In early 2022, the North Carolina General Assembly convened a non-standing Joint Legislative Oversight Committee in order to gather data and learn from state and national experts in health care access and Medicaid expansion. The Committee on Access to Healthcare and Medicaid Expansion convened six times from February to April 2022 and aimed to identify several key topic areas to inform the 2022 legislative session. These topic areas included:
Joint Legislative Oversight Committee on Access to Healthcare and Medicaid Expansion: Highlights
Health Care Workforce Development
Erin P. Fraher, director of the Program on Health Workforce Research & Policy and deputy director of the Cecil G. Sheps Center for Health Services Research at UNC-Chapel Hill, presented to the committee about NC Nursecast, a new interactive tool that allows users to access customized data by nurse type (RN/LPN) and geography (statewide, Medicaid regions, AHEC regions, and metro/non-metro). Dr. Fraher identified data on nursing shortages, driving factors for these shortages, and best practices in our state for recruiting and retaining a strong nursing workforce.
Hugh Tilson, director of North Carolina Area Health Education Center (NC AHEC), discussed the work of NC AHEC in developing and training the existing health care workforce. He also described NC AHEC’s Pandemic Health Care Workforce study, which provided data to illuminate the many ways that “health workforce shortages and maldistribution have been a persistent issue in North Carolina – and the COVID-19 pandemic made an already challenging situation worse.” Recommendations from this study included: ensure an adequate health care workforce for current and future health crises; address structural issues that impede the delivery of high-quality health care; evaluate and strengthen system-wide capacity for telehealth services; and enhance behavioral health services across the health care system. Tilson also discussed the need for a dedicated Center on the Workforce for Health to gather data and facilitate the identification of health workforce solutions.
Experiences with Medicaid Expansion in Other States
Hemi Tewarson, director of the National Academy for State Health Policy, reviewed North Carolina’s health and health system rankings; uninsurance rankings (overall and compared to states that have and have not expanded Medicaid); and national data on access to care, utilization, costs of care, behavioral health care, and health outcomes across expansion and non-expansion states. Key findings in health outcomes included: reduced overall mortality (including reduced overdose deaths and reduced infant and maternal mortality), improvement in cardiac surgery outcomes, and improvements in self-reported health and health behaviors. Tewarson also discussed economic impacts of Medicaid expansion, citing national studies showing a link between expansion and increased employment, increases in income, and decreases in income inequality for low-income individuals, also sharing that state-specific studies show significant job growth resulting from Medicaid expansion.
In later meetings, representatives from Ohio, Michigan, Indiana, and Montana discussed their states’ experiences with Medicaid expansion:
David C. Smith presented on the Marketplace voucher alternative to Medicaid expansion, encouraging the Committee to learn from examples of other states where individuals and families purchase coverage through the ACA Marketplace in lieu of expanding enrollment in the state’s Medicaid system. Smith argued that this solution allows for closing the coverage gap without needing to expand Medicaid.
North Carolina Experiences with Medicaid Managed Care
Peter T. Daniel, executive director of the North Carolina Association of Health Plans, provided an update on North Carolina’s Medicaid transformation, specifically the launch in mid-2021 of Medicaid managed care. Daniel reviewed the establishing legislation for Medicaid transformation, the five prepaid health plans and Medicaid regions, covered benefits, and early results and experiences with the move to Medicaid managed care. Highlights of early results include all health plans meeting network adequacy requirements in all regions and early technical challenges with billing codes being addressed quickly at NCDHHS and across all health plans.
Rural North Carolina
Patrick Woodie, director of the North Carolina Rural Center, discussed the potential impact of Medicaid expansion on rural North Carolina. Woodie presented data on the numbers of uninsured adults in rural NC counties and the ways in which closing the coverage gap could boost economic development, support small businesses, and improve health care delivery in rural areas.
Casey Cooper, CEO of the Cherokee Indian Hospital Authority, discussed Western North Carolina, the structure of and funding for the Indian Health Service, health outcomes and disparities within North Carolina’s American Indian populations, and the ways in which expanding Medicaid could impact health outcomes and economic stability. Cooper also discussed the Indian 100% FMAP rule, under which states are eligible for 100% federal medical assistance percentage reimbursement for Medicaid services that are received through the Indian Health Service or tribally recognized programs, including services by non-IHS providers with the proper care coordination agreements.
Access and Policy for Telehealth Services
Several state experts also presented data on telehealth services to the committee. Scott Rissmiller of Atrium Health discussed telehealth services including school-based virtual health and virtual integrated behavioral health services and the accompanying outcomes of these services. Josh Archambault, senior fellow at the Cicero Institute and president of Presidents Lane Consulting, presented best practices on providing telehealth services across state lines, noting that since the start of the COVID-19 pandemic, support has grown for interstate telehealth services among both patients and providers. Other speakers discussed the health insurance mandate for telehealth services, telehealth licensure reciprocity, and telehealth interstate licensure reforms.
Full Practice Authority
The March 29 meeting of the committee was dedicated solely to discussions on the SAVE Act and full practice authority across several provider types, including advanced practice registered nurses, certified nurse-midwives, certified registered nurse anesthetists, and nurse practitioners. Winifred Quinn spoke from the AARP Policy Center about the consumer side of full practice authority, presenting the argument that full practice authority improves access to care and quality of care for patients and families. Karen Smith, a family physician, spoke about the necessity of collaborative physician-guided care teams and presented data showing that expanding full practice authority may not result in improved access to care or additional providers in rural areas.
Certificate of Need
On April 11, the committee focused on discussions of North Carolina’s certificate of need law, which prohibits health care facilities from adding, acquiring, or replacing health care facilities or equipment without prior authorization by the state Department of Health and Human Services (see NCIOM blog post explainer on certificate of need here). Matt Mitchell, senior research fellow at the Mercatus Center at George Mason University, presented data comparing access, cost, and outcomes of care in states with and states without certificate of need laws. Brian Floyd, COO of Vidant Health Hospitals, presented about the role of certificate of need laws in maintaining and improving access to care in rural areas.
As the 2022 session of the North Carolina General Assembly approaches, committee members have thoughtfully examined data to inform their decisions on potential legislative approaches to improving access to health care. These decisions will have a broad impact on health policy across North Carolina, and on the health and well-being of the state.