Abstract
To better the health of all North Carolinians, policymakers must come together to improve access to care, expand broadband, and close the coverage gap.
As a legislator representing Avery, Mitchell, and McDowell counties in Western North Carolina for four terms, I have seen the disparities in health care access and outcomes along income and geographical lines. In my work at the General Assembly, I have identified three primary legislative priorities for improving the health of North Carolinians: access to care in underserved regions, expansion of broadband access, and closing the health care coverage gap.
Addressing these critical needs will require significant collaboration between stakeholders across the state, including lawmakers on both sides of the aisle at the General Assembly. With rural hospitals closing (including five in North Carolina since 2010) [1], our state's persistent digital divide [2], and more than 1 million citizens living without health insurance [3], we cannot wait until suggested bills and policies come to us; we have to build relationships with each other and with the community and develop new policies to improve health now.
Access to Care in Underserved Areas
One of the counties I serve, Mitchell County, has a population of 13,000. That population is continually declining, week by week, month by month, year by year. Twenty of our 100 counties (80 of which are considered rural) have fewer than 3.5 primary care providers, while three counties have none [1]; 20 counties had no pediatricians, 26 no OB-GYNs, and 32 no psychiatrists as of 2018 [4]. If we are not able to attract health care providers and others who can make underserved areas like Mitchell County financially sustainable, we will continue to see poor levels of access and poor health outcomes in these regions.
Expanding Broadband
I grew up in Avery County (population 17,000) and attended Avery High School. Currently, one out of every two students there does not have access to high speed internet in their home (personal communication), while the county as a whole has an availability score of 64.6 [2]. Mitchell County's score is 57.4, and McDowell's is 58.9 [2]. That is unacceptable for North Carolina.
Some recommended solutions for increasing education access in rural areas include online courses for middle and high school students. While these are attractive options for those who might otherwise have to travel far for education, they remain inaccessible to the many families who do not have high-speed internet access. Similarly, there has been a boom in support and action around telehealth in North Carolina. Again, while these efforts are important for reaching some of the most underserved North Carolinians—especially in areas with few primary care physicians, hospitals, and/or mental health resources—they are moot for those who cannot connect to the internet.
Closing the Coverage Gap
Though we can all agree on the goal of a healthier North Carolina, the question of how to make sure our citizens have adequate access to coverage—and therefore care—will require significant collaboration and compromise at the policymaking level. It will take setting ideology aside on both sides to come to the best solution for closing the health care coverage gap.
One potential solution is laid out in a bill introduced last year: NC Health Care for Working Families (HB 655), also known as Carolina Cares [5]. The bill lays out Medicaid eligibility requirements including adjusted gross income lower than 133% of the federal poverty level, no enrollment in Medicare Part A or B, age between 19 and 64, and mandatory employment [5].
Most of North Carolina's citizens are hungry for a kind of politics that sets aside ideology and looks for ways to come together. On the right, we need more discussion of the importance of getting people covered; on the left, more transaction-focused discussion. A work requirement might have struck this balance, but is no longer allowed as of a recent federal court ruling [6].
Changing the Political Approach
In North Carolina, one of the biggest threats to us continuing to move forward in health care is the gridlock in the capital on Jones Street and in the Governor's Mansion.
The brokenness of our politics is something that worries me going forward. The most basic function of a government is to pass a budget, and we have not done that in North Carolina this year. There is plenty of blame to go around, but this is something we have to fix so that we can continue to make the investments in North Carolina that have to be made to improve the health of our citizens.
There is no silver bullet. Simply expanding Medicaid, passing Carolina Cares, or reforming rules around Certificate of Need will not solve the coverage gap alone.
Focus on Integrated Care
There is hope for collaborative, bipartisan approaches to improving health care coverage in North Carolina. In the lead-up to Medicaid managed care, Democrats, Republicans, North Carolina Department of Health and Human Services Secretary Mandy Cohen, and other health care stakeholders worked together to prioritize integrated care, ensuring patients' physical and behavioral health needs would be addressed under managed care, also known as Medicaid transformation.
When we initially passed managed care in 2015, we focused on physical health. When Secretary Cohen took office in 2016, she argued for including integrated care in the initial push toward managed care. Members of the state house and senate signed on, bills were passed in both houses, and the result was signed into law by Governor Roy Cooper in June 2018 [7]. The legislation helped set up the eventual makeup of managed care, with a standard plan focused on both physical and behavioral health facilitated by managed care companies for most of the Medicaid population, and tailored plans managed by local management entities for the most vulnerable North Carolinians.
It was a proud moment when we were able to actually work together and get to a consensus on integrated care for the Medicaid population. But that work has been threatened by our inability to pass a state budget.
What it Will Take
While serving on a panel at a symposium hosted by the National Academy of Medicine (NAM) last fall, titled Vital Directions for Health and Health Care: The North Carolina Experience, NAM President Victor Dzau asked me what it would take to bring policymakers together politically to do the right thing for the people of North Carolina.
My answer: We have a consensus here. We are in it every day. We work on these things and we know what things we could do to achieve success in North Carolina. I think that relationships matter. I think that knowing your legislators, knowing your congresswomen and congressmen is critical because you can't wait until something's come up in the General Assembly or in Congress to acknowledge a problem. It's easier if those of us across the state who have a stake in this—provider groups, advocacy groups, etc.—build those relationships on the front end so that when the time comes and the lights come on, we can all try to work together because we already have those relationships.
Acknowledgments
Potential conflicts of interest. J.D. serves in the North Carolina House of Representatives as the Republican representative for NC District 85. He is currently running for North Carolina Labor Commissioner. He reports no further conflicts of interest.
- ©2020 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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