coaches who can help clients in recovery navigate the job market. The commission’s recovery ecosystem initiative, he said, is a step in the right direction because it reminds people that finding a job can be a part of wellness.

“[Addiction is] a health care problem, it’s a workforce problem, it’s an education problem, it’s a criminal justice problem,” he said. “So with them leading with that approach of bringing people together, this ecosystem, they’re saying ‘we’re gonna bring all the stakeholders to the table.’”

No Wrong Door

But more than 80 miles southwest of Asheville in Macon County, that table, and the number of stakeholders around it, is far smaller. And it isn’t because people don’t care, said Sheila Jenkins, executive director of the Franklin-based No Wrong Door to Support and Recovery. The peer support organization, which began operating last March, has been grappling with a general lack of resources for people seeking recovery.

Recovery Resources

In honor of recovery month, Google has created a dedicated recovery resources search page, complete with a searchable map for meetings, recovery centers and other supports. The website also has a drug disposal sites map and Naloxone locator.

The system in the county, she said, isn’t set up to help people succeed, piling barrier upon barrier on people with limited resources. Transportation options are limited, she said. Many clients either cannot afford a car or don’t have a license. Though the county has an informal shelter, it lacks transitional housing options such as sober or halfway houses, she added.

These and other gaps make it difficult for Appalachian people to stabilize their lives enough to even seek work, she said. And those who are ready to find a job may be rejected from positions because of their criminal record.

“We really struggle, and they struggle,” she said. “We have seen [participants] come back into the home they left and then relapse.”

But, she added, No Wrong Door has made some strides in supporting people seeking recovery at the jail and in forming some relationships with local employers to change the stigma of a criminal record. Down the road, Jenkins said, she hopes to encourage more local employers to follow suit. People in recovery need jobs, she said.

“You have to have employment in order to succeed because most of the time you have probation fines you have to pay and you just have to live.”

long distance landscape photo of mountains receding into the distance.

Mission Hospital purchase drives change for multiple local health foundations in WNC

August 21, 2019 by Carolina Public Press

Mission Hospital purchase drives change for multiple local health foundations in WNC - North Carolina Health News

A group of western hospital foundations, faced with a changed financial and legal landscape, double down on addressing social determinants of health problems in their communities.

By Neil Cotiaux

Carolina Public Press

When HCA Healthcare purchased nonprofit Mission Health, the rules of charitable giving in communities across Western North Carolina changed.

With a for-profit owner running medical facilities, the foundations that raised funds from donors to support the local hospitals that had become part of Mission Health over time could no longer do so.

Transylvania Regional Hospital Foundation, which had raised $40 million since its inception, was one of six such affected charities across the 18-county region. Lex Green, the Brevard-based foundation’s former executive director, talked with Carolina Public Press about the change.

“So it begged the questions for the entities that were established supporting the hospitals, ‘Do you want to ride off into the sunset, just end operations, or do you want to reconstitute yourself and go out into the community and focus on a different cause and that’s promoting the health and wellness of the communities?’” Green said.

Green and other community leaders decided to move forward, and Transylvania Regional Hospital Foundation is now the Pisgah Health Foundation.

Similar transformations occurred throughout the region as the Spruce Pine-based Blue Ridge Regional Hospital Foundation became AMY Wellness Foundation, Asheville-based CarePartners Foundation became WNC Bridge, Highlands-based Highlands-Cashiers Hospital Foundation became the Highlands-Cashiers Health Foundation, and Marion-based Mission Hospital McDowell Foundation became Gateway Wellness Foundation.

In Franklin, where the foundation for Angel Medical Center had ceased operating earlier, the startup Nantahala Health Foundation will fill the same role as the other new foundations.

All six foundations are now helping to build the capacity of local nonprofits to meet community needs.

Targeting ‘social determinants,’ not hospitals

Janice Brumit, board chair at the $1.5 billion Dogwood Health Trust formed with proceeds from Mission Health’s sale, told CPP the six are now “free to give grants to any organizations they want in their communities.”

Dogwood Health Trust announced the hiring of a new CEO, Antony Chiang, earlier this month. Chiang, 51, comes from Washington state where he has been running the Empire Health Foundation, which serves eastern Washington, another largely rural region.

“His commitment to health equity and inclusion, his talent for forging meaningful partnerships, and his ingenious approach to solving chronic problems that affect health and wellness will be invaluable as we enter this next important chapter,” said Dogwood Health Trust Board Chair Janice Brumit in a press release announcing the hire.

Chiang will start his new position in November.

shows a man looking confidentially at the camera — Future Dogwood Trust CEO Antony Chiang. Photo courtesy: Empire Health Foundation

“The thing about that is that we hope that they will agree that ‘social determinants’ are a good place to place their money,” she said.

Addressing social determinants of health – conditions that impact an individual’s well-being such as housing, education, nutrition or substance use – is the central focus of Dogwood’s mission.

Asheville-based Dogwood views its relationship with the new foundations as partnerships, sweetened with $15 million over three years to each of them, according to Brumit. First-year funding comes from Mission Health, the final two installments from Dogwood.

All six foundations have agreed to support the social determinants mission.

“So the contract has specific parameters that we have to meet on a quarterly basis, and then there is an additional reporting requirement in this year’s contract where we have to share our strategies in three different areas – community outreach, resource development and grant-making,” explained Green, now executive director of Pisgah Health Foundation.

With the first $5 million parked in an investment account, Green and his staff are wasting little time educating would-be beneficiaries across Transylvania, Buncombe, Haywood, Henderson and Madison counties about his organization’s work.

Over the past couple of months, he said, Pisgah held about 25 “listening sessions” and heard from dozens of nonprofits to better understand their needs.

On Aug. 6, Sara Coplai, a grants expert at Dogwood, arrived in Brevard to work through the grant-making process with the first 50 applicants. Pisgah is asking them for letters of intent before inviting them to apply for grants to ensure that social determinants of health will be addressed.

The first grants will be awarded in October. About the same time, a second grant cycle will open.

Green expects the $15 million that Pisgah receives will only be used to fund grants. He expects operational costs to be covered through community donations.

Pisgah has developed a conflict-of-interest statement, and potential conflicts will be addressed early when reviewing applications, board chair Cathleen Blanchard said.

Dogwood, which continues to assess community needs across Western North Carolina, won’t start making grants until next year.

Far western counties

In the westernmost counties – Cherokee, Clay, Graham, Jackson, Macon and Swain – one successor foundation and one startup will support Dogwood’s mission.

Walter Clark, board chair at Highlands-Cashiers Health Foundation, said his organization is flush with money for grants. The foundation serves all six westernmost counties and the Qualla Boundary, which is located within several of these counties and is home to the Eastern Band of Cherokee Indians.

In the final year or so of the hospital’s foundation, its board contributed more than $7 million toward the facility’s renovation despite members being aware that HCA could acquire Mission Health.

“We were probably left with about 13 million, 12 million dollars” before receiving the $5 million for the new independent foundation, Clark said.

The foundation has already approved its first grants and is notifying recipients.

Some area residents believe those awards, while helpful, will fail to address a chronic need.

Highlands-Cashiers suffers from an acute shortage of doctors and conducted a recent Concerned Citizens Health Forum to address the problem.

Because the new foundation is prohibited from supporting for-profit HCA, its grant money cannot be used for physician recruitment, the group was told. HCA must address recruitment directly.

Regardless, Highlands Mayor Patrick Taylor believes investing in social determinants will prove beneficial.

“The foundations really need to focus on some big-ticket items,” Taylor said.

Having the new foundations and Dogwood operate on parallel tracks helps coordinate the organizations’ activities and provides Dogwood with “eyes and ears,” he added.

In Franklin, the new Nantahala Health Foundation is getting off the ground. A board is in place, and Lori Bailey, whose nonprofit work focused on youths and families in crisis, will start as executive director in September.

With Nantahala and Highlands-Cashiers serving the same counties, the foundations may eventually divide some geography, Clark said.

Across the region

Across all 18 counties, the foundations are taking note of what they hear from citizens and setting priorities while coordinating with Dogwood.

In the easternmost counties of Avery, Mitchell and Yancey (AMY Wellness) and Burke, McDowell, Polk and Rutherford (Gateway), Luke Howe is serving double duty as executive director.

He and assistant director Nora Frank point to a groundswell of support for addressing a shortage of affordable housing. As a result, a planning grant is being developed to allow nonprofits to collaborate and determine how safe, healthful and less expensive housing can be created.

Domestic abuse, elder abuse and child abuse are also on the agenda, Howe said.

As the new foundations build capacity to address such issues, an initiative of the N.C. Department of Health and Human Services will make it easier to tap into those resources.

The N.C. Resource Platform enables health care providers, insurers and nonprofits to refer individuals to the services they need to remain healthy.

The digital platform incorporates website, database, care coordination and call center features, available at no cost.

The platform is not yet operational in Western North Carolina.

shows a coal plant with steam puffing from one of the smokestacks, a concern in the fight against climate change, air pollution

Judge sides with DEQ on Duke Energy coal ash removal

August 2, 2019 by Greg Barnes

Judge sides with DEQ on Duke Energy coal ash removal - North Carolina Health News

The judge finds that the Department of Environmental Quality had authority to order Duke Energy to excavate all of its coal ash pits.

By Greg Barnes

A North Carolina administrative law judge ruled Friday that the state Department of Environmental Quality had the proper legal authority to order Duke Energy to excavate each of its coal ash pits across the state.

The decision by Judge Selina Malherbe to grant DEQ’s partial motion to dismiss will limit the scope of Duke’s appeal of the state’s lawsuit against the company as it moves forward, according to the DEQ.

“I am very pleased with the judge’s ruling. It confirms that DEQ has the authority to select the method of closure for coal ash impoundments,” DEQ Secretary Michael Regan said in a statement. “DEQ stands by its determination that the best way to protect public health, communities and the environment is to excavate coal ash impoundments across the state. ”

A map of Duke Energy's 14 coal ash sites — A map displaying Duke Energy’s 14 coal ash sites. Duke now owns Progress Energy’s former sites. Graphic courtesy NC DENR

On April 1, the DEQ ordered Duke Energy Progress LLC to excavate all remaining coal ash impoundments in North Carolina, saying it had “determined excavation of all six sites is the only closure option that meets the requirements of Coal Ash Management Act to best protect public health.” There are nine coal ash basins on the six sites — Allen in Gaston County, Belews Creek in Stokes County, Cliffside/Rogers in Cleveland and Rutherford counties, Marshall in Catawba County, and Mayo and Roxboro in Person County.

Duke Energy appealed the order on April 26, saying it wants to protect customers from excessive cost and disruption, and that it has been safely closing coal ash basins according to state and federal law.

The state wants Duke Energy to excavate all of its coal ash pits and to move the sludge to lined pits in other locations. Duke Energy wants to cap some of the pits in place.

“While we are disappointed in the ruling on this issue, we will proceed with the appeal, standing firm in our belief that the NCDEQ decision is wrong, not based in science and engineering – and not in the best interest of our customers and communities,’’ Duke Energy said in a statement.

Duke alleges that the state’s order “mandates the most extreme option for the lowest-risk basins, ignoring information that clearly shows capping the ash in place would continue to fully protect people and the environment.”

The judge ruled that Duke Energy failed to state a claim for relief and dismissed the following claims:

That DEQ erred by electing the method of closure for each of the nine coal ash impoundments subject to this litigation.
That DEQ erred in making its closure elections before Duke Energy submitted its closure plans.
That DEQ erred in determining that closure must be fully implemented by Dec. 31, 2029.

Named as defendants in Duke’s appeal are the DEQ, Appalachian Voices, the Stokes County Branch of the NAACP, Mountaintrue, the Catawba Riverkeeper Foundation, Waterkeeper Alliance, The Sierra Club and The Roanoke River Basin Association.

Waterkeeper Alliance, the Catawaba Riverkeeper Foundation and the Southern Environmental Law Center issued statements saying they are pleased with the judge’s ruling. The law center represents the community organizations.

“Today’s dismissal puts to rest the notion that DEQ was premature in selecting a remedy for Duke’s coal ash pollution…. and allows the case to focus instead on DEQ’s decision to require a full cleanup,” said D.J. Gerken, senior attorney at the Southern Environmental Law Center.

“Duke Energy’s coal ash should not be left covered up in unlined pits to pollute in place for generations beside our lakes and rivers and continue to put North Carolina’s communities at risk.”

A county by county map of US colored to show opioid death risk, including access to medication-assisted treatment

Forty-one N.C. counties classified as “high risk” in new opioid study

July 23, 2019 by Yen Duong

Forty-one N.C. counties classified as “high risk” in new opioid study - North Carolina Health News

In a national study, researchers classified 41 North Carolina counties as “opioid high-risk” with few providers of medication-assisted treatment and many opioid-related deaths.

By Yen Duong

While conversations about the national opioid epidemic often focus on hardest-hit states such as Ohio, West Virginia and Kentucky, few people have analyzed county-by-county trends, where those state’s policies can make a difference.

But a new study, published last month in an open-access version of the Journal of the American Medical Association, classified 412 counties as “high-risk” and 1,485 as “not high-risk.” Among those, 41 of North Carolina’s 100 counties qualified as “opioid high-risk” counties.

“That was one of the highest states that we found in terms of the number of counties relative to the total number of counties in the state,” said Rebecca Haffajee, a University of Michigan public health professor who ran the study. “That tells us that North Carolina and these counties in particular need to think about how to get more providers to those areas.”

Counties were deemed high risk if they had higher than the national rate of 12.5 opioid-related deaths per 100,000 people, and lower than the national rate of 9.7 providers of medication-assisted treatment, or MAT, for opioid use disorders.

North Carolina’s Department of Health and Human Services is spending two-thirds of a recent $12 million federal grant to fight the opioid epidemic on direct treatment for uninsured people with the remaining third spent on “linkages to care” or support for housing, case management, employment and other social factors, said Kody Kinsley, who works in behavioral health for DHHS.

“A lot of other states that have expanded Medicaid are able to use their Medicaid program to pay for treatment, and they can pump almost all of their federal grant money into linkages to care,” Kinsley said. “That’s a big reason why we continue to struggle in this fight.”

What ‘high risk’ means

High-risk counties had a few common characteristics: fewer primary care physicians per 100,000 residents, higher unemployment, a higher proportion of whites, fewer people with a high school education and fewer residents under the age of 25.

Of rural counties in the U.S., 71 percent had no publicly listed providers of any of the three medications, versus 46 percent of all counties with no such providers. But urban areas were also likely to be high risk.

“We were a little surprised by that finding,” Haffajee said. “The reason, we think, is because we use more recent death data … We’re picking up the risks of fentanyl and [other] illicits that other studies haven’t yet, because those hadn’t become super prevalent and saturated urban areas in the earlier years.”

41 of 100 N.C. counties were classified as opioid “high risk” counties in a recent JAMA study, with higher than national rates of opioid overdose deaths and lower than national rates of providers of medication assistant treatment. Map: Yen Duong

Although Henderson County, south of Asheville, has a federally qualified health center that offers methadone, it was classified as high risk. Steven Smith, the health director in Henderson County, thinks that may be because, with more education, more deaths have been identified as opioid-related.

“Henderson County overall is a pretty well-off county in terms of their percentage of primary care physicians and relatively low amount of uninsured,” said Smith, who is also the president of the North Carolina Association of Local Health Directors “We have been focused with community partners for years here, doing a lot of work upstream with prevention and harm reduction.”

Many barriers to MAT

People who want to get medication-assisted therapy face multiple barriers before they can access the three forms of MAT: buprenorphine, methadone and naltrexone. To dole out buprenorphine, the most common MAT, doctors complete an eight-hour training and apply for a federal waiver to prescribe to up to 30 patients. They can apply for a waiver to prescribe up to 100 patients, and after a year they can reapply to prescribe to 275 per year.

Currently, only about 7 percent of the nation’s physicians have taken the extra time and effort to train for prescribing the medications.

Methadone can only be given under a physician’s supervision in opioid treatment programs approved by the federal Substance Abuse and Mental Health Services Administration. There are 76 such approved programs in North Carolina listed on the SAMHSA website.

“It’s still crazy that both buprenorphine and methadone are regulated more strictly than opioid analgesics,” Haffajee said. “Any prescriber can prescribe hydrocodone or oxycodone [opioid painkillers] without any hoops they have to jump through.”

For naltrexone, patients need to be entirely free from opioids for seven to 10 days before starting treatment; otherwise, they’ll have serious side effects. For those with opioid use disorder, that means withdrawing from opioids first, a hurdle that can be insurmountable for many. But naltrexone has no waiver requirements for prescribing and can be useful for some patients.

“What might work for one patient might not work for another,” Haffajee said. “Having the full panoply of options available and you try one and then [if] that doesn’t work as well, you try other is the best course of treatment.”

Because of how costly MAT is, DHHS funds have gone toward treating “ten to twelve thousand people,” which is not enough, Kinsley said.

“The truth is, we’re still scratching the surface. We suspect one in 20 people have a substance use disorder in North Carolina,” Kinsley said. “It’s a long-term treatment. It’s a chronic disease like diabetes; people don’t go to one dialysis visit and they’re done. It’s a lifetime thing. We’re really behind the curve in keeping up with that.”

Ideas to address the whole person

The study argues that increasing access to these medications in high-risk opioid counties could reduce deaths by up to 60 percent. Haffajee said states should encourage doctors to prescribe more buprenorphine, help more doctors get the waiver, and also focus on policies that address the other conditions of high-risk counties—the linkages to care mentioned by Kinsley.

“If you don’t have a high school education, if you don’t have a safe place to live, if you don’t have access to transportation, the least of your problems is getting a provider to give you a medication for your substance use disorder,” Smith said. “You have to start addressing that whole person in a meaningful way to give them even a chance of climbing out of that abyss.”

Right now, federally waivered doctors who prescribe buprenorphine must also register with the state. House Bill 325, which was just signed by Governor Cooper, gets rid of that requirement and gives more support to needle exchange programs and people who test drugs for contaminants.

In addition to that legislative change, DHHS is hoping to change rules to build up “satellite” dosing offices. In that case, patients could go to a usual MAT provider for their first few doses, and then the provider could send out a nurse or doctor out to rural satellite offices near the patient a few times a week, Kinsley said.

“Right now, if you live in Rutherford County, and you’re on medication-assisted treatment, you’re probably driving to Buncombe County two to three times a week to receive your dose,” Kinsley said. “I couldn’t drive 60 miles somewhere three times a week and keep a job and maintain a family and that sort of stuff.”

Smith said that even if lawmakers do not expand Medicaid, “the cost of this crisis does not go away.”

“Communities are paying for it every day, in terms of support services, human services, legal intervention, detention facilities, emergency departments,” Smith said. “We’re all paying for this, one way or another, regardless of whether or not it shows up on the balance sheets at the state.”

close up shot of an african american woman who looks very compassionate, looking at someone who is off camera

Seeking Conviction: Questions of consent can make NC sexual assault cases tough to prosecute

March 21, 2019 by Seeking Conviction Investigative Collaboration

Seeking Conviction: Questions of consent can make NC sexual assault cases tough to prosecute - North Carolina Health News

North Carolina is the only state where withdrawing consent doesn’t make continued sex after someone changes their mind into a crime.

By the Seeking Conviction Investigative Collaboration

Even if a rape case makes it to trial, it can still be tough to convince juries — especially if the perpetrator says it wasn’t a crime at all, but a consensual act.

In fact, Cumberland District Attorney Billy West said he believes that “getting a conviction in a sex offense case from a jury of 12 may be the most difficult one to get in our system.”

It’s because most sex offense cases involve people who know each other, West said. They may have had a prior relationship or were on a date or together at a party, he said, and sometimes the evidence boils down to the victim’s word against the defendant’s.

It can be easier, West said, to obtain a conviction if the defendant is a stranger or there otherwise is no plausible noncriminal reason for the defendant to have had sexual contact with the victim.

This problem exists in the criminal justice system nationwide. It’s heightened in North Carolina because of a 40-year-old legal precedent that says a person cannot revoke consent to a sex act. Continuing after being asked to stop does not constitute a crime.

This is part of an investigative series, Seeking Conviction, examining the issue of sexual assault prosecutions and convictions in North Carolina, from a team of 11 media partners across the state.

North Carolina is the only state in the nation where this is true, according to Skye David, staff attorney for the N.C. Coalition Against Sexual Assault.

While state law defines sex with an incapacitated person as rape, court precedent says those laws don’t apply if the person caused the incapacitation through drinking or drug use.

That could change if a bill proposed in the passes through the legislative process.

These legal complications make it difficult for prosecutors to get convictions on many sexual assault cases in which consent is disputed.

Victim blaming and consent

Regardless of the rules, public attitudes about consent can lead to blaming sexual assault survivors. When these attitudes are prevalent among jury members, prosecutors face an uphill battle, even on cases that otherwise seem clear-cut.

In Macon County several years ago, a 16-year-old high school student disappeared during a party.

“She was brutally raped,” said Ashley Welch, who is district attorney over seven southwestern counties. The teen made a report immediately and made the long trip to Asheville to have a Sexual Assault Nurse Examiner collect the evidence from her body, now a crime scene.

Welch wanted to prosecute the boy accused in the case. She asked the grand jury to review the details in the case and grant probable cause to proceed to trial.

The first time the grand jury turned down charges, Welch said, she sat down with the girl and her mother.

“I didn’t see it coming,” Welch said. “That had never happened to me before. I was shocked. I told them I was going to try again, and not to worry.”

“And then it happened again,” she said.

The third time, Welch said she just cried with them and told them how sorry she was.

“I sent it to a grand jury three times, and they wouldn’t give me (an indictment),” Welch said. “She was so victimized and she was in high school.”

“What the grand jury said is, it was her fault,” Welch said. “His story from the get-go was that it was consensual.”

shows hands, black and white clasped. — Donyetta Gilmer, sexual assault and domestic violence advocate, holds the hands of a sexual assault victim during a counseling session. Photo credit: Robert C Reed/Hickory Daily Record

“I couldn’t get a grand jury to give her probable cause, because she had gotten drunk at a party,” Welch said. “The last time I checked, that doesn’t mean you deserve to get raped.”

Welch thought she had all the hallmarks of a solid case: The girl reported it immediately. There were injuries and her clothes from the night of the incident, Welch said, noting that the girl’s testimony was consistent.

“I had other people at the party who talked in detail about how she disappeared with the person and how she acted immediately after. Crying. Hurt. Devastated. Scared — and I still couldn’t get a grand jury to let me prosecute him,” Welch paused. “I’ll never forget that.”

Even when a grand jury indicts, if consent is in question during a rape trial some jurors will blame the victim for what happened, said Lt. John Somerindyke, who heads the special victims unit at the Fayetteville Police Department.

“All a defense lawyer has to do is have one juror buy into victim-blaming, and the case is gone,” he said.

But Angelica Wind, executive director of Our VOICE, a rape crisis center in Asheville, believes an alleged perpetrator who claims consent should not be an automatic loss.

“The sense is that, perhaps it’s not a winnable case because it’s ‘he said, she said,’” is wrong, Wind said. “What that means is bringing in more expert witnesses to court to talk about trauma and what that looks like.”

Despite the challenges of investigating a case involving disputed consent, Somerindyke said his agency is willing to take a chance if the victim wants to pursue justice.

“I can’t speak for every agency in the state, but I feel like we are a little more proactive with our investigations and are willing to take a chance if the victim is willing to move forward with the court process, and put her hand on the Bible and testify in court,” Somerindyke said.

“If we have a good solid investigation … we aren’t going to worry about what the DA is or isn’t going to do, or what a jury is or isn’t going to do.”

Victim-blaming isn’t just an impediment when it comes from juries. Survivors can experience social victim-blaming that discourages them from pressing charges or testifying.

People bring up their past relationships and ask for details about intimate partners, said Sgt. Stephanie Vest with the Forsyth County Sheriff’s Office.

“Some opt not to go forward because they don’t to be labeled in their peer groups, they don’t want information to get out, and they don’t want others to think, ‘If I hadn’t worn that dress …’ They don’t want to be drug through the trenches,” she said.

Consent ‘under the influence’

Some of the victim-blaming runs counter to both the law and logic, noted Donna Miller, executive director of Esther’s House, a rape crisis center in Stanly County.

“You’ve still got that mentality, if (the rape survivor was) drinking or doing drugs, then they’re not credible,” Miller said. “But the general statute says, if they’re under the influence, they cannot give consent. So where is that line?”

However, that line in many cases may be interpreted in light of the legal precedent drawn in the 2008 N.C. Court of Appeals decision, State v. Haddock, which has made prosecuting second-degree rape and second-degree sex offense more complicated, experts said.

Prosecutors can prove second-degree rape and second-degree sex offense two ways: by force and against a person’s will, or against a person who is mentally disabled, mentally incapacitated or physically incapacitated.

The court ruled that a person could not be considered “mentally incapacitated” when the person was responsible for the incapacitation, according to Amber Lueken Barwick, a domestic and sexual violence resource prosecutor for the N.C. Conference of District Attorneys.

Forsyth County Assistant District Attorney Elizabeth Dresel said that means prosecutors can’t show mental incapacitation if the person who was assaulted willingly drank alcohol and became impaired as a result, although prosecutors could still pursue charges if there is other evidence the sex act was forced and was without consent.

Vest, the Forsyth County Sheriff’s Office sergeant, echoed Dresel’s statement that a case that involves alcohol may be harder to prosecute but said sexual assault survivors should still speak out.

“An inebriated account is sometimes skewed,” Vest said. “But we have to consider, ‘no means no,’ no matter how much someone’s had to drink. And it’s a huge factor in why people don’t immediately report, especially if they are under (legal drinking) age. They have to explain to their parents where they’ve been, that they were drinking and what happened.”

Prosecutors may accept the challenge and move forward with a jury trial in an alcohol-related case, especially if the accuser is eager.

Ted Bell, the district attorney in McDowell and Rutherford counties, recalled one such case.

“It was a consent case, based on whether or not the defendant was intoxicated and whether or not she gave consent,” Bell said.

“There were text messages in that case that … appeared to be sexually suggestive. It could be read either way. The defense portrayed them as sexually suggestive, and the jury ultimately came back ‘not guilty.’ ”

Withdrawn consent in North Carolina

Some cases are more difficult than others, especially if the initial act began with consent.

In 1979, the Supreme Court of North Carolina ruled that once a sex act begins, a woman cannot withdraw her consent.

The court wrote: “If the actual penetration is accomplished with the woman’s consent, the accused is not guilty of rape, although he may be guilty of another crime because of his subsequent actions.”

DA Welch called it a “troubling” precedent.

“I feel like you are able to withdraw consent at any time,” Welch said. “If you have consented to one act, to me it doesn’t mean that act can keep going as long as necessary.”

However, again it comes back to juries and how they view consent.

“You will see somebody that is consenting to a particular act, and all of a sudden it gets rougher than what they bargained for, or they change their mind, and we’re stuck,” Welch said. “If it goes from one sex act to another, I don’t feel like that law applies, but you still have to deal with that issue in front of a jury, and that’s going to be very hard to convict.”

Wind said she’s seen a few cases where a woman consents to sex with a condom, and then the partner in mid-act removes it. It’s called “stealthing,” but under that 1979 ruling, it’s legal to continue having sex even if the other person tells you to stop — as long as there was consent for the initial penetration.

Monika Johnson Hostler, executive director for N.C. Coalition Against Sexual Assault, started to keep a notebook about 10 years ago when she heard from women who tried to revoke consent. They are stymied by prosecutors who feel a jury won’t convict because of that 40-year-old ruling.

“A lot of these are generally younger women, teens or college-aged,” she said. “They are frustrated.”

Two cases she’s heard recently are very similar. Prosecutors told both there’s nothing they can do.

Even though the women did not consent to sex, “the offender felt like consenting to fooling around was consenting to sex,” Johnson Hostler said.

Although the precedent came from a one-time court ruling that has not been tested recently, some North Carolina lawmakers have attempted to offer a legislative solution. Mecklenburg County Democrats Rep. Chaz Beasley and Sen. Jeff Jackson proposed a bill in 2017 to make continued sex after revocation of consent a crime.

The proposal read, “A defendant who continues the act of vaginal intercourse after consent is withdrawn is deemed to have committed the act of vaginal intercourse by force and against the will of the other person.”

But the General Assembly never acted on the measure.

Tuesday afternoon, Reps. Beasley, Jay Adams (R-Hickory), Gale Adcock (D-Cary), and James Boles Jr. (R-Southern Pines), filed a bill proposing changes to existing law on incapacitation. A 2008 legal precedent interprets language in that law to mean raping someone who is mentally incapacitated is illegal only when victims didn’t voluntarily cause their own incapacitation by drinking or drug use.

House Bill 393 would remove language from the existing state statute on which that legal precedent is based. Other parts of the measure would make it a felony to drug a person’s drink, broaden the definition of “caretaker” in the juvenile code, and remove the word “forcible” from several of the statutes that define rape crimes.

As of late Wednesday afternoon, the bill had another 56 cosponsors.

Johnson Hostler called the proposed legislation “a great first step for North Carolina” during a Wednesday afternoon press conference in Raleigh.

A reporter asked why revocation of consent wasn’t included in the bill. Beasley said it was something lawmakers discussed.

“My understanding is that there very well may be more movement on that issue as well,” Beasley said at the press conference. “Stay tuned there.”

Beasley also fielded a question about Carolina Public Press’s analysis of statewide court data, published Monday, which found that more than 75 percent of those arrested for serious sexual assault offenses are ultimately not convicted of a sexual assault charge.

“Do you think your legislation will help with that?” the person asked.

“I do,” Beasley said. “There are some folks who don’t feel comfortable sharing their stories because they are concerned that nothing’s being done. We definitely want to provide a space where, if people go to law enforcement or they go to DSS, or they go to someone whose job it is to address these problems, … they will be heard and they will be remedied.”

Attitudes toward rape

If issues like North Carolina’s rules on consent lead to a public perception that rapists will go unpunished in the state, it could impact survivors’ decisions about whether to contact police.

Johnson Hostler said communities that do not prosecute rapists may see a drop in these reports.

“In small communities the word gets out. ‘I don’t need to report this because nobody is going to do anything,’” she said. “It only takes one person in a small community to say, ‘If you are sexually assaulted, nothing’s going to happen.’

“That may or may not be true. But for survivors that’s what they believe.”

DA Bell, from McDowell and Rutherford counties, described wanting justice for survivors in difficult sexual cases, especially those hinging on consent.

“Justice, to me, is trying to get as close as I can to what the victim feels they need, to be able to get past this,” he said.

“Sometimes, justice is them getting on the witness stand and telling, to people who are wanting to listen to them, what happened. And sometimes, with some victims, that’s all they want. They want to get up and say this is what he did to me and so sometimes for that person just testifying is justice.

“Sometimes justice is the defendant being held responsible to some level that the victim is satisfied. Yes, they’re going to be held responsible for their crime.”

But prosecutors also feel personally invested in these cases.

“For me as a prosecutor, when I try somebody for one of these crimes and the jury comes back not guilty, in my mind they are getting away with it,” Bell said.

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