By Jaymie Baxley, Anne Blythe, Rachel Crumpler, Jennifer Fernandez, Rose Hoban and Taylor Knopf

For hundreds of thousands of North Carolina residents, 2023 will be the year the state finally expanded Medicaid and gave them access to health care that had eluded them for more than a decade.

Much more was going on in the health care world in 2023, as North Carolina Health News focused on in its reporting over the past 12 months.

There were issues that affected the growing population of people 65 and older. Mental health initiatives got more funding with new federal incentive money for expanding Medicaid. Legalization of medical marijuana seemed to have a moment until it got caught up in budget negotiations that nixed any new laws for 2023.

NC Health News readers homed in on these and other stories over the past year.

Many of these themes will continue into the coming year, so we’ve developed synopses to help refresh your memory about a small portion of our reporting from 2023.

Cooper pushes major aging plan

The number of people in North Carolina who are 65 and older is expected to grow significantly over the next decade, and aging advocates and others say new statewide strategies are needed to deal with the demographic shift.

There could be a more prominent need for assisted living and adult day care — and for an effort to alleviate the costs of social and medical interventions that often wreak havoc on families’ finances for the 1.8 million people older than 65.

In 78 of North Carolina’s 100 counties, the older population is projected to increase. Wake and Mecklenburg counties, urban areas with an array of health care facilities and other attractive amenities, could feel a disproportionate impact from the new wave of older adults, according to the North Carolina Office of State Budget and Management.

Gov. Roy Cooper issued an executive order in May for a “whole-of-government approach” to build a state that’s friendly to an aging population. In only seven years — for the first time ever — there will be more older adults than children in North Carolina.

With that, Cooper heralded “All Ages, All Stages NC: A Roadmap for Aging and Living Well.”

By 2031, one in five North Carolinians will be older than 65, according to demographers, and there will be more people over the age of 65 than 17 and younger. Alzheimer’s Disease and dementia diagnoses are expected to rise to 400,000 in only two years, according to Cooper’s executive order.

“We know that there is a critical shortage right now to look after seniors and to make sure they receive the direct care that they need,” Cooper said.

2024 is an election year. State-imposed term limits mean that it will be Cooper’s final year as governor. Any state-supported aging plan released next year will need buy-in from North Carolina lawmakers, who control the budgetary purse strings, and the next governor.

— Anne Blythe

Medical marijuana remains a hot topic of debate — and disagreement — in the state legislature  

State lawmakers have been divided for years over whether to allow the legal use of cannabis — and even hemp products. They had another round of debate over the issue during this year’s legislative session. 

Powerful Senate Rules Committee chair Bill Rabon (R-Southport), a colon cancer survivor, has been pushing for several years to legalize the medical use of marijuana. This year he spoke in detail publicly about his use of the substance during chemotherapy treatments. Meanwhile, many conservative members of the House of Representatives object to any form of legalization. 

Those members brought people who claimed they or their family members were injured in traffic incidents by drivers impaired from smoking or ingesting marijuana to speak at a public hearing of Rabon’s Compassionate Care Act. The bill, if it had been enacted, would have allowed for limited use of medical marijuana for a handful of diagnoses.

Rabon’s bill made it through the Senate but hit a dead end when it reached the House of Representatives. 

Meanwhile, members of the House proposed a bill that would crack down on the presence of delta-8 tetrahydrocannabinol (THC), a psychoactive element present in small quantities in legal hemp. 

The North Carolina 2018 Farm Bill made it legal to grow and sell hemp so long as the plant has a concentration of delta-9 THC of less than 0.3 percent on a dry weight basis.

Hemp product manufacturers soon realized that definition meant that they could sell products containing delta-8 THC, delta-10 THC and even delta-9 THC, so long as the concentration falls under the legal limit. Some manufacturers have exploited that loophole to sell that in multiple products that allow users to get high.

Several members of the House have championed House Bill 563, which would put an end to what they call the “Wild West” of hemp products. That bill passed the House and was sent to the Senate, where it is likely to languish as members of the two chambers negotiate over a way forward.  

— Rose Hoban

Medicaid expansion

In December, North Carolina became the 40th state to expand access to Medicaid under the Affordable Care Act, making more than a half million low-income residents eligible for health insurance.

Expansion came after more than a decade of resistance from Republicans in the General Assembly. The promise this year of $1.8 billion in federal financial incentives nudged the state’s GOP leadership to reconsider, allowing the measure to finally move forward with bipartisan support.

Gov. Roy Cooper signed expansion into law on March 27, but one last hurdle remained: The law contained a provision requiring the General Assembly to enact a state budget before expansion could actually take effect. 

Budget negotiations dragged on through the summer, forcing the N.C. Department of Health and Human Services to postpone its planned October rollout for expansion.

As lawmakers debated the budget, existing Medicaid participants lost coverage en masse. A federal mandate that prevented states from kicking beneficiaries off the rolls during the first three years of the COVID-19 pandemic expired in April, allowing North Carolina to resume regular eligibility checks for the first time since March 2020.

From June to November of this year, more than 22,000 North Carolinians were deemed ineligible for Medicaid based on the state’s pre-expansion criteria. Many of these people would have continued to qualify for coverage had expansion not been delayed.

The budget impasse finally ended in late September, with both chambers of the legislature agreeing to move forward with an almost $30 billion spending plan. While Cooper was strongly opposed to several aspects of the budget, he let it become law without his signature to avoid further delaying expansion. 

The state officially implemented expansion on Dec. 1. About 273,000 people participating in Family Planning Medicaid, a limited-coverage program for reproductive health services, were automatically upgraded to full coverage. An additional 300,000 adults whose incomes are within 138 percent of the federal poverty level will eventually be added to the rolls, according to DHHS. 

“This is a historic moment that will change North Carolina for the better, improving the health of our people and the health of our economy,” Kody Kinsley, head of DHHS, said after expansion launched. “It is the most significant investment in health care in North Carolina’s history.”

— Jaymie Baxley

What’s Blue Cross Blue Shield NC up to?

In the spring, legislators introduced a bill that would change regulations and allow Blue Cross Blue Shield of North Carolina to create a holding company that would become the corporate parent for the insurer and any for-profit subsidiaries. In speaking about the bill, company lobbyists argued that regulations were slowing the company down in a fast-paced competitive business environment. 

But immediately, the proposal raised hackles with state Insurance Commissioner Mike Causey, state Treasurer Dale Folwell and lawmakers on both sides of the aisle, as well as many health care and consumer advocates across the state.

By early 2023, BCBSNC had a reserve topping $7 billion. The company, which has been a not-for-profit since its founding in the 1930s, has paid corporate taxes since at least the mid-1980s, but it has also amassed capital in a nonprofit environment. 

In the 1990s, the legislature passed statutes that would require BCBSNC, if the company ever chose to convert to a for-profit status, to create a mechanism to give back the assets it had amassed tax-free. This could take the form of a charitable foundation to address health needs in the state, similar to how the Dogwood Health Trust was created when Asheville’s nonprofit Mission Hospital was sold to the for-profit HCA.

In an interview with NC Health News, company CFO Mitch Perry put the company’s “statutory capital” at around $4.7 billion, money that could potentially move to the holding company. But he also said at the time that he couldn’t quote an estimate of the company’s fair market value.

It was this potential transfer of funds that was the crux of the conflict at the legislature over whether to allow the regulatory changes to move forward. The conflict played out in an insurance environment where consolidation has created larger national insurance entities that wield increasing leverage over health care providers. And while Blue Cross NC is a big player in North Carolina, with as much as 80 percent of the state’s group health insurance market, it’s a relatively small player when compared to behemoth national insurers such as UnitedHealthcare or Aetna.

Lobbying activity around the bill was intense at the legislature, with BCBSNC staffing up to 14 people representing the company at the capitol, while consumer advocates worked the phones and hallways to stop the bill from moving forward. The advocates found a vocal ally in Causey, but in the end, he was unable to stop the company’s momentum.

After Blue Cross NC made some concessions, legislators overwhelmingly passed House Bill 346, allowing the company to move ahead with creating a holding company. In October, Blue Cross NC reached an agreement with the Raleigh-based urgent care provider FastMed to acquire that company’s North Carolina clinics. Blue Cross NC has been a minority investor in FastMed since 2012. 

The terms of that deal were not made public.

— Rose Hoban

Psychiatric hospital failed to provide a safe and therapeutic environment

Earlier this year, after a series of visits to the facility, federal regulators threatened to terminate Medicare funding to a psychiatric hospital in eastern North Carolina. The controversy started with a complaint alleging mistreatment and sexual assault of an 11-year-old patient. 

State regulators made a surprise visit to Brynn Marr Hospital, a privately owned facility in Jacksonville, after a joint news report published by NC Health News/ News & Observer/ Charlotte Observer detailing the alleged mistreatment and assault of the child placed in their care. Among other violations, state regulators substantiated the claims that the hospital “staff failed to supervise to provide a safe and therapeutic environment for behavioral health patients” and “failed to ensure daily visits from a psychiatrist.”

State and federal regulators conducted on-site investigations at Brynn Marr in December, January, February and March. In February, regulators put the hospital under “immediate jeopardy” after they determined that an adolescent patient had escaped the facility. Immediate jeopardy is the most severe citation a hospital can receive from federal regulators, and it indicates that serious injury, harm, impairment or death has occurred or is likely to occur to one or more patients, and immediate action is necessary.

The hospital was instructed to make changes to get back in compliance by June 2 or its ability to bill federally funded programs would be terminated. According to a spokesperson with the Department of Health and Human Services, the hospital did take the necessary actions before the deadline. 

“The last visit to Brynn Marr Hospital on May 25 found no deficiencies and found evidence the hospital was substantially complying with the federal rules/regulations with regard to which they had been found to be noncompliant during the previous visits,” a department spokesperson said in an emailed statement in December. “In other words, Brynn Marr has made the necessary changes to resolve the substantiated investigation findings and their IJ [Immediate Jeopardy] status.” 

DHHS also provided NC Health News with a copy of Brynn Marr’s plan of correction, which details the training and safety measures the hospital put in place as a result of the investigation. 

— Taylor Knopf

Changes for young drivers

Teen drivers no longer have to practice for a year before getting a limited provisional license, thanks to a law change approved last year by the General Assembly that takes effect on Jan. 1.

Now, teens must only be supervised for nine months before being able to advance to a limited provisional license, the second level of the state’s graduated driver’s license program.

During the COVID-19 pandemic, that time period was reduced to six months through 2022, and then until the end of 2023, to help tackle a backlog of young drivers waiting to take the mandatory road test. The backlog was created by the pandemic, when in-person contact was curtailed, and then got worse because of a shortage of workers available to teach the behind-the-wheel portion of driver’s ed.

Another change in the law, which took effect last August, allows teens who’ve moved to the limited provisional license stage — where they no longer must have a fully licensed driver supervising them — to ferry a second passenger under age 21 as long as they are only going to and from school. 

Child health advocates and driver’s education officials point to data from other states showing that the added distraction of another passenger and the reduced driving practice will lead to more accidents for young drivers.

Mike Chappell previously told NC Health News he saw a big difference once the state passed the graduated driver’s license law in 1997 when he was a driver’s ed teacher.

“It was a big relief to me because I knew then the kid was going to get six hours with me … but the parent had them for a year,” said Chappell, human resources director for Jordan Driving School in Garner, which provides the driver education classes for Wake County Public Schools.

After North Carolina switched to its graduated driver’s license program in 1998, crashes involving 16-year-old drivers declined by 38 percent, according to data collected by the UNC Highway Safety Research Center. Fatal and serious injury crashes declined by 46 percent.

There’s no data on the effects of shifting from a 12-month learning period to a nine-month period.

“The main reason teens crash is because they’re inexperienced,” Natalie O’Brien, a senior research associate with the UNC Highway Safety Research Center, told NC Health News before the law change. “It’s just a dangerous thing. It’s a complicated task to learn. Trying to learn to be a master at something can’t be compressed.”

— Jennifer Fernandez

Advanced practice registered nurses fight for more independence

For more than a decade, advanced practice registered nurses in North Carolina have pushed for more independence in their practice. For just as long, doctors have fought against granting it, arguing that supervision improves patient safety.

For a brief period, it looked like the balance could finally change this year — that advanced practice nurses might gain their long-sought independence as part of Medicaid expansion. 

That’s because the Senate originally included scope of practice changes for more highly trained nurse practitioners, nurse anesthetists and nurse-midwives as part of its Medicaid expansion proposal. However, the House rejected that idea, and the language was ultimately left out of the milestone Medicaid expansion deal reached in March between the two chambers. 

Nurses remain undeterred in lobbying to change what they say is a mind-boggling supervision requirement. For many nurses, the supervision translates into as few as two meetings a year with a supervising physician, who may not even be in the same county or state. Many advanced practice nurses note they pay fees of as much as $1,000/month for the supervision that allows them to work in their chosen profession.

To gain the greater autonomy that dozens of other states already allow, advanced practice nurses are rallying support behind a separate bill: the SAVE Act. The legislation has been introduced in every legislative session since 2015, and this year, the bill had 59 sponsors in the House and 21 sponsors in the Senate. Senate leader Phil Berger (R-Eden) — one of the most powerful politicians in North Carolina — vocalized his support for the SAVE Act and the role advanced practice nurses can have in addressing provider shortages. 

Despite this, the bill did not move this year. That’s because powerful opposition remains, primarily from physicians and anesthesiologists, who want to maintain the status quo. 

More independence for a small group of advanced practice nurses came from an unexpected place this year — a provision inserted into the state’s 47-page abortion bill that removes the physician supervision requirement of certified-nurse midwives. 
Supporters hope it’s just the beginning for lawmakers enacting policy changes loosening restrictions to full practice authority in North Carolina for the more than 17,000 advanced practice registered nurses in the state.

— Rachel Crumpler

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