Sen. Phil Berger

There's sign with red letters that says "Emergency Trauma Center." That sign is near the entrance to the New Hanover Regional Medical Center ER

‘Behavioral health emergency’: NC health organizations ask state leaders for help

June 25, 2021 by Taylor Knopf

‘Behavioral health emergency’: NC health organizations ask state leaders for help - North Carolina Health News

The heightened demand for behavioral health services due to the COVID-19 pandemic is crashing down on North Carolina’s already fractured mental health system. Hospitals and health leaders are calling for emergency help.

By Taylor Knopf

Some of the state’s top health organizations are asking North Carolina leaders for a meeting to address what they’re calling a “behavioral health emergency.”

The COVID-19 pandemic caused immeasurable stress and loss, resulting in more people needing mental health services. The demand increase has strained North Carolina’s already fractured mental health system.

People who struggle to access mental health services when they first experience symptoms frequently end up in crisis and find themselves in jail or the emergency room. During the pandemic, North Carolinians flooded ERs looking for help, particularly for children, according to the North Carolina Healthcare Association.

The rate of kids in the emergency room because of a behavioral health concern nearly doubled in 2020. By December, the rate of emergency room discharges for pediatric patients with a behavioral health condition had increased by 70 percent over the prior year, according to the NCHA’s patient data system.

“That’s alarming to us,” said NCHA lobbyist Nicholle Karim. “We know that the system was already strained prior to COVID-19, and now we’re seeing a growing need, particularly around children and youth coming into EDs or needing to access services for the first time.”

Warning flare fired

NCHA and 11 other leading health organizations outlined these concerns in a letter to state leaders last week, calling on both public and private entities to work together and look at ways to improve access to mental health services in the state, Karim said.

Spokespeople for the governor and senate leader said they have received the letter. Gov. Roy Cooper’s office is working on a response and Sen. Phil Berger’s spokesperson said he is “open to meeting with the organizations to discuss the letter and their concerns.”

This graph compares the rate of pediatric patients discharged from emergency rooms across North Carolina between 2019 and 2020. These are children who were primarily at the hospital for a behavioral health concern. Data and graph courtesy of the NC Health Care Association

The letter points out that North Carolina ranks 44th nationally in access to mental health care, according to Mental Health America’s 2021 report. The same report ranked the state 45th overall for pediatric mental health care.

Additionally, the letter references a 91 percent increase in involuntary commitments over the past decade, even before the pandemic hit. This trend was first reported by NC Health News after advocates dug up IVC data that was not publically available.

“It was already a crisis, and now it feels like it’s reaching an emergency where we cannot ignore this anymore,” Karim said.

Hospital leaders across the state have reached out to the healthcare association to express their concerns, saying that the behavioral health care trends they see are not sustainable, Karim said.

“From the hospital perspective, the over-utilization of emergency rooms is a canary in the coal mine, so to speak,” she explained.

She said more people are using emergency rooms as a safety net, which “generally signals that something else is going on in the system that we all need to pay attention to.”

While lack of access to behavioral health services and mental health patients filling emergency rooms are problems that have existed for decades, they are heightened under the weight of the pandemic, Karim said.

Support from the business community

Business leaders are also concerned about this trend because they know their employees have been through a lot over the past year and a half and may struggle to bounce back at work.

The NC Chamber, which advocates on behalf of the state’s business community, also signed on to the letter asking for a meeting with state leaders to discuss the behavioral health crisis.

“Our most immediate concern is how do we address the needs, how do we identify them and how do we connect businesses of all sizes with the mental health system and with their local health care system to start the process,” said Gary Salamido, NC Chamber president and CEO, during a phone interview.

He added that business leaders are acutely aware that their employees have been impacted by loss, prolonged isolation, and caring for additional family members during the pandemic.

“When people have support, we can make great strides in our state,” Salamido said. “Our physical health, our fiscal health, and our mental health is a key to North Carolina being a great place to live, grow, work and raise your family.”

This graph compares the rate of adult patients discharged from emergency rooms across North Carolina between 2019 and 2020. These are patients who were primarily at the hospital for a behavioral health concern. Data and graph courtesy of the NC Health Care Association

Including people with mental illness

In order to truly address the many issues facing North Carolina’s mental health system, long-time advocate Laurie Coker said the state must bring people with lived mental health experience, herself included, into the conversation.

“We have found that we have by and large been excluded from any of the discussions where the plans are being made for how to implement mental health services,” Coker said during a community discussion on the overuse of involuntary commitments hosted by NC Health News.

“So we don’t have a very well-informed system, and therefore all the little things that look like on paper — that are supposed to be helping myself and my peers — they’re not working. And we have no way of giving feedback to help them get better.”

Coker said that many people have struggled to access services or have not benefited from them, so they just drop out of the system altogether.

“What we’re seeing right now is things are really coming home to roost,” she said. “It’s not like the system was really working well before.

“We need to think about how to make services accessible and welcoming to people early on, before they go into crisis,” Coker concluded.

shows three politicians who are usually at odds on the same dias, they're there in order to sign bills to provide COVID relief

State Senate presents budget, with a bump up in spending for health and human services

June 23, 2021 by Mona Dougani

State Senate presents budget, with a bump up in spending for health and human services - North Carolina Health News

The budget proposal expands Medicaid coverage for postpartum women, but leaves many other uninsured North Carolinians behind.

By Greg Barnes, Anne Blythe, Mona Dougani, Rose Hoban

In a much-delayed and much-anticipated bill, the state Senate presented their proposed biennial budget on Monday that includes billions of dollars to shift North Carolina’s Medicaid system from one run by the state to a new apparatus largely run by private managed-care insurance organizations.

“Our nonpartisan fiscal analyst told us that we had an even bigger surplus than we initially thought,” Senate leader Phil Berger, an Eden Republican, said during a press briefing Monday before releasing the spending plan. “The Senate is proposing to reduce taxes even more and advance a 10-year $12 billion cash infrastructure and capital plan that includes $3 billion in cash over the next two years for projects.”

The $25.7 billion proposal would reduce tax rates for individuals and families, as well as phase out the corporate income tax in North Carolina. State coffers are temporarily overflowing with billions in federal coronavirus relief spending, courtesy of the American Rescue Plan, a $1.9 trillion bill passed by the U.S. Congress and signed into law by President Joe Biden in March.

Despite federal incentives, the Republican-majority legislative body defied Democratic Gov. Roy Cooper once again, refusing to fund one of his long-held priorities, namely expanding the state’s Medicaid program to sweep in more than a half-million uninsured state residents who are mostly low-income workers.

“The offer from the feds is additional one-time funds,” responded Sen. Ralph Hise (R-Spruce Pine) when asked about why there was no expansion during a press conference Monday afternoon. “We’ve made the same arguments about not expanding Medicaid for a lot of years now.

“We felt very important that our real focus instead of just finding general population to expand to was to focus on those of the greatest need.”

“For no additional state tax dollars, we can expand Medicaid which would insure more than half a million working people, reduce businesses private insurance premiums, expand mental health services, help save rural hospitals and create thousands of new jobs,” retorted Mary Scott Winstead, from Cooper’s office in an email. “Republican leaders have told the Governor that Medicaid Expansion is still on the table for negotiations even though they have not included it in their own budgets.”

The Senate proposal does extend Medicaid benefits for low-income pregnant women. Currently, their Medicaid benefits expire 60 days after they’ve given birth, but the American Rescue Plan allows for states to extend those benefits for a year, with the program beginning in April 2022 and available to states for five years. According to the Kaiser Family Foundation, this could result in fewer uninsured low-income mothers.

“Many of the conditions that account for a significant share of pregnancy-related mortality and morbidity, such as cardiovascular diseases, hypertension, and depression often require care over a longer-term,” a KFF review states.

The budget also would add 1,000 slots for people with disabilities to receive enhanced community services under the Innovations Waiver, which has a current 10-year waiting list of more than 15,000 people. The spending plan also allows for people who have children in the foster care system to retain their Medicaid benefits, so long as they’re in a treatment program or “making reasonable efforts to comply with a court-ordered plan of reunification” that would eventually return them to their children.

Increased wages for direct care workers

The proposed Senate budget includes bumping wages to $15 an hour only for the state employees working in intermediate care facilities that serve individuals with mental health and intellectual disabilities.

Other direct care workers not employed by the state of North Carolina would receive a one-time bonus of $1,500 if employed by eligible providers who are enrolled in the Medicaid or North Carolina Health Choice program.

Rep. Tim Moffit (R-Hendersonville) supported HB 665, the Address Direct Sup. Staffing Crisis/Medicaid bill, and who championed HB 914, a measure to provide boosted Medicaid reimbursement for non-state agencies providing care for people with disabilities. He said he did not have any opinion on the proposed Senate budget yet.

“Their budget was released last night, and I’ve not had a chance to review their budget,” Moffit said. “I’m not sure what they’re providing for in their budget… I really don’t have any comment regarding that.”

Currently in North Carolina, the average hourly wage for direct care workers is $10.31/hour making it difficult for facilities to hire and retain staff.

In the proposed budget, senators insisted that 80 percent of the direct care worker increase be allocated to those workers’ salaries. The remaining 20 percent of funds could go to supervisor salary, pensions, health benefits, facility maintenance and more.

Some advocates worry that this could cause wage compression, resulting in supervisors and direct care workers receiving similar wages.

“If you raise the hourly wage of the worker, what about the supervisor,” said Rep. Gale Adcock (D-Cary), a nurse practitioner. “Then you lose your most experienced supervisory staff.”

“Those of us who don’t provide this, these services, and deal with this business model shouldn’t be the ones telling the people who do it, how to do it.”

A total of $17,500,000 will be used to provide the rate increase for state direct care workers for the 2022-2023 fiscal year.

Money to improve school buildings

The senate’s proposed budget would allocate $150 million in one-time funding to test and remove lead found in excessive concentrations in public schools and child care centers. Removal of asbestos from the schools and child care facilities would also be part of the appropriation.

“Right now there’s no funding for schools to do testing and mitigation for lead in drinking water. It would be an enormous support to allow schools to get the testing that they need and then also pay for mitigation,” said Jennifer Hoponick Redmon, a senior environmental health scientist and chemical risk assessment specialist with RTI International in Research Triangle Park.

RTI, along with the state’s Division of Public Health, have now tested nearly all of the licensed child care centers in North Carolina for lead in drinking water. Hoponick Redmon said 9 percent of the 3,000 centers and Head Start programs tested had lead levels exceeding the 15 parts per billion threshold the U.S. Environmental Protection Agency considers safe to drink.

In 2019, the Charlotte-Mecklenburg school system tested for lead in water used for drinking and cooking at its schools. The testing found that 41 of 89 schools had taps exceeding the EPA’s lead limit of 15 parts per billion.

The testing is being done largely through an EPA grant. Researchers are advising centers on how to remove the lead from their faucets, but it is up to the centers to take remedial action, Hoponick Redmon said.

The EPA has not provided funding to test for lead in public schools, but researchers know the contaminant is present in some of them, especially in schools built before a federal law approved in 1986 banned lead use in pipes and fittings.

Under the Senate’s budget proposal, $32.8 million of the $150 million would be used for lead testing and remediation. The budget bill creates a mechanism to provide funding to replace lines, pipes and fixtures found to contain the heavy metal.

Children are especially vulnerable to high lead concentrations. Exposure can damage their nervous systems and cause learning disabilities, stunted growth, hearing loss, low IQ, increased aggression, and impaired formation and function of blood cells.

Asbestos, a known carcinogen, has also become a growing concern, especially in older schools. It can be found in construction materials behind walls, above ceilings and under floors. Asbestos becomes a problem when its fibers come loose and can be inhaled.

According to the EPA, asbestos fibers can cause serious health problems. If inhaled, they can disrupt the normal functioning of the lungs. Three specific diseases – asbestosis, lung cancer, and another cancer known as mesothelioma – have been linked to asbestos exposure. A federal study in 2015 found that two-thirds of more than 5,000 schools tested contained asbestos.

The remaining $117.2 million of the appropriation would be used to fund a program for lead paint abatement and asbestos removal in the schools and child care centers.

Beyond child care pandemic woes

Child care centers were hit hard during the pandemic, highlighting an industry that’s crucial to keeping the economy churning while also exposing this necessary societal infrastructure that often lacks the support it needs from state and federal governments.

Many centers operate on very thin margins, trying to keep costs for parents as low as possible while also working to bring in enough money to attract a faithful and helpful workforce.

Such a financial model means many centers in North Carolina can only offer staff $10 to $13 an hour, a wage that can’t compete with what some fast food restaurants and other jobs offer.

The Senate spending proposal makes a nod to the issue, albeit a slight one, according to early childhood education advocates.

The plan proposes to put $1.7 million in each of the two fiscal years to increase base reimbursement rates for child care centers participating in the state Department of Health and Human Services North Carolina Prekindergarten Program by 2 percent from last year’s rates and an additional 2 percent next fiscal year.

The intent, according to the Senate bill, is for the additional funds to “be used to increase the salaries of teachers working in child care centers as a means to address disparities in teacher salaries among teachers working in child care centers versus those working in public schools or Head Start centers.”

“I think it’s a good step forward,” Michelle Rivest, senior campaign director for the North Carolina Early Education Coalition, said on Tuesday. “It’s a good step, a small step forward in recognition, that we don’t have equity in pay for public or private early childhood educators.”

She pointed out, though, that “$1.7 million won’t go far.”

The Senate plan includes some $20 million for start-up grants for NC pre-K classrooms and child care centers across the state after it was exposed recently that some 30 counties did not have the infrastructure to expand Pre-K programs.

Rivest also was happy to see that Smart Start, an early childhood education program, would receive $15 million in one-time state funds.

“It really is an important step forward for Smart Start,” Rivest added.

Many advocates for an early childhood education program relied on by more than 60 percent of North Carolina families have been pushing for a broader discussion on government subsidies.

They were optimistic that such talk might materialize after the administration of President Joe Biden announced in April that $39 billion in federal aid coming to states should be used to “address the child care crisis caused by COVID-19.” North Carolina’s share was $1.3 billion.

Some of that federal money was included in the Senate’s proposed spending plan to help stabilize the child care industry. The question is what happens after that money is not available.

Other proposed budget appropriations:

$15 million for research into PFAS and a dozen new positions at the state Department of Environmental Quality for research into emerging compounds such as GenX.
$30 million to fund the legislature’s GREAT program, as well as $700 million in federal dollars to improve rural broadband.
$1 billion in federal American Rescue Plan spending on water and sewer grants to local governments
$250,000 in the next fiscal year only for grants to schools for feminine hygiene products for students.
$30 million to the North Carolina Policy Collaboratory for COVID research grants, including up to $18 million to the Rapidly Emerging Antiviral Drug Development Initiative at the University of North Carolina at Chapel Hill.
$5.9 million over the two-year period to the residency program at the East Carolina University Brody School of Medicine.
$7 million to Wake Forest Institute for Regenerative Medicine for a research project to accelerate the development of treatment to harmful chemical and biological agents.

shows the front of the legislative building in Raleigh, general assembly

Legislative leaders press pause on PED reports, could skew analysis on state health care spending

April 7, 2021 by Thomas Goldsmith

Legislative leaders press pause on PED reports, could skew analysis on state health care spending - North Carolina Health News

Despite a history of reports sparking changes, the legislature wants more member involvement in oversight. But the analysis will now be performed by partisan staffers.

By Thomas Goldsmith and Rose Hoban

In 2016, the state prisons’ medical system was allowing millions to slip away by passing up federal discounts from costly inmates’ prescriptions, a legislative watchdog team observed.

Then came a pointed report from the agency, the Program Evaluation Division, that brought about a mandate for change in 2018. And legislation changing the practice resulted the next year.

Despite legislators’ agreement that the PED report was of value and their action based on it, this February, the legislature’s leadership dissolved the division, laying off its staff and suggesting that politically appointed committee staffers could do the work instead.

One of the last reports generated by the Program Evaluation Division started to look at how billions in federal CARES Act coronavirus relief dollars were spent around the state. Included in that analysis were breakdowns of allocations made to hospitals under the state’s General Hospital Relief Fund ($15 million) and the Rural Hospitals Relief Fund ($65 million). Data courtesy: PED; Map: Liora Engel-Smith

All the work is still on the legislative website, for those who know how to find it. But easy links to sharp critiques and piercing analysis of state programs is now even harder to find.

In announcing the change, Republican leaders suggested that legislators should have more input into the evaluation process, which state agencies have sometimes found lacking in including knowledge of the reasons things are done.

“The leadership of the North Carolina General Assembly has decided to end the current operations of the Program Evaluation Division and take the oversight and audit functions in a new direction, giving members more involvement in the oversight,” an announcement of the move said.

“All current study projects and inquiries are being suspended for the immediate future.”

The prison medical system research was only one of multiple health care-related studies generated by the division, which had been in existence since 2007.

Sometimes unwelcome conclusions

This year, PED had multiple health care-related tasks on its work plan, a document that had been devised with the help of lawmakers. Planned projects included tracking where $3.6 billion in funding from the federal CARES Act and dispersed by the state had gone.

And the division was in the middle of an assessment of the state’s Medicaid Innovations Waiver program, which funds services and supports for Medicaid beneficiaries with intellectual and other developmental disabilities who are at risk for institutional care.

The program sometimes counseled against state support for an initiative it was asked to assess, which happened in several recent instances for health care initiatives examined by the organization.

One such conclusion was around a proposal to make permanent a pilot overnight respite service in adult day care facilities.

“PED identified several state-run facilities offering overnight respite at substantially lower rates than nearby adult day care facilities,” a 2016 report said.

In 2017, a report found that for North Carolina schools to meet national staffing standards for school nurses could cost $79 million a year.

“Of course, with the pandemic, we’ve got kids that are coming back into school right now that have, I’m sure, been exposed to many challenges in their lives, not just health related, but emotionally emotional situations in their families, and so forth,” said Rep. Cynthia Ball (D-Raleigh) who introduced a bill to fund school nurses in 2019 and this year.

“It would have meant a whole lot to have nurses this past year.”

By this year, the estimate to place a nurse in each of the state’s schools had grown to $102 million, according to a bill filed by Democrats in both the Senate and the House of Representatives.

And a report released last year found that the NC FAST software system developed under a state contract and designed to provide integrated applications for human services programs was functional, even as it was also difficult to use. PED analysts’ top conclusion was that issues in the child welfare system were not only attributable to the software, but that lack of consistency in practice and management was a hindrance to the state’s ability to implement a child welfare case management system.

This conclusion complicated the narrative around the software package.

Other health care related reports generated by PED in the past decade include:

A 2019 analysis of child welfare services screening and intake services that found the county-run system lacked consistency;
A 2018 look at disability services in schools that found little evidence of duplication of effort among school children with disabilities who were also Medicaid recipients. The report also found that the Department of Public Instruction was not performing systematic reviews of how effective services for children in the school system were;
A 2016 report which found Medicaid systems for identifying waste, fraud and abuse were inadequate, potentially costing the state millions annually;
A 2015 report which suggested the state could save $64 million annually by moving state-supported retirees to Medicare Advantage, a move eventually taken by the state Treasurer’s office;
A 2014 review of the state standards for opioid prescribing which made recommendations to strengthen guidelines and drive increased use of the Controlled Substances Reporting System.

Equivalent service?

Sen. Phil Berger, president pro tem of the Senate, and Rep. Tim Moore, House speaker, decided to discontinue the program.

Instead, if these issues are studied at all, they’ll be picked apart by staff members of a committee chaired by the two legislative leaders. The newly reconfigured Joint Legislative Commission on Government Operations will be staffed by analysts hired by members from the two political parties, according to a March report in the NC Insider, a legislative affairs newsletter.

This past week, the NC Insider reported there has not been movement on making hires to staff the replacement commission.

John Turcotte, former executive director of the program, worried that with analysts hired by the Democratic and Republican caucuses, the issues studied will turn into political footballs.

“I think that’s one thing that was driving this change, firing the PED staff, etc, because [legislative leaders] didn’t have direct control over the PED staff,” he said.

Turcotte had advised on the formulation of North Carolina’s Program Evaluation Division as it was being formed. Then he moved to North Carolina to run PED in 2007.

“In those days, you had a Democratic legislature overseeing a Democratic administration, and now we’ve got this highly partisan Republican legislature overseeing a Democratic administration,” Turcotte said.

“So I’m guessing that the whole process ends up being that much more politicized.”

Since 2007, the division had been sending investigators to look into more than 100 government functions at the official requests of state legislators.

It’s not likely that these newly hired legislative staff can achieve the same in-depth, on-site probes of state agencies achieved by the Program Evaluation Division, former state Rep. Craig Horn (R-Weddington) said in a telephone interview.

Retired from the General Assembly, Horn was co-chair for six years of the supervising Joint Legislative Program Evaluation oversight committee.

“You still have to have someone do the research,” Horn said. “Legislators are not known personally for their deep dives.

“I don’t see how this is going to save the state any money, nor in my own opinion, will it add any particular efficiencies.”

Horn wants to know who will conduct the hard research that it takes to make sure state projects aren’t spending millions unnecessarily.

Exhaustive work

A spokesman for Moore told the Associated Press that staff of joint legislative committees could make sure that state agencies provide information in full and on time. Attempts were unsuccessful to reach Berger and Paul Coble, a former Raleigh mayor who was involved in the move as director of Legislative Services.

Turcotte said its work couldn’t be replaced by committee staff or the Fiscal Research Division of the legislature. The fiscal research staff, he said, remains in high demand during, before and after legislative sessions, leaving them with no time or inclination to do field work, he said in an interview.

“They’re trying to get information from OSBM (Office of State Budget and Management) and from the agencies, and to work with the agencies and the legislators and craft a legislative version of the budget. It’s exhaustive work,” Turcotte said.

“But they don’t do statewide surveys; they don’t do site inspections. An agency might take them to one of their facilities and show them around stuff. But it’s not anything like we would do.”

Turcotte wondered what agency would do the analysis of how effectively North Carolina spent federal dollars sent to address the coronavirus pandemic in 2020. Congress passed three multi-billion dollar spending packages which totaled more than $6 billion coming to North Carolina.

In one of its last reports, PED detailed North Carolina’s spending from the Coronavirus Relief Fund created when the federal CARES Act – Coronavirus Relief Fund allocated $3.6 billion to North Carolina. That money was appropriated by the General Assembly across more than 130 state departments and divisions.

The division was able to produce a high level report on spending to counties, hospitals and other health care providers. But a deeper understanding of the spending may end up taking more time, and be more opaque, without PED’s analysis.

shows a man at a podium holding up a face mask used as a COVID preventive as he speaks from behind a podium.

Gov. Roy Cooper’s proposed budget could get things hopping in the legislature

March 25, 2021 by Editor

Gov. Roy Cooper’s proposed budget could get things hopping in the legislature - North Carolina Health News

The legislature started out slowly this year, but will negotiations between the GOP and Democrats about Medicaid expansion kickstart other priorities?

By Anne Blythe, Thomas Goldsmith, Rose Hoban, Taylor Knopf

Two weeks have passed since Gov. Roy Cooper stood with Democratic and Republican lawmakers outside the North Carolina Museum of History to announce that, in a new spirit of bipartisan negotiating, both sides of the aisle had come to consensus on how and when to reopen the state’s public schools.

On Wednesday, Cooper presented his proposed biennial state budget that called for spending $27.4 billion in the next fiscal year that begins July 1, and $28.5 billion for the fiscal year after that.

The governor’s proposal calls for expanding Medicaid and giving teachers higher raises than other state employees, hot-button political issues that created an impasse between the Democratic governor and Republican lawmakers and left the state without an orthodox two-year budget in 2019.

Since the 2020 election in which North Carolina voters again elected a Democratic governor while filling both General Assembly chambers with Republican majorities, lawmakers and the governor have made noises about trying to work together more.

The months ahead will tell whether the historic moment displayed outside the history museum two weeks ago is a harbinger of a more bipartisan future, or if the budget process once again will break down along party lines.

“Unlike the last budget cycle that we had, I have had numerous conversations with both Republican and Democratic leadership,” Cooper said during a briefing with reporters Wednesday. “One thing we agreed on is, first, the people of North Carolina elected us again so we’re back in the same situation that we were, and we owe to them to do the best that we can to find a path forward. We’ve all agreed that everything is on the table.”

Trying to persuade Sen. Phil Berger, the Rockingham County Republican leading the state Senate, to change his mind could prove difficult.

In an interview with the Associated Press a week ago, Berger dampened the enthusiasm among Democrats and some Republicans for the substantial incentives contained in the American Rescue Plan for states that have yet to expand Medicaid as allowed under the Affordable Care Act. The federal COVID-19 relief package would direct some $1.7 billion to North Carolina over the next two years if the state enacts the policy.

While acknowledging some gaps in health care coverage during the Associated Press interview, Berger described the federal assistance as temporary aid that might create a new level of dependence on government for able-bodied adults.

Charlie Perusse, the state budget director, added context for how the carrot being offered by the federal government could be used.

In North Carolina, that would mean some 600,000 people who are low-income workers without health insurance, people with disabilities and others who don’t now qualify for Medicaid, would have access to health care under the expanded federal program. The state would owe between $350 million to $400 million per year, Perusse estimated, for its share of the expanded coverage.

If North Carolina, one of 12 states to resist Medicaid expansion, received the $1.7 billion from the federal government, Perusse added, the state could cover its share of the expansion costs for four to five years without having to consider looking for a new revenue source or assessing health care providers.

“This is a very good incentive that the feds are providing us,” Perusse said. “There’s no better time than the present to expand Medicaid.”

GOP responds

After many school children did remote learning for nearly a year because of the COVID-19 pandemic, Cooper’s plan directs some $80 million to help the state’s 115 school districts hire more nurses, psychologists, social workers and counselors. Democrats in the legislature filed a bill to fund nurses this week and another one to fund school mental health professionals in February.

Cooper recommends putting a $4.7 billion general obligation bond on the November 2021 ballot to help public schools meet infrastructure needs, to do health and safety projects and more at UNC System campuses and more.

Cooper’s plan does not call for a tax increase.

Nonetheless, Republicans, who are weighing the possibility of income and corporate tax cuts, quickly responded to the Cooper proposal with concerns, raising questions about how much room there is for negotiations in the months ahead.

“We have concerns about the very high spending growth and billions in borrowing in Gov. Cooper’s proposed budget,” Sen. Brent Jackson, a Sampson County Republican and Senate budget writer, said in a prepared statement posted to Senator Berger Press Shop. “We don’t want to return to an era of rollercoaster-style budgets with huge spikes in the boom years followed by huge cuts in the lean years.

“Thanks to a decade of predictable, responsible budgeting, North Carolina weathered the COVID-19 pandemic and recession without cutting state services or freezing teacher pay.”

The lawmaker concluded his statement with an olive branch, of sorts.

“We look forward to working together to achieve an enacted budget,” Jackson said.

Starting to perk

Just a short hike from the governor’s Capitol offices, the General Assembly building on Jones Street typically bustles with lobbyists and lawmakers, but this year the scene has been unusually quiet. Most office doors were closed this week, only a handful of people hung around in areas usually humming with activity.

“Lobbying is about being down at the building, being in the committee rooms and meeting with legislators in the elevator or hallway,” said Valerie Arendt, a registered lobbyist for the NC Chapter of the National Association of Social Workers. “A lot of us are not prepared to do that because of COVID. Some legislators are willing to meet with us virtually and some are asking us to come into the office.”

She said that’s made her job harder.

But now that lawmakers, lobbyists, staff, and even members of the media are getting vaccinated against COVID-19, people are beginning to drift back into the building.

“People seem to be coming back. A bit more each week,” texted Cone Health lobbyist Ryan Blackledge.

Nonetheless, lobbyists and advocates have been making their priorities known, albeit less efficiently.

“There’s texts, there are phone calls, there are the painful Zoom meetings,” said Blackledge in a later call. He talked about the things he couldn’t do, “like after a committee meeting, grabbing three other people, getting the bill sponsor and having a three-minute conversation where you fix something that would take hours texting back and forth between people.”

Mental health funding priorities

When the pandemic hit and the need for mental health and substance use treatment services surged, North Carolina’s provider organizations were already at a disadvantage, according to advocates.

Because state legislators were unable to pass a new budget in 2019 or 2020, some programs were left hanging.

“New programming couldn’t come to fruition, and it was harder for programs to pivot and meet the new needs when the pandemic hit,” Arendt said.

Due to pandemic-related hardships and job losses, North Carolina saw an increase in Medicaid enrollment last year, Arendt said.

“There’s going to be a tsunami of behavioral health needs because of the pandemic, even if everyone does get vaccinated and things go ‘back to normal,’” Arendt said. “Folks are going to need mental health and substance use services for a long time.”

This increase in demand comes on the heels of five years of cuts — totaling $500 million — to mental health single-stream funding, the money set aside for people with critical behavioral health needs and intellectual and developmental disabilities. Cuts and use of this funding received a good deal of scrutiny from the state auditor in 2019.

In a letter to lawmakers, Arendt listed the state’s mental health budget needs and priorities on behalf of more than 30 organizations that make up The Coalition on Mental Health, Intellectual and Developmental Disabilities, and Substance Use Disorders.

“As a collective voice, we are louder,” she said of the coalition, which has jointly advocated for the mental health needs of North Carolinians for several decades.

Headlining their list of 14 budget priorities is the need for lawmakers to restore the single stream funding.

The coalition also requests that the 5 percent Medicaid provider rate increase allowed by federal and state lawmakers in response to the COVID-19 pandemic be extended to providers working in mental health, IDD and substance use.

“[Our] providers are experiencing the same financial stress as hospitals, nursing homes, and primary care physician practices,” Arendt wrote to lawmakers.

“Clinics are competing for expensive PPE resources, implementing special COVID infection prevention measures for clients living in congregate settings, and struggling to keep their direct care workers employed and their patient or client populations out of hospital emergency rooms,” she said. “More support is needed so that current services do not have to end.”

Helping older North Carolinians

A raft of significant legislation for older North Carolinians also fell along the wayside in 2020. Their advocates are hoping to make up some of that lost ground in the wake of the pandemic, which proved so devastating to so many older people.

Heather Burkhardt, executive director of the North Carolina Coalition on Aging, said the pandemic “shed light on existing lack of funding, certainly for home- and community-based services for older adults to be able to get adequate care in their homes, and the support needed for family caregivers.”

A product of the Older Americans Act and state funding, Home and Community Care Block Grants are parceled out to counties for needs including senior centers, congregate meals, transportation, respite care, and adult protective services. A “waitlist” for the services has stood at 10,000 people for years, but the demand likely exceeds that level.

Among other services that will seek funding are Community Alternatives Program for Disabled Adults (CAP/DA) and Program for All-Inclusive Care for the Elderly (PACE).

Also missing the cut was a bill pushed by Rep. Donna White (R-Clayton) that would have created a task force to look at the growing number of caregivers in the state.

NC Adult Protective Services is required to work in each North Carolina county to make sure vulnerable people remain safe from physical, mental or financial abuse. Despite mandating the work, the state picks up only a small portion of the cost, with major support flowing from already strapped counties and the federal government.

“By 2025, 89 counties in North Carolina are projected to have more people aged 60 years of age than 17 years and under,” the independent North Carolina Senior Tar Heel Legislature said in its list of upcoming priorities. “Many of these adults may be at risk of becoming victims of abuse, neglect or exploitation.”

A provision that’s been ripe for change for many years almost crossed the finish line in 2019 that would have increased the Personal Needs Allowance, money which residents of skilled nursing and assisted living homes use to buy cigarettes, toiletries, transportation and many other needs not covered by long-term care funding.

Advocates hope the Personal Needs Allowance provision isn’t the only priority left over from the past two years that receives some long overdue attention during this legislative session.

shows a man in a suit sitting at a desk signing a paper that strengthens Medicaid, in the background, a woman in a mask to prevent COVID transmission stands, watching.

The federal pandemic relief bill contains a big carrot to expand Medicaid. Will North Carolina bite?

March 18, 2021 by Rose Hoban

The federal pandemic relief bill contains a big carrot to expand Medicaid. Will North Carolina bite? - North Carolina Health News

The bill includes substantial incentives for states to expand Medicaid, as well as provide spending boosts to improve care for new moms, people with disabilities. But only if lawmakers in Raleigh say yes.

By Rose Hoban

For the third year in a row, leaders from rural parts of North Carolina came out to say that they believe the state should move to close the health care coverage gap that’s only widened since the start of the pandemic.

In a statement released on March 4, the five rural members of Gov. Roy Cooper’s Council on Health Care Coverage, which met throughout the winter, said they believed the answer was “obvious.”

That answer was to expand Medicaid.

Since 2013, the option to add more than 500,000 low-income North Carolinians to Medicaid has been on the table. But Republicans in the legislature have firmly resisted this policy, one of the most significant aspects of President Barack Obama’s landmark law, the Affordable Care Act (often called Obamacare). In the past year, countless numbers of North Carolina workers have lost their jobs, and their health coverage with it, because of the pandemic. That’s made the issue of expansion that much more urgent, as the probable number of people who would benefit from the policy has climbed.

By now, 38 other states have made the move to expand Medicaid, including a number of Republican-led states, including Montana, Oklahoma, Idaho and Ohio.

Now, another landmark piece of legislation, the American Rescue Plan (ARP), signed into law by President Joe Biden last week, provides substantial incentives for the holdout states to finally expand. The question is, will North Carolina legislators, who have firmly resisted expansion in the past, take the plunge?

Cooper has said he’s hopeful. In an interview with Politico, he said he’s been meeting with Republican leaders of the General Assembly hopes he can make a “grand bargain” with them.

NC Health News asked for comment from the offices of Senate leader Phil Berger (R-Eden) and House of Representatives Speaker Tim Moore (R-Kings Mountain) but has not received a response.

Mo’ money

The ARP amps up the incentives to Medicaid expansion in several ways, most of which include providing states with a lot more money, more flexibility or both.

The biggest chunk of change could come if North Carolina decided to allow those extra people onto the program.

For the past few years, states that expanded Medicaid have had the federal government pick up 90 percent of the costs for people earning up to 138 percent of the federal poverty line, which comes out to about $26,500 in annual income for a family of four. States that acted earlier had an even higher percentage paid by federal dollars for the first few years.

The incentive for states to add people onto their Medicaid rolls doesn’t come with adding extra dollars to pay for the expansion population, many of whom are low-income workers who are likely healthier than many of the traditional Medicaid adults – people with disabilities, low-income seniors, people who are blind. Instead, the ARP’s incentive is to pay more for those more expensive people.

“Which, actually, is more money in many states,” said Hemi Tewarson, a visiting policy fellow at the Duke Margolis Center for Health Policy. “It’s some of the other populations that are covered by Medicaid that can be more costly.”

bars represent Medicaid recipients: children, people with disabilities, pregnant women, elderly. Health, working aged adults are not eligible — Graph courtesy: Duke Margolis Center for Health Policy

Usually, the federal government pays the lion’s share for these “regular” Medicaid beneficiaries. In North Carolina, the federal government usually pays 67.62 percent out of every dollar spent on care. Since the passage of the Families First Coronavirus Response Act in early 2020, that percentage was bumped up for every state through the end of the federal emergency declaration, meaning that right now, the feds pick up close to 74 percent of each Medicaid dollar spent in North Carolina.

The American Rescue Plan would increase that even more, adding another 5 percent of federal matching dollars for two years after initiation of the policy. An estimate by the Kaiser Family Foundation found that for North Carolina, that boost to the bottom line would be about $1.7 billion overall, while the cost to the state would be about a half-billion dollars a year, a net gain of as much as $1.2 billion for the state.

State Medicaid director Dave Richard said his office’s estimate of the costs to the state is higher, in the neighborhood of $700 million, before any offsets that could take the form of a tax on insurers or hospital assessments, both of which were proposed in recent years.

Either way, there’s a lot of money on the table.

“There’s 1.2 million people uninsured in North Carolina, that’s a lot of people,” Tewarson said. “I think there’s a sincere interest in sort of doing something to address that. And, you know, this gives them some more money.”

“States already have a very good incentive to expand the 90 percent match,” said Edwin Park, a researcher at the Georgetown University Center for Children and Families. “This is an additional incentive to entice states to expand to finally get them over the line.”

Park said that any argument made against this incentive by state lawmakers, at this point, is not about finances.

“This is something else, you know, an ideological opposition that can’t be swayed by the numbers one way or the other because this is clearly going to be a big net win for the state in terms of its budget,” he said.

Resistance cracks in other states

Tewarson came to the Duke Margolis Center from the National Governors Association, where she was a health policy analyst. She said that of the 38 states that had already expanded, all of those governors felt they were able to continue paying for the expansion programs once any incentives expired, politics notwithstanding.

“[In] Montana, in Ohio, in Arizona, that have expanded earlier, I think they found that these investments have led to some really good coverage options for people in their states,” she said.

“Providers were able to expand operations and things like behavioral health, they were able to redirect state funding that had been focused on paying for some of those programs into other programs, which is helpful to make broader investments in healthcare and beyond health care.”

Park said that in some states the numbers had already become too compelling to ignore, even before the ARP dangled this new carrot in front of governors and legislatures in the holdout states.

“Wyoming, for example, reported out a Medicaid expansion bill out of committee, and obviously a very Republican legislature,” he said. “It’s headed toward the floor of one of their houses.”

He said there’s also a movement toward expansion in Alabama, which, like most other southern states, has resisted enacting the policy.

“The governor, unlike some other Republican governors hasn’t rejected it out of hand,” he said, noting that one or two states per year have opted into the policy.

“Hopefully this will, sort of, grease the wheels a little bit, overcome some opposition, because it’s such a good deal for states,” he said. “It was already a good deal. But this is an unequivocably great deal for states.”

“Medicaid expansion is extremely popular in North Carolina. And we’ve seen other red states pass it and pass it through referendum, we know people understand it, and why it’s important,” Cooper told Politico.

Extra coverage for new moms

Also included in the American Rescue Plan is an incentive targeted at helping address issues of maternal mortality in the U.S. About 700 women die after giving birth annually in this country, and the maternal death rate in the U.S. easily dwarfs the rate in other developed countries.

graph showing other countries represented by blue bars. The U.S. bar, represented in orange, doubles the rate of the next highest country — Other developed countries do a much better job at keeping new mothers healthy throughout pregnancy and beyond birth.
Data: OECD Health Data 2020, showing data for 2018 except 2017 for Switzerland and the UK; 2016 for New Zealand; 2012 for France.
Graph courtesy: The Commonwealth Fund

A paper prepared by the Commonwealth Fund last fall details how only fewer than half of maternal deaths happen during pregnancy or on the day a woman gives birth.

“The vast majority of pregnancy-related deaths occur after delivery,” said Mara Youdelman, an attorney with the National Health Law Program. “While about 21 percent [of deaths] occur between one and six weeks postpartum, 12 percent occur after that time.”

In North Carolina, the maternal mortality rate is around 27 women per 100,000 live births, according to America’s Health Rankings. For Black women, that number jumps to an eye-popping 56.8 per 100,000.

Federal rules currently allow states to use Medicaid to cover pregnant women up to birth and for 60 days afterward. That’s what North Carolina does, providing the benefit for women earning up to about twice the national poverty level, an annual income of $25,760 for a single woman.

In states that have expanded Medicaid already, women don’t need to be pregnant to get coverage, and so can continue with extended postpartum care.

“In Medicaid non-expansion states, like North Carolina, after the postpartum period, the person could lose Medicaid and may not understand that they could go to the marketplace and get coverage,” Youdelman explained.

But the COVID relief bill allows for states to extend that time period for up to a year, starting in April 2022.

This new ability to cover for the entire first year after pregnancy could go a long way to reducing complications that can lead to death in new mothers, Youdelman said.

Richard, the state Medicaid head, said he heard support for this kind of move during the governor’s health care council meetings this winter.

“I think that one probably has broad support across, you know, both Republican and Democrat legislators,” he said. “Certainly, we believe that’s absolutely an appropriate change in Medicaid to go forward.”

Richard said he’s cautiously optimistic that North Carolina will take advantage of this provision in the federal bill. He said that during the health care council meetings getting more coverage for postpartum women was one of the places for consensus.

The catch in the ARP is that this extended pregnancy benefit would expire after five years.

By then“a couple years of data will show that maybe it’s chipping away at the maternal mortality issue,” Youdelman said. “Then states will be induced to say, ‘Hey, it doesn’t cost too much, because most of these women are relatively healthy.’”

shows a man with a mask on rolling up his sleeve and receiving a COVID vaccine in his left arm as he looks ahead.

Coronavirus Today – March 9 – More than 1.1 million vaccinated with hugs on horizon; NC works on equitable distribution

March 9, 2021 by Anne Blythe

Coronavirus Today – March 9 – More than 1.1 million vaccinated with hugs on horizon; NC works on equitable distribution - North Carolina Health News

With nearly 10 percent of the NC population vaccinated, Gov. Roy Cooper offers cautious optimism.

By Anne Blythe

“Fast and fair.”

That’s how Gov. Roy Cooper describes the state’s mission to get coronavirus vaccines into as many arms across the state as possible.

In a state with more than 10.5 million people, nearly 1.1 million of them have been fully inoculated against the now not-so-novel coronavirus that upended so much of 2020 and continues to pose challenges and risks in 2021.

“This is a huge milestone,” Cooper told reporters at a briefing Tuesday afternoon. “This puts us even closer to a time when we can hug our loved ones and gather without fear of severe illness.”

The Centers for Disease Control and Prevention issued new guidance this week for vaccinated people, giving a go-ahead for the fully vaccinated to visit others who also are fully vaccinated without masking or distancing themselves as they have had to do for nearly a year.

The CDC even opened the door for fully vaccinated people to visit indoors with children, grandchildren and others in a different household if those still not inoculated are at low risk for serious illness from the virus. The agency still discourages any gatherings larger than those small one- and two- household events.

Since the arrival of vaccines from Pfizer, Moderna and Johnson & Johnson over the past three months, many in North Carolina are beginning to think about times ahead when children will be in school five days a week, families can gather for holidays, and some of the more valued aspects of pre-pandemic life return.

Many school districts have brought students back for in-person instruction, a measure that Cooper, state lawmakers and education leaders have pushed for nearly a month.

“With children back in school and vaccine distribution well on the way, there are more signs of hope that we are making progress toward putting this pandemic behind us,” Cooper said.

shows a woman in a black dress and a facemask receiving an injection of COVID vaccine in her right arm as she stares straight ahead. — Department of Health and Human Services Secretary Mandy Cohen received her COVID-19 vaccine at the Wake County Health Dept’s vaccination clinic last week at PNC Arena. Rev. William Barber also received a vaccine that day during a widely publicized event. Photo courtesy: NC DHHS

North Carolina, with a total 875,905 lab-confirmed cases, reported only 997 new cases on Tuesday, a large drop from the highs shortly after the Christmas and New Year’s holidays when nearly 11,000 new cases were reported in a day.

The percentage of tests coming back positive hovers at the 5 percent rate now, a level that public health officials say they can accept. The number of people hospitalized on Wednesday was 1,147, nearly a third of the cases of severe illness that filled hospital beds in January and parts of February, and about the same as the number in the hospital in October.

Cooper, who has taken a more cautious approach than many southern governors steering the state through the pandemic, counseled North Carolinians to stay the course, using masks where needed, keeping gatherings small and following the social distancing measures touted by public health officials.

A sports fan and former high school athlete, he used a football analogy to remind North Carolinians that while the other side of the pandemic might seem close, that milestone hasn’t been reached yet.

“You know there are times in football when the runner nears the goal line and begins celebrating too early and is stripped of the football,” Cooper said. “Let’s not get caught celebrating too early.”

Praise for vaccine data collection

Cooper has celebrated the national attention that North Carolina has received recently for providing racial and ethnic data for nearly 100 percent of the people vaccinated for the coronavirus.

Bloomberg News has pointed that accomplishment out in its nationwide vaccine tracker. The kudos come after state lawmakers, mostly Republicans, criticized Cohen and Cooper in early January for a slow vaccine rollout as county health departments and other providers complained about how cumbersome it was to enter information into the state database created to track the vaccine distribution.

On Tuesday, the state Department of Health and Human Services announced that its vaccine data dashboard would be expanded to include even more data with week-by-week county-level data on the race, ethnicity, gender and age of those vaccinated.

The dashboard also will break down the information so users can see the percent of the population fully vaccinated or partially vaccinated.

There are some limitations. The data by demographics does not include information on doses administered through federal programs.

Hugs ahead

Cooper and Mandy Cohen, DHHS secretary, received vaccines last week.

Cooper received a first dose of the Pfizer vaccine at WakeMed and Cohen received a Johnson & Johnson one-dose vaccine at the Wake County health department’s vaccination clinic at PNC Arena.

“My arm was sore and I did feel a little achy that evening,” Cohen said. “But the reaction was mild and it didn’t last long.”

Cohen will be fully protected from COVID-19 after two full weeks, she said.

“It’s a great feeling of relief,” Cohen added. “One and done.”

Cohen, who has spoken about having to miss Thanksgiving and other annual events with her family, said she looks forward to embracing her loved ones again.

“I’m looking forward to hugging my parents for the first time in more than a year,” Cohen said. “They are now fully vaccinated and will be visiting at the end of the month.”

Nonetheless, vaccinated people should still wear masks in grocery stores and around others not yet vaccinated, Cohen said.

More work needed to vaccinate Hispanic North Carolinians

Although North Carolina has received accolades for its collection of demographics on vaccine administration, both Cooper and Cohen acknowledged that works need to be done for more equitable distribution.

Black North Carolinians make up 23 percent of the population but represent only 16.2 percent of the people vaccinated, the DHHS dashboard shows.

Though Hispanic people make up nearly 10 percent of the population, only 3 percent have been vaccinated, according to the DHHS dashboard.

“It’s important to point out that you can’t know about a problem until you can see it,” Cooper said, crediting DHHS and Cohen’s team for building a vaccine database that collects race, ethnicity and more for each shot administered.

The state has been working with churches, community leaders and the federal government to set up vaccine clinics, including a Federal Emergency Management Agency clinic that opens in Greensboro on Wednesday and will get a visit from the governor.

“There has been strong, intentional effort,” Cooper said. “That number needs to get better.”

Who will decide about schools?

Before Cooper’s briefing with reporters, Sen. Phil Berger, a Rockingham County Republican and president pro tempore of the state senate, and Sen. Deena Ballard, a Watauga County Republican, held a briefing with reporters to give an update on negotiations over Senate Bill 37.

The bill is an attempt by mostly Republican lawmakers to force school districts across the state to open their doors for in-person instruction as long as there are online options for at-risk students.

Cooper vetoed the bill on Feb. 26, issuing the following statement: “Students learn best in the classroom and I have strongly urged all schools to open safely to in-person instruction and the vast majority of local school systems have done just that.

“However, Senate Bill 37 falls short in two critical areas. First, it allows students in middle and high school to go back into the classroom in violation of NC Department of Health and Human Services and CDC health guidelines. Second, it hinders local and state officials from protecting students and teachers during an emergency. As I have informed the Legislature, I would sign the bill if these two problems are fixed.”

Three days later, the state Senate failed to get the supermajority necessary to override Cooper’s veto. Democrat Ben Clark, a state senator representing Hoke and Cumberland counties, had been a sponsor of the bill but was absent for the override vote, leaving 29 votes supporting override with 20 against.

After the failed override, Cooper issued another statement.

“The question on SB 37 that I vetoed is not whether our children should be in the classroom in person,” Cooper said. “They absolutely should. The question is whether we do it safely.

“The bill allows middle and high school students to be in school without following NCDHHS and CDC guidelines on social distancing. SB 37 also removes authority from state and local officials to put students in remote learning in an emergency like a new COVID variant hitting our schools. I have asked legislative leaders to compromise with me on these two issues but so far they have not. I will continue talking with legislators and I will work diligently with the State Board of Education and the Superintendent of Public Instruction to make sure all of our children and educators are in the classroom, in person and safe.”

Berger said Tuesday he thought a compromise could be close, but neither Ballard nor Cooper offered details about where there was common ground and what issues had yet to be resolved.

Cooper told reporters later that afternoon that he had not seen legislation that would envelop a compromise, but he acknowledged that he had been negotiating with Berger and others.

Coronavirus by the numbers

According to NCDHHS data, as of Tuesday afternoon:

11,552 people total in North Carolina have died of coronavirus.
875,903 have been diagnosed with the disease. Of those, 1,147 are in the hospital. The hospitalization figure is a snapshot of people hospitalized with COVID-19 infections on a given day and does not represent all of the North Carolinians who may have been in the hospital throughout the course of the epidemic.
837,824 people who had COVID-19 are presumed to have recovered. This weekly estimate does not denote how many of the diagnosed cases in the state are still infectious. Nor does it reflect the number of so-called “long-haul” survivors of coronavirus who continue to feel the effects of the disease beyond the defined “recovery” period.
To date, 10,581,557 tests have been completed in North Carolina. As of July 7, all labs in the state are required to report both their positive and negative test results to the lab, so that figure includes all of the coronavirus tests performed in the state.
People ages 25-49 make up the largest group of cases (39 percent). While 15 percent of the positive diagnoses were in people ages 65 and older, seniors make up 83 percent of coronavirus deaths in the state.
485 outbreaks are ongoing in group facilities across the state, including nursing homes and correctional and residential care facilities.
As of Thursday, 300 COVID-19 patients were in intensive care units across the state.
As of March 8, 2,938,543 North Carolinians have received at least one dose of the coronavirus vaccine. At this point, 17.4 percent of North Carolinians have had at least one shot, and 10.6 percent of adults in the state have received both vaccinations.

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