Abstract
The following is a review of current policy and proposed legislation related to clinical care 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 (NCDHHS) 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]. In this issue of the NCMJ, authors focus on North Carolina’s uninsured rate, ratio of primary care providers to residents, early prenatal care access, and suicide rate (Figure 1). Suggested solutions include but are not limited to: expanding Medicaid eligibility criteria; investing in rural economies; encouraging workforce diversity and cultural competence; ensuring coverage of group prenatal care, childbirth education, and doula services; implementing policies targeted at decreasing access to lethal means; and increasing access to mental health services and support for LGBTQ youth. See the Healthy NC 2030 report, pages 81–92, 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 also proposes expanding Medicaid eligibility criteria, in addition to increasing publicity and funding for open enrollment, ensuring high-speed internet access for telehealth equity, increasing rural health clinical rotations for physician assistants and advanced practice nurses, and creating trauma-informed schools with access to mental health providers, among other proposals (Figure 2).
Source. Healthy NC 2030. NCIOM and NCDHHS; 2020.
Source. State Health Improvement Plan. NCDPH; 2020.
Policies In This Issue
Insurance and Access to Care
Several authors in this issue, as in the previous two in this series, pointed to Medicaid expansion as the primary policy for improving North Carolina’s performance on the health indicators listed in Healthy NC 2030. Specifically, in this issue Medicaid expansion is tied to improved insurance coverage and better access to prenatal and mental health care as levers for decreasing the number of North Carolinas who are under- or uninsured, increasing those who have access to primary care and early prenatal care, and decreasing the rate of suicides.
Additionally, guest editor Adam Zolotor and coauthors call for increased attention to and resources for improving the primary care physician-to-population ratio in the state, especially in rural areas. They suggest, “Students from rural communities should be introduced to the range of career opportunities, recruited into health professions schools, trained and mentored for—and eventually recruited into—rural practice” [3]. Further, Whitman and colleagues recommend increased investment in rural, community-based family medicine residency training programs as agents for “positive, immediate, and long-term change” [4].
Cykert and colleagues focus on disparities in access to care, especially among historically marginalized populations. They note that “transparency through real-time digital data; accountability through quality improvement that is mindful of disadvantaged groups; and serial, enhanced communication incorporating community voices have all been shown to markedly reduce disparities and improve health care for everyone” [5]. Key efforts, Cykert writes, should include both additional efforts surrounding social determinants of health and interventions designed specifically to address the physiologic effects of racism [5].
Of note, the 2021-2022 state 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 [6]. 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. In Zolotor’s interview in this issue with Senator Joyce Krawiec, the senator discusses her participation on this exploratory committee, before which, she states, “nothing is off the table” [7].
Reducing the Suicide Rate
Ames Simmons writes about the unique mental health concerns among LGBTQ individuals in North Carolina, and emphasizes the role of health care providers in advocating for upstream interventions that may reduce suicide disparities that negatively affect transgender North Carolinians specifically. According to Simmons, these interventions include Medicaid expansion, family acceptance therapy, improved access to name and gender marker changes, continuation of telehealth, and trauma-informed schools [8].
According to Carrie Brown, this year NCDHHS will release a comprehensive suicide prevention plan that includes a campaign to raise awareness of the new upcoming nationwide suicide hotline, which will be accessible by simply dialing 9-8-8 [9]. Future recommendations Brown describes include implementation of statewide safe gun storage practices; “gatekeeper” counseling on access to lethal means; educating and training the health care workforce about suicide risk for veterans; building a comprehensive crisis system that covers the entire state; expanding telehealth; further implementing crisis intervention training for law enforcement; and, again expanding Medicaid [9].
Graves makes similar recommendations, and also highlights strategies for lowering North Carolina’s suicide rate including: expanding public awareness about adverse childhood experiences, identifying a backbone agency or team responsible for coordinating the statewide work, and building partnerships to fund trauma-informed care policies [10].
Recommendations Born of COVID-19
Morrison and coauthors write that, despite the stress and burnout affecting North Carolina’s federally qualified health center workforce, they are “ready to work with elected officials, local and state health departments, federal partners, and others to rebuild and strengthen the system that everyone needs: patient-centered, affordable care of all type … based in the communities where people live, and offered under one roof” [11].
In examining disparities in COVID-19 vaccination uptake, Wong touts the benefits of community collaboration, focusing on listening to individuals’ concerns and answering their questions with transparency, while also investing in community organizations to increase COVID-19 vaccinations among historically marginalized populations [12]. With this in mind, Wong writes, NCDHHS will work to quantify existing disparities, measuring changes in outcomes among selected disadvantaged groups, rather than focusing on average impact on the health of a whole population [12]. See the full issue and read more about these policies at www.ncmedicaljournal.com.
- ©2022 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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