The following is a review of current policy and proposed legislation related to social and economic health indicators in North Carolina. It is not an endorsement of any policy or bill; it is meant to serve as a resource for policy makers, health care stakeholders, and other readers of the NCMJ.
Healthy NC 2030
The North Carolina Department of Health and Human Services has released a set of health indicators and goals every 10 years since 1990. The latest iteration, Healthy North Carolina 2030 (Healthy NC 2030), draws attention to more non-medical factors than ever, aims to reduce inequities in outcomes for each indicator, and calls out institutional racism as a health indicator for the first time [1]. Healthy NC 2030 serves as a roadmap for the state, local health departments, health systems, and communities to address negative health outcomes and health disparities. It uses a population health model established by the Robert Wood Johnson Foundation that estimates 70% of health outcomes stem from non-medical factors such as social and economic status, clinical care, health behaviors, and the physical environment.
In this issue of the NCMJ, authors focus on social and economic factors, including individuals below 200% of the federal poverty level, unemployment, short-term suspensions per 10 students, incarceration rate per 100,000 population, adverse childhood experiences, and third-grade reading proficiency (Figure 1). Suggested solutions range from expanding Medicaid eligibility and raising the minimum wage to improving education outcomes and increasing teen pregnancy prevention. See the “Healthy North Carolina 2030” report, pages 35–50, for more information on these indicators, desired results, potential levers for change, and developmental data needs [1]. See also the “State Health Improvement Plan,” a companion report to Healthy NC 2030 and the 2019 North Carolina State Health Assessment [2]. In addition to policy recommendations highlighted throughout this issue of the NCMJ, the State Health Improvement Plan proposes increasing the state earned income tax credit, raising the minimum wage to $15 per hour, increasing access to broadband, expanding transit options in rural and low-income communities, and more (Figure 2).
Source. Healthy NC 2030. NCIOM and NCDHHS; 2020.
Source. State Health Improvement Plan. NCDPH; 2020.
In This Issue
Decreasing Poverty and Increasing Economic Security Through Innovative Investment
Crystal Wiley Cené, MD, MPH, makes four suggestions for health systems to invest more in their local communities: hire locally, purchase locally, volunteer locally, and invest locally. “Considering the current strains on the health care workforce, health systems can build their staff while supporting employment opportunities and job training for low-income, rural, and historically marginalized individuals,” she writes [3]. Specific policy recommendations include: providing local applications and interview opportunities in communities; removing the requirement to divulge information about criminal history; prioritizing sourcing from diverse local suppliers; encouraging and allowing paid time off for team members to share their skills and expertise with local community organizations; and allocating at least 1% of their investment portfolio to targeted place-based community investments [3].
Carl Rist, a public policy expert and former senior fellow at Prosperity Now, suggests that North Carolina should follow the lead of states such as Maine, Nevada, California, and Pennsylvania to open seeded children’s savings accounts (CSAs) automatically for all children at birth [4]. One option, he notes, is to use funding from the American Rescue Plan to support this effort, as in California. Rist also recommends increased use of individual development accounts (IDAs), which are usually managed by public or nonprofit service providers in partnership with a financial institution and are limited to use for home purchases, business start-ups, or paying for college; and automatic enrollment in state-administered individual retirement accounts (auto-IRAs) as an alternative for workers who do not have access to employer-based retirement plans [4].
Dismantling Structural Racism With Strategic Equity Work
Jim Johnson, PhD, urges the implementation of evidence-based “equity tools” such as finance packages that support sustainable community development and procurement policies that focus on historically marginalized businesses. These steps, as well as immigration reforms and employment-based visa programs, Johnson argues, can “minimize economic and residential dislocations caused by the influx of wealthier newcomers” to North Carolina [5]. Additional policy suggestions include business audits focused on ensuring inclusive and equitable workplaces and creation of entrepreneurship and workforce development programs, particularly for the population that has been forced into early retirement by the COVID-19 pandemic [5].
Reuben Blackwell, president and CEO of OIC, Inc., in Rocky Mount, writes about the need for intentional prioritization of employment initiatives for historically marginalized populations in the health care and health care administration fields. “Clinical providers and support team members who look like their patients and have shared life experiences help build trust with people who have suffered from the indifference of inequitable health care institutions,” Blackwell writes [6].
Latoya B. Powell, JD, deputy general counsel at the North Carolina Department of Public Safety, shares the goals of the Chief Justice’s Task Force on ACEs-Informed Courts, which began meeting in August. The task force’s objectives include providing judges and other court administrators with practical education on the effects of ACEs so that they can identify them when they encounter them in court; equipping juvenile court officials to recognize young offenders and victims impacted by ACEs; identifying both existing and new programs that intervene in the lives of youth who have experienced ACEs and put them on a path away from the courthouse and into a successful life; and providing a platform from which court officials can offer feedback to educators regarding their experiences, with hope of creating further avenues for research [7].
Improving Child Well-being Through State and Local Policy Change
Kimberly Montez, MD, MPH, highlights Executive Order No. 95, signed by Governor Roy Cooper in 2019, which provides eight weeks of paid parental leave to eligible state employees, which the University of North Carolina Board of Governors later adopted [8]. Sharing her personal experience and citing research on the benefit of paid leave for increased health care access and decreased disparities in women’s and children’s health outcomes, Montez recommends passing a universal statewide program that covers all working North Carolinians.
Muffy Grant, executive director of the North Carolina Early Childhood Foundation, shares the successes of the Pathways to Grade-Level Reading initiative and its influence on policy at the state and local levels. “We encourage stakeholders in North Carolina and across the country to continue to adopt the Pathways model to support collaborative planning in the service of improving early childhood outcomes,” Grant writes [9].
Velma V. Taormina, MD, president of the North Carolina Obstetrical & Gynecological Society, focuses on recently revised policies surrounding health inequities for women and children in the state, especially highlighting the passage of HB608, Dignity for Women Who are Incarcerated [10]. HB608 is also known as the “anti-shackling” law, as it provides protections for pregnant people who are incarcerated, that include limiting the use of restraints and ensuring access to food and dietary supplements. Taormina urges all parties involved in the housing and care of incarcerated people to continue to support such efforts, and listen to the voices of those who are pregnant and incarcerated as a guide [10].
Several authors, including Annette Taylor, MSL, chair of the NC Council for Women Advisory Council, write in support of Medicaid expansion as a way to improve health care access for families and reduce disparate health outcomes. Taylor also highlights a list of recommendations made by her organization, including mandating paid leave; sustaining CARES Act levels of funding for domestic violence and sexual assault and providing emergency support for child welfare; investing in the care economy; adequately protecting and compensating essential workers, including women; supporting the social sector and women, Black, Indigenous, Latino, and other people-of-color business owners; and more [11].
2021 State Budget
On November 18, Governor Roy Cooper signed the 2021 Appropriations Act, outlining $25.9 billion in spending for North Carolina over the next year [12]. Funding related to social and economic factors includes:
Medicaid. The new budget extends Medicaid benefits for low-income mothers for one year after a child is born and appropriates $62.8 million through 2023 for this purpose. A joint House and Senate committee will study and propose legislation on the potential for Medicaid expansion and present its findings to the next legislative session.
Health care safety net. The budget provides $15 million in funding to the North Carolina Association of Free & Charitable Clinics and $36 million to local health departments. It also provides $4 million to support loan repayments for health care workers recruited to rural areas of the state; $90 million to help underserved households connect to broadband; and $1 million for school-based virtual health services.
COVID-19 relief. The budget uses $500 million from the American Rescue Plan to make grants to entertainment and hospitality businesses that experienced losses due to the pandemic.
- © 2022 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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