Surry County

shows people on a dias who are wearing masks to prevent the transmission of COVID

Coronavirus Today – Nov. 23 – Mask mandate tightened; Greensboro toughens enforcement

November 23, 2020 by Anne Blythe

Coronavirus Today – Nov. 23 – Mask mandate tightened; Greensboro toughens enforcement - North Carolina Health News

Gov. Roy Cooper tightens mask order as NC COVID-19 case counts jump quickly. "We are in danger," he said as he ordered stricter enforcement of mask mandates.

By Anne Blythe

Gov. Roy Cooper minced no words on Monday when he gave an update on North Carolina’s COVID-19 trends and metrics.

“We are in danger,” Cooper told reporters during an afternoon briefing. “This is a pivotal moment in our fight against the coronavirus. Our actions now will determine the fate of many.”

The state reported 2,419 new lab-confirmed cases of COVID-19 on Monday, a positivity rate of 7 percent and 1,601 hospitalizations.

As health care systems, particularly in the Triad region of Greensboro, Winston-Salem and High Point, worry about capacity limits, Cooper strengthened his statewide mask mandate.

Three days before Thanksgiving, Cooper issued a new executive order that makes it clear that anyone who is in the presence of someone outside their immediate household needs to wear a mask.

And as the holiday shopping season begins, the order also requires any business with more than 15,000 square feet to post an employee near the entrance to ensure that occupancy limits are followed and anyone shopping there is masked.

“Our statewide mask requirement has been in effect since June,” Cooper said. “It is still our best weapon in this fight. Today’s executive order will further tighten the mandate making it clear that everyone needs to wear a mask whenever you are with someone you don’t live with. That means wearing a mask when you’re at home, with friends or family visiting, and it means a mask at work, at the gym, at the store, at school.”

Cooper and Mandy Cohen, secretary of the state Department of Health and Human Services, stress that a mask is most effective when it covers the mouth and nose, not just one or the other.

“Masks, distance, small gatherings,” Cooper said. “All of these are critical during the holidays and cold months ahead.”

The order takes effect on Wednesday and extends the protections through Dec. 11.

Dire alerts in 20 counties

The North Carolina public health team rolled out a new tool last week to highlight the counties with viral hotspots.

In the color-coded system, which designates red for the highest level of concern, the state has seen the number of counties in that classification double in just one week from 10 to 20.

The public health team had intended to issue the alert system map monthly but updated it on Monday, less than a week after presenting the first report because the virus is spreading so rapidly in some counties.

Alamance, Alexander, Avery, Bertie, Catawba, Columbus, Davie, Gaston, Guilford, Hoke, Mitchell, Montgomery, Perquimans, Robeson, Surry, Swain, Vance, Wilkes, Wilson and Yadkin counties are now all designated as in the red zone. They could have COVID-19 case rates of more than 200 per 100,000 people over the past 14-day period, or at least 42 cases in that two-week period. They might have a positivity rate greater than 10 percent or a caseload that has a high impact on county hospitals.

Counties classified as orange have had a case rate of 101 to 200 per 100,000 people over the past 14 days, or at least 21 cases in 14 days, a positivity rate in the 8- to 10-percent range or caseloads having a “moderate impact” on hospitals.

shows a map of North Carolina with many counties colored in yellow, some counties colored in orange and a handful of them red, to denote critical levels of COVID activity — A new mapping tool created by the Department of Health and Human Services looks to highlight which parts of the state are seeing critical increases in the number of COVID-19 cases and hospitalizations. This screenshot from DHHS shows the report from Nov. 17. Red counties have “critical” community spread, orange have “substantial” and yellow have “significant” community spread.

Forty-two counties were in orange zones, according to Cohen, with “substantial community spread.”

Thirty-eight counties were classified as yellow with “significant community spread.”

Simple actions, profound effects

“Remember, we still have a high level of concern for our yellow counties,” Cohen said. “People who are in counties that are yellow should take action to ensure they don’t become orange or red.”

This comes as Cohen and Cooper urge North Carolinians to keep Thanksgiving gatherings small, outdoors and travel-free.

“Our statewide metrics and county alert map show that we are on very shaky ground,” Cohen admonished. “I do not want to see the bottom fall out. I’m particularly concerned about our record number of people in the hospital.”

Some health care systems have begun to scale back elective surgeries again to ensure that they have an appropriate number of workers and beds for quality care of all patients.

“The coming weeks will be a true test of our resolve to do what it takes to keep people from becoming sick, to save lives and to make sure you have hospital care for whether it’s a heart attack, a car accident or COVID-19 when you need it,” Cohen said. “We know so much more about this pandemic than we did back in March when we had our first case. We need to put that knowledge to use, particularly when the actions are simple and the effects are profound. Masks work.”

Greensboro declares state of emergency

Greensboro Mayor Nancy Vaughan spoke at the briefing with Cooper and Cohen to share with the state actions that the Guilford County city is taking to try to tamp down COVID-19 spread.

“Our positivity rate is increasing and our hospital beds are decreasing,” Vaughan said.

Guilford is one of the red zone counties and Cone Health is one of the systems groaning from the weight of caring for a high number of patients suffering serious illness related to the virus.

In the early days of the pandemic, Cone Health put its recently decommissioned Women’s Hospital in Greensboro back into use.

The facility has 118 beds and is the place where people with illness related to the novel coronavirus have been segregated.

“In essence, it became our field hospital,” Vaughan told reporters at a briefing with the governor on Monday. “Without these additional beds, we would already be over capacity.”

Two months ago, the mayor said, there were an average of 36 patients in the Cone Health system with severe illness related to COVID-19. That number jumped to an average of 81 cases a month ago.

This past weekend, there were 133 patients hospitalized, 27 of whom were in intensive care units.

“Based on Cone’s internal projections, we are on track to have 200 to 300 people by February or March,” Vaughan said. “Our numbers are doubling every 27 days.”

Cone Health reports that 230 people have died in Guilford County since the start of the pandemic.

“At the rate we are going, they predict we could have 100 more by the end of this year,” Vaughan said.

North Carolina passed the 5,000-death milestone over the weekend, and it was only a month ago that the death toll topped the 4,000 mark.

Vaughan, the Greensboro mayor since 2013, issued an executive order on Friday declaring a state of emergency in the city.

‘We all need to do our part’

Through the order, Vaughan directed local officials to enforce Cooper’s statewide mask order while also setting up the possibility for civil fines and temporary closures of businesses for those out of compliance.

Businesses can be fined $100 for every person inside the establishment who is not wearing a mask or violating the occupancy limit.

City officials fanned out over the weekend to let businesses known for their non-compliance that enforcement was going to tighten. Initially, businesses will get warnings. If enforcers return and the order is being violated still, the business could be forced to close for at least 24 hours, and perhaps as many as 72 hours.

“It’s simple, in a time of a health emergency, we all need to do our part,” Vaughan said. “Supplies are limited. Frontline health care workers are doing a great job, but their capacity is limited. Many business owners have expressed to me their fear of another shutdown. I don’t want that either. I want to keep them in business.”

Cooper held up what Greensboro is doing as a model he would like to see duplicated elsewhere.

“We want people to follow the safety guidelines to slow the spread,” Cooper said. “If they don’t, the rules need to be enforced and we’re working with state and local governments to do just that. We don’t want to go backward, but we will if it’s necessary. The next seven to 14 days will tell us whether we are stemming the tide or whether we need to ratchet it up even more.”

With the promise of vaccines in the works, Cooper noted that “the other side of this pandemic is not very far off.”

“Until then,” he said, “our safety measures will save lives and keep our economy going until we get across the bridge.”

Coronavirus by the numbers

According to NCDHHS data, as of Monday afternoon:

5,039 people total in North Carolina have died of coronavirus.
339,194 have been diagnosed with the disease. Of those,1,601 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.
293,555 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, 4,965,564 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 (40 percent). While 15 percent of the positive diagnoses were in people ages 65 and older, seniors make up 82 percent of coronavirus deaths in the state.
419 outbreaks are ongoing in group facilities across the state, including nursing homes and correctional and residential care facilities.
There are 3,477 ventilators in hospitals across the state and 923 ventilators in use, not just for coronavirus cases but also for patients with other reasons for being in the hospital. As of Monday, 242 suspected COVID-19 patients were in intensive care units across the state.

shows a video conferencing call with six people who were talking about Cardinal Innovations

Union, Cabarrus, other counties look to cut ties with Cardinal

October 20, 2020 by Rose Hoban

Union, Cabarrus, other counties look to cut ties with Cardinal - North Carolina Health News

Union and Cabarrus counties are exploring changing mental health management organizations ahead of a critical deadline. Others may follow suit.

By Rose Hoban

With little debate, members of the Union County board of commissioners voted unanimously Monday afternoon to disengage the county from their relationship with Cardinal Innovations, which has managed mental health services there for years.

Several hours later, Cabarrus County commissioners followed suit, initiating the process of severing ties with the organization, which once built a multimillion dollar corporate headquarters there.

In front of PBH's Kannapolis office. — In front of Cardinal Innovation’s Kannapolis office, which was the corporate headquarters until they were moved to Charlotte. Photo credit: Lydia Wilson for NCHN

The moves come after commissioners in both counties received repeated complaints, particularly about children in need of services who were difficult to place because of the complexity of their care.

According to Union County deputy manager Michelle Lancaster, who also manages county human services, people have been frustrated that Cardinal has dragged its feet on getting the appropriate level of care for kids in foster care, some kids with Medicaid, and other children with extensive needs.

“And we have providers of services in the community who have expressed frustration, about the difficulty of working with Cardinal around approvals and feeling like the array of services was appropriate for the clientele,” she said.

Cabarrus County commissioner Blake Kiger said that he’s been hearing complaints about Cardinal almost since taking his seat in 2017.

“I’m sure it predates me. That, at least, is the reference point that I have for how long … we’ve tried to work through some of the issues,” Kiger said. “This is not something that we just have decided to do on a lark or a whim, to a lot of people, this is long overdue.”

The changes come even as state Department of Health and Human Services deadlines are looming for behavioral health providers to apply for contracts to serve people with the most complex needs. Once those “tailored plans” are put into place, it will be a more complicated process for counties to change their behavioral health managers.

Rocky past, present

Cardinal, and its predecessor organization Piedmont Behavioral Health, has managed mental health services in both Union and Cabarrus counties for at least 20 years. The two were part of the five involved in the original PBH pilot program that got counties out of the business of providing mental health services directly to patients. Instead, the state allowed these organizations to pivot and act as mini-insurance companies, contracting with counselors, psychologists, psychiatrists and other providers to deliver care to people with behavioral health issues.

That pilot program eventually spurred North Carolina to completely transform the state’s mental health system to have all care managed by similar “local management entities/ managed care organizations,” a change that went into effect in 2013. Under this managed care system, the agencies, known as LME/MCOs, get a pot of money for every Medicaid mental health consumer in their area to pay for all mental health services a person might need. In addition, the LME/MCOs receive state dollars to cover costs for some people who have no insurance.

The organizations have the power to approve or deny the claims providers submit on consumers’ behalf.

Check out our 2012 series on how Piedmont Behavioral Health spurred changes to North Carolina’s mental health system

The changes were controversial and turned the lives of some patients upside down as the whole way of receiving care changed. The changes also were rough on providers who saw their revenues shift and had to reorganize themselves as well.

As the changes took effect, some LME/MCOs went out of business, at least one ran its finances millions in debt. All the while, Cardinal grew and grew, taking over the management for patients in more counties, growing from the original five-county system in the southern Piedmont to covering more than 20 counties in far-flung parts of the state.

Throughout its history, Cardinal had often gone its own way. Leaders at the organization seemed impervious to criticism about agency spending and about the way they presented themselves and their agency. They long insisted that Cardinal did not need to adhere to state rules, but that as a “quasi-governmental agency” it was free from legislative oversight.

That facade began to crumble in 2016 when then-secretary of DHHS Rick Brajer publicly took former Cardinal CEO Richard Topping to task for his million-dollar-plus compensation package.

Cardinal CEO Richard Topping was finally pushed out of his position by state officials after a headline-grabbing audit revealed a million-dollar-plus salary, lavish parties and travel on chartered jets at state expense. Image courtesy Cardinal Innovations

Then came a headline-generating report from the state auditor in 2017 that found senior management at the agency were paying themselves handsomely, throwing lavish parties on the public dime and flying board members to resorts for meetings in private jets. Topping’s compensation package was well north of a million dollars a year.

Later that year, a new DHHS secretary, Mandy Cohen, took over the agency, expelling the CEO and the board of directors and installing new upper-level managers. Cohen said Cardinal’s consistent flouting of state rules, Topping’s and the board’s defiance of her agency’s attempts to rein them in, and the added tussle over Topping’s salaries finally pushed her to act.

With a new CEO hand-picked by DHHS leaders and a new board, Cardinal seemed to enter a quieter period, during which it expanded but stayed out of the limelight.

But troubles persisted.

“For years and years and years, these same issues just keep coming up,” said Cabarrus County commissioner Lynn Shue. “Even after all the changes that the Department of Health and Human Services made with the appointment of a new board and all of that, it seems as though we’re not getting things that we’re looking for.

“We’re looking for collaborative effort.”

Cardinal losing its grip

On Monday evening, Cardinal’s management expressed their disappointment.

“We have been committed partners in Union and Cabarrus counties for decades,” wrote Cardinal CEO Trey Sutton in an email to NC Health News. “We have been working hard at these relationships and feel that our joint efforts have been headed in the right direction, so today’s activities were especially disappointing.”

Sutton argued Cardinal has been working to “do the right thing for our most vulnerable citizens.”

He pointed out that under state law, the final decision over whether to allow counties to disengage from Cardinal as their mental health manager will have to come from DHHS leadership. He also noted that the multi-month process is “lengthy and certainly not guaranteed.”

Both Union and Cabarrus counties have resolved to move their county contracts to Partners Health Management, an LME/MCO based in Gaston County which covers nearly a million people in Burke, Catawba, Cleveland, Gaston, Iredell, Lincoln, Rutherford, Surry and Yadkin counties.

shows people sitting at long meeting tables, with hands raised — In 2017, commissioners from 19 counties met to choose new board members for Charlotte-based Cardinal Innovations. Photo credit: Rose Hoban

An official in Forsyth County said she’s putting finishing touches on a letter outlining her commissioners’ issues with the organization. She said her commissioners weren’t quite ready to jump ship, but they were open to exploration.

“Local citizens wish for more locally based leadership that is responsive to community stakeholders, especially consumers and families, but instead sense internal chaos and frequent staff changes,” said Winston-Salem-based mental health advocate Laurie Coker.

Rutherford County actually switched to Partners last year. In a presentation to that county’s board of commissioners earlier this month, a representative of the organization outlined the increased level of service.

“The Partners presentation of their first year serving the citizens of Rutherford County was impressive,” county commission chair Bryan King told the Daily Courier. “The news of an increase in providers, and an increase in citizens served was welcomed news.”

Changes coming for complex patients

One of the long-held complaints about the LME/MCO system has been that it disincentivizes spending big dollars on people who have some of the most complex needs. For Union County’s Michelle Lancaster, the big issue was treatment and placement for children with exceptional needs.

“They’re typically hard-to-place kids. They may have,” Lancaster paused and sighed, “It is what it is – over-sexualized behaviors, they may have a history of violence, things that wouldn’t make a traditional foster home appropriate for their care.”

She said her county has ended up spending local dollars to provide the appropriate level of care for these children, sometimes for months or years because the county couldn’t get satisfaction from Cardinal.

“They really see their job as providing treatment and the role of DSS is to provide placement,” Lancaster said. “However, these are complicated kids, you cannot separate the two of those things. You can’t say, ‘Hey DSS, go place that kid somewhere, and we’ll come and catch up with you on the treatment side.’ It just doesn’t work that way.”

These children are among the complex patients whose care will be addressed in upcoming changes to the state’s Medicaid program. In the coming month, DHHS will ask provider agencies to put in their proposals for how to create tailored plans for the most complicated patients.

It’s expected that LME/MCOs will put in applications for contracts that will last for four years. Once counties start down the road with whoever gets chosen to administer these tailored plans, it will be difficult to disentangle themselves, said Corye Dunn, an attorney with Disability Rights North Carolina.

“It’s the rollout of tailored plans that really put the decision point right in front of counties right now,” she said.

The request for applications will open up in November, with contracts awarded sometime early next year.

“And at that point, managed care entities are going to get a multi-year contract to serve a fixed catchment area,” she said. “I can imagine that if I were a county official, and I were unhappy, I’d be pushing for change now.”

Correction: All local management entities/ managed care organizations, transferred to the new system in 2013, not 2015.

A field scientist drags a cloth across the ground to gather ticks

Ticks continue creeping southward in North Carolina

August 5, 2020 by Greg Barnes

Ticks continue creeping southward in North Carolina - North Carolina Health News

The coronavirus pandemic may have slowed reporting of tick-borne diseases in the state, but the insects are more prevalent than ever and are heading south, some carrying relatively new diseases.

By Greg Barnes

Alexis Barbarin isn’t sure why North Carolina is reporting fewer cases of tick-borne diseases this year.

Normally, by this time, hundreds of cases would have been reported, said Barbarin, the state’s public health entomologist, whose job it is to track diseases transmitted by insects. Instead, she said, only 76 confirmed and probable cases of Lyme disease and 74 cases of Rocky Mountain spotted fever have been reported.

One would think, in this time of the coronavirus pandemic, that people would be communing more with nature — hiking, having picnics, exploring the great outdoors — in places where ticks love to live.

Figures from the state Division of Parks and Recreation show that to be the case.

The pandemic forced the closure of all but 12 state parks for several weeks in the second quarter of 2020. But visitors to parks shattered last year’s attendance numbers over the Memorial Day and the Fourth of July holidays, and people have flocked to the parks that remained open, the figures show.

“The dramatic increase in visitation in some of our parks have shown us the critical importance of state parks to our citizens, particularly during this difficult time,” division spokeswoman Katie Hall said in an email. “People are seeking outdoor experiences for both relaxation and active recreation as a way to process the big changes and stressors our citizens have faced in their lives due to COVID-19.”

Cases going unreported

So why haven’t there been more reported cases of tick-borne illnesses?

Barbarin said one likely reason is that health care professionals have been so slammed with coronavirus patients that they haven’t had time to regularly log cases of tick-borne infections. Another reason, at least for Rocky Mountain spotted fever, is that the case definition changed in January, increasing the threshold for reporting positive cases, she said.

Another way to get an idea of tick activity is to look at the number of times people have gone to the website Tick-Borne Infections Council of NC, or TIC-NC. In the early months of the coronavirus pandemic, the website got little traffic. That changed in May, when Gov. Roy Cooper lifted his stay-at-home order and traffic spiked and continues to be elevated.

shows an adult brown tick wiht a bright white marking in the middle of its back, sitting on a leaf — Amblyomma americanum tick, commonly known as the Lone Star Tick. Photo credit: Wikimedia Commons

“There’s no way to prove this, but I think it’s pretty safe to assume that the hits increase because people are getting tick bites and have questions,” said Marcia Herman-Giddens, an adjunct University of North Carolina professor and the scientific adviser for TIC-NC.

Some things are certain, though: Ticks are spreading southward in the state, more tick-borne diseases are being discovered and the problems aren’t going away.

Ticks on the move

In the spring of 2019, state health officials were notified that three children attending a wilderness day camp near Asheville had contracted Lyme disease, a bacterial infection transmitted by the bite of an Ixodes scapularis tick — often referred to as the deer tick or blacklegged tick — that is infected most commonly with the bacterium Borrelia burgdorferi. A fourth child had been infected at the camp in 2017.

According to a report by the Centers for Disease Control and Prevention, it was the first time a cluster of Lyme disease patients with a common exposure had been found so far south. The report was co-written by Barbarin.

Since then, a resident in Cherokee County submitted a tick Barbarin believes is Ixodes scapularis to the NC Animal Tick Identification Program. Although awaiting national verification, Barbarin said that would be the farthest south and west the species of tick has been found in North Carolina. She said the tick has also been found in Mecklenburg County and many counties to the east.

map showing where Lyme Disease occurs in North Carolina, by county. — In North Carolina, the reported number of confirmed and probable cases of Lyme disease has increased over the past five years. The highest incidence of Lyme disease in 2019 is clustered to the northwestern portion of the state, particularly in Ashe, Alleghany, Surry, Stokes, Watauga, and Yancey counties, according to the CDC. Map courtesy: NC DHHS

Lyme disease is not particularly prevalent in North Carolina — the incidence rate last year was 3.3 cases per 100,000 people, compared with the national average in 2018 of 7.2 cases per 100,000, according to the N.C. Department of Health and Human Services.

But North Carolina’s incidence rate for Lyme disease has increased over the past five years, led by Ashe, Alleghany, Surry, Stokes, Watauga and Yancey counties in the northwest.

‘A whole different world’

Herman-Giddens said she has been hiking in the woods in Ashe County for 40 years. She owns a cabin there.

In all of those years, she said, she had never been bitten by a tick until last year, when she pulled two blacklegged tick nymphs off her skin.

“It changed everything because it used to be a refuge going to the mountains,” she said. “You could just plow off into the woods and not worry about ticks, but now you do.

“It’s starting to be a whole different world, tick-wise, up in the mountains, sadly.”

Herman-Giddens didn’t contract Lyme disease, but she considers herself lucky. About 25 percent of the ticks in Ashe County carry the bacteria that causes the disease, she said. The nymphs are so small — about the size of a poppy seed — that most people don’t initially even recognize that they have been bitten, she said.

“Imagine trying to find a poppy seed stuck somewhere on your body, especially if it’s someplace you don’t see, you know, like the back of your neck or under your arm,” she said “That means if it’s on you 24 to 48 hours or more, it’s highly likely to have been transmitted so that means you’d have a one in four chance of getting it. It’s scary.”

The incidence of Lyme disease in Ashe County has skyrocketed since 2016, largely because of the migration of deer — the primary carrier of the blacklegged tick — from Virginia to the north, Herman-Giddens said.

Symptoms of Lyme disease

Lyme disease, like other tick-borne illnesses, can be debilitating. Early signs include fever, chills, headache, fatigue, muscle and joint aches, swollen lymph nodes, and a rash resembling a bullseye at the point of the bite that can take up to 30 days to appear.

Deer_Tick_-_geograph.org.uk_-_105508 — Ixodes scapularis, commonly known as black legged ticks, carry Lyme disease bacteria. Photo courtesy Stuart Meek, Wikimedia Creative Commons

Untreated, Lyme disease can cause severe headaches and neck stiffness, arthritis with severe joint pain and swelling, particularly in the knees and other large joints, facial palsy, and heart conditions, according to DHHS.

The blacklegged tick is just one species in North Carolina that causes disease. Others include the Lone Star tick, the brown dog tick and the American dog tick. Rocky Mountain spotted fever is the most prevalent tick-borne disease in the state, occurring largely in the central and eastern portions of the state.

But there are other types of ticks, as well, and the state keeps discovering new species and new diseases.

Fierce Asian longhorned tick

North Carolina faces a new threat from the Asian longhorned tick, which was first reported in the United States in 2017.

Last year, the state confirmed that a Surry County farmer lost five cows to the Asian longhorned tick from acute anemia. According to the Southern Farm Network, a young deceased bull was brought into the state’s Northwestern Animal Disease Diagnostic lab with more than 1,000 ticks on it. The owner had lost four other cows under the same circumstances.

Basically, they had all bled to death.

At that time, the Asian longhorned tick had been confirmed in four North Carolina counties; Surrey, Polk, Rutherford and Davidson. Barbarin said the tick has now been found in 10 of the state’s counties. The others are Madison, Alexander, Haywood, Wilkes, Rowan and Macon.

The CDC reports that although no people have fallen ill from an Asian tick bite in the United States — it “appears to be less attracted to human skin” — disease has been spread to humans in other countries. Barbarin said an Asian tick was removed from a person in Davidson County.

“With ongoing testing of (Asian) ticks collected in the United States, it is likely that some ticks will be found to contain germs that can be harmful to people. However, we do not yet know if and how often these ticks are able to pass these germs along to people and make them ill,” the CDC reported.

The CDC says a recent study found that Asian ticks are unlikely to carry the bacteria that causes Lyme disease, but another study found that they can carry the bacteria that causes Rocky Mountain spotted fever.

Barbarin said the state Department of Health and Human Services is working with a researcher at N.C. State University’s College of Veterinary Medicine. Whenever an Asian longhorn tick is found it is sent to the researcher to test for pathogens, Barbarin said.

“So far, she hasn’t found any pathogens in any of the tests that we’ve submitted,” Barbarin said. “But the numbers of ticks that we’re getting, again, is fairly low, so we would need a more robust sample to determine if these ticks are actually infected.”

Other tick-borne diseases

While the Asian longhorned tick becomes a growing concern, researchers are watching out for other tick-borne diseases in the state, including those caused by the Bourbon and Heartland viruses.

The Bourbon virus, or Thogotovirus, Orthomyxoviridae, was first discovered in Kansas when a patient with a history of multiple tick bites died from an unknown infection.

According to the NC Medical Journal, the Bourbon virus has been detected in antibodies of white-tailed deer in North Carolina. The journal reports that the incidence of Bourbon infection in humans in this state is unknown but has likely gone unnoticed or possibly misdiagnosed.

The virus, which is linked to the Lone Star tick, is rare but can be fatal.

Map highlights states as far west as the middle of Texas, north into Nebraska and the Minnesota border, and into New England, as far north as the Maine coast. — Geographic distribution of Lone Star Ticks, as of 2013. Map credit: Centers for Disease Control and Prevention

The Heartland virus was first discovered in Missouri in 2009, when two farmers with multiple tick bites were hospitalized for 10 to 12 days. One of the farmers fully recovered, but the other reported fatigue and headaches two years later, according to a 2013 report in the National Center for Biotechnology Information. The virus has now been found in seven states, including North Carolina. The virus typically requires hospitalization and can be fatal.

If that’s not enough to make your skin crawl, there is growing evidence that ticks may be responsible for causing an allergic reaction to beef, lamb, pork and other meat. Called Alpha-Gal Syndrome, people have a reaction to the tick bite several weeks after being bitten. Once the infection takes hold, a person will have an allergic reaction typically three to six hours after consuming meat. This delayed reaction often makes it hard for physicians to diagnose the problem.

The allergy is believed to be caused primarily by the Lone Star tick, which bites a person, sensitizing the victim to reacting to a type of carbohydrate found in the flesh of commonly-consumed meats.

Precautions urged

With the increasing prevalence of ticks in North Carolina, Barbarin and Herman-Giddens urge people to take the threat seriously and to take precautions, such as using insect repellent containing Deet, wearing long clothing, treating clothing and gear with permethrin and avoiding wooded or brushy areas with high grass and leaf litter.

After an outing in the woods, people should check their bodies closely for ticks, take a shower and wash their clothes.

The CDC estimates that 30,000 cases of Lyme disease are reported in the United States every year, about 10 times fewer than the number of cases that the agency believes actually occur. The number of reported cases has tripled in the United States since the late 1990s.

Despite those numbers, the North Carolina General Assembly in 2011 abolished the Division of Environmental Health, which included the public health pest management section, severely limiting the amount of tick surveillance and public information efforts being done today in the state.

But a new pot of money that aims to improve the federal government’s response to tick-borne diseases became available late last year with the passage of the Kay Hagan Tick Act. The act is named after former U.S. Sen. Kay Hagan, a North Carolinian who died in 2019 after a lengthy battle with a rare tick-borne disease called the Powassan virus.

The act appropriates $150 million that will be used in the battle against ticks “to help expand research, improve testing and treatment and coordinate common efforts across federal agencies,” according to Lymedisease.org

Clarification: We updated this story to clarify that with Alpha-gal syndrome, the first reaction takes place several weeks after being bitten by a tick. Subsequently, when a person eats meat, they have an allergic reaction several hours later.

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

New dollars target opioid misuse, workforce revitalization in WNC

September 11, 2019 by Liora Engel-Smith

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

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

By Liora Engel-Smith

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

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

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

The Appalachian Regional Commission covers 29 counties in North Carolina

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

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

Source: ARC

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

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

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

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

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

‘Not just a job coach’

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

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

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

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

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

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

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

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

No Wrong Door

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

Recovery Resources

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

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

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

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

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

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

Image of money with a caduceus superimposed on the bills. We're using this image to denote Medicaid managed care.

Budget impasse delays Initial Nov. 1 rollout of Medicaid managed care

September 4, 2019 by Sarah Ovaska

Budget impasse delays Initial Nov. 1 rollout of Medicaid managed care - North Carolina Health News

Instead of one quarter of the state program going live this fall, the entire state will make the transition to managed care in Feb. 2020

By Sarah Ovaska-Few and Rose Hoban

The standoff between North Carolina’s state government power brokers over the state budget and Medicaid expansion has claimed a victim: the planned roll-out this fall of Medicaid managed care.

N.C. Department of Health and Human Services Sec. Mandy Cohen announced Tuesday morning she was pushing back the Nov. 1 start date of Medicaid managed care, given the uncertainty caused by the lack of a state budget more than 60 days into the fiscal year that started on July 1.

“We don’t have the budget, and so we can’t move forward,” Cohen said in a mid-morning call with reporters.

shows Cohen standing at a podium with a presentation displayed on a screen behind her. — HHS Secretary Mandy Cohen spoke to a crowd at a Medicaid managed care listening session in 2017. Photo credit: Rose Hoban

November was when Medicaid recipients in a significant portion of the state – a 27-county area including the Triangle and a large swath of the Piedmont – were scheduled to switch from the current fee-for-service system to a managed care system.

Now, the entire state will move over all at once to managed care on Feb. 1, 2020, a scenario that will affect an estimated 1.6 million mostly low-income children and their moms; along with some seniors and disabled persons who qualify for Medicaid.

[An additional half-million Medicaid recipients with complex physical and behavioral health needs will move over to tailored managed care plans in 2021.]

Cohen said having the entire state switch over at once to managed care isn’t ideal, but the best option given the current budget impasse.

“Sometimes we don’t get the ideal, we have to work in the practical realities of what we have,” Cohen said.

Medicaid is one of the largest providers of health care in the state – nearly 1 in every 5 North Carolinians, many of them children, depend on the federally administered program. It’s also one of the largest government programs run by the state of North Carolina. Its $14 billion annual cost funded through a mix of federal and state dollars with the federal government chipping in $2 for every $1 the state spends.

North Carolina had long been using a fee-for-service system, where the state managed and paid for every Medicaid patients’ flu shots, hospital stays and other health care needs. The Republican-led legislature called for a switch to privatized managed care in 2015 in hopes prepaying for health care would bring about budget predictability and better health outcomes. North Carolina is also the largest state that does not have a significant presence of commercial managed care companies running Medicaid. The state does have locally grown managed care organizations running the state’s mental health Medicaid programs, but the legislature retains significant control over those organizations.

shows a map of North Carolina broken up into six regions — Four companies were awarded statewide contracts, while a partnership made up of managed care giant Centene, the North Carolina Medical Society and the North Carolina Community Health Center Association received the nod to provide services in regions 3 and 5. Regions 2 and 4 were slated to “go live” in November, with the rest of the state following next year. But now, the entire state will make the switch at the same time. Map courtesy: NC DHHS

In the new managed care system, the state will pay an agreed-upon monthly rate per Medicaid recipient to four managed care companies– AmeriHealth Caritas, Blue Cross and Blue Shield of North Carolina, United Healthcare and WellCare – that will, in turn, handle the entirety of a person’s medical needs. A fifth group, Carolina Complete Health, which is a partnership between the managed care company Centene and the N.C. Medical Society, can serve people in a region of the state that includes Charlotte and the southeastern corner of the state.

Politics behind the delay

N.C. Gov. Roy Cooper, a Democrat, has also made clear his desire to expand Medicaid coverage to low-income adults currently without health care insurance in the state, a signature piece of the Obama administration’s Affordable Care Act.

But the Republican-led North Carolina state legislature has so far been staunchly opposed. This has lead to a standoff over the state budget, which Cooper vetoed on June 28, with Cooper saying he won’t agree to a budget unless Medicaid expansion is in the mix.

Once the governor sent the budget back to the legislature, it became clear that there are not enough votes in the state House of Representatives to override Cooper’s veto. The two sides have been in a stalemate since early July.

In a recent attempt to do an end-run around Cooper, the legislature has been passing “mini-budgets,” such as increases to many state employee salaries, which Cooper signed last week. But on Friday Cooper vetoed the General Assembly’s attempt to pass a partial budget that would have funded the switch to managed care.

“Health care is an area where North Carolina needs us to do more, and to do it comprehensively,” Cooper wrote in his veto message.

On Tuesday, Cohen also gave hints that when it comes to the transformation funding at least, negotiations may be making headway between the Cooper administration and state Sen. Phil Berger, the Republican state leader. A proposal to cut Cohen’s department that was originally contained in the funding bill was amended out on the Senate floor last week.

“We’re getting to a better understanding that cutting the department at the time that we’re making a huge transition is not the way forward,” Cohen said.

She’s hopeful that a final budget, whenever it does come, would include enough to see the switch to the new managed care system through.

Managed care still happening

Cohen said the delay announced Tuesday isn’t a sign that managed care is at risk, but rather that the state legislature and the governor missing the July 1 deadline for a two-year budget was causing too many uncertainties for the massive roll-over to happen so soon.

“We’re still committed to managed care,” she said. “We are trying not to lose any time on the back end here.”

The financial impact on the state because of the delay will be minimal, she said, with no financial penalties for putting off the Nov. 1 start date.

Her assessment was echoed by Matt Salo, head of the National Association of Medicaid Directors, who said delays in rolling out managed care programs occur for many reasons.

“You know, maybe there’s an impasse with the legislature on the budget, maybe there is an impasse with a particularly powerful provider type, say, for example, the hospitals are [not] completely on board and you still got a lot of work to do,” Salo said. “Or maybe the impasse is that you’re not completely confident in the plan of attack for the rollout.”

He said that sometimes state health departments simply delay or stop a rollout because their early indicators show that a program is not quite ready.

Medicaid – say what? Two terms – Medicaid transformation and Medicaid expansion – are being bantered around a lot these days in Raleigh. Though related, they’re different.

Medicaid transformation is the ongoing switch to a privatized managed care system from North Carolina’s current fee-for-service model, where the state pays for every doctor visit and hospital stay for the 2.1 million low-income North Carolina seniors, disabled persons, children and their mothers already on the federal safety net program. In the new managed care system, the state will pay preselected managed care companies a per-person rate to handle all of an individual’s health care needs.
Medicaid expansion is an outgrowth of the Obama administration’s Affordable Care Act and would use mostly federal dollars to extend Medicaid coverage to low-income adults currently unable to afford to buy their own health insurance on the open marketplace. North Carolina is one of 14 states, mostly in the Southeast, who have not expanded Medicaid.

“It’s kind of like launching a rocket, you know, you want to launch it on time,” he said. “But if there’s anything that goes wrong, it’s much, much safer to just scrap the launch, rather than go ahead and try to meet an artificial deadline.”

The delay does, however, raise the stakes come February, with no partial rollout to learn from before having 1.6 million Medicaid recipients switch to a new system.

Extra time for loose ends

Medicaid recipients in the rest of the state will begin open enrollment – when they get to choose which managed care company to sign up with – in October and make their final decisions by mid-December, she said. And there needs to be a state budget by mid-November, at the latest, in order to meet the new Feb. 1 start date.

The delay came as a relief to many, with concerns mounting that the Nov. 1 start date may have been too ambitious given the complexity of the move to managed care.

“We’ve been worried for a while that the state hasn’t really tested anything,” said Cody Hand of the N.C. Healthcare Association, which represents various hospital and health care systems around the state. “They weren’t ready to go live Nov. 1.”

Beneficiaries in the 27 counties who were, up until this week, expected to switch over to the new system on Nov. 1 were likewise having issues figuring out how to navigate the coming changes for themselves and their families, said Ciara Zachary, health program director for N.C. Child, an advocacy group for children in the state.

One problem is that providers – such as primary doctor offices and specialists — have been slow to sign contracts with the managed care companies.

That meant beneficiaries on Medicaid or who have children on Medicaid or getting benefits through N.C. Health Choice were going to have to choose a managed care plan without knowing if their favored practitioners would ultimately be in their networks, Zachary said. N.C. Health Choice is a program for low-income children who don’t qualify for Medicaid but are still otherwise uninsured.

“It’s a big change and not enough education and awareness has been deliberately targeting enough beneficiaries,” she said.

She’s hopeful the delay will allow for more time for providers to sign up with care networks, and for the state to assess how it and the enrollment broker it hired is communicating with those beneficiaries.

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

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

July 23, 2019 by Yen Duong

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

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

By Yen Duong

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

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

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

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

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

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

What ‘high risk’ means

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

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

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

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

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

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

Many barriers to MAT

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

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

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

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

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

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

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

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

Ideas to address the whole person

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

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

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

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

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

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

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

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