By Taylor Knopf
Between federal COVID relief funds and the $1.4 billion sign-on bonus North Carolina received for expanding Medicaid, state lawmakers were able to make significant investments in mental health services in the latest state budget.
Though state budget negotiations are done almost entirely behind the closed doors of the majority party in the General Assembly — currently the Republicans — health leaders in the House and Senate said they took care to listen to patients, families and providers while creating their mental health spending plan while also working closely with Department of Health and Human Services Secretary Kody Kinsley.
“Everybody saw that to make big changes was gonna take a lot of money,” Sen. Jim Burgin (R-Angier) said in an interview with NC Health News this week.
“And I think one of the attractions to Medicaid expansion for all of us was this once in a generation or maybe even once in a lifetime opportunity to say, ‘Mental health is a big deal,’” he said, explaining the significance of the federal sign-on bonus that came with Medicaid expansion, which lawmakers decided to use to invest in mental health services.
The result is pages of mental health policy and spending in this year’s budget document, where lawmakers committed to significant rate increases, bonuses and education for a variety of mental health workers. They set into motion big structural changes to the way behavioral health services are delivered to the most vulnerable populations across the state. And they directed hundreds of millions to support children in foster care and expand preventive mental health care and crisis care services.
‘A sense of urgency’
Burgin said he has long been committed to improving the mental health system. He demonstrated that commitment when he embarked on a listening tour with Kinsley and other legislative guests to learn about the mental health needs across the state. After more than a dozen town halls, Burgin said he saw “a different face with the same heartbreaking stories about not being able to get services. We heard that at every meeting.”
“You don’t know how bad something is until you go see it yourself,” Burgin said. “You get a sense of urgency that we have to do something.”
Rep. Donny Lambeth (R-Winston-Salem) has been dedicated to improving health care through his six terms in the state House, and he said he’s never had a better working relationship with a DHHS secretary than he does now. Lambeth described Kinsley as being an open-minded problem-solver. Burgin was also quick to praise Kinsley for the time he’s invested in helping others understand the mental health needs of the state and forming the relationships necessary to move things forward.
“We’re actually getting a lot done, but we’re having a good time doing it because we enjoy talking about it and working on it,” Burgin said. “In the next 24 months, you’re going to see some fantastic things happen in North Carolina.”
Alternatives to the emergency room
Lambeth said that last summer he received three phone calls in one week from families with a child in a mental health crisis asking him what they should do to get help.
“Unfortunately, the only thing I could tell them is, ‘You need to go to the emergency room,’” he said. “We’ve got to get these individuals into a proper care site, not the emergency room.”
Going to the emergency room during a mental health crisis can be a traumatic experience for many, as emergency departments are not set up to treat mental health crises.
In recent years, ERs across the state have been overwhelmed by mental health patients, who often end up waiting days or weeks for an available inpatient psychiatric facility bed. Once that bed does open up, the patients are often transported under an involuntary commitment court order. They are handcuffed and driven by law enforcement officers in marked police vehicles.
Burgin said he gets similar phone calls from families with loved ones in distress. He also said the number is only increasing.
“What a shame that the entry point for mental health has become the door to the emergency room,” Burgin said. “And that’s what we’re trying to stop. There’s got to be a better entry point into mental health care.”
The expansion of Medicaid to about 600,000 low-income North Carolians who previously didn’t have health insurance is the first big step to get people into primary care offices instead of emergency rooms, Lambeth said.
“The foundation of expansion really is developing better access points, primary care — taking care of individuals who historically have not had good access,” he said.
‘It’s primary care’
Because of a lack of psychiatrists and child psychiatrists in the state, primary care providers often find themselves out of their depth with patients who come to their offices with mental health issues. To address this, the state spending plan also includes $2 million per year in recurring dollars for the Psychiatry Access Line (NC-PAL), a partnership between DHHS and the Department of Psychiatry & Behavioral Sciences at Duke University.
“Any health care provider, usually a primary care provider or pediatrician, can pick up the phone and speak to behavioral health experts,” Kinsley said.
The budget states that required annual reports be made to state lawmakers that include the number of consultations, counties using the services and the “estimated number of avoided emergency department visits resulting from the services provided through NC-PAL.”
State lawmakers provided $5 million to advance a collaborative care model — where common mental illnesses are treated in primary care settings, rather than sending patients to another provider, often after a wait. This model of care is something DHHS has been scaling up across the state.
“Behavioral health has been thought of as a specialty-level service. It’s not. It’s primary care. Everybody needs access to it,” Kinsley said in explaining the importance of expanding this model.
The budget allocates $80 million over two years for new mobile crisis teams and for crisis and respite facilities. These are alternatives to the emergency room for people who are experiencing mental health distress. The mobile crisis units consist of specialized teams of behavioral health providers that can meet someone where they are located. Respite facilities give people who are having emotional issues the opportunity to spend time in a therapeutic environment, receiving support from behavioral health workers or peer support specialists, people with lived experience of mental illness, all outside of a hospital setting.
Kinsley said he was happy to see $20 million over two years to fund a non-law enforcement pilot program for transporting patients for voluntary and involuntary psychiatric admissions. Putting distressed mental health patients in handcuffs in the back of a police vehicle is “not trauma-informed. That is not appropriate,” Kinsley said.
This spending plan offers “more access points. There’s more prevention. There’s better crisis services and more trauma-informed services if we need to go down that path,” Kinsley said.
Workforce investments
The budget includes hundreds of millions in ongoing funding, which will increase reimbursement rates for several health care positions, including skilled nursing facility workers ($71 million in state dollars), personal care service providers ($50 million in state dollars), direct care workers for people on a state- and federally funded Medicaid program that serves people with intellectual and developmental disabilities ($55 million in state dollars).
Rates for mental health providers have not increased since 2012, and Lambeth and Burgin said they consistently hear about this issue. For years, health leaders have called for rate increases to attract and retain workers for these types of positions.
The budget includes, for example, increasing the hourly rate for direct care providers for people with disabilities who receive enhanced community services. Additionally, the budget provides $10 million in ongoing annual funding for 350 more people to receive services through the program, which makes it possible for people with disabilities to live in the community instead of a facility.
Due to the job’s time commitment and low wages, it’s become increasingly difficult for people with disabilities to keep their direct support providers who help them with simple everyday tasks — from bathing and dressing to going to appointments. Meanwhile, workforce shortages have also led to unstaffed inpatient psychiatric beds at the state’s psychiatric hospitals, thus reducing the overall number of beds available, even as people in need sit and wait in emergency departments for psychiatric beds.
“We can’t do this if we don’t have people to take care of the folks, and we’ve got hundreds of beds empty across the state because we don’t have workers,” Burgin said.
Kinsley said he applauded state lawmakers for committing continuing money to sustain these raises, instead of allocating one-time funding.
“It really unlocks a lot of potential,” he said.
The budget also includes one-time funding of $40 million over two years for sign-on and retention bonuses for employees of state mental health facilities. The spending plan includes $18 million over two years to “establish a workforce training center that would provide no-cost training to public sector behavioral health providers, and to administer grants to community colleges to enhance behavioral health workforce training programs.”
There is also a $2 million grant in the budget to pilot a “mental health in the workplace” program. Truusight Health Solutions will enter into a two-year public-private partnership in Cabarrus and Stanly counties aimed at helping employees access behavioral health services and supporting employers who are navigating the state’s complex behavioral health system.
Improving access in rural communities
Rural communities have long lacked medical care, particularly mental health care.
“We’re desperately short of people that are highly-trained, especially psychiatrists and family practice doctors. So we put dollars aside to pay them up to $100,000 to work in tier-one or tier-two counties,” Burgin said.
The state budget includes large expansions to the N.C. Loan Repayment program — to the tune of $50 million over two years. The North Carolina Area Health Education Center programs will develop and implement plans to recruit and enroll participants, and the state’s Office of Rural Health will track related data. The loan repayment programs are specifically aimed at recruiting and retaining primary care and behavioral health providers to rural or underserved areas of the states.
And with the expansion of Medicaid, more patients with health insurance will be able to walk through the doors. Having insured patients will help financially sustain these rural health practices.
The state spending plan also includes $20 million for grants over two years to rural health care providers for start-up equipment for telehealth, which will improve access for patients with transportation or other barriers to in-person medical care.
Mental health services for children, foster care system
North Carolina’s foster care system has been struggling for years with high-profile failures that include children living in emergency rooms and sleeping on the floors of social services offices. The state health department has also had to take over some failing county operations.
“[The foster care system] is a high priority to us,” Burgin said. “We think that has got to be completely renovated, rejuvenated and reconstituted into a well-run statewide plan, where we can keep up with these kids.”
He said his goal is “limiting the number of times that they have to change places where they lay their little heads.”
The state budget includes the creation of a statewide specialty Medicaid plan for kids in foster care and their families that aims to streamline their physical and mental health care. The groups responsible for providing this care have pushed back on the statewide plan for a couple years, but state lawmakers and Kinsley have said the groups have not made enough progress toward improvement.
The state budget directs DHHS to issue requests for proposals from agencies who wish to hold the contract for the statewide foster care plan, with the new services set to begin by December 2024.
State lawmakers also instructed DHHS to form a work group of child welfare experts and agencies to identify innovative Medicaid service options to address gaps in the care of children receiving foster care services.
Additionally, the state spending plan instructs DHHS to develop a proposal for federal approval to provide more Medicaid-paid mental health services to adults with serious mental illness and to children with serious emotional issues. The goal of this waiver would be to provide more community-based services for these populations while reducing psychiatric hospitalizations and emergency room visits.
The budget provides $80 million over two years “to support families and other caregivers of children with high behavioral health or other special needs by expanding intensive supports in the community and increasing structured options for meeting the needs of these children” and “to strengthen specialized treatment options for children with complex behavioral health or other special needs.”
Diversion and treatment
The budget provides $99 million over two years for community-based, pre-arrest diversion programs and programs to help people reentering the community after incarceration. The money will fund local partnerships between law enforcement, counties and behavioral health providers, as well as community-based and detention center-based restoration programs for those with mental illness and substance use disorders.
Scattered across the budget are several provisions aimed at services for those with substance use disorders, using money from the nationwide opioid settlement funds coming into the state.
The General Assembly is given a small portion of those settlement dollars to distribute, while the majority flows directly to the counties to spend in their communities according to set guidelines. Many of those dollars are flowing to smaller organizations in lawmakers’ home districts, some which have thin track records.
The legislature also set aside nearly $11 million to make grants available on a competitive basis to each campus of the University of North Carolina system for opioid abatement research and development projects.
Meanwhile, at a time when people are dying at record numbers from drug overdoses, state lawmakers eliminated annual funding of $100,000 to the North Carolina Harm Reduction Coalition which was used to purchase overdose reversal medications.
One substance use allocation that pulls from funds outside of the opioid settlement funding is $2.3 million to DHHS for administration, about half of which to be used to create nine new positions to help administer substance use grants.
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