By Clarissa Donnelly-DeRoven

In recent years, illicitly manufactured fentanyl has tainted the supply of street drugs, leading to skyrocketing rates of overdoses and deaths.

Of late, though, there’s growing hope for those who want treatment for their substance use disorder. Two medications — buprenorphine and methadone — can be effectively used to help people break the cycle of addiction. 

But that’s only if the drugs are available. Too often, they’re not, according to a recent analysis from the Centers for Disease Control and Prevention. 

The researchers found that more than 75 percent of counties across the country don’t have opioid treatment programs, which are the only places where people can receive methadone, while about 30 percent of counties don’t have any clinicians who can prescribe buprenorphine, which also gets prescribed under the brand name Suboxone. 

Rural North Carolinians suffer disproportionately from those provider gaps, according to an analysis by NC Health News. 

Across the state, the numbers are slightly better than the national picture: 52 counties don’t have an opioid treatment program, while 14 of the state’s 100 counties don’t have a buprenorphine provider. 

But of the 52 North Carolina counties without opioid treatment programs, 50 are rural — leaving 65 percent of the state’s rural areas without access to methadone, while all 14 of the counties without a buprenorphine prescriber are rural. 

While in recent years the state has seen its population increasingly move from rural areas to urban ones, the Office of State Budget and Management estimates that about 42 percent of residents live outside of municipal areas, and North Carolina has the second largest rural population in the U.S.

Nonetheless, the state’s 22 urban and suburban counties have 75 percent of the state’s nearly 1,600 authorized buprenorphine prescribers. 

Structural barriers — from general clinician shortages across rural areas to unsustainable work loads for those who fill the gaps — prevent health care workers from getting these life-saving medications into their patients’ hands. Many also say the persistent stigma against people who use drugs plays a role. 

Time consuming 

A 2019 analysis by researchers at the CDC found that North Carolina was one of just five states where the rate of deaths from overdoses was higher in rural areas than urban ones. 

The dearth of medical providers in rural areas affects all types of patients, but for those who are taking buprenorphine or methadone, the small provider networks can pose an even greater problem since the medications come with strict federal regulations.

“Most of my patients are on a monthly schedule,” said David Sanders, a physician assistant. He’s the only authorized buprenorphine prescriber in Stokes County, where he works at a family medicine practice, though he sees most of his buprenorphine patients at a clinic in High Point dedicated to substance use disorder. 

“We’d be there two or three days a week, and people would come from the surrounding areas,” he said. “They’d come from Greensboro, it’d attract a lot of people from Eden and Reidsville and a lot of the rural areas.”

A monthly visit to the doctor is pretty standard for patients who are taking buprenorphine and are stable on the medication, but at the beginning of someone’s treatment, they may need to come in every week, or every few days. For patients without a clinician in-county, this means a lot of time driving, a lot of money on gas, and a lot of time off work. 

That’s if they even have a vehicle.

“A lot of the people in the area have actually gone to buying Suboxone or buprenorphine off the street, due to the fact that it’s just very much interfering with their schedule,” said Leslie McPherson, the only buprenorphine prescriber in coastal Currituck County. “And it’s very, very, very expensive and a lot of insurance companies don’t reimburse for it either.” 

Multiple hoops to jump through

In order to prescribe buprenorphine, clinicians must complete a training and receive a waiver from the U.S. Drug Enforcement Administration. For physicians, the training is eight hours. For advanced practice nurses and physician assistants, it’s 24 hours. 

The course can be completed online, but for some rural clinicians who are already overloaded with patients and administrative duties, it can be hard to find time. Once the training is over, caring for patients with substance use disorder requires a big commitment. 

“There was no way — no way — I could handle more than 10 [patients taking buprenorphine] at a time in a small office,” McPherson said. “There are a lot of other factors involved in getting them their medication: they couldn’t make it to their urine drug screen, they couldn’t make it to one of their mental health appointments.” 

To continue receiving buprenorphine, per federal rules, patients need to complete regular drug tests and counseling appointments. When somebody missed one of these components of their care, McPherson did everything she could to help them get back on track. Oftentimes, it was just because life got in the way: a car broke down, a family emergency, chronic pain prevented them.

“There’s so many reasons,” she said. “We’d have to go to a modified monitoring schedule.

“My solution wasn’t to just cut somebody off, because I think that’s stupid. I think it’s a very stupid way to practice medicine. You don’t cut off your hypertension patient and just say, ‘You can’t come here anymore because you stopped taking your blood pressure medicine,’ right?”

Daily dosing

While the barriers to getting buprenorphine are great, the ones for methadone are even greater, as patients often must visit a doctor daily to get their dose.

The two medications work differently. Buprenorphine partially activates the brain’s opioid receptors and blocks other opioids from binding to those receptors. This has the result of reducing drug cravings and use and the possibility of overdose. Methadone activates those same opioid receptors to prevent other opiates, such as heroin, from using them. Both medications reduce withdrawal symptoms. 

A third medication, naltrexone, can also be used to treat addiction. It blocks opioid receptors entirely, but it cannot prevent withdrawal symptoms, meaning it’s designed to be used after a person has detoxed to prevent relapse and overdose. There isn’t a similar registry used to track prescribers of naltrexone as there is for buprenorphine and methadone, and the data on how well it helps people get – and stay – off of substances is less compelling.

Because each medication impacts the brain differently, health professionals say it’s critical that people have access to all three to find their best fit. 

In practice, though, that doesn’t happen. 

Racial and rural disparities 

In 12 counties — Anson, Camden, Chowan, Gates, Graham, Hyde, Jones, Martin, Northampton, Pamlico, Tyrell and Warren — residents don’t have access to an in-county opioid treatment program or a buprenorphine provider. 

In half of these counties, between 100 and 83 percent of people live outside of municipal limits, according to Michael Cline, the state demographer at the NC Office of State Budget and Management. 

The CDC analysis on access to these medications found that nationally, as the percentage of Black and Latino residents increased in a county, so did the availability of both treatment options.

But NC Health News found that of the 12 counties in the state without opioid treatment options, 10 have higher proportions of Black or Indigenous residents — two groups that suffer from overdose deaths at disproportionate rates — than the rural average.

“What we do see in North Carolina is what we see across the country — significant health disparities across the board, and a lot of that is driven by the adverse social determinants of health,” said Ronny Bell at a May webinar hosted by the National Indian Health Board. Bell is a professor at Wake Forest University, the chair of the NC American Indian Health Board, and an enrolled member of the Lumbee tribe. 

Mary Beth Cox is a substance use epidemiologist at the state health department who studies disparities in treatment access.

“If we were to just look at the counts, then you might say, ‘Yes this is primarily a non-Hispanic white problem.’ However, when we standardize for population in our state and look at the rates per 100,000,” she explained at the webinar, “we see a much different story unfold.”

American Indians in North Carolina have the highest proportional rate of deaths from overdose. During the pandemic, it got even worse: in 2020, Indigenous people in North Carolina died from drug overdoses at a rate of nearly 84 per 100,000, compared to a white death rate of 36 per 100,000.

Stigma and lack of support

Eight counties without access to methadone have just one authorized buprenorphine prescriber. 

In southeastern Bladen County, that’s Robert Rich — or, it was. 

“I’m not currently prescribing,” he said. He only works part time at Bladen Medical Associates, and he has many administrative duties that keep him from seeing patients. 

There are three providers at the site currently in waiver training — one doctor, and two PAs/NPs — but Rich doesn’t think it’s safe to go back to prescribing until there are back-up prescribers for when he’s unavailable. While he’s not prescribing, the clinic arranged to send patients to nearby Robeson County for their medication.

Rich has had his prescriber authorization for about four years, and he’s represented the American Academy of Family Physicians in many different opioid initiatives. 

“I’ve been intimately aware of the issue for several years,” he said. “You see and hear about it in the community all the time.”

He, Sanders and McPherson all agree that stigma against people who use drugs is partially to blame for the prescriber shortage. 

“Before I got into it, I even had this stigma,” Sanders said. He didn’t recognize the names of the medications, and all of the additional steps needed to become a prescriber fueled his skepticism.

“It’s weird,” he said. “You have to get this waiver, so you have to do extra training whether you’re a doctor or a PA or a nurse practitioner. And even the wording — instead of initiating a medicine, which is what I would do with any other medicine on the planet, when we do this it’s called ‘induction.’” 

“It’s just unfamiliarity with the medicine and so people are hesitant and uncertain about it,” he said. “But I’ve grown to have a high comfort level with it, and I think it’s a wonderful, wonderful medicine because it is so relatively safe.”

Building the needed workforce

Part of increasing the number of prescribers, especially in rural areas, Rich said, is showing models for how this care can work. New prescribers need to feel like they have a community of other clinicians they can turn to when issues or questions arise. 

“The more examples that you have of a prescriber that is doing it, is making it work, and can serve as a mentor to other individuals — you can get those individuals to say ‘I’ll give it a try as long as I have someone else to back me up and help me through the process of learning how,’” Rich said.

A recent bill in Congress, which has rare bipartisan support, would require doctors be trained in treating opioid use disorder. If passed, it could help increase the number of prescribers who feel equipped to care for people experiencing addiction. 

The American Medical Association has come out against it. 

Even if the bill were to pass, other structural barriers remain, said McPherson, from Currituck. She prescribed buprenorphine from her small, independent family medicine practice. She started after patients she was seeing for primary care asked if she could prescribe it. 

Once the word got around she realized how significant the need was.

“It got really complicated at my office because I had to say, ‘Look, I’ve got the max amount of patients. And yes, I do want to help, but I can’t afford it. I can’t afford the resources to do it. I can’t afford the time,’” she remembered. 

“This is really something that should be taken up by every, in my opinion, every primary care office,” she said, but it’s hard because “providers don’t have the support they need.”

Lack of insurance reimbursement proved to be one of the most significant barriers.

“Every Suboxone patient I had was negative income,” she said. “A lot of insurance companies will not reimburse primary care providers for certain mental health codes, especially if [the patient] already is seeing a mental health provider.” 

She said many patients would make an appointment to see her for their medication and a mental health provider for counseling on the same day. That way, they didn’t have to take extra time off work or spend the extra money on gas.

But, her office soon realized that a patient’s insurance company wouldn’t pay for two mental health visits on the same day.  

“They couldn’t see a primary health care provider and a mental health care provider using a mental health care code on the same day,” she said. “I didn’t get paid for a lot of people.”

“I chose to do it because our community needed it, but I could only do as many as I could.”

The post Gaps in NC addiction treatment disproportionately hit rural residents of color appeared first on North Carolina Health News.

By Ivey Schofield

Troaria Sampson wanted to be a mom. 

But Sampson, who weighed 360 pounds and had diabetes, said her doctors in Robeson County discouraged her from pregnancy, warning that her baby could die. 

In 2015, after trying for five years with her husband, Sampson got pregnant at age 27 – a milestone that should have excited her but instead filled her with guilt and dread. 

“There are people like me who don’t have insurance and are being judged by their outer appearance,” said Sampson, who is Black and worked at the time as a cashier at Food Lion. “But it didn’t lessen my want to be a mother.” 

Sampson visited doctors in the early weeks of her pregnancy, but many women in Robeson County do not receive such prenatal care that health officials say is crucial for the well-being of mothers and their babies.  

Robeson is not considered a maternal care desert, according to the March of Dimes, which tracks access across the country. UNC Health Southeastern in Lumberton says it delivers about 1,200 babies each year. 

But Robeson ranks last among North Carolina’s 100 counties for the percentage of pregnant women who receive early prenatal care, with 53% visiting a doctor during their first trimester, according to Healthy Communities NC. 

Other counties in North Carolina’s Border Belt aren’t far behind, with about 56% in Columbus County, 58% in Scotland County and 61% in Bladen County, data shows. 

The state’s goal is for 80% of pregnant women to receive health care during their first trimester by 2030.

Several organizations across southeastern North Carolina, including health departments, hospitals and pregnancy centers, are trying to increase awareness and access to prenatal care. Health officials say Medicaid expansion, which the state legislature adopted in March, will help ease the financial burden for low-income women who are pregnant.  

A lack of prenatal care increases the chances for labor complications, birth defects, and hypertension and postpartum hemorrhages, said Dr. Donald McKinley, an obstetrician and gynecologist at UNC Health Southeastern.

“Prenatal care is absolutely one of the most important aspects of having a healthy pregnancy,” he said. “When pregnant, the patients need to be seen as soon as possible to change medication or start medication to survive a very important developmental stage.”

Pregnant women might be hesitant to seek care for a variety of reasons, including illegal drug use, lack of health insurance, lack of transportation to appointments and previous negative experiences with doctors, experts say. 

Sampson said her interactions with medical professionals added to her skepticism during her subsequent pregnancies. She now has three children. 

About 12% of married Black women report facing at least one barrier to receiving prenatal care, compared to 9.8% of white women, according to a 1997 study. Black women have the highest maternal mortality rate in the United States, with 69.9 per 100,000 dying due to their pregnancy, compared to 26.6 per 100,000 white women, according to 2021 data from the Centers for Disease Control and Prevention. Data was not available for Native American women. 

Sampson said she ultimately got the support she needed from Healthy Start, a program at the University of North Carolina at Pembroke that has been funded by the federal government since 1998 to reduce the infant mortality in Robeson County.

“Every appointment,” Sampson said, “they were there.”

Megan Knight, who lives in the Bladen County town of Dublin, said early prenatal care changed her experience. She had complications during her first two pregnancies. When she got pregnant for a third time, she saw a doctor who told her she had a defect with MTHFR, a gene that tells the body to metabolize folic acid. 

Knight said she started taking blood thinners and didn’t experience any complications during her third and fourth pregnancies. 

“Complications occur because we’re afraid, we don’t seek help or we say, ‘I can’t get a ride, I don’t want to tell my mom or my boyfriend I’m pregnant,’” Knight said. “And that creates risk. But those risks can be easily eliminated.”

Local resources

Knight, who recently opened a pro-life pregnancy center called Mercy House in Elizabethtown, wants to help pregnant women in Bladen County access prenatal care. 

Bladen County is considered a maternal care desert, where there is no hospital or birth center that offers obstetric care and there are no obstetric providers, according to a recent report by March of Dimes.

Mercy House offers free medical-grade pregnancy tests, online pregnancy and parenting classes, diapers, clothes and emotional support. 

“I know that when women are in crisis, their immediate response is I need to get rid of this,” Knight said. “And we want them to know they’re not without hope, they can do this and there are resources.”

Janet McPherson, who oversees Living Hope, a Christian-based pregnancy center in Columbus County, said many pregnant women don’t know about local resources. 

“There’s not any one place you can go and say, ‘If you’re pregnant, this is what’s available,’” she said. “This is a real problem. There is no coordination among ministries and groups.”

Pregnant women should contact their county health department to find if they qualify for Medicaid and WIC, a nutrition program for mothers and young children, said Carlotta Rivers, maternal health coordinator at the Scotland County Health Department. Parenting and breastfeeding classes are also available.  

Women with high-risk pregnancies due to substance misuse, domestic violence, homelessness or other factors can qualify for pregnancy care case management that includes monthly check-ins from social workers, said Barbie Britt, nurse supervisor at the Robeson County Health Department. 

“We try to do as much as we can here,” Britt said.  

Coastal Horizons, a Wilmington-based nonprofit with a pregnancy and postpartum office in Whiteville, offers specialized help for pregnant women struggling with addiction, program coordinator Gayle Beese said. 

The office communicates with local medical providers to make sure patients go to their prenatal appointments and provides transportation when necessary. It also offers Suboxone, which Beese said is safe to take during pregnancy and breastfeeding. 

Beese said shame often prevents pregnant women who struggle with addiction from getting prenatal care early in their pregnancy. They worry they’ll be judged by their medical provider or their baby will get taken away by the Department of Social Services. 

“Recovery doesn’t get easier just because you have a baby,” Beese said. “They deserve care too.”

In Robeson County, UNC Health Southeastern has a doctor who specializes in pregnant women struggling with addiction. 

One in every four pregnant patients at the hospital, which has several satellite offices across the county, has been diagnosed with an opioid use disorder, McKinley said.   

Helping others

Healthy Start helps connect women in Robeson County with resources across the region and provides transportation, said Erica Little, the program coordinator. 

In 2019, when Sampson’s child stopped breathing and needed to be induced, a Healthy Start worker drove her to the hospital. In 2021, when Sampson got pregnant with her third child, the program connected her with a provider who prescribed anxiety medication. 

“Even though I’m saying our county has a biased way of looking at people, Healthy Start is in our community,” Sampson said. “They do not treat you with the same bias our community has. They’re trying to overcome the bias in our county.”

Because of her experience with Healthy Start, Sampson has become an advocate for pregnant women. 

Sampson said a pregnant 17-year-old came to her after being disowned by her mother and kicked out of her church choir. Sampson helped the girl get a job at a local boutique, where she became employee of the month. Since then, the girl has gotten engaged and found a new job.

“I was so proud of her,” Sampson said. 

Sampson also encourages her sixth-grade students at Deep Branch Elementary School and her youth group at Deep Branch Missionary Baptist Church to talk about sex education. She carries around a few brochures about the free services at Healthy Start, just in case.

“Never let guilt and shame prevent you from getting the health care you need,” Sampson said. 

The post More pregnant women need prenatal care in North Carolina’s Border Belt. But how? appeared first on North Carolina Health News.

By Trista Talton

Coastal Review Online

State-by-state emergency plans aimed at minimizing the impacts of natural disasters overwhelmingly understate extreme heat as a hazard to human health, according to a Duke University analysis.

The recently released policy brief, “Defining Extreme Heat as a Hazard: A Review of Current State Hazard Mitigation Plans,” highlights the need for states to better evaluate the growing threat of extreme heat as the climate changes, identify populations of people most vulnerable to high temperatures, and implement plans to educate and assist those populations.

Ashley Ward, a senior policy associate with Duke’s Nicholas Institute for Energy, Environment and Sustainability and co-author of the brief, said the report is not a critique, but rather a guide to help states’ emergency management departments better incorporate extreme heat in their hazard mitigation plans.

“We want to give them some easy-to-pick-up roadmaps about how they can do so,” Ward said in a telephone interview. “Our hope is to make their job easier and to supplement what’s already happening at FEMA. We want to be of assistance. That’s what we’re trying to do here.”

Not planning for heat

The Federal Emergency Management Agency recently announced states must incorporate climate change into their hazard mitigation plans, a move Ward called a “really big deal” in part because it prioritizes extreme heat as a hazard.

Extreme heat is when daytime temperatures rise above 95 degrees and nighttime temperatures do not dip below 75 degrees.

Unlike natural disasters such as hurricanes or tornadoes, extreme heat is not a Stafford Act hazard.

The 1988 Robert T. Stafford Disaster Relief and Emergency Act, which amended the Disaster Relief Act of 1974, authorizes the president to declare disasters and provide financial assistance to state and local governments.

The law mandates states update their hazard mitigation plans every five years. Many states are in the process of renewing their plans, Ward said.

So, the report focuses on current states’ plans, half of which lack a dedicated section to extreme heat, the analysis found. 

Ward and co-author Jordan Clark, a postdoctoral associate for the institute’s Water Policy Program, used a scoring system created by the National Resources Defense Council, or NRDC, to assess each states’ plan.

The NRDC used the scoring system to look at the incorporation of extreme heat in southeastern states’ hazard mitigation plans.

“As we know, this is certainly a pressing problem in the southeast, but we know the southeast isn’t the only region in which heat is a problem,” Ward said.

Heat, she said, is one of the most misunderstood weather events.

Ten years ago, researchers in her field focused on something called the urban heat island effect, which is created when natural landscapes are replaced with pavement, buildings and other surfaces that absorb and retain heat.

This effect is very important and very real, Ward said, but its sole focus is on urban areas, leaving out whole populations impacted by extreme heat.

“In North Carolina, heat illness rates are about seven to 10 times higher in rural areas than they are in urban areas,” she said. “And, in fact, what we’re seeing in the small amount of research that’s coming out of the southern part of the United States is that’s not a North Carolina phenomenon. A recent study came out of Florida that showed the same thing. There’s a lot of reasons this is the case, but that just gives you one example of how broadly heat has been misunderstood.”

Where N.C. stands

North Carolina has an enhanced hazard mitigation plan, also referred to as the 322 Plan, which includes natural hazards as well as man-made, technological and human-caused hazards.

The plan addresses different populations identified by the North Carolina Department of Health and Human Services, which narrows down the largest group of people who suffer heat injuries as men between the ages of 18-34 either involved in athletics or outdoor work such as farming and construction.

The plan was updated last year and approved by FEMA in February. The current plan expires February 12, 2028, according to Chris Crew, North Carolina Emergency Management mitigation plans manager.

Crew explained in an email responding to questions that the plan’s definition of extreme heat is taken from the U.S. Centers for Disease Control and National Weather Service, which identify extreme heat as hotter and/or more humid than average summertime temperatures and unusually hot and humid weather lasting at least two days.

The first recommendation offered in the report is for states to establish their own, specific standard definition of extreme heat.

“That is because extreme heat in North Carolina is not the same as extreme heat in Oregon and it’s important that people think about their geography with respect to how we define extreme heat,” Ward said.

That and other recommendations are intended to provide education and awareness about the complexities of heat, she said, how things like how extreme heat correlates to effects on human health.

Take temperature metrics. Heat index, a metric that combines air temperature and humidity, is a common metric decision makers use to define extreme heat, but it is less robust in determining potential adverse health outcomes than a metric known as wet bulb globe temperature.

Wet bulb globe temperature, or WBGT, measures heat stress in direct sunlight and includes temperature, humidity, wind speed, sun angle and cloud cover. This standard metric is used by the military and high school athletic associations, Ward said.

“And that’s important because if you’re sweating outside and it’s very humid there’s a lot of moisture in the air so your body is not evaporating that sweat off of your skin,” she said. “However, if it’s windy outside then the wind is drying the sweat off your skin and that mimics that evaporative cooling process and actually provides a protective factor for you.”

Therefore, in coastal counties especially, it’s important to think about wind speed, Ward said.

Building resilience

North Carolina’s Sandhills region has the highest rate of heat-related illnesses in the state. Roughly 75 percent of those who go to emergency departments for treatment are men between the ages of 15 to 45, Ward said.

Counties within that region, including Bladen, Hoke, Robeson, Sampson and Scotland counties, are included in a heat-health alert system through the N.C. Building Resilience Against Climate Effects program.

This CDC-funded program is tailored to vulnerable populations, including low-income and elderly communities, farmworkers, and youth in sports, according to the state’s plan.

“The State’s position is ‘Extreme’ heat is more of an individual and regional value than a specific value for everyone across North Carolina,” Crew said in an email. “Setting a statewide definition of extreme (heat) would limit the State into responding to a single type of weather scenario statewide when the State health agencies need the flexibility to respond to different weather conditions in different regions to the State.”

Ward praised North Carolina’s emergency management department, calling it a “gold star in the nation.”

While the state does include an assessment for heat hazard, it could better incorporate socially or medically vulnerable populations and teach residents how to protect themselves from extreme heat, she said.

Some ways to cool off after being exposed to extreme heat include taking a cool shower then sitting in front of a fan or placing your feet in cool water.

North Carolina’s plan notes the North Carolina Climate Science Report, which projects that much of the Piedmont and coastal plain will experience a jump in very hot days by 10 to 20 days per year between 2021 and 2040 as compared to the 1996-2015 average.

The number of warm nights in those regions is projected to increase anywhere from three to 15 nights a year. Some areas within those regions could see an increase by 18 or more nights a year.

The post States greatly underestimate extreme heat hazards: Study appeared first on North Carolina Health News.

By Thomas Goldsmith

During a recent congregate lunch with Hertford County peers, Laura Sessoms, 71, reflected on her early years on a tenant farm, her 14 years in military service and her life these days as an older North Carolinian.

In mid-conversation, Sessoms brought up adult day care centers, a state-backed service that provides daily support and nurture for qualifying people with dementia and other conditions. Having a safe place for older people who can’t stay at home also makes it possible for caregivers to have jobs and take care of daily errands.

“There used to be one in the area, but the closest one now is over 40 miles away, in Halifax,” she said. “I don’t know whether people have interest in doing it anymore.”

At the state capital in Raleigh, roughly a two-hour drive away, low-profile discussions of state funding for older people’s services — such as adult day care, senior centers, respite for caregivers, congregate meals and protective services for vulnerable adults that collectively cost tens of millions of dollars — tend to give way to louder debates with billions on the line. 

Gov. Roy Cooper’s administration is working on a plan called All Ages, All Stages NC, employing government, businesses and nonprofits that would address many concerns of older people like Sessoms, contingent upon buy-in by the state General Assembly. 

Tops on the list is a cross-department structure to confront the state’s dire shortage of direct-care workers who provide hands-on help for frail older people, Cooper said after a May event announcing efforts to boost services for aging people. 

“We hope they take us up on it, because not only are we going to need that, we’re going to need housing,” he told NC Health News. “We’re going to need money for transportation. I know the Department of Transportation wants to put in more plans, particularly in communities where we know we have a lot of seniors.” 

Parts of the program are already underway: matching provider companies who need direct-care workers with nonprofit agencies partially funded with state tax dollars.

But even as Cooper proposes such plans to support older North Carolinians, the reality is that few of those plans can be realized without new funding — something that’s largely under the control of the General Assembly. And as Republican-led lawmakers there have held the purse strings for the past decade, funding for priorities for seniors have received scant funding increases and sometimes have even been on the chopping block.  

NC residents older than 85 to more than double

Over the past 10 years, the number of North Carolinians older than 65 has risen from more than 1.4 million, or 14.3 percent of the state’s population, to 1.8 million, or 17 percent. The number of people older than 85 is projected to more than double in the next 20 years — a sharp increase in a demographic that is more likely to need medical and long-term care. 

“For the seniors, it needs to get better,” said Rosa McMillan, 64, of Murfreesboro, who was also at the congregate meal. “You notice the seniors have been put on the back burner. 

“What we’re putting on the back burner we look at as being useless.” 

McMillan returned to her childhood home of Hertford County after building a career as a senior project analyst at Memorial Sloan Kettering Cancer Center in New York City.

Cooper’s ongoing plan will involve picking priorities so that leaders can put together resources — including state spending amounting to hundreds of millions of dollars — among the legislature, local governments, business and nonprofits, according to state documents and interviews with principals. 

“There’s been a lot of work done so far,” Cooper said. “But now if we can put this blueprint in place, I think we’ll have a more specific action plan to follow.”

In practice, Cooper and the Republican legislative majority have tussled over frying bigger fish: legislation that will determine how deeply taxes should be cut for individuals and corporations, whether Medicaid will be expanded and how much state employees, including teachers, can expect in raises. 

Adult day care center numbers fall

Several topics often listed as priorities for the state’s capital-based North Carolina Coalition on Aging and other advocates for older people soon arose in talks with people and officials on the ground in low-income, diverse counties.

For example, the regional shortage of adult day care centers that Sessoms mentioned isn’t just a Hertford County or northeastern North Carolina problem. A waiting list has grown to more than 11,000 people for this and other mostly state-funded aging services because of the legislature’s and Cooper’s focus on those billion-dollar priorities, political observers say, as well as the pandemic and competition among provider agencies.

A recent NC Department of Health and Human Services list of North Carolina providers of the in-demand adult day care centers listed them in only 32 of 100 counties. Overall, adult day care agencies fell from more than 125 in 2007 to about 80 in early 2020 and have continued to drop. Their ranks were decimated by the pandemic and seemingly haven’t been rescued by legislation that lets county commissions adjust fees that were long stuck in place by North Carolina statute.

Was Sessoms interested in making use of adult day care?

“Not right now, but I’d like it to be there in case I had to do it myself later on,” she said. 

She then noted that adult children’s role in looking after older parents has in many cases been lost to changes in small-town economies and changing patterns of family life: “Some people around here don’t have their children around.” 

Within a few minutes, Sessoms had touched on North Carolina caregivers’ need for support, short-funded agencies competing for state-federal NC Home and Community Care Block Grants, and many counties’ situation of having more residents older than 65 than they do 17 and younger. Hertford County is among 85 North Carolina counties where young people tend to leave home.

“They have no choice,” said Claude Odom, 76, also among those gathering at the Murfreesboro NC Nutrition Site. “To have a decent quality of life, they need to go where the jobs are. The county has a limited number of people making hires.”

‘A bath on Tuesday and Thursday’

Like several of the older North Carolinians interviewed in mid-May, Odom has a deep, diverse background. He’s a decorated Army veteran and ordained Missionary Baptist pastor who retired in 2012 as the eastern counties administrator of the state Division of Juvenile Justice. 

Odom cited the value of state-supported congregate meals for Hertford County’s older population as a chance for people to tell their widely varying stories in a setting in addition to church.

“Seniors like the fellowship; they like to socialize,” he said.

Another county seeing an outflow of young people who could take care of their elders is Robeson, in the southeastern corner of the state.

In Pembroke, Jo Ann Chavis Lowry, 75, head of the Lumbee Elders women’s group, related her own observations on low levels of state-mandated staffing at adult care homes such as Red Springs Assisted Living, where a relative lived. 

“I’m from a big family, and we were in and out at odd times, so that was a plus,” Lowry said.  “But some of those folks didn’t have anybody come in to check on them.”

On a weekend visit, she alleges she heard a staff member respond to other residents’ complaints about insufficient staffing. 

“That gentleman at the desk says, ‘We don’t have but two people on staff this weekend,’” Lowry claimed. ”He says, ‘And they don’t get past [residents’ rooms] every day.’ He said, ‘They only get a bath on Tuesday and Thursday.’”

In 2021, the state Department of Health and Human Services fined Red Springs Assisted Living an amount settled at $1,000 after investigating an incident in which staff failed to provide “adequate supervision,” according to a state report. 

The result was that a resident with dementia was documented as “wandering from the facility and being found by a local citizen on a busy road,” the report said.

Legislators looking at the issue in 2022 heard that state inspectors had cited 54 centers in the previous year for staffing lower than the mandated number: one personal care aide for 20 or fewer residents on first and second shifts and one aide per 30 residents overnight. 

Long-term care industry leaders have long asserted that low staffing stems from inadequate state reimbursements for Medicaid residents.

Earlena Lowery, 80, of Pembroke, said her fellow members of the state-founded advocacy group Tar Heel Senior Legislature have worried that essential agencies such as the state-mandated, but largely county-funded Adult Protective Services units seem to take a back seat to similar services for children. 

Two kinds of protective services

“One of the issues that we’ve been pushing ever since I’ve been with this group has been Adult Protective Services,” she said after the Lumbee Elders gathering at tribal headquarters in Pembroke.

Figures from the state NC Office of State Budget and Management show that Child Protective Services support rose from $181.89 million in 2017 to $231.7 in 2022, about a 27 percent increase. Making comparisons in actual spending is difficult given the sections’ varying purposes, funding and the variety of people served. 

Could state government favor children above seniors? She’s aware that such a claim could set off alarm bells.

“The state doesn’t give Adult Protective Services any money,” Lowery said. “But when you look at Child Protective Services for children — don’t get me wrong now; they need that money —  But then when you look at what they do for adults, it’s nothing. We need to be protecting all of our people.”

State coffers have provided little funding for Adult Protective Services, relying on county and federal taxpayers to pick the tab. 

In 2021, the state budget directed a federal grant of $2,579,576 to support Elder Justice and Adult Protective Services. The legislature sent $893,041, also in federal funds, to pay state workers to assist counties, whose funds were running thin to meet their state-mandated charge to protect vulnerable adults under Adult Protective Services. 

In the most recent budget, the state listed $574,871 for both Adult Protective Services and Guardianship for the year, up less than $25,000 from $520,649 per year in the 2017-19 biennium. In the same budget, legislators provided $21,006,583 annually in state funds to Child Protective Services.

Lowery also cited the value of socialization after a meeting at one of the tribe’s 15 such sites; Robeson County operates one senior center, paid for in part by federally- and state-funded Home and Community Care Block Grants. 

“Someone had the foresight to do this,” Lowery said during a gathering of the Lumbee Elders women’s group. “Sometimes we come in and just talk. We have a business meeting the first of the month and sometimes all that morning is spent, just to share what’s going on.”

Also at the Pembroke gathering, Jo Ann Lowry brought up the modest state Personal Needs Allowance that the General Assembly increased last year for Medicaid-assisted residents of assisted living facilities. Under a House bill with bipartisan sponsors, residents of nursing homes who rely on Medicaid would also get an increase in the allowance. Residents have said the amount goes quickly when needed to pay for anything from snacks to haircuts, sodas to rides to church. 

“If they got her a drink, it was a canned drink,” Lowry said of a relative’s stay at a Robeson County assisted living home. “It came out of her personal money.”  

Small counties’ aging funding can fall short  

Based on changing county population levels, money to pay for services such as senior centers varies widely across the state. Funding formulas are such that counties losing population can see overall decreases. That’s what happened with a reduction of nearly $25,000 for aging services in largely rural Hertford County, where more than one in five of about 21,000 residents is 65 or older. 

Diedra Evans, 61, director of the Hertford County Center for Aging in Winton, population 625, said when asked whether she would like to see more state support for older people in her county: “I can’t imagine anybody in my position saying anything different. There’s always more need than we can provide for.”

A long-standing complaint in state government and politics, held by many in eastern and western counties, that big shots in “Raleigh” — shorthand for government and legislative leaders — only give lip service and run out of money when it comes to meeting their needs.

Feeling neglected across the state

“East of [Interstate] 95 we kind of get neglected,” said Claude Odom, the minister and retired state official in Hertford County.

In a telephone interview from Western North Carolina, Norma Duncan, 86, nearly echoed Odom’s take from her vantage point as a longtime state employee and speaker of the Senior Tar Heel Legislature. 

“In the west, we are left out. We feel left out,” Duncan said. “We are aging in the west, we are older and not as affluent. 

“We need some help from the General Assembly — a feel for how it’s different here.” 

The post Stories by older NC residents illuminate needs unmet by state government appeared first on North Carolina Health News.

By Thomas Goldsmith

Enduring threads of North Carolina’s past — such as bygone industries and separate public schools for whites, Blacks and Native Americans — still affect older state residents, as harmful holdovers and even, in some cases, as positive forces.

Interviews with residents of small counties showed that the forces affecting the lives of North Carolina’s 1.8 million residents who are 65 and older often date to decades past.

The interviews were conducted as budget writers at the state General Assembly seemed to ignore calls to boost funding for lower-profile — but vital — agencies such as NC Adult Protective Services. Instead, lawmakers focused on proposals that would cut personal and business income taxes and increase support for private-school vouchers that would cost nearly $500 million annually by 2030. 

Meanwhile, older residents in Robeson County recalled the experience of learning in separate public school systems for white, Black and Native American students. 

“We were not furnished books,” Geraldine Lowry, 78, said of her primary education in schools attended by Lumbee students under the divided county system. 

“They wouldn’t let us have a lot of books, and, when they came, they were the ones that the other schools would throw away,” she said. 

Lowry was talking with members of the Lumbee Elders women’s group that meets regularly in the Pembroke headquarters of North Carolina’s Lumbee tribe, who number about 55,000 people in Hoke, Robeson, Scotland and Cumberland counties. 

“We did the best we could with what we had,” she added. 

Making do

As illustration, Lowry recalled the way Lumbee and Black children learned to play baseball with a rock wrapped in tobacco twine. 

After seeing tribe members save up to help the schools stock books and supplies as she learned, Lowry went to college and enjoyed a long career as a Robeson County teacher. She’s seen her own children and grandchildren head off to colleges that would have been closed to her as a high school senior. 

Lumbee Elders member Earlena Lowery, 80, also graduated from Robeson County’s Normal schools for Lumbee students, then moved on to earn master’s and doctoral degrees — far from home, she said.

“The mentors, the older teachers with experience, their recommendations were: ‘To the West, go to schools in the West,’” she said in August during a telephone follow-up to the Lumbee Elders gathering. 

“Not your East Carolinas and those other schools. No, it was Appalachian, Western Carolina or Peabody [Vanderbilt University’s school of education]. You couldn’t go to those other [North Carolina] colleges because of who you were.” 

Have the Lumbee people who were students of the segregated decades before the 1970s, felt disadvantaged by the experience as the years have worn on? 

Perhaps, but not necessarily, Lowery said. She recalled dedicated teachers, saying that many among her peers have gone on to successful careers in business, education and the ministry. 

“It’s just like today,” she said. “You’ve got barriers, and you’ve got to be strong enough to work through them. There were probably students that, I won’t say were held back, but students who didn’t work through the barriers like some of us do.”

Life without a diploma 

Today, almost a quarter (23.6 percent) of Robeson County adults over the age of 25 lack a high school diploma, compared with the state average of 13.7 percent who did not complete high school. The county also lags when it comes to higher education, with only 12.6 percent of adults over 25 holding bachelor’s degrees, compared with a state rate of 29 percent. 

Mary Locklear, another attendee at the Elders meeting, said only one word, “Proud!” when asked her feelings about growing up as a member of the Lumbee tribe. But her life’s choices were limited, she said, when she left the schools segregated by ethnic background before 10th grade to labor alongside her family on a tenant farm.

“We had to work,” Locklear said. ”We worked on this other man’s farm. It was seven of us, working in tobacco, cotton, cucumbers — you name it — hoeing tobacco and all that good stuff.” 

Another barrier, she said, was her father’s failure to provide for the large family. “I never knew my daddy to work,” Locklear said. “He run the road and [was] drunk all the time. 

“I never seen him cut a piece of wood to keep us young’uns warm nor nothin’. We had to do it.” 

Alcohol misuse continues to be an issue in Robeson County. Between 2009 and 2021, the data show, more than 900 deaths of North Carolina residents in Robeson were listed as  attributable to alcohol, which works out to a per capita rate that is much higher than in larger counties such as Wake, Mecklenburg and New Hanover. In 2021, Robeson County had a alcohol death rate of 105 per 100,000 population. Only two other counties in the state — Jones and Pamlico — had higher rates.

Buffeted by global winds of change

Changes detectable for decades can arise through international trade developments and by decisions of state departments from the Division of Health and Human Services to the Marine Fisheries Commission. 

Robeson and Hertford counties have felt the impact of departing plants and companies that had been mainstays of employment in communities, said E. Frank Stephenson, 83, a Hertford County resident, historian and former Chowan University official. Stephenson has chronicled instances such as the collapse of the herring fisheries that were central to northeastern North Carolina, in part through decisions by the state. 

The state herring trade reached a peak of 20 million pounds in 1969, but it dwindled first because of foreign competition for the bony fish, then because of overfishing and the fisheries commission’s efforts to manage the catch. The community events, extra income and household barrels of salted herring have become endangered species. 

“People depended on herring fishing for food,” Stephenson said. “During the spring when the herring came up here, people would catch them and salt them down. That was to have them just in case during the year you had a bad crop year in a rural area.” 

Another business development that hurt the incomes and community of lower-income residents came with the shutdowns in 1970 of large Hertford County factories devoted to making baskets of gum-tree wood. Stephenson called the basket-making Riverside Manufacturing Company a “lifeblood” for its hundreds of employees. His daughter Caroline Stephenson, 52, runs a local nonprofit and has worked with Frank Stephenson on his books. 

“It really got bigger and up and running in the ’30s and ’40s after the war,” Caroline Stephenson said of Riverside Manufacturing during a joint interview in Murfreesboro. “It enabled a lot of African Americans to basically stop sharecropping and move into town and to become homeowners.

“It created this, I wouldn’t say Black middle class, but it certainly got people off of the farm and away from dire, extreme poverty — which is sharecropping.”

Leaving, only to return

Another way out has involved simply leaving home and extended family, a route chosen by Rosa McMillan, 64, a project analyst who retired from New York City’s famed Memorial Sloan Kettering Cancer Center and recently returned to Hertford County. At the Murfreesboro Nutrition Center, she reminisced about working as a sharecropper from the late ’60s to the early ’70s while living with her grandmother after the deaths of her mother, father and great-grandmother. 

“We grew up on a dirt road,” she said. “I worked in the fields from the time I was eight until I was 16 — tobacco fields, cotton fields, cornfields. We was up in the morning, and we was on the back of somebody’s truck going to their fields.” 

But that wasn’t all it took to keep the household going, as McMillan’s grandmother raised and dealt in pigs, chickens and bootleg whiskey.

“My grandmother sold liquor here in Hertford County. That’s how we was raised,” McMillan said.

People visited the large farmhouse with no air conditioning in summer or heat in the winter every day of the week to have a drink and listen to soul-music performers such as James Brown and Marvin Gaye on a jukebox that was called a piccolo for its small size.

McMillan recalled: “They came and said, ‘Miss Mary, could I have a pint?’ ‘Miss Mary, could I have a shot?’ and they’d get a shot and they’d sit there drinking.” 

McMillan left Hertford County as soon as she could, but she still values what she learned in the big house set back from a dirt road. 

“We went to school in the morning and came home at night,” McMillan said. “It was a hard life, but it was a good life. [My grandmother] told us that if you want something you’re going to have to work for it, because nobody’s gonna give it to you.” 

Older people like McMillan and Berna Stephens, who have enjoyed success after years as working professionals in other states, still deal with remnants of old stresses and biases now that they’ve returned to Hertford County. 

After years working with the U.S. Census Bureau near Baltimore, Maryland, Stephens, 76, serves as a town council member in Murfreesboro. She sometimes deals with screeds from people who move out to avoid paying property taxes within town borders. 

But with a family reunion coming up, she’s been visited by memories of an incident that touched her deeply even though it happened in the ’30s, before she was born. 

Her maternal grandfather had lent money to a church fund, putting up his farm as surety. 

But, according to Stephens’ family lore, fellow parishioners didn’t follow up on their promises to pitch in on loan payments, so her grandfather lost the farm, with no help or understanding from an all-white legal establishment, she said. 

North Carolina had more than 12,000 Black operators of entire farms in 1930 and more than 900 “Indian” operators in the same year, according to the U.S. Department of Agriculture’s Census of Agriculture Historical Archive, Black farmers once operated 25 percent of the state’s farms; that share had dropped to three percent as of 2017. The most recent Census of Agriculture report showed that Black operators in Hertford County owned nine farms. In Robeson, the number was 42. 

There’s no way to calculate how much the loss of each farm cost the displaced owners in family wealth, self-esteem or future prospects. 

“You think you get over things until that subject comes up again and you think about the effect it may have had,” Stephens said. 

A lack of money for transportation, which better-off families could have provided, meant that one of Stephens’ aunts had to bypass an early road to what her family believed would be better prospects.

“She was 16, and that probably kept her from going to college,” she said. “She had a scholarship, but she couldn’t go.”

Correction: Initially a photograph of Frank Stephenson misidentified him as Frank Sullivan.

The post Old North Carolina policies, patterns keep hold on some seniors’ lives appeared first on North Carolina Health News.

By Ben Rappaport

This is the first in a two-part project about the children’s mental health crisis in Bladen, Columbus, Robeson and Scotland counties. Read the second story, which focuses on the foster care system, story here.

A 9-year-old girl who spent four months last year inside the Columbus County hospital’s emergency department lashed out at nurses and clawed at the drywall. She wasn’t allowed to use a fork over fears she would use it as a weapon. 

Each day, staff at the Columbus Regional Healthcare System tried desperately to secure a bed for the child at a pediatric mental health facility. But such placements can be hard to find in North Carolina. 

The girl had been in numerous foster homes where she experienced physical and mental abuse, said Dr. Jugta Kahai, the pediatric medical director at Columbus Regional in Whiteville. “Here is a 9-year-old who’s been severely traumatized,” Kahai recalled during a recent interview. “Yet, she’s sitting in a concrete bunker with no window, no therapist and heavily medicated.”  

Nationwide, children are dealing with a mental health crisis that experts say is fueled by bullying, the COVID-19 pandemic, discrimination and other stressors. Health care professionals in rural southeastern North Carolina say more and more children are suffering – and struggling to find help in a poor region that needs more mental health specialists. 

As a result, children end up staying days, weeks or even months in emergency departments or at local departments of social services, both of which are considered by the state “inappropriate crisis settings.” 

Eastpointe, a health management organization that serves Robeson, Scotland and several other counties, saw an average of six Medicaid-enrolled children at any given time in such settings during the first three months of 2023, data shows – an average of five in emergency departments and one in a DSS office. The figure marks a 20% increase from the previous three-month period but doesn’t include children with private insurance who were awaiting treatment.

Trillium Health Resources, which serves much of eastern North Carolina including Bladen and Columbus counties, saw a 55% decrease during the same period, with an average of four Medicaid-enrolled children at any time in emergency departments and one in a DSS office. 

The decrease doesn’t paint the whole picture, however. Kahai estimates that more than a quarter of her patients have behavioral and mental health concerns. In her 24 years as a pediatrician, including the past seven in Columbus County, she said she has never seen such intense need.

The 9-year-old she treated was one of countless children in the area who have been involuntarily committed to emergency departments for extended periods with nowhere to receive proper psychological care, Kahai said. The girl was eventually placed in an out-of-state psychiatric care facility.  

Greg Wood, the outgoing chief executive at the Scotland Health Care System, said a young teenager had to stay so long at the Laurinburg hospital while waiting for a behavioral health placement last year that staff arranged for local first responders to show up in a fire truck to ease the kid’s boredom.

“He always wanted to see a fire engine,” Wood said. “He got to climb on the fire engine.” 

Officials say rural southeastern North Carolina needs more of every kind of health care provider, from nurses to specialists. The shortage has been felt acutely in behavioral health.  

In Columbus County, home to 50,000 residents, there are about 600 patients per mental health provider, according to the 2023 County Health Rankings from the University of Wisconsin Population Health Institute. The number is even higher in neighboring Bladen County – 1,020 patients per provider.

Columbus, Bladen and Scotland are among 68 North Carolina counties that don’t have a children’s psychiatrist, according to the American Academy of Child & Adolescent Psychiatry. Robeson County, home to 117,000 people, has one. 

Meanwhile, suicides per 100,000 children increased from 1.1 in 2018 to 1.7 in 2022 in North Carolina, according to the latest “report card” from NC Child. More than one in five high school students said they have seriously considered attempting suicide, reported the nonprofit organization, which gave the state an “F” grade in April after examining 15 indicators of child health.

Adverse childhood experiences

In one afternoon at Advanced Pediatrics & Family Care in Whiteville, Kahai saw a newborn who tested positive for opiates, a toddler who was cared for by great-grandparents because the child’s mother was using drugs, two children with attention-deficit/hyperactivity disorder and one with clinical anxiety. 

The same day, she was scheduled to see two patients under the supervision of the local Department of Social Services, but neither showed up.

Children everywhere and from all backgrounds are experiencing mental health concerns, experts say. Adolescents in rural southeastern North Carolina have challenges that include poverty, drugs, racism and climate uncertainty. Some families are still displaced from their homes following hurricanes in 2016 and 2018. 

The percentage of children living in poverty in Columbus County declined by 8.4% between 2014 and 2022. But last year’s poverty rate of 26.6% remained much higher than the statewide rate of 17.9%, according to Data USA.

Poverty is considered among adverse childhood experiences – often called ACEs – that can have lasting negative impacts on children. Others include experiencing or witnessing abuse, growing up in a household with substance use or mental health struggles and being separated from parents who are incarcerated, according to the Centers for Disease Control and Prevention. 

Nineteen people died of drug overdoses in Columbus County in 2022, the highest number since the N.C. Department of Health and Human Services began tracking on its data dashboard. In Robeson County, 103 people died.

The opioid epidemic is contributing to an overburdened foster care system. The number of children in foster care more than doubled between 2018 and 2022, according to the local Department of Social Services.

Columbus County has seen an increase of more than 84% in the number of children under DSS supervision since 2018, according to the local Department of Social Services. As of August, there were 112 children in foster care – and not enough foster families to care for them.  

“When you come from a strapped rural county where funding is cut every year,” Kahai said, “you have to manage by compromising. It’s a sad reality. Often those kids need the facilities the most, yet they end up deprived.”Dr. Jugta Kahai

Meanwhile, North Carolina’s hesitancy to expand Medicaid has compounded the mental health crisis, officials say. More than 23,000 additional people in Bladen, Columbus, Robeson and Scotland counties could qualify for the health care program once Medicaid expansion begins in December, according to the Cone Foundation. 

Between 43% and 56% of residents in the four counties currently receive Medicaid, according to the N.C. Department of Health and Human Services. 

Some say Medicaid expansion will help lure mental health professionals to rural, low-income areas. But North Carolina has not increased Medicaid rates for psychiatric care since 2012, giving psychiatrists and other mental health professionals little incentive to accept payments from the federal program run by states. 

Wood said Scotland Health has tried twice over the years to bring psychiatrists to town. Both times, he said, the hospital system lost money. Unlike counselors or therapists who might see patients once a week, psychiatrists make money by prescribing medication less frequently – and when there aren’t enough patients, there isn’t enough money. 

“They’ve got to see an awful lot of patients,” Wood said.

Kahai said trying to manage any clinic on Medicaid patients alone is “a non-viable situation.”    

“When you come from a strapped rural county where funding is cut every year,” Kahai said, “you have to manage by compromising. It’s a sad reality. Often those kids need the facilities the most, yet they end up deprived.”

Over the last decade, funding for health care in Columbus County has plummeted. Between 2010 and 2019, the county’s health department saw a 68% decrease in revenues, the BBI previously reported. 

Funding issues

David Pope, who will succeed Wood as chief executive of the Scotland Health Care System in December, said changes are needed in pediatric involuntary commitments, or IVCs, which are put in place when patients are deemed dangerous to themselves or others. 

Patients who are held under IVCs “lose the right to make their own decisions while being treated under a court order for psychiatric problems or substance abuse,” NC Health News explained in an article in September. They can’t walk out of emergency departments, where the average wait time is 16 days for a placement at a state psychiatric hospital, according to NCDHHS.

“Keeping patients in [emergency department] settings for three, four, five months is a really bad way to care for people,” Pope said. “If I kept you in a small room for an extended period of time, that’s the sort of thing that tends to lead folks to aggravating mental health issues.”

While there are private mental health facilities available — including Holly Hill in Raleigh, Old Vineyard in Winston-Salem and Keep Hope Alive in Greenville — beds are still hard to come by, according to Kahai. It’s also difficult for children on Medicaid, who account for the majority of pediatric IVC cases in the region, to receive treatment at these facilities.

Long stays at emergency departments are largely a result of underfunded and understaffed state psychiatric hospitals. Nearly 3,700 positions were vacant at the state’s three psychiatric hospitals earlier this year, more than triple the vacancies reported in 2020, according to NC Health News. In turn, only 600 of the state’s 894 psychiatric hospital beds are being used, according to DHHS.

North Carolina lawmakers overhauled the mental health care system more than two decades ago, when the state had nearly 1,600 psychiatric beds. The state’s psychiatric facilities saw a 57% decrease in people served, from 5,754 in 2011 to 2,450 in 2020, according to a state report.   

State lawmakers and health care providers are trying to combat the crisis. UNC Health announced last year it would build a 54-bed inpatient psychiatric hospital for children and adolescents in Butner in partnership with NCDHHS and a substance abuse treatment provider. The facility is scheduled to open later this year.

The recently passed state budget also invests hundreds of millions of dollars for mental and behavioral health services. That includes $50 million for UNC Health’s construction of a new children’s mental health hospital in the Raleigh-Durham region. The budget also includes $20 million in bonuses for workers in the state’s psychiatric hospitals and increased rates for mental health and substance use service providers. Over the next two years, the state also allocated $80 million for families with children suffering with mental health challenges.

Funding is also provided to establish the Psychiatry Access Line, which allows primary care physicians and pediatricians increased access to behavioral health specialists when they see patients with mental health needs.

To fill the need for child psychiatrists in rural communities, the state established funding to pay mental health specialists up to $100,000 to work in economically distressed Tier One and Tier Two counties, including Bladen, Columbus, Robeson and Scotland. New psychiatrists can also have part of their medical school debt relieved if they agree to work in rural communities for five years, under the $50 million expansion to the N.C. Loan Repayment program.

“Community-based mental health care options should be upstream,” Pope said. “But because those options don’t currently exist, we end up far down the river, very close to the waterfall.” David Pope

Medicaid expansion could also help people in mental health crises seek help from primary care providers instead of emergency rooms. Pope said IVCs and placement in emergency settings should be a last resort, but due to a lack of community-based mental health services, it’s become the go-to option for many pediatric patients.  

Pope said community care should attempt to intervene early so an individual’s mental health doesn’t end up in crisis. 

“Community-based mental health care options should be upstream,” Pope said. “But because those options don’t currently exist, we end up far down the river, very close to the waterfall.”

Seeking solutions

Kahai takes time to build relationships with her young patients and their families. She says the effort brings a clear picture of the state of her community. 

“It’s a new crisis every day,” she said. “And somewhere in between I have to find the time to see the other sick kids, too.”

While she may have a strong exterior, Kahai said the burden of patients’ mental health issues, lackluster communication from the Department of Social Services and the need to work longer hours at the hospital is beginning to take its toll.

“I really have not been sleeping well,” she said. “And with all I see every day, it’s hard to turn the work off and de-stress when I do get home. It’s just always something.”

According to a 2022 Addiction Professionals of North Carolina survey, 85% of behavioral health workers reported at least one symptom of burnout in the last few months. The most commonly reported symptoms were emotional or physical exhaustion, feeling overburdened or overwhelmed with the workload, increased strain on the ability to provide consistent resources and energy to work, and procrastination and trouble focusing on tasks.

“The folks that I know that work in hospitals are doing it because they truly care for people, and they want to make things in their communities better,” said Pope, whose academic dissertation focuses on access to mental health care in rural North Carolina. “But when the very person that you’re trying to care for is physically violent toward you, is verbally assaulting you, it’s hard to sustain that level of compassion.”

Pope’s dissertation was published earlier this year for the UNC-Chapel Hill Gillings School of Global Public Health, where he graduated last spring. In his research, which included interviews with more than 20 experts in mental health, he found “compassion fatigue” was a persistent problem leading people to leave the field. 

Kahai said she is not planning to leave pediatrics any time soon, but she said there is a need for systemic changes when it comes to treating children’s mental health.

To avoid staff burnout and create more community-based care, Pope says the state needs to invest money toward mental health organizations. The state budget gives Trillium $2.5 million annually for the next two years and Eastpointe $1.6 million, which is similar to the organizations’ allocations for the past three years.  

Making the investment Pope would like to see would “ensure that every county has access to robust mobile crisis response, a regional facility-based crisis center, and outpatient involuntary commitment for Medicaid and uninsured patients,” his dissertation reads.

Trillium already provides some of the community-based approaches Pope recommends, including mobile crisis units, which give patients access to doctors and therapists via telehealth and on-site certified medical assistants and peer-support specialists. The three mobile clinics in Bladen and Columbus counties each serve about 50 residents per week, the BBI previously reported. Robeson County also received funding in this year’s state budget to establish its own mobile crisis unit. 

In June, Trillium announced an investment of more than $1 million for a family solutions program that will support the recruitment and training of additional foster care families. More than $89,000 of that funding is going toward the Boys & Girls Homes of North Carolina in the Columbus County town of Lake Waccamaw.

Other efforts are underway. UNC Health announced in August that it will partner with Bladen County Schools to bring four in-person therapists to the district. Students struggling with depression, anxiety and other issues will have access to telehealth appointments with specialists and psychiatrists through “virtual care centers” within the schools.

“Youth across our state are experiencing a behavioral health crisis, and a lack of resources in rural areas is compounding the challenges,” Dr. Mike Steiner, pediatrician in chief at UNC Children’s Hospital, said in a news release. “We are optimistic that this project presents a terrific opportunity to turn the tide and improve treatment for behavioral health conditions.”

Another important solution is improving health literacy, said Cindy Ehlers, chief operating officer at Trillium. Making sure adults are aware of the signs of depression, anxiety and other illnesses is an important step in providing children with proper treatment. 

According to the UNC-Chapel Hill Health Literacy Map, a majority of neighborhoods in Bladen, Columbus, Robeson and Scotland counties rank in the state’s lowest quartile when it comes to health literacy. 

“Health literacy is the first step in educating people so we can collectively work toward a solution,” Ehlers said. “When we don’t do enough to teach our young people about anxiety, depression and trauma, we perpetuate this stigma around mental health.”

The mental health care system in North Carolina is “profoundly broken,” Pope said. But he and Kahai both say they are hopeful that change is possible through a strong community spirit and a desire to help one another.

Hanging in Kahai’s office in Whiteville is a poster of a rainbow jaguar with pink and purple lettering that reads, “Pediatrician: an expert in all things related to booboos, owies and calming down parental nerves.”

Kahai knows that some of the worst booboos and owies are the ones that can’t be seen. 

The post Crisis in children’s mental health takes a heavy toll in rural southeastern NC  appeared first on North Carolina Health News.

By Rachel Baldauf

Amanda Price and her husband were finally in the process of adopting their three daughters in 2022. The couple had fostered the girls for four years and had planned to adopt them in 2020, but the COVID-19 pandemic caused delays.

The wait was hard on the biological sisters, who are now 6, 10 and 11. The older girls struggled with memories of being shuffled around the foster care system. The oldest lived in three different homes before landing with the Prices. At school, the middle child was teased for having a different last name than her parents. “They’ve been through so much in their short years,” Price said. 

Finding mental health specialists near the Robeson County town of Orrum where they live was challenging. By 2022, the girls had already changed therapists three times when their providers relocated. 

The situations weren’t ideal anyway, because the therapists were better suited to treat adults. So the Prices were ecstatic when they found a provider who specializes in children. They didn’t even mind the 40-minute drive to the office. 

A year later, however, they got the dreaded news: That provider was also leaving the area. 

“It can be sad for the girls because they really do get close,” said Price, 42. “I’ve seen my girls cry because their therapist was leaving. … It was just another loss for them.” 

Like much of rural North Carolina, the southeastern part of the state suffers from a severe shortage of mental health care providers. Columbus, Bladen and Scotland counties don’t have any children’s psychiatrists, according to the American Academy of Child & Adolescent Psychiatry.

The need for more specialists has been especially apparent amid a children’s mental health crisis that experts say is driven by social and academic stressors that were exacerbated during the COVID-19 pandemic. More than one in five high school students in North Carolina said they have seriously considered attempting suicide, according to a report released this year by the nonprofit group NC Child.

More resources are especially crucial for children in the foster care system, experts say. A 2003 study by Casey Family Programs showed that former foster care youth experienced post-traumatic stress disorder at a rate nearly five times higher than the general population. They also experienced other mental health conditions like depression, anxiety and drug dependence at increased rates.

Children in foster care are likely to experience traumatic events early in life, including poverty, displacement and abuse. Being exposed to numerous adverse childhood experiences – often called ACEs – puts children at risk of negative outcomes in adulthood, including mental health struggles and substance abuse, said Barbara Hallisey, chief of clinical programs at Eastpointe, which manages mental health care in several North Carolina counties. 

“It’s like a strike against you,” Hallisey said.

Children in foster care are likely to have trauma even if they don’t experience abuse, said Donna Yalch, chief of community-based services at Boys & Girls Homes of North Carolina in Lake Waccamaw. “When a child is taken from their parents to be put into foster care, they already have one trauma, and that’s being removed from their family,” she said.

More children in foster care

Most local counties have seen significant increases in the number of children in foster care. In Columbus County, the number more than doubled between 2018 and 2022, from 66 to 135, according to Algernon W. McKenzie, director of the county’s Department of Social Services. By the end of August this year, 112 children in the county were in foster care. 

Robeson County has 368 children in foster care, officials say. Durham County, where the population is more than twice as large, had 297 children in foster care in June.

The growing mental health crisis among young people, including those in foster care, often means lengthy stays in emergency rooms or DSS offices. During the first three months of 2023, an average of half the children who received Medicaid through Eastpointe and Trillium and were in such “inappropriate crisis settings” were under DSS supervision, data shows.  

Eastpointe and Trillium are care management organizations that serve many eastern North Carolina counties, including Bladen, Columbus, Robeson and Scotland. 

Experts attribute much of the increase in children in foster care to the opioid epidemic that has shattered local communities. Since last year, more than half of all children who entered foster care in Bladen, Columbus and Robeson counties did so because at least one parent was misusing drugs, NCDHHS data shows. In Robeson, the figure exceeded 74%. 

The strain on the foster care system is exacerbated by a shortage of foster care families. From 2021 to 2022, the number of licensed foster care homes statewide dropped by nearly 25%, federal data shows.

“I’ve had people that I’ve talked with, and they’re like, ‘You know, I can barely afford to feed my own family. How can I add another mouth to feed?’”

Carrie Decker

The COVID-19 pandemic worsened the problem, said Carrie Decker, the foster home licensing social work supervisor for the Boys & Girls Homes of North Carolina. Decker runs regular training courses for aspiring foster care parents. Before the pandemic, 15 families regularly attended – the maximum under state regulations. Post-COVID, classes often have fewer than five people.

The pandemic made many potential foster care parents afraid of health risks, and inflation has increased the financial burden of fostering, Decker said. “I’ve had people that I’ve talked with, and they’re like, ‘You know, I can barely afford to feed my own family,’” she said. “‘How can I add another mouth to feed?’”

Monthly stipends for foster care parents in North Carolina were raised more than 15% in July through the passage of Senate Bill 20, a controversial measure that restricts abortion access. Foster care parents statewide now receive between $702 and $810 a month per foster child, depending on the age of the child.

In the Border Belt region of Bladen, Columbus, Robeson and Scotland counties, where more than 20% of residents live in poverty, the stipend often doesn’t cover expenses. “It’s not enough to feed and clothe them for an entire month,” Decker said.

Some people say the state should better prioritize placing children with family members or friends instead of foster families. But that too can pose financial challenges. 

Denise Shepherd cares for her 18-year-old grandson and three other children, ages 8, 13 and 14, who are not related to her. The children’s parents signed over custody to Shepherd to prevent the kids from entering the foster care system. Because she’s not a licensed foster parent, she doesn’t get financial support from DSS. 

Shepherd, 66, said she has had to use a credit card to pay for food for the past four months. “Groceries are a challenge,” she said. “I’ve got three teenagers here, and the 8-year-old can eat almost as much as they can.”

Shepherd said she struggled to afford clothes for the youngest child ahead of summer camp. “That was unacceptable. He’s not going to look like a throwaway child,” she said. “For his self esteem, and for what he needs, he needs to look good.”

Accessing mental health care for children can also be expensive. Decker said local foster families often travel at least an hour to Wilmington or Fayetteville for therapy sessions.

For many families, traveling means taking time off work. “We’ve had foster parents say, ‘If I ask for one more day off, I’m gonna lose my job,’” Decker said.

Identifying those in need

Decker said the lack of providers who accept Medicaid poses a particular problem for children in foster care. In North Carolina, all foster children must be enrolled in Medicaid even if their foster parents have private insurance.

“If a medical practice does not accept Medicaid, that foster child can’t go there,” Decker said.

The Boys & Girls Homes of North Carolina offers therapeutic services to some children living in its licensed homes, but Decker said hiring providers is a constant struggle. “As a nonprofit agency,” she said, “we can’t offer a competitive salary.” 

Despite the many barriers to care for foster children, Hallisey said she’s hopeful that new solutions can help. The COVID-19 pandemic led to an increase in virtual mental health care access. For people living in rural areas, virtual appointments mean they no longer have to drive long distances for care.

“I think that has been one of the barriers that has improved with COVID,” Hallisey said. “You know, good things come out of bad things all the time.”

Hallisey is also excited about new programs that allow students to access mental health care at school.

In August, UNC Health announced a partnership with Bladen County Schools that will place four in-person therapists at schools throughout the district. “Virtual care centers” on campuses will also provide access to telehealth appointments with specialists and psychiatrists.

For foster children, Hallisey said early identification of mental health issues is key. Eastpointe currently holds a daily 30-minute phone call with local DSS offices to identify particular children who are struggling and need extra care, Hallisey said.

“Early identification and early encouragement to access services really makes a difference,” she said.

“I want to see if they can get some of their innocence back.”

Amanda Price

Amanda Price’s daughters haven’t been back to therapy since their last provider moved away. Working to gain the trust of new therapists became emotionally taxing for the girls, Price said.

“They go talk to the therapist and tell them all this stuff. Then all of a sudden, this one is leaving, and they’ve got to earn the trust of somebody else,” Price said. “They’re not just gonna start talking to somebody until they start trusting them.”

This year, the Prices decided to homeschool their daughters. The teasing that the girls experienced at school was a factor in their decision.

“I don’t want them to have to grow up any faster than they already have,” Price said.

Today, Price’s daughters spend their days going to soccer games, singing at church and playing with their dog Cookie. They might return to therapy in the future. But for now, Price said they need time to settle in without having to worry about appointments and paperwork.

“I want to see if they can get some of their innocence back,” Price said.

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By Jaymie Baxley

If not for Medicaid, the majority of residents of Robeson County wouldn’t have health insurance.

Fifty-four percent of people in this rural community — home to 116,530 at the 2020 Census — are beneficiaries of the government-funded program. The county had 63,549 Medicaid enrollees in October, the eighth highest number recorded of the state’s 100 counties. 

Even more are expected to join the rolls after Medicaid expansion takes effect on Dec. 1. The long-awaited measure will raise the state’s income limit for Medicaid, extending eligibility to hundreds of thousands of North Carolinians who make 138 percent of the federal poverty level or less.

Single adults, a population that was effectively ineligible for coverage before expansion, will qualify if they earn less than $20,000 a year. The threshold increases by $7,094 for each additional household member, meaning a person with a family of four would qualify if their annual income is less than $41,400.

Expansion will be particularly impactful in economically distressed areas like Robeson County, where the median household income is less than $37,000. Many people in Robeson who are not currently enrolled in Medicaid have no health insurance at all.

This year’s national County Health Rankings report from the University of Wisconsin Population Health Institute found that 20 percent of the county’s residents are uninsured — higher than the statewide average of 13 percent. The report also ranked Robeson as the least healthy county in North Carolina.

The work of managing the county’s anticipated surge in Medicaid applications will largely fall on the Robeson County Department of Social Services.

Gene Downing, who oversees Medicaid enrollment for Robeson County DSS, said the department has hired more people to handle the workload. The agency is also in the process of creating a call center to help residents with questions about eligibility. 

“There’s a little bit of fear because it’s a new policy that we’re trying to learn [while still] managing everyone that we already had,” Downing said.

Expanding amid ‘unwinding’ 

The N.C. Department of Health and Human Services knows that local agencies such as Robeson County’s DSS will play a crucial role in implementing expansion.

In a letter to county managers and DSS directors issued on Friday, DHHS deputy secretaries Jay Ludlam and Susan Osborne acknowledged that the “important work to expand health coverage across our state begins at local DSS offices.” The state, they wrote, is “focused on providing policy changes, automation improvements, training opportunities, and financial support to help counties meet this increased demand.”

Ludlam and Osborne also noted that expansion comes as local DSS offices are dealing with the “unwinding” of the continuous coverage requirement, a federal mandate that prevented states from kicking Medicaid participants off the rolls during the first three years of the COVID-19 pandemic. 

Medicaid benefits were automatically renewed while the provision was in place, even if a person no longer qualified for the program. The requirement expired shortly after the federal Public Health Emergency ended earlier this year, forcing social workers in North Carolina to verify the continued eligibility of 2.5 million enrollees for the first time since March 2020.

More than 162,000 North Carolinians have lost Medicaid since the state resumed terminations in June. About 141,955 of those people, or 87 percent, lost coverage from June to October for “procedural reasons,” according to the latest available data from DHHS. Procedural disenrollments typically occur when a local DSS office does not have all the information needed to verify a Medicaid participant’s current income and household size.

DHHS has said the state is making “many efforts to reach beneficiaries to get their information” during the unwinding, including through letters, emails, text messages and automated phone calls. But if a caseworker is using an outdated address or phone number, the beneficiary may never receive the message.

The state’s other 20,183 unwinding-related disenrollments involve residents who were deemed ineligible for coverage based on criteria that will change once expansion takes effect. 

Many of these people are expected to qualify for Medicaid again under expansion.

Medicaid or Marketplace?

The situation can be vexing to expansion-eligible people who recently lost coverage. 

Some have turned to the N.C. Navigator Consortium for guidance. The federally funded organization offers free consultation and support to people in need of health insurance. 

“We have been helping folks since early summer who were affected by the unwinding, but still there’s a lot that’s happening in the Medicaid space in North Carolina right now, and that’s been one of our concerns,” said Nicholas Riggs, director of the consortium. “Is this going to be confusing for folks with so many different changes?

“Obviously, in the end, Medicaid expansion is absolutely a good thing as far as making sure that folks have access to coverage across the state and are covered under full Medicaid benefits and able to access doctors and essential services. But I think with just so many things happening at one time, it does lend itself to perhaps a little bit of confusion.”

Further complicating matters, North Carolina’s expansion date will coincide with the open enrollment period for health insurance plans through the Affordable Care Act. Many North Carolinians might be wondering if they should sign up for insurance now through the federal Marketplace or wait until Dec. 1 to apply for Medicaid. 

Riggs, however, doesn’t see the overlapping events as an issue. On the contrary, he said, “they kind of compliment each other.”

“Folks who have heard about Medicaid expansion and want to see if they’re potentially eligible [may] find out that their income is projected to be above 138 percent of the federal poverty level,” Riggs said. “They haven’t explored the Marketplace before, so we’re able to help them enroll in a Marketplace plan with, a lot of times, a $0 premium.”

As for the people who do meet the new income threshold for Medicaid, Riggs said the consortium’s health insurance navigators can “reschedule them for an appointment” to apply for coverage after expansion launches. 

“Having the two at the same time has definitely been more work for our staff,” Riggs said. “But as far as how it helps the folks across the state, I think the two kind of coinciding, from our perspective, has increased awareness around both Medicaid and the Marketplace. We are able to capture folks that maybe we wouldn’t have had this happened outside of open enrollment.” 

‘A blessing’ 

Kody Kinsley, head of DHHS, said the state has “all hands on deck” to implement expansion. 

“We’ve been working on this for a long time,” Kinsley said in an interview last week with NC Health News. “Every part of the department is involved and excited about this.”

Among other preparations, DHHS is conducting outreach to soon-to-be eligible North Carolinians and has beefed up its technology systems to handle the anticipated surge in activity when expansion launches. The agency has also been working to bolster the state’s provider network to ensure that new Medicaid participants have access to care.

On Wednesday, DHHS announced it was raising the minimum Medicaid reimbursement rates for behavioral health providers for the first time since 2012.The increased rates, which take effect on Jan. 1, will be permanent thanks to $200 million in recurring funds allocated by the General Assembly as part of this year’s state budget.

The first residents who will benefit from expansion are those enrolled in Family Planning Medicaid, a limited-coverage program for reproductive health services. DHHS estimates that 300,000 of the 450,000 people currently participating in Family Planning Medicaid will be automatically upgraded to full coverage.

Another 300,000 people are expected to join the rolls through the traditional application process for Medicaid. Kinsley said this can be done using the state’s ePASS website.

“Getting all of your application documents there and submitting is going to be the fastest way that people can get through the system because of all the technology that we’ve been able to put in place,” he said.

It generally takes about 45 days for Medicaid to kick in after a person is approved. But Kinsley said the benefits will retroactively cover medical expenses dating back to the first day of the month that the application was submitted.

“Your doctor is going to be able to bill us, and that’ll all be taken care of,” he said.

Despite all the work that has gone into preparing for expansion, Kinsley stopped short of promising a seamless rollout. 

“I’m confident that we’re going to have a bolus of people that come forward … that is going to be larger than what the performance of the statewide system, as far as our staff and our DSS office, can manage all on one day,” he said, referring to the state Division of Social Services. “That’s normal for any type of new launch — any new product launch — that you bring out.”

Kinsley likened the state to an Apple store “with a line down the street” waiting to buy the latest iPhone. DHHS, he said, anticipates seeing “some full waiting rooms” once expansion goes live.

But Kinsley believes that’s a small price to pay to give working families the “peace of mind” that comes with having health insurance.

“It’s a blessing to these folks,” he said. “I’m so excited to be a part of bringing that blessing to 600,000 people on Dec. 1.”

This article has been updated to include information about Family Planning Medicaid.

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By Jaymie Baxley

Nearly 273,000 people were enrolled in Medicaid on Day One of the long-awaited expansion that started Dec. 1, according to data released last week by the N.C. Department of Health and Human Services. 

Hundreds of thousands more low-income North Carolinians will begin the new year eligible for health insurance under the expansion — a policy change that was a decade in the making.

Expansion raised the state’s long-standing income limit for Medicaid, extending eligibility to adults who make up to 138 percent of the federal poverty level for their household size. The previous limit was 100 percent, which prevented many single residents without children from qualifying.  

Most of the new enrollees were automatically upgraded from Family Planning Medicaid, an existing limited-coverage program for reproductive health services. 

About 7,000 more residents joined the rolls soon after. In a recent interview with NC Health News, DHHS Sec. Kody Kinsley said 280,000 people have received coverage through expansion as of Dec. 12.

Data for December is not yet complete, but the early numbers offer a glimpse into how the state’s Medicaid population might grow in the months ahead. Following are some key takeaways. 

Who’s getting coverage?

While the majority of the state’s initial group of expansion enrollees are white, Kinsley said distribution among other races has been “quite equitable” overall.

“It’s on par with, or above, where the state is from a population perspective,” he said.

Black residents, who make up 22.2 percent of the state’s population, accounted for 38.1 percent of enrollment on the first day of expansion. Hispanic residents, who represent 10.5 percent of the population, made up 9 percent of Day One enrollment.

Kinsley said the early data showed a surprisingly large number of older residents joining Medicaid, with people ages 50 to 64 accounting for 22.3 percent of new enrollees.

“That was really interesting,” he said. “If you’re in that coverage gap and you’re not getting health insurance until you’re over 50, you’ve probably been struggling with this challenge for some time.”

Where do they live?

Nearly a quarter of the first wave of expansion beneficiaries live in rural counties, according to geographical classifications used by the N.C. Office of State Budget and Management. 

Robeson County, an economically distressed county in southeastern North Carolina, saw the biggest spike in enrollment relative to its size. More than 7,100 residents of Robeson, or 10.5 percent of the county’s adult population, received coverage under expansion on Dec. 1 — the largest share recorded among the state’s 100 counties. 

Other rural counties that recorded high portions of adults enrolled in expansion include Edgecombe (9.5 percent), Richmond (8.7 percent) and Anson (8 percent).

How’s expansion going? 

Despite the huge influx of new enrollees, Kinsley said expansion has gone off without a hitch. 

“We’ve had no technology issues,” he said. “The call center increases that we were seeing are being managed and leveled off. We’ve had no major issues with long lines.”

ePass, the state’s online system for fielding Medicaid applications, had 15,800 visits during the first 12 days of expansion. That’s up from a monthly average of about 1,000, according to Kinsley. 

“We’ve had 15 times our normal volume and haven’t had a hiccup,” he said. 

About 600,000 people are expected to eventually receive Medicaid through expansion. This new population of health insurance recipients will likely push down North Carolina’s rate of uninsurance into single digits. 

Right now, North Carolina ranks among the states with the most uninsured residents, with 11.1 percent of residents between the ages of 18 and 64 lacking access to health coverage, according to the U.S. Census. That number is somewhat lower than before the COVID-19 pandemic crisis, during which Congress ordered states not to kick anyone who had qualified off of the Medicaid rolls. 

That policy swelled the Medicaid population across the country and pushed down rates of uninsurance nationwide. But for the past eight months, states have been “unwinding” their Medicaid rolls, reviewing eligibility for all recipients — including those who became eligible during the pandemic — and disenrolling those who no longer qualify. 

North Carolina’s expansion will reverse that trend somewhat. 

More complete data from the first month of the measure should be released in mid-January.

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By Will Atwater

Vickie Mullins recalls a traumatic moment in her 8-year-old grandson’s life. 

She said the family, who live in Cumberland County’s Cedar Creek Township, near the Bladen County line, were visiting relatives in the mountains last summer when her grandson saw something that caused a visceral reaction. Mullins said that when his older brother grabbed a glass and went to the sink to fill it with water, the younger brother lost it.

“All of a sudden, he starts yelling, ‘Don’t turn on that water!’” Mullins said. “He was screaming, ‘You know we’re not allowed to drink water from a spigot!’” 

Mullins said she was crying as she bent down, hugged him and told him: “This is how normal people live.” 

Living under the shadow of contamination from per- and polyfluoroalkyl substances — also known as  PFAS or “forever chemicals” — has robbed Mullins’ grandchildren of some of life’s simple pleasures. 

“He’s always cried, wanting to take a bath, but we don’t let him […] How do you tell an 8-year-old that he can’t play in a bubble bath?”

There are thousands of the manmade chemicals known as PFAS in the environment, according to experts, and more are being discovered. The compounds are ubiquitous — found in such items as cosmetics, nonstick cookware, upholstery, water-resistant fabrics used in raincoats, umbrellas and tents, microwave popcorn wrappers and dental floss.

PFAS compounds accumulate in people’s bodies, and researchers have found evidence that suggests a link between PFAS exposure and weaker antibody responses against infections, elevated cholesterol levels, decreased fetal and infant growth, and kidney cancer in adults, among other problems.

What’s more, a study published in December 2023 found that children with prenatal exposure to two types of PFAS compounds — perfluorooctanoate (PFOA) and perfluorononanoate (PFNA) — were more likely to experience childhood obesity.

Consent order limitations

Mullin’s grandson was 3 in 2019 when Chemours, the North Carolina Department of Environmental Quality and Cape Fear River Watch established a consent order with the state and an environmental group consent order. The order requires Chemours to “address PFAS sources and contamination at the facility to prevent further impacts to air, soil, groundwater, and surface waters,’ according to N.C. DEQ.

But Dana Sargent, executive director of Cape Fear River Watch — the Wilmington-based environmental organization which was party to the consent order — argues that the mandate doesn’t go far enough.

Under the consent order, Chemours “is only testing for 12 PFAS,” she told an audience  gathered at Gaston Brewing in Fayetteville on Jan. 31 to view a screening of the WRAL documentary Forever Chemicals: North Carolina’s Toxic Tap Water.  

She added: “The consent order also required that this company conduct what’s called a non-targeted analysis to find what we don’t know. That analysis found 257 PFAS coming out of this facility, and they’re sampling for 12? It’s ridiculous!”

There’s growing momentum across the country to address the thousands of known PFAS as an entire class, according to a report released by Safer States, a national alliance of environmental health organizations that’s working to protect people and the environment from toxic chemicals.

One of the requirements mandated by the consent order is that Chemours test private drinking wells for PFAS contamination in Bladen, Cumberland, Robeson and Sampson counties, which are near the company’s Fayetteville Works. For those whose wells have 10 parts per trillion of PFAS, Chemours is required to provide “replacement drinking water supplies.” The options range from bottled water, to a water filtration system, or a connection to the public water supply if feasible.

A shaky water supply

The Mullins family well test revealed the PFAS contamination level was 14 ppt. As a result, the family has received 30 gallons of water bi-weekly per the consent order for five years — the majority of Mullins’ 8-year-old grandson’s life — Mullins said.

In the most recent Consent Order Progress Report, the company published that by the fourth quarter of 2023, 2,569 households were receiving bottled water in the “Fayetteville Counties area” because they qualify for “replacement drinking water actions.” However, many feel that the number does not reflect those whose well water contamination is below the 10 ppt threshold, residents who buy bottled water because they don’t trust the public water supply or those who suspect their wells are contaminated but haven’t been tested.

Recently, the Environmental Working Group, a nonpartisan environmental advocacy organization based in Washington, D.C., reported that the Environmental Protection Agency found that 70 million U.S. residents have drinking water that tested positive for PFAS. The advocacy organization reported that the “number is based on the latest test results from only one-third of public water supplies.”

The information is contained in the EPA’s Fifth Unregulated Contaminant Monitoring Rule report, mandated under the Safe Water Drinking Act, and was released earlier this month from tests conducted in 2023.

In 2020, the Environmental Working Group also reported that “more than 200 million Americans are served by water systems with PFOA or PFOS — two of the most notorious PFAS — in their drinking water at a concentration of 1 part per trillion, or higher.” 

Problems with plastic water bottles

As if life isn’t complicated enough for people like Mullins, a study published in January by Columbia and Rutgers University researchers found that a liter-sized plastic bottle of water contains about 240,000 nanoplastic particles. 

N.C. Health News has reported on the impact of microplastic pollution, including a study that suggests links between nanoplastic particles and a brain protein that may increase the risk for Parkinson’s disease and some forms of dementia. Microplastics can be as large as a pencil eraser or as small as a speck of dust. 

Nanoplastic particles are even smaller than microplastics, ranging in size from 1 nanometer (about half the width of a strand of DNA) to 1 micrometer (about the width of a typical bacterium). 

While there is no known link between microplastic ingestion and disease in humans, a study published in 2022 found that people with inflammatory bowel disease had more microplastic particles in their feces than healthy people. (Crohn’s disease and ulcerative colitis are two forms of IBD.)

Toxicologist Linda Birnbaum, former director of the National Institute of Environmental Health Sciences, said that while more research is needed, knowledge is growing when it comes to the impact of microplastics on the human body.

“We know enough now to know that the microplastics and the nanoplastics that we are using in everything are getting into us,” Birnbaum said. “And we know that the plastics often contain chemicals like PFAS, for example, or BPA, or phthalates that […] leach from the plastic and get into us. And we know that those have adverse effects.”

Could glass containers be the solution?

Beyond the risks microplastics pose to humans, not all plastics are recyclable and not all recycling programs are equal. In 2018, polyethylene terephthalate (PET), the plastic material used to make plastic water bottles, was recycled at a rate of 28.6 percent, according to a report   by the Environmental Protection Agency. That same year, plastic accounted for nearly 18.5 percent of municipal landfill waste. 

“The beverage sector is one of the most well-poised sectors to transition to reusable packaging — especially because many of the same companies selling Americans our drinks in disposables are selling them to the rest of the world in returnable, reusable containers,” said Sydney Harris, policy director for Upstream, a reuse advocacy group. 

Birnbaum agrees that having more glass and fewer plastic containers on the market would be better for the environment and human health, but she thinks it’s a tall task.

“We need to start tremendously reducing our use of plastics, but that’s going to be very hard in a society that is almost totally dependent upon plastics,” she said.

“The fastest way to bring about change very honestly is for [consumers] to speak. If people were to start saying, ‘I don’t want to buy water in plastic bottles; I don’t want to buy my Coke or Diet Coke in plastic bottles,’” she said, “that would have an impact, but I don’t see that [happening]. It’s too easy right now.”

“While we do want to see the beverage sector transition to returnable, reusable containers,” Harris said, “that will not relieve society of the responsibility to upgrade our water supply systems and ensure communities have access to safe drinking water from the tap.” 

Thinking about what she and her family have endured after discovering PFAS contamination in their well, Mullins said, “I want a normal life back for our family because this is ridiculous.”

Clarification: 

The text now reflects that the fourth number of people receiving bottled water is a total count to date rather than the count just in the fourth quarter.          

Also, the story now states that in addition to PFOA and PFOS, Chemours is only testing for 12 out of 257 PFAS coming out of the facility, according to Dana Sargent, who said she misspoke during a panel discussion when she stated the number the company was testing  for was 13.

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