Sen Ralph Hise

Psych nurses want freedom from old law putting their practices at risk

March 17, 2021 by Taylor Knopf

Psych nurses want freedom from old law putting their practices at risk - North Carolina Health News

Psychiatric nurse practitioners are helping fill the huge gaps in mental health care across the state. But North Carolina’s law tying them to a physician has put some of their practices and patients in jeopardy.

By Taylor Knopf

Olehonna Lynch started Pembroke Center for Wellness in 2010 because she wanted people in her home community to receive the best mental health care possible.

Lynch, a psychiatric nurse practitioner, said that before she started her practice the residents of Robeson County waited up to three months for an outpatient psychiatric appointment. When people can’t get help for their mental health issues in the community, they often end up in an emergency room in crisis.

Once they are stabilized, those patients return back home to again wait weeks for an outpatient follow-up appointment.

In contrast, Lynch said she can get a new patient in to see her in less than a week.

“It came down to one of those things where if you want it done right, do it yourself,” she said. “So that’s what I ended up doing. I realized there weren’t many options besides working at the hospital.”

Lynch has a background as a family nurse practitioner and later got her post-master’s certification in psychiatry because she said there was such a “huge need.” Lynch is the owner of her practice where she sees 80 to 100 patients a week and employees an individual and family therapist.

But her practice is tied to a psychiatrist who acts as her “supervisor.”

A North Carolina law passed in the 1970s requires advanced nurse practitioners to have a “collaborative agreement” with an overseeing physician. Essentially, Lynch pays $500 per month for that psychiatrist’s signature twice a year. The supervising physician doesn’t need to approve any treatment decisions or medications for Lynch’s patients. The physician doesn’t even need to be in the same building, or the same city or even the same county.

“I try to utilize her expertise more so that it’s not just a signature,” Lynch said. “If I have a difficult case, I will set up an appointment for my patient to meet with her for a second opinion. So I try to get more out of the collaborative agreement than just a signature and exchange of money.”

Lynch’s supervising psychiatrist works for Veterans Affairs at the local hospital and is planning to retire soon. When she stops practicing, the only psychiatrist in Robeson County — a county with 130,000 people — will be gone.

Unfortunately, this is not uncommon in North Carolina. In 2017, the Sheps Center for Health Services Research at the University of North Carolina found that 10 counties have no psychiatrists and 28 counties have less than the equivalent of one full-time psychiatrist per 10,000 people.

The retirement of Lynch’s collaborating psychiatrist also puts Lynch’s practice in jeopardy. Unless the law changes this legislative session, Lynch must have a supervisor to continue running her practice.

The SAVE Act

A bipartisan group of lawmakers has been trying for several years to pass a bill called the SAVE Act to remove that collaborative agreement requirement and allow advanced nurse practitioners to practice in North Carolina with more autonomy.

If the SAVE Act passes, Lynch said she will continue to collaborate with mental health professionals as needed. She said as it is, she consults other medical specialists regularly. Lynch said other advanced nurse practitioners contact her interested in starting their own practices, wanting to learn more about how to do it.

But the collaborative agreement requirement does deter some from moving forward, she said.

Healthier patients, cost savings

If lawmakers would have passed the SAVE Act in 2019, North Carolina could have already saved at least $866 million in health care expenses, argued Sen. Joyce Krawiec (R-Kernersville).

“We can cut costs without cutting corners, and that’s what this bill does in a very effective way. Most bills that are introduced in these chambers usually cost a lot of money,” Krawiec said. “This legislation costs the citizens of North Carolina nothing and the benefits will be staggering.”

The North Carolina Nursing Association cited a 2015 study from the Duke University Center for Health Policy and Inequalities Research which concluded that removing barriers such as the physician supervision requirement would save the state “between $433 million and $4.3 billion per year while creating more than 3,800 jobs.”

“This is an opportunity to lessen the impact of physician shortages without compromising quality of health care,” said Sen. Jim Burgin (R-Angier). “Modernizing regulations is an important part of an evolving health care system.”

Rep. Gale Adcock (D-Wake), the only advanced practice registered nurse in the General Assembly, said the health outcomes of advanced nurse practitioners’ patients are “as good and sometimes better” than their physician colleagues.

Rep. Gale Adcock_2021 — Rep. Gale Adcock, the legislature’s only advanced practice nurse, during a 2021 press conference introducing the SAVE Act. Photo credit Taylor Knopf

“We intend to continue to work with our physician colleagues as true colleagues interdependently as all health care providers do,” said Adcock, who has been a practitioner for 34 years. She just retired from a job where she actually was the boss to the physicians who were her supervisors.

The state is in the middle of transitioning the Medicaid program from one where reimbursement comes for every visit, test and procedure to one where providers get paid a lump sum to deliver more value and healthier patients.

Patient outcomes will be one of the key benchmarks for measuring how well providers are doing.

“You’re paying for how healthy your patient is, and that is not just how healthy is your healthiest patient, but how healthy is your sick patient,” Adcock said. “Advanced practice registered nurses bring a lot of bang for the buck. Because we keep people out of the hospital, we keep them in their homes and out of nursing homes.”

They also tend to be less costly to employ than physicians.

Adcock said that 23 other states and the District of Columbia have allowed their advanced nurse practitioners more autonomy, “and their citizens have not suffered from it.” And no state has reversed that decision, she added.

Mental health provider shortage

Dona Francis is a psychiatric nurse practitioner who runs a mental health practice in Sunset Beach where she sees around 100 patients a week. Right now, she has a big dilemma. The 69-year-old wants to retire but cannot find someone to take over her practice. She says the collaborative agreement requirement is a contributing factor.

Francis’ supervising psychiatrist lives in the Charlotte area, and there are no psychiatrists practicing in Brunswick County. Francis is the only mental health provider in her county of 142,000 residents. The closest psychiatrist is in Wilmington, and the wait for an appointment is at least a month, she said. Many of her clients in Sunset Beach are older and do not want to travel that far.

“A lot of people don’t want to have to go an hour away when they’re already dealing with anxiety and depression,” Francis said. “And COVID has added another layer to that. They feel isolated being unable to see their family, children and grandchildren. Anxiety and depression has increased tenfold from where it was a year ago.”

She’s received a lot of new patients during the pandemic and said she gets new referrals every week. Francis said primary care providers don’t feel comfortable treating a psychiatric diagnosis, and they often don’t feel qualified or have time to do talk therapy with a patient.

“They have people for 15 minutes in their office and they’re out,” Francis said. “They don’t have an hour to sit with someone, help them process what’s going on, deal with their grief or help them with coping skills.”

Francis has been actively talking to nursing schools in the state in a quest to find her replacement. But she said graduating psychiatric nurse practitioners struggle to find a collaborating psychiatrist.

As she continues to search, Francis said she feels like she has an “ethical responsibility to stay the course, until I can get someone here.”

shows a woman at a table with a laptop and implements to give a vaccine talking to a man. The're both wearing masks to prevent COVID.

Providers, health directors push back on complaints of slow vaccine rollout

January 15, 2021 by Rose Hoban

Providers, health directors push back on complaints of slow vaccine rollout - North Carolina Health News

Some local health officials say vaccine administration would have started faster if there had been more certainty and funding for their efforts.

By Rose Hoban

It’s hard to tell that the mass vaccination clinic set up by UNC Health was only a few days old.

There was no crush of patients at the door. Instead, a steady stream of gray-haired people, some on canes, walkers or in wheelchairs, arrived at the Friday Center on the campus of the University of North Carolina at Chapel Hill to find a registration desk to check their appointments once they got inside the door.

Then people moved through a series of lines marked by ropes and circles on the floor denoting the correct distance to stand apart from the other people in the queue. Then to a phalanx of a dozen desks where people sat to give information and answer questions to a pair of lines feeding into the vaccination room, which had 15 stations.

Finally, people were escorted to an observation area, where they waited 15 minutes to be sure no one had an allergic reaction.

There was even a branded cloth that people could stand in front of to take their vaccination selfies. About 45 minutes for a round trip.

“It’s all worked out really well,” said Robert Engler, 76, from Chapel Hill who got his first dose of Moderna vaccine on Thursday morning. His wife received the Pfizer vaccine at the same location on Tuesday. “We heard all the horror stories about Florida and people were having to stay in line for nine hours overnight. And this has been perfect.”

As people walk out the door, they have in hand a card with their second dose appointment time on it.

“We’re able to see 600 new patients today, we’re hoping to ramp up to around 1,500 patients a day,” said Elizabeth Ramsey, who was managing the operation.

She explained that UNC Health has gotten different allotments of vaccines. Thursday it was Moderna. Earlier in the week, the site had been distributing the Pfizer/BioNTech jabs. She also said there’s been some uncertainty about future allotments of vaccine, and whether the UNC mass vaccination site would receive enough in several weeks’ time to administer both first doses and accommodate people who need their follow-up shots.

Slow ramp up

On Tuesday, Mandy Cohen, secretary of the Department of Health and Human Services got a grilling from legislators who complained that North Carolina trails the pack when it comes to getting vaccines into the arms of an eager public.

“Most of us don’t feel that this process has not moved as quickly as it could or should have to this point, and we’re wanting to deal with it,” said Sen. Ralph Hise (R-Spruce Pine).

He reminded Cohen that in the past, the state’s emergency management director Mike Sprayberry had critiqued a storm disaster response system as using counties for getting aid out to and rebuilding damaged properties to each hard-hit site.

Looking for a vaccine, check out our county-by-county guide!

“He said we have learned from experience that many local governments lack the staff expertise and capacity to administer disaster relief, and further, said that a lack of a uniform process can cause inefficiencies,” Hise said. “Why did we choose that administrative structure for that was something that we knew would be problematic from history?

“We merely handed it over to basically 100 county health departments and hospitals and said, ‘Have fun.’”

Cohen pushed back, noting that some county agencies have done, “spectacularly well” calling out health departments in Iredell and Robeson counties and the Albemarle Regional Health Services, which encompasses eight northeastern counties.

“Then there are others that aren’t doing as well and that is our job at the state to support them in improving,” Cohen added, noting the challenges of getting vaccines to some of the most remote corners of a state with 80 rural counties. “I think for us at this stage, we needed to rely on the infrastructure that we have.”

Scaling up quickly

The announcement came this week that the state would open high-throughput vaccination clinics with large institutional partners, which included the UNC site in Chapel Hill and one in Hillsborough.

UNC Health infectious disease physician David Wohl said that while his institution knew for a long time the vaccines were coming, a lot was unclear until they were finally approved.

“It got released on us like a ton of water. And we just had to stand up systems really quickly,” he said.

an elderly woman with gray hair sits while receiving a COVID vaccine shot in her left arm — Chapel Hill resident Judy Konanc, 80, receives her COVID vaccine from medical assistant Teona Gittens at a UNC Health mass vaccination clinic in Chapel Hill on Thursday. Photo credit: Rose Hoban

The experience of operating high throughput testing sites all year gave UNC and other institutional entities the needed knowledge to get up and running quickly.

“UNC, Duke, Wake Forest, we know how to do that,” he said, gesturing around the Friday Center site, which practically hummed with efficiency. “We have systems, people, we can make that happen. Smaller places, I just feel for them.”

He pushed back against lawmakers’ critiques.

“We’ve been hamstrung by the availability of supply of vaccine, we’ve had to close down scheduling in the future because we don’t want to schedule people for vaccine that we don’t have right now,” Wohl said. “There’s just not enough supply of vaccine here in a state. I feel like if we had more vaccine, people wouldn’t have to be more parsimonious about how to get it out to the different places.”

He said he believed North Carolina has been penalized because the state followed federal rules and guidelines about getting the vaccines out, whereas other states did their own thing.

“We’ve been following the phased approach. We haven’t taken just anyone who comes along and vaccinated them like they do in other states,” he said. “We’re following the rules by registering people in the system that the federal government and the state is now complying with that as an extra step.”

“We’ve done what we were supposed to do.”

High-speed hamster wheels

Some health directors in smaller counties also pushed back on the idea that they had been slow, or disorganized.

“I think it’s hard for everyone across the state to understand the complexity of planning these events so that we keep our most vulnerable populations to COVID-19 as safe as possible as they’re being vaccinated,” said Lisa Harrison, who heads Granville Vance Public Health.

Harrison was speaking from a mass vaccination clinic at the Granville County Convention and Expo Center in Oxford on Thursday morning where her team planned to give out about 500 doses of vaccine to older seniors and members of their households.

“This is not like when you were a kid, and everyone got polio vaccination at a gymnasium in a school. There’s very different constraints here,” including COVID being highly transmissible through the air and the population in the room being especially vulnerable if they contract it, she said.

“People have to understand that there are systems that have to be in place to do this very safely,” she said.

Harrison also pointed out that there’s a limited supply of staff to administer the vaccines, especially inrural areas. She had to tap all the public health nurses, school nurses and staff from the senior center to get it all done.

“We have real staffing challenges, especially in local health departments where we received the vaccine on top of already working 12 to 14 hour days on COVID response,” she said. “You know, the same people who are expected to give vaccines every day, all day, are the same people who are doing case investigation and contact tracing, data management, outbreak investigation, community outreach and communications.”

All without additional funding.

shows a woman in red scrubs giving a COVID vaccination to a woman sitting in a chair and wearing a jaunty hat — Morgan Cash, a nurse from Vance County Schools gives a vaccination to a local resident during a mass vaccination clinic at the Granville County Convention and Expo Center in Oxford on Thursday. Photo credit: Lisa Harrison

“We’re a mighty staff, but we’re still pretty small and so having to get off one high-speed hamster wheel of response all day, every day, seven days a week, holidays and weekends… and get on another hamster wheel of high-speed response for vaccination, it’s taken a minute,” Harrison said.

That was a point Wohl also made.

“A lot of thought went into let’s invest billions in these different companies, like pre-purchasing vaccine,” he said. “Great, but not a lot of thought went into how are people going to actually deliver the vaccine.”

Harrison planned to administer 1,500 doses by the end of the weekend. But uncertainty about future allocation of vaccine second doses made her hesitate to schedule too many extra people.

“We have over 7,000 individuals over 75,” Harrison said. Now, federal officials have said doses could be given to those over 65, which she said increases the potential demand to more than 11,000 people. “We [also] have to get through a lot of frontline and essential workers, and school teachers, and the staff of our local jails.”

Harrison has also had to send three nurses out to the dozens of long-term care facilities and group homes in her two-county area, providing vaccinations on-site for staff and residents.

She predicted that to get through all the current priority groups would take most of February and March, based on the speed of the allocations her department has received.

shows a man standing at a podium speaking to the camera, his arms spread wide as he talks about the COVID pandemic and vaccine response

Coronavirus Today – Jan 12 – Cooper calls out “dangerous rhetoric;” Lawmakers criticize vaccine rollout; Large vaccine events coming

January 12, 2021 by Rose Hoban

Coronavirus Today – Jan 12 – Cooper calls out “dangerous rhetoric;” Lawmakers criticize vaccine rollout; Large vaccine events coming - North Carolina Health News

NC lawmakers grill Mandy Cohen, DHHS secretary, about slower than expected COVID vaccine administration, on a day when Gov. Cooper drew parallels between political violence and coronavirus denial.

By Anne Blythe

Gov. Roy Cooper took time on Tuesday to draw parallels between what led to the assault on the nation’s Capitol almost a week ago and the continued effort by some to downplay the coronavirus pandemic and efforts to prevent and slow the spread of COVID-19.

It comes at a time when the presidential administration is about to change in Washington, D.C. and lawmakers are set to return to the state capital to begin a new legislative session.

“Just a few days ago, our country endured a violent attack on our nation’s Capitol, the seat of democracy,” Cooper said. “It left death and destruction, along with threats by some that there is more to come. This assault on our democracy was the result of dangerous rhetoric, lies and disinformation that spread far and wide.”

“It’s a stark reminder that our words matter,” Cooper continued. “Words are powerful and can be used to help or harm. Last week, we saw how the words of elected leaders cost lives. Lies and misinformation have cost lives during this pandemic as well.”

Just one day after the violence at the nation’s Capitol, an event that prompted House of Representatives members to introduce articles for a second impeachment of President Donald Trump, the country reported its highest daily COVID-19 death count at 4,085.

Throughout the pandemic, Trump has openly defied mask wearing, encouraged his supporters to gather in large rallies, where social distancing measures are not adhered to and left much of the COVID-19 response planning to the states.

Trump’s administration, though often praised for Operation Warp Speed, which brought two brands of COVID-19 vaccine to the public for distribution in an unprecedented amount of time, again has left it to the states to figure out the nuts and bolts of distributing vaccines.

On Tuesday, Mandy Cohen, secretary of the state Department of Health and Human Services, faced a barrage of tough questions from mostly Republican lawmakers as to why North Carolina has had a bumpy rollout of its vaccine distribution plan.

Questions came from some of the Republican lawmakers who have pushed back on COVID-19 prevention measures put forward by her department and Cooper, a Democrat who polled well during his re-election campaign for his response to the pandemic.

“More people could be alive today, but for dangerous falsehoods that have been spread about the critical importance of masks, social distancing and other common-sense safety rules,” Cooper said during a briefing with reporters on Tuesday.

“Words matter,” he repeated several times. “People listen to leaders and often follow their calls and imitate their actions.

“As the death toll from this pandemic continues to increase, our leaders must listen to science, focus on the facts and tell the truth with their words and the examples that they set. The truth is that this disease is spreading fast. We are in a dire situation.”

Race, ethnicity and the Capitol violence

In North Carolina, there have been 635,975 lab-confirmed cases of COVID-19 since the first case was reported in the state in early March.

As of Tuesday morning, 7,638 people had died from illness related to COVID-19 and 3,940 people were in hospital and intensive care unit beds, suffering from severe symptoms related to the virus.

“The events of last week brought home how dangerous and deadly misinformation can be,” Cohen said.

In the hours and days after the assault on the Capitol, many have highlighted the contrast between the law enforcement response for a rally of mostly white Trump supporters to the response to Black Lives Matter events and protests against social injustice in which heavily armored police and National Guard members awaited the crowds.

The events in Washington, D.C., “also exhibited clearly how different people experience what it is to be American based on their race and ethnicity,” Cohen added. “Too often it is the color of someone’s skin that predicts their outcomes. In almost every health measure, communities of color fare worse, including in this pandemic through causes that are complex, interconnected and rooted in implicit biases and longstanding inequities.

“The pandemic didn’t create the disparities. It just made them acutely visible for all to see.”

Black leaders tout vaccine

In this state, Cohen asked the North Carolina Institute of Medicine to convene a COVID-19 Vaccine Advisory Committee to provide feedback to her public health team on how to equitably distribute vaccines to the Black and Latinx populations to try to curb further disparities.

Knowing that many in communities of color have expressed hesitation around taking vaccines and distrust in the process, Cohen and her team rolled out a video on Tuesday showing many well-known Black leaders who are 75 and older taking a COVID-19 vaccine.

“I want all of the people my age to enjoy their golden years,” Harvey Gantt, a former Charlotte mayor, says in the DHHS video.

“I’ve got great grandchildren out there I haven’t seen and I’m looking forward to that,” said John W. Hatch, a professor emeritus in the UNC-Chapel Hill Gillings School of Global Public Health.

“What you do to keep yourself healthy helps keep your neighbors and friends and relatives, helps keep them healthy, too,” said Mickey Michaux, a nonagenarian and former state legislator from Durham.

Vilma Leake, a Mecklenburg County Board of Commissioners, encourages young people and seniors to get immunized. “You have a special spot,” Leake says. “So please take your shot.”

Lawmakers push for answers

Earlier in the day, lawmakers on the Joint Legislative Committee on Medicaid and NC Health Choice had tough questions for Cohen on the state’s vaccine distribution plan.

A COVID-19 vaccine tracker updated by Bloomberg on Monday puts North Carolina toward the tail-end of the percentage vaccines distributed to those administered.

In the chart, Bloomberg reports that 820,825 doses have been distributed to North Carolina and 211,572 have been administered.

During the hearing, Cohen agreed that the state needs to ramp up its administration of vaccines, but she questioned whether the Bloomberg chart showed the correct number for how many doses the state had received.

In her report to lawmakers, Cohen said that as of Tuesday morning, the state had allocated 583,450 doses of vaccine — 165,900 of which have gone to a federal program through which pharmacy giants CVS and Walgreens plan to inoculate residents and staff in the state’s 900-plus long-term care facilities and nursing homes.

A vaccine data tracker on the website of the Centers for Disease Control and Prevention puts North Carolina in a higher position among its peers than the Bloomberg chart, showing it in a better position than South Carolina, Georgia, Alabama, Mississippi, Arkansas and other states when it comes to the administration of cases per 100,000 people in the state. North Carolina, as of Tuesday, had administered 2,017 doses per 100,000 people.

Cohen estimated that perhaps the higher Bloomberg number of doses distributed included the federal allotments that had not yet been received by the state.

Vaccine distribution plans have had bumpy rollouts across the country, and North Carolina has not been an exception.

Residents have been confused about when they can get the vaccine and who they should call for answers. With limited supplies, there have been reports of people from other states crossing into North Carolina for vaccines that others are clamoring for.

Cohen explained that because the vaccine distribution is a federal plan, there cannot be limits on where people can get vaccines. People can get vaccines outside their home counties, but are encouraged to call their county health departments and health care systems first.

Republican lawmakers, many of whom have ignored public health appeals to wear face masks while indoors with people outside their immediate households, were critical of how slowly administration of the vaccine has been in North Carolina.

They described the multi-phased distribution plan as cumbersome and difficult for residents in their jurisdictions to understand. They were critical of a statewide system that relies so heavily on individual county health departments to get shots in arms.

“We basically handed it over to 100 county health departments and said, ‘have fun,’” Ralph Hise, a Republican state senator from Spruce Pine, said while questioning Cohen.

The questions come as a new legislative session is set to begin in a year where there is likely to be much focus on the pandemic and resources needed to continue the fight against COVID-19 as well as economic recovery efforts.

Cohen speculated on Tuesday that it could be late summer before the state has vaccinated up to 75 percent of the population to achieve the expected herd immunity. Those predictions, though, are variable since there could be other vaccines available in the coming months in addition to those produced by Pfizer and Moderna.

Johnson & Johnson is testing a single dose COVID-19 vaccine in a phase 3 trial, and could have efficacy data available toward the end of the month. If that vaccine proves to be safe and effective, it could put a request in to the federal Food and Drug Administration by February, according to some estimates, and add more options for immunization plans.

Lawmakers wanted to focus on the here and now.

They shared stories from their districts.

‘We’ve got to do better’

Jim Burgin, a Republican state senator from Angier, recounted the scene at a vaccine administration site in Benson, where a long car line formed in the middle of the night in which people 75 and older waited for the shot at a vaccine.

“We’ve got to do better,” Burgin said. “We’ve got to figure this out.”

“We send out guidance to all of the vaccine providers on best practices. And we said specifically, please try to avoid the exact situation that you are referring to,” Cohen responded.

“Every county is approaching this slightly differently. And some of them are doing a first come, first serve and then you get hours of lines because look, the numbers just don’t add up,” she continued. “Even if we were able to get all the vaccines out today, we have more 75 year olds than have vaccine here in our state.”

Now that North Carolina has distributed vaccines to each of the 100 counties, Cohen said the state will shift its focus to large events in some areas.

County health departments in Robeson and Iredell counties got a special shout-out from Cohen for swift administration of the vaccines. Other county health departments have been hampered by exhausted staff members, learning how to use a new data entry system created by the state to keep track of distribution and dosing, and sluggish starts that leave vaccines still in vials.

Throughout the pandemic, many public health advocates have likened much of their response to building the plane as they fly it.

Cohen told lawmakers before the press briefing on Tuesday that now that the state knows that some counties were unable to distribute all the doses that they have, they have offered to help them with staffing needs as well as shifted their weekly distribution plans.

Sen. Joyce Krawiec, a Forsyth County Republican, who often speaks highly of Cohen, praised her willingness to sit down with members of both parties and listen to them and explain why she supports or doesn’t support certain efforts. Nonetheless, Krawiec had a harsh summation of a distribution plan that has only been in place for four weeks.

“The administration had 10 months to draft and refine a plan to distribute a vaccine that everybody in the world knew was in development, but they didn’t even effectively plan for something as simple as what to do when too many people call asking to schedule their vaccination,” Krawiec said. “The status quo is completely unacceptable, and the failure of the county-centric model was known before planning even began.”

Large vaccine events ahead

Cohen calmly responded to questions throughout the meeting, noting that North Carolina submitted its vaccine distribution proposal to the federal government several months before the election when they had not seen any of the safety and efficacy data from Pfizer or Moderna.

Cohen said she expected to increase the administration of vaccines exponentially in the coming week with 10 large events.

The state is distributing 45,000 doses of its weekly allotment from the federal government to 10 large scale testing events:

In Forsyth County;
At Albemarle Regional Health Services in the northeastern corner of the state;
Through Vidant in eastern North Carolina;
At Cone Health in Guilford County;
Through Atrium Health in Mecklenburg and surrounding counties;
To UNC Health and Orange County clinics;
Duke Health in Durham;
WakeMed in Wake County; and
A collaboration in the western part of the state with Dogwood, the Mountain Area Health Education Center and federally qualified health care centers in the region.

CDC guideline change

Cooper participated in a phone call Tuesday afternoon with Vice President Mike Pence, Alex Azar, secretary of the federal Department of Health and Human Services, Robert Redfield, director of the CDC, White House Coronavirus Task Force members and other governors. It was there that he learned about the latest shift in response to the pandemic by the federal government.

On Tuesday, the CDC announced that it was changing its vaccine distribution guidelines to include people who are 65 and older in the first phase of people eligible for vaccination.

The new guidelines had not been sent to the states by mid-afternoon, so neither Cohen nor Cooper could elaborate on how that might change their distribution plan.

“We haven’t even seen them in writing yet, but we will examine those and understand how that fits into the work that we’ve been doing,” Cohen said. “We have a North Carolina vaccine advisory committee that has been pulled together as well. We’re going to want their input and then we’ll come back, obviously very quickly. Getting this kind of advice in the middle of all of this, obviously is very challenging, but will take a look at that and incorporate it into our work going forward.”

Cohen’s sentiment was echoed earlier Tuesday in a speech given by the head of the American Medical Association, Susan R. Bailey, who called for a more coordinated and comprehensive federal response.

“The most important lesson for this moment … and for the year ahead … is that leaving state and local officials to shoulder this burden alone without adequate support from the federal government is not going to work,” Bailey told the National Press Club. “The urgency of this moment demands a comprehensive and coordinated federal response.”

Millions allocated, spent

In the legislative oversight committee meeting Tuesday, deputy DHHS secretary Susan Gale Perry told lawmakers that funds they allocated this spring to help DHHS fight the COVID-19 pandemic are almost completely exhausted.

The Coronavirus Relief Fund contained $485 million to cover the costs of COVID-19 testing, contact tracing, creation of the SlowCOVIDNC tracking app and a public messaging campaign, not to mention the money that flowed to local county health departments to help them cope with the onslaught of work created by the pandemic.

pie chart shows spending done for COVID relief — Chart courtesy: NC DHHS

“Our projected spending is $479.5 million by the end of December, so that’s 98.6 percent of all funds allocated to us,” she said. “So leaves a very small portion, 1.4 percent, that we would like we plan to continue, and not for very many months into 2021.”

The funding also covered the cost of emergency child care subsidies for essential workers and teachers, food aid for families that lost income, the salaries of community health workers and other community supports, and more than 65 million pieces of personal protective equipment.

The money came to North Carolina as a result of the federal CARES Act and was mandated to be spent by the end of 2020.

Coronavirus by the numbers

According to NCDHHS data, as of Tuesday afternoon:

7,638 people total in North Carolina have died of coronavirus.
635,975 have been diagnosed with the disease. Of those, 3,940 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.
521,475 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 COVID who continue to feel the effects of the disease beyond the defined “recovery” period.
To date, 7,669,546 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 COVID-19 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.
700 outbreaks are ongoing in group facilities across the state, including nursing homes and correctional and residential care facilities.
There are 3,620 ventilators in hospitals across the state and 1,214 ventilators in use, not just for coronavirus cases but also for patients with other reasons for being in the hospital. As of Wednesday, 839 COVID-19 patients were in intensive care units across the state.

shows basketball players from Duke and UNC on a court

Duke-UNC basketball rivalry has lessons for Medicaid transformation

February 12, 2020 by Anne Blythe

Duke-UNC basketball rivalry has lessons for Medicaid transformation - North Carolina Health News

NC lawmakers get a bit of locker room talk with their latest Medicaid transformation update.

By Anne Blythe

Whether you believe that politics has become a blood sport or sports have become too political, it’s hard to dispute the long-standing comparisons between the two.

So on Tuesday, when key North Carolina lawmakers came together to talk about the state Department of Health and Human Services’ decision to put an indefinite pause on the long-awaited transformation of Medicaid to a managed care system, Rep. Donny Lambeth, a Republican from Winston-Salem, offered a sports analogy.

“It is unfortunate where we are, but we are there,” Lambeth said nearly an hour into a meeting of the Joint Legislative Oversight Committee on Medicaid and Health Choice. “It reminds me of the UNC game against Duke last weekend. … Up by 13. We’re playing well as a team. We have all of our momentum and it starts slipping away. Not just one, but two miraculous plays, and we lose the game.

“And now, we’re in the locker room, wondering what happened. Why are we in this situation?”

The situation is tied to a standoff between Gov. Roy Cooper, a Democrat, and Republican lawmakers at the helm of the General Assembly.

Cooper vetoed the General Assembly’s $24 billion spending plan nearly eight months ago, in large part, he said, because he thought the budget should include higher raises for teachers and funding to expand Medicaid eligibility to potentially 550,000 low-income adults who could qualify for the federal aid.

The Republican leadership has resisted such efforts, digging their heels in against the expansion opportunity borne out of the Obama administration’s Affordable Care Act.

How’d we get here?

That political clash was part of the game-changer behind the Medicaid transformation launch. In November, 75 days before the state was set to abandon its fee-for-service Medicaid model and essentially turn the management of the $14 billion annual program to managed care companies that had been awarded contracts, the state secretary of Health and Human Services put on the brakes. Mandy Cohen, appointed by Cooper, said there just were not enough funds in the department’s budget to move forward.

Last year, before the General Assembly adjourned its session, Republican lawmakers assembled enough votes to pass one in a series of mini-budgets that would have released $502 million for the transformation project.

But Cooper vetoed that plan, saying he had hoped that lawmakers would have entertained a broader discussion about health care in North Carolina that also included Medicaid expansion.

Dave Richard heads North Carolina’s Medicaid program. Image courtesy: NC DHHS

Dave Richard, the deputy secretary for NC Medicaid, and Jay Ludlam, the assistant secretary for Medicaid and a key shepherd of the transformation project, told the Joint Legislative Oversight Committee on Tuesday, that planned budget cuts would throw a wrench in further plans for transformation. They mentioned $40 million in cuts that lawmakers had included in their overall spending plan as well as a proposal to move DHHS headquarters out of Wake County to Granville County.

The “mini-budget” resolved some of those issues, but DHHS leaders worried it failed to protect the department from the cuts had Republican lawmakers managed to find the votes to override Cooper’s veto of the full state budget.

The administrators also outlined work that continued on the transformation project even though it is uncertain whether a new launch date will be in two years, as several lawmakers speculated. It could be sooner if a compromise can be reached between the governor and state Senate and House leaders in an election year.

“I think it’s really important that we talk about what it is that a budget means to us,” Richard said. “There’s really not a chance for us to go forward with managed care if those cuts continue.

Man wearing dark suit and yellow tie speaks at a podium. He is DHHS official Dave Richard and he's talking about Medicaid transformation. — Dave Richard, deputy secretary for Medicaid at the N.C. Department of Health and Human Services, updates the Joint Legislative Oversight Committee on Feb. 11, 2020, on Medicaid transformation. Photo credit: Anne Blythe

“I want to say that I know that your conversations with the governor and others continue to be much broader than that. So the right budget means not just the Medicaid part, but it means some of these other items that we will be talking about,” he said. “I hope personally, when y’all come back in April that there’s a chance to get that right budget moving forward.”

If that funding were to come, there still would be much to do to get the transformation to managed care systems flowing again.

Data would have to be refreshed.

Personnel at some of the managed care systems and other organizations involved in the planned launch have changed and the new people on board would have to be brought up to speed.

The state would have to update the waiver proposal that went to the federal government to allow for such a switch and then wait for the wheels of bureaucracy there to churn at whatever pace is set.

“None of us are pleased about the position where we are today,” Richard said. “What we’ve tried to do is do the things we can without spending money.”

Teeming with questions

Sen. Ralph Hise, a Spruce Pine Republican, again asked a question raised in November about whether suspending the transformation was legal.

Richard dodged that question, acknowledging that he was not a lawyer but that the department’s legal team had looked it over and opined that the authority to do so was there.

Hise also asked how the department prioritized what it decided to dial back on, given the funding shortages. Richard and Ludlow explained that the priorities funded were either already up and running or further along in the implementation process than the transition to managed care.

Rep. Donny Lambeth (R-Winston-Salem) Image courtesy of the NC General Assembly website

Other lawmakers raised questions about whether managed care companies that had been awarded contracts might have a claim against the state.

The state administrators told the lawmakers that the department had maintained close contact with the contractors and none had tried to jump ship yet.

The meeting ended after an hour and a half of discussion, with DHHS administrators agreeing to develop reports that attempted to address the cost of the indefinite stall on transformation as well as other data and analysis sought.

In closing, Lambeth sent the lawmakers and day’s speakers out into the world again with his reference to last weekend’s college basketball game when Duke topped UNC 98 to 96 in a nail-biter, in which the Tar Heels, with a 13-point lead, looked as if they might be cruising to a victorious conclusion.

“Well we need to put our uniforms on and get back out there and get going again, “ Lambeth said.

Young man loads a medical needle from a bottle with a clear substance

What stories grabbed you in 2019? NC Health News most-read stories of the year

December 30, 2019 by Editor

What stories grabbed you in 2019? NC Health News most-read stories of the year - North Carolina Health News

What piqued your interest this year? We review which stories grabbed peoples' attention, got passed around and shared widely.

By NC Health News Staff

Lessons from Abroad: How Europeans tackled opioid addiction and what the U.S. could learn from them.

For years, NC Health News has reported on the drug-related deaths, diseases and losses that have resulted from the opioid crisis. Life expectancy in the United States has dropped for two years in a row for the first time in more than 50 years, largely due to overdose deaths among people in the prime of life. While various groups of medical professionals and advocates have tried their best to help people with addiction, the death count continued to rise.

Read stories from our series about how countries in Europe confronted their opioid problems and drove their overdose rates down.

So we wanted to know what it would take to end a drug crisis. With the help of a grant from the Solutions Journalism Network, we were able to send reporter Taylor Knopf to France and Switzerland, two countries that have a lot of experience dealing with opioid addiction. A few decades ago, many European countries saw similar spikes in heroin use and overdoses, along with high rates of HIV and hepatitis C infections. Countries such as France and Switzerland took radical approaches to solve their opioid crises and cut death and infection rates drastically.

“The goal was not to fight drugs anymore. It’s completely ridiculous to fight drugs,” said Jean-Félix Savary, secretary general of the Romand Group of Addiction Studies in Geneva. “It was a big revolution. We don’t try to ask people not to take drugs but take care of problems generated by the situations around people being addicted to drugs.”

The Swiss embraced solutions such as drug consumption rooms and full access to an array of treatment options, including prescription heroin. After that, drug overdose deaths dropped by 64 percent, HIV infections dropped by 84 percent and home thefts dropped by 98 percent.

With the help of interpreters, we talked to addiction psychiatrists, doctors, nurses, social workers, educators, policy influencers, chemists and drug users.

In France, the harm reduction strategies are not quite as cutting edge as in Switzerland. Instead the French work to support drug users through full-service harm reduction centers that offer wrap-around services, such as clean needles, medication-assisted treatment, counseling, medical treatment, hot showers, laundry machines, life skills classes, and places to sleep.

Given the readership and comments on these stories, it appears people are ready to entertain new approaches to addressing the nation’s opioid crisis.

North Carolina prepares to transform the Medicaid system

It was a roller coaster of in 2019 for what was billed as the most dramatic transformation to the state’s health care landscape in decades – the planned switchover to managed care for the state’s Medicaid program.

Medicaid is the public health care program that, at its core, provides healthcare for 2.1 million poor children, seniors and disabled persons in North Carolina, meaning one in every five North Carolinians depends on Medicaid for care. As part of former Pres. Barack Obama’s Affordable Care Act, many states have opted to extend Medicaid coverage to low-income, single adults, with the federal government ponying up most of the funds for that coverage.

North Carolina has not expanded Medicaid to cover between 365,000 and half a million adults largely now without health care coverage, the issues have been the root cause of this year’s unprecedented standoff over the state budget between Gov. Roy Cooper, a Democrat, and Republican state legislative leaders. (In short, Cooper is for Medicaid expansion; Republican state lawmakers are not.)

Nancy Baker, a board member with Vaya health spoke about Medicaid transformation — Nancy Baker, a board member with Vaya Health in Asheville expressed frustration at the delay of Medicaid transformation. “My main concern is our legislators have lost sight of the human aspect of this,” she said. Photo credit: Rose Hoban.

Caught in the crosshairs of this fight over the state budgets and Medicaid expansion is a years-long planned switch to move the state’s existing Medicaid program, which costs about $14 billion in state and federal funding. The program currently has the state essentially cutting a check for every flu shot, hospital stay and therapy visit beneficiaries need.

The switch would hand off the bulk of the Medicaid rolls to managed care companies, paid with a per-person rate, to handle people’s health care needs – $30 billion worth of state money in contracts to five managed care groups over five years. Medicaid transformation, the phrase that the N.C. Department of Health and Human Services has adopted, also will put in place a series of ambitious changes addressing what are called social determinants of health, life experiences such as homelessness, food insecurity, and exposure to violence that undermine people’s quality of health.

The state had planned to see part of the state rollover to this new system by November and then have the whole state on board by this February. But DHHS Sec. Mandy Cohen pulled the plug on the planned switch, citing uncertainty from the lack of a state budget.

“To date, we have been able to use other Medicaid funds to continue this work but at some point we need the new budget in order to keep going and so as of now, we have to suspend,” DHHS Sec. Mandy Cohen told N.C. Health News in November.

So, for now, there’s no set plan or date as to when the state will get back on track with moving Medicaid to managed care.

“We do not want to set a date until we have absolute certainty about the budget,” Dave Richard, the N.C. DHHS deputy secretary in charge of Medicaid told NC Health News. With the other two delays “people were geared up to do that work, they were prepared to do that work, and then we changed it and that just creates lots of chaos and conflict with folks.”

Medication-assisted treatment has the potential to tame the opioid crisis, if it’s available

In July, we reported that North Carolina used $54 million in federal grant funding to help more than 12,000 people receive treatment for substance use disorders. But according to data from the state, most of the people who benefited from these grants were disproportionately white.

Of roughly 10,000 participants who entered treatment in the last two years, more than 9,000, or 88 percent, were white, about 7.5 percent were African American, and fewer than 1 percent were American Indian. Yet opioid death rates are far higher among North Carolina’s American Indians, according to the North Carolina Medical Journal.

woman talking expressively with hands — At the NC Opioid Opioid Misuse & Overdose Prevention Summit Tuesday, DHHS Sec. Mandy Cohen said that expanding Medicaid will get more people with substance use disorder into treatment, and that’s her number one legislative goal for state. Photo credit: Taylor Knopf

Racial bias in access to substance use disorders treatment is a persistent problem in North Carolina and across the nation, and many people of color don’t have the same access to medications such as Suboxone and methadone as their white counterparts. These disparities are particularly important because the federal Substance Abuse and Mental Health Services Administration considers medication-assisted treatment or MAT, to be the gold standard in treating addiction, along with counseling.

Access to such medications isn’t only hampered along racial lines. Also in July, we reported that 41 of North Carolina’s 100 counties had few providers who could prescribe these medications, coupled with higher rates of opioid-related deaths.

We’ve also reported on efforts to increase access to medication-assisted treatment in one North Carolina county jail and statewide efforts and a program to increase the number of providers who can prescribe these medications across the state and improve patient access to these services.

APRNs, other practitioners, seek more practice autonomy

North Carolina continues to have wide disparities in where health care practitioners see patients. According to data from the Sheps Center for Health Services Research at UNC Chapel Hill, in more than two dozen counties, there are only dentist or none, in 28 counties there are no obstetricians or gynecologists to provide care for women or deliver their babies and in 28 counties there are no psychiatrists, 35 lack psychologists.

That’s on top of the low number of primary care practitioners in the state. North Carolina has 132 family medicine doctors per 100,000 residents, compared to neighboring Virginia with 144 per 100,000 or even West Virginia with 168 family docs per 100,000 residents.

Family physicians were the most in-demand specialty for the 13th year in a row, earning average national salaries of $239,000, according to physician search firm Merritt Hawkins’ annual report of clinician recruitment.

That’s part of the reason why so-called “mid-level” practitioners feel like there is a case to be made for removing restrictions on their scope of practice, the set of laws and rules that dictate what each type of health care licensee can do. These providers point to decades of research that indicates their care is safe and effective and point to positive outcomes in dozens of other states with more liberal practice guidelines.

an african american man stands surrounded by women, he's looking at some papers — Sen. Paul Lowe, Jr. speaks with students from the Wake Forest Nurse Anesthesia Program in Winston-Salem about the new bill to remove physician supervision from advanced practice nurses. Pictured (L to R) to the left of Lowe, Hannah Garcia, Mandy Engel, Leah Bezzo, Caroline Killmon. Photo credit: Rose Hoban

Earlier this year, nurses came to the legislature to press their case for an expanded scope of practice. Nurse midwives, nurse practitioners and certified registered nurse anesthetists have hired lobbyists, made strategic political donations, and made a more aggressive push for legislative action to give them increased practice autonomy.

In February, identical bills were filed in both the House and Senate to change nursing practice and bring the state in line with 22 other states and the District of Columbia which allow these advanced practice nurses more autonomy.

“Most of the counties I represent you will find that from 5 p.m. on Friday to 9 a.m. on Monday your only option for health care is the emergency room,” said Sen Ralph Hise (R-Spruce Pine), who represents six rural mountain counties as he introduced the Senate version of the bill.

Hise cited research showing that APRNs are more likely than physicians to practice in a rural area and North Carolina data showing that nurses who train locally are more likely to practice in a rural area than physicians.

But the bills didn’t move far in the legislature.

In the world of dental care, hygienists seemed to be making more progress in gaining the ability to practice without a dentist in the same building.

Hygienists in North Carolina have pressed for years to be able to clean teeth, check gum health, apply sealants and take x-rays without needing a dentist nearby.

A proposed rule change endorsed in 2019 by the N.C. Board of Dental Examiners cleared many hurdles in 2019 and garnered numerous favorable comments at public hearings, as well as in written comments.

The notion, supporters explain, is to take the step forward with a goal of moving toward a giant leap in the next decade toward an even broader scope of practice for hygienists.

Allowance hike for NC adult care home residents advanced, but stalled along with budget

A proposed increase in the spending money available to tax-financed residents of North Carolina assisted living centers got a strong push from legislators and advocates in 2019, and nearly passed into law.

Called the personal needs allowance, the stipend for residents on Medicaid has been stalled since 2003 at $46 a month. This paltry amount is intended to cover items such as toothpaste and shampoo, transportation, snacks, prescription drugs and even medical copays.

Budget writers from both parties in the state House included an increase to $70 a month, while GOP legislators in the state Senate crafted a hike to $58 month in the current fiscal year, then to $70 in 2019-2021.

But this provision was vetoed by Gov. Roy Cooper, along with the rest of the budget, because the legislature failed to include Medicaid expansion, a policy which would add about 500,000 people to the publicly funded program. Despite months of effort, Republicans have not succeeded in overturning the governor’s veto of the budget.

The legislature has passed and Cooper has signed a series of mini-budgets to fund many state services, but none of the funding has included revised levels for health and human services. That means that funding for the personal needs allowance has remained at the long-unchanged rates.

shows a man with glasses sitting in a wheelchair that has a headrest, in a room with a bed and photos on the wall. — Michael Rubins, who lives in an assisted living center in Harnett County, advocates for himself and fellow residents, recently about raising the state’s personal needs allowance. Photo credit: Thomas Goldsmith

During budget preparations, North Carolina Health News and other outlets reported on the downside of a low-end allowance for residents trying to maintain quality of life.

Reporter Thomas Goldsmith heard from Judy Vines Hendrickson, a resident of Sharpsburg, who told NC Health News that the rate has affected both her adult son, who has mental illness and lives in a group home, and her late sister, who traded sex for spending money while a resident of an assisted living center in eastern North Carolina.

“I really wish that the people making these decisions would have a panel of people like me come up there and talk to them,” Hendrickson said.

The future of hemp debated in North Carolina

Hemp, a newly legalized crop, took center stage during legislative debates on the 2019 Farm Act this year. The bill pitted farmers against law enforcement, two groups with a lot of pull at the North Carolina General Assembly.

NC Sheriffs and prosecutors filled committee rooms asking lawmakers to classify raw hemp flower as marijuana, a controlled substance.

Hemp and marijuana look and smell exactly the same; however, one has been grown for its psychoactive properties while the other has been bred to not induce a mind-altering high. Law enforcement argued that raw hemp should be illegal because they could not tell the difference between the two and would not be able to enforce the state’s current marijuana laws.

“The state crime lab does not have the testing equipment to test a green leafy substance to tell if it’s smokable hemp or to tell if it’s marijuana,” said Eddie Caldwell, general counsel of the NC Sheriffs’ Association. “And without the ability to get a test from the state crime lab, it puts the district attorneys in an impossible situation trying to try the case in court.”

Meanwhile, farmers who are suffering from plummeting commodity prices and hurricane losses say they are finally reaping some real profits from growing hemp. They begged lawmakers to leave the crop alone and allow them to continue farming it.

older man and a younger man, they have their arms around each other's shoulders and look at the camera — Marc Simon and his son, came to the legislature in May to advocate for continued hemp cultivation. They have a farm and hemp store in Winston-Salem. Photo credit: Rose Hoban

“Last year we ventured out into hemp and some other crops trying to diversify our farm, but the hemp has been a blessing for us,” said Bryan Atkins, a 27-year-old farmer from Moore County.

“We want a future in agriculture,” he said. “With commodity prices and all, we cannot make a sustainable living off of soybeans and corn, especially since our tobacco is gone. The hemp has given us the opportunity to explore other options.”

Lawmakers engaged in heated debate over whether or not to impose restrictions on the hemp flower, with powerful legislative leaders backing each argument. Ultimately, the bill was withdrawn and has not been passed. Lawmakers could take it back up when they reconvene in Raleigh in January.

We’ll have more from our year-end review tomorrow.

two men stand at a podium, surrounded by other people. One of them is talking.

House budget override narrows path to Medicaid expansion

September 12, 2019 by Rose Hoban

House budget override narrows path to Medicaid expansion - North Carolina Health News

The path for North Carolina to extend health insurance benefits to low-income workers was always rough, but events at the legislature Wednesday made the path rockier.

By Rose Hoban

In a dramatic turn of events early Wednesday morning, House Republicans successfully held a vote to override Gov. Roy Cooper’s veto of the state budget when few Democrats were in the chamber to vote against the measure. (See box.)

The vote means now the budget override moves to the Senate chamber, where Republicans hold a majority that requires them to only peel off one Democratic vote in order to override Cooper’s veto. A handful of gubernatorial vetoes have already been overridden by the Senate, only to be sustained in the House, where Republicans need to capture at least seven Democrats to get to 72 votes, enough to thwart the governor.

“He said… he said.”

As reported in multiple outlets, House Democrats cried foul Wednesday over the budget override vote taken by the Republican majority in the House of Representatives.

As Speaker Tim Moore (R-Kings Mountain) called for the vote a few minutes into the 8:30 a.m. session, Democrats jumped up to object, with Rep. Deb Butler (D-Wilmington) yelling, “I will not yield,” even as Moore cut off her microphone.

Only about a dozen Democrats were in the chamber, while Republicans had at least 55 members present, which satisfied the requirement for a 61 member quorum. The vote was 55-9 in favor of an override.

Rep. Deb Butler (D-Wilmington) grew furious as House Speaker Tim Moore (R-Kings Mountain) moved to vote on the budget override. Screen grab courtesy: Rep. John Autry

Democrats argued they had believed there would be no votes during Wednesday’s morning session. House Rules Chair David Lewis (R-Dunn) and Moore both argue they never said there would not be budget votes taken Wednesday morning.

Minority leader Darren Jackson (D-Raleigh) said it was his understanding from a conversation held with Lewis on Tuesday afternoon that the legislature would take no votes at all Wednesday morning. His legislative aide sent an email to Democratic members to that effect, resulting in one side of the chamber being almost empty.

Now as the budget bill moves to the Senate for their override attempt, Cooper’s leverage at using the budget to force discussions on Medicaid has potentially been dealt a mortal blow.

Cooper said since the start of this legislative session in February that he wanted to see the General Assembly use the ability created in the Affordable Care Act to extend Medicaid coverage to as many as half a million people. These are mostly low-income workers who make too much to qualify for the program, but who also make too little to qualify for subsidies for coverage in the Obamacare health insurance marketplace.

When he vetoed the budget passed in late June, Cooper tied Medicaid expansion to any budget agreement, and the governor and the legislature have been in a standoff over the two issues which have become closely intertwined.

Now with the budget veto override over its most difficult hurdle, the path forward for any sort of Medicaid expansion has become more challenging.

Tweaks and tucks

The legislature wrested control over making any decision around Medicaid expansion back in 2013. Since then, Democrats have filed multiple bills for expansion which quickly died.

Legislative Republicans have been staunchly resistant to adding more people to the Medicaid rolls. In particular, Senate leader Phil Berger (R-Eden) has said multiple times he is uninterested in allowing an expansion to come to a vote in his chamber.

But supporters of expansion felt like they finally had their opening after Democratic gains in the 2018 elections broke Republican super-majorities in both the House and the Senate. Advocates hoped Cooper’s veto this summer would force Republicans to the negotiating table to talk about some way forward.

Shows a man standing behind a podium, looking off camera. — Gov. Roy Cooper held a press conference in the wake of Wednesday morning’s House override vote. When asked about the prospects for any form of Medicaid expansion in light of the vote, Gov. Roy Cooper said he didn’t know. Photo credit: Rose Hoban

Publicly, legislative leaders and the governor have traded barbs and testy press releases over Medicaid and the budget. Multiple sources say that there has been some quiet back and forth on what form of Medicaid expansion might be acceptable.

Rep. Donny Lambeth (R-Winston-Salem) has continued to push for using Medicaid to extend health insurance coverage to low-income workers. After Wednesday’s contested House vote, Moore said he would honor his prior commitment to have a vote on Lambeth’s Health Care for Working Families Act, which has 21 Republican co-sponsors.

On Wednesday, however, Lambeth asked Moore to wait until next week to run that bill, as he tweaks the bill to appeal to more Republicans.

House Bill 655 would expand Medicaid while adding a small monthly premium and a work requirement for some beneficiaries. The program, usually reserved for low-income children, some of their parents, people with disabilities and low-income seniors, would add people who earn less than $35,535 for a family of four. Caregivers, students, people who are in drug treatment programs and those with medical conditions would be exempted from the work requirement.

Lambeth said he’s recently been tweaking the bill to make it more palatable to his Republican colleagues.

“Last week while we were on break, I worked with the staff that have helped me on this,” he said Wednesday afternoon. One change he’s been making is to make it so that more people would qualify for subsidized coverage on the exchange.

“My Senate colleagues talked about utilizing the exchange, because that is an option,” he said. “I was working toward an amendment on the floor, something that we would do when that bill came back up. And I told the staff, ‘Got a little time, probably another week,’ and I met with them as recently as yesterday.”

“I did not anticipate that I would need to get that done so soon.”

Lambeth said it’s probably not a bad thing to give it a few days, as emotions have been running high in the wake of the morning’s vote.

“You know, obviously the Dems are upset today with the events, and whether they will support this as an alternative to basic expansion is a question,” he said. “I don’t know the answer to that.”

For the bill to pass, it needs almost unanimous Democratic support plus a handful of Republicans to come along.

Lambeth and his co-sponsor Rep. Donna White (R-Clayton) said they would be whipping the votes as much as they could in the coming days.

White said she was “cautiously optimistic,” with an emphasis on “cautiously.”

Senate wild card

The razor-thin margin of error for Democrats in the Senate had health care advocates concerned on Wednesday. Only one Democratic defection is sufficient to give Republicans the 30 votes they need for an override in their 50-person chamber.

“Obviously the big thing that’s changed is the status of the budget,” said Rob Thompson, deputy director of NC Child, an advocacy organization. “If the senate moves forward and overrides the governor’s veto of the state budget, then there’s a lot less political pressure on senators to negotiate and work on [Lambeth’s] bill.”

The budget bill also contains several poisoned pills for the Department of Health and Human Services, namely a nearly $70 million budget cut over the coming two years and an initiative to move the department out of Raleigh and to Granville County.

“The budget and the House vote process are profoundly disappointing,” said HHS Sec. Mandy Cohen in a press release Thursday. “In a time of a surplus, this budget makes massive cuts to DHHS that will potentially impact everything from health inspections of restaurants to the safety of drinking water to child protective services.”

“I think both of those things, the cut and the move, if enacted are going to be really damaging to our state’s ability to manage its health care and public health system,” Thompson said.

He noted that Berger has said some “more positive and open statements,” of late. But he also worried that without the pressure of the budget standoff, Berger has less incentive to allow for Lambeth’s bill to come to a vote, should the House pass it and send it to the Senate.

Who’s on board?

People around the legislative building were counting their fingers all day, trying to discern if there were any senate Democrats who might cave to pressure applied by the Republican leadership.

Sen. Don Davis (D-Greenville), who sided with the Republican majority on a contentious abortion bill earlier this year, told numerous reporters that he would be a reliable vote to sustain Cooper’s veto. Similarly, Sen. Floyd McKissick (D-Durham) said he was confident in a vote to sustain.

“I’ll put it like this. I think the governor’s veto will be sustained without a doubt,” McKissick said.

“I know they’re going to twist arms but we’ve talked as a caucus throughout this process and again today, and we’re going to hold firm,” assured Durham Democratic Sen. Mike Woodard.

But members of the Republican majority expressed their own confidence that their side would prevail.

“The question is when,” said Sen. Ralph Hise (R-Spruce Pine).

“We have made the offer to the governor, to come to a special session to discuss changes to Medicaid,” he said. “Don’t know that that offer has changed. And we have always said that the discussion of changes to the Medicaid, its population … has to be separated from the budget conversation in order to move forward.”

And should the budget veto fall in the Senate?

“It’s hard to see a political landscape where the Senate would stick around to have that [Medicaid] vote,” Thompson said.

Update: This story has been updated with a comment from DHHS which was sent Thursday.

Additional Thanks

Categories

Sen Ralph Hise

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Lessons from Abroad: How Europeans tackled opioid addiction and what the U.S. could learn from them.

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