By Will Atwater, Anne Blythe, Rachel Crumpler, Clarissa Donnelly-DeRoven, Thomas Goldsmith, Rose Hoban, Taylor Knopf
What will a Republican supermajority in Raleigh mean for health care?
This year will be the first legislative “long session” since 2019 that won’t feature heavy reliance on video hearings and remote work as the pandemic recedes from people’s lists of concerns.
The General Assembly will return in mid-January to swear in dozens of new representatives and senators. Then they’ll leave town and won’t return until several weeks later when they’ll really knuckle down to work until midsummer.
One other change from the past three legislative years is that the spigot of federal money that bolstered states’ budgets – including North Carolina’s – during the pandemic will likely not be flowing with as many new dollars. But North Carolina has billions in reserve that it has available for spending on legislative priorities and lawmakers’ preferred projects, if lawmakers choose to dip into the rainy day fund.
Top health care issues that will likely receive attention on Jones Street will include proposals around new restrictions on abortion, another run at Medicaid expansion, and the increasing likelihood that hospitals will have to swallow changes to long-standing laws and rules around competition in the health care space.
I also expect that nurses – encouraged by the success of their SAVE Act in the state Senate – will try again to get legislation through the General Assembly to loosen the laws around their licensure.
Other health care issues that I’ll be watching for in 2023 include something to address the current mental health crisis (particularly in children) and access to opioid treatment. Children’s advocates are hoping that lawmakers will pass funding for a gun safety initiative.
On top of that, there’s always surprises at the General Assembly. We’ll be there to follow them!
— Rose Hoban
Tracking water quality across the state
One of the things we’ll be following in 2023 is whether environmentalists seeking legislation to reduce single-use plastics will receive support from local governments. Environmental groups in Asheville, Boone and Durham represent a growing number of advocates calling for change.
As NC Health News has previously reported, single-use plastics often end up in landfills and waterways, where they break down into smaller particles known as microplastics. Those minute plastic particles are ingested by marine life and have also been found in the human digestive system.
A 2019 study suggests that humans may be digesting as much as 5 grams of plastic, roughly the amount found in a credit card, on a weekly basis. The study states that both tap and bottled water are primary contributors to human ingestion of microplastics.
To limit the flow of plastic waste into local waterways and, eventually, into the ocean, riverkeepers assigned to each of the state’s watersheds rely on volunteer cleanup days. The cleanups also provide an opportunity for riverkeepers to spread awareness about water quality issues to the public. In 2022, riverkeepers across the state installed trash trouts in watersheds across the state to trap plastic waste and prevent it from ending up in the ocean.
Several environmental activists and organizations are encouraged by bans/ordinances that are being put in place across the country — nine states have banned plastic bags and more than 300 U.S. cities have implemented bans or fees for use of plastic bags. What’s more, in 2022, Wegmans, a national food chain, stopped carrying plastic bags in its stores. There are four Wegmans located throughout the Raleigh-Durham area — Chapel, Raleigh, Cary and Wake Forest.
— Will Atwater
How are current — and potentially future — abortion restrictions impacting people?
New abortion restrictions are certainly to be discussed this legislative session, though the outcome of any potential legislation remains unclear.
Both House Speaker Tim Moore (R-Kings Mountain) and Senate leader Phil Berger (R-Eden) have expressed interest in imposing greater restrictions. They did not pursue any last year because they knew efforts would be useless since Democratic Gov. Roy Cooper, an abortion rights supporter, said he would veto any legislation imposing further restrictions.
Republicans had hoped to gain a supermajority in the state General Assembly in the midterms to overcome this issue, but ultimately fell one seat short in the House of Representatives. Under the new balance of power, Republicans still cannot override a veto from Cooper along party lines. However, with the help of just one Democrat, a veto would be possible, allowing legislation to pass if all Republicans are on board. The question is whether Republicans can gain the support of a Democrat for abortion restrictions. It’s likely a tough sell for a party that campaigned hard on protecting abortion rights, though not impossible.
Moore has expressed his confidence that he’s got a “working supermajority” in his chamber.
NC Health News will be following what legislative action is taken regarding abortion. We will also be watching the state’s abortion clinics and talking to physicians who provide abortions to continue to understand and uncover how various stakeholders are adjusting to the new reality of life without Roe v. Wade. What are the implications of reduced abortion access? Do we have the infrastructure to serve a continued influx of out-of-state residents seeking abortions in North Carolina? Do we have the resources to support additional births if fewer abortions end up meaning more births in the state?
— Rachel Crumpler
Health care during and after incarceration
It’s well-established that people with substance use disorders and mental illnesses are overrepresented in U.S. jails and prisons. Federal statistics show nearly two-thirds of people who are incarcerated have a substance use disorder and about 2 in 5 people have a history of mental illness. Historically, treatment for these conditions has been inaccessible but there is growing recognition that they should not go untreated.
Last year, providing opioid use disorder treatment in jails found new momentum after the U.S. Department of Justice issued guidance stating that it is a violation of the Americans with Disabilities Act if correctional facilities do not continue individuals on the medications they were receiving to treat their addiction in the community prior to incarceration.
We will continue to build on our past coverage of how jails and prisons roll out programs to treat opioid use disorder. We will also be looking into more emerging programs that seek to better address mental health conditions, such as Forsyth County jail’s behavioral health unit. Guiding these stories will be a search to understand what is both allowing progress and holding it back — are the problems due to budgets, staffing, stigma?
Aside from the health care people receive while incarcerated, we are interested in how individuals fare after leaving incarceration. About 98 percent of people incarcerated in North Carolina are eventually released back into the community. Without effective reentry resources, they could end up reoffending and/or experience health care challenges. Incarcerated and formerly incarcerated people are frequently sicker than the general population, with higher rates of diseases such as diabetes or hepatitis C.
— Rachel Crumpler
Rural health and Medicaid
I was trying to think of a throughline for the stories I’m working on and thinking about for the coming year, and what kept popping up for me is access.
A story I just started looks at what has happened to one rural community in the more than five years since the labor and delivery unit at their local hospital shuttered — where do patients go now? What happened to all the OB-GYNs, midwives and other nurses who staffed the unit? Did they stay in the community, or scatter? And what does all that mean for the growth of the community? Do young families want to move to this county, or do they want to live in a place that has a hospital or birthing center nearby where they can safely deliver their babies?
That story feeds into a handful of others in my slow cooker about the many provider shortages facing both rural North Carolina residents and people on Medicaid. Home health nurses, direct support professionals, primary care doctors — name a kind of health care worker — and there’s a good chance we need more of them somewhere in this state.
The health care worker shortage doesn’t just impact people looking for care, it also impacts state policy. One of the reasons state lawmakers give for their hesitancy to expand the state’s Medicaid program is they say they don’t know if there will be enough providers for all these newly insured people. It’s also one of the main reasons why we see yearslong waitlists for some Medicaid waiver programs — the Innovations Waiver, for example, allows people with intellectual and developmental disabilities to get Medicaid. Medicaid is critical for people with disabilities because private insurance historically does not cover disability services very well, but the Innovations program has a 10-year waitlist.
Waitlsts, provider shortages, and poor reimbursement rates from Medicaid and private insurance all make it so people cannot access the care they need. And that’s unsustainable — advocates say we can’t be a state that thrives and grows if people are sick.
I don’t know if there are solutions yet, but I’ll be looking for them in 2023.
Possible mental health legislation?
This year, state lawmakers will come back to Raleigh for a longer legislative session where we are likely to see more action than last year. Advocates, lobbyists and reporters will be on the lookout for movement on different key issues, and I will be watching for mental health legislation.
The pandemic spotlighted the fractures in our health care system, including care for short- and long-term mental health issues. Some of our most read stories over the past few years have documented the rise in patients seeking psychiatric crisis care in hospital emergency departments and the long wait times for available psychiatric beds. We’ve written about how these patients are often involuntarily committed and transported by law enforcement to a psychiatric hospital. And for many, these psychiatric hospitalizations aren’t very helpful. Sometimes, they leave patients more hurt, like the case of an 11-year-old who was allegedly sexually assaulted inside a private psychiatric hospital.
This pattern of mental health crisis care isn’t working for patients and their families, hospital emergency departments or law enforcement. Several lawmakers have commented on aspects of this system and called for changes.
In response to our recent story about the 11-year-old, Rep. Graig Meyer (D-Durham) posted to Twitter that the General Assembly “should take swift action in 2023 to address our youth mental health crisis” by building additional in-patient mental health facilities, revising involuntary commitment laws and funding mental health transportation “that doesn’t depend on police cars and handcuffs.” Meyer concluded by saying lawmakers should “consider creating an Office of the Inspector General to give us an independent watchdog over children in the state’s care — including those receiving mental health care and those in foster care.”
Meyer was elected to the state senate where he will join Sen. Jim Burgin (R-Angier) who has also taken a special interest in mental health. Burgin has promised to introduce reforms during various mental health town hall meetings held in communities by the state health department this year. I’ll be watching to see what those look like while continuing to report on the lack of community mental health treatment options for patients, particularly children at risk for suicide.
— Taylor Knopf
Investing in home-based and community care for North Carolinians with disabilities
Disability rights advocates cheered when Superior Court Judge Allen Baddour issued a sweeping ruling on Nov. 2 to give the state 10 years to give people with disabilities and their families more options for community-based care..
Those celebrations might have to be put on hold for much of the next year as the state Department of Health and Human Services appeals Baddour’s order.
The state is asking for portions of the order to be put on hold while they go back to court to protest the outcome in the case known as Samantha R. and Disability Rights North Carolina v. State of North Carolina DHHS and Kody Kinsley, in his official capacity as Secretary of DHHS. Attorneys representing DHHS and Kinsley want transcripts of the hearings in the case to help them better hone their arguments.
The wheels of the court system can grind slowly at times.
At issue is the state’s Innovation Waiver, a Medicaid-based program which gives DHHS leeway to allow people with disabilities to receive care in their homes or community settings.
The program has been underfunded for years, creating long waitlists as the number of people who need services grows. There are 16,000 more people waiting for services than there are slots available. That can result in people seeking home-based or community services ending up in institutionalized care.
Baddour’s order gave the state 10 years to move people with disabilities who qualify for community services out of institutions if they chose that route. DHHS officials argue that part of Baddour’s order could mean some people are moved out of care facilities on which they and their families have depended.
“I have grave concerns about keeping pieces of that decision that would limit choice for individuals and potentially push over a thousand, if not more, individuals in small community-based homes and other spaces out of those stable environments that their family members and they rely on every day, in a short period of time,” Kinsley said.
Despite the state’s plans to appeal Baddour’s ruling, Kinsley said the state needs to do more for people with disabilities. Achieving some of those goals will require legislative funding. Whether Kinsley can persuade lawmakers to invest in such needs will become clearer as the budget debate progresses throughout 2023.
Kinsley told reporters in late November that he had the governor’s support.
Lawmakers, though, control the purse strings.
— Anne Blythe
With COVID fight still on, older North Carolinians’ advocates seek help from NCGA
With the end of the state’s public health emergency, people watching the welfare of older North Carolinians will fight to maintain some COVID-driven measures for long-term care residents and others.
Heather Burkhardt, director of the North Carolina Coalition on Aging, runs one of several advocacy organizations preparing lists of priorities for the state legislature’s budget-focused long session.
“We’ve got a few big ticket items there and one is making permanent rates and rate settings for Medicaid providers, which have not kept up pace,” Burkhardt said on the phone. “They received temporary rate increases because of COVID, which was helpful.”
During the public health emergency in place from March 10, 2020 to Aug. 15, 2022, money was flowing into the state under the federal American Rescue Plan Act, making possible increased reimbursement for facilities and direct care workers. With a devastating worker shortage affecting levels of care, both health care providers and advocates want to make sure that the higher rates remain in place.
“I think you’re going to see a lot of activity around trying to address the direct care workforce shortage and adjusting Medicaid provider rates, whether that’s in skilled nursing facilities or personal care services or even adult-care homes,” Burkhardt said.
In another, long-standing budget matter, low-income people who live in North Carolina adult care homes, or assisted living centers, saw in April an increase retroactive to January from $46 to $70 in the monthly allowance that has to cover everything from snacks to cellphones to rides to church or the grocery store. Legislators will get a push this year, Burkhardt said, to make the same sort of adjustment, from $35 to $70, in the personal needs allowance for low-income residents dependent on Medicaid living in the state’s nursing homes.
— Thomas Goldsmith
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