By Rose Hoban

When hundreds of North Carolina public health leaders met in a Raleigh hotel recently for an annual conference, they could not help but look back at this most extraordinary time in health care and incorporate lessons learned from the pandemic as they planned for the future.

One theme that emerged from the gathering of the state’s county health directors, medical directors and state workers was an old one: How long will North Carolina continue to leave billions of federal dollars out of state coffers by refusing to expand Medicaid?

That money, the conference participants said, could help free up state dollars to shore up the public health infrastructure and bolster behavioral health programs that will become more important.

Now, a week after the Public Health Leaders’ Conference, Republicans in the state Senate are circulating a draft omnibus health care bill that would expand Medicaid to hundreds of thousands of low-income adults while also making changes to health care laws that their party has been pushing for years.

The bill would also give advanced practice registered nurses more independence to care for patients without being directly supervised by physicians, which is likely to be controversial among the powerful medical lobby.

It was unclear when such a bill would be introduced.

Sen. Phil Berger, the Republican from Eden who has warmed to the idea of Medicaid expansion after being a roadblock for years, has seen the proposal, according to Lauren Horsch, the Senate leader’s spokesperson.

“Senate Republicans continue to have discussions about how to address the rising costs of health care and how to increase access in the state,” Horsch said during a phone interview with NC Health News on Monday.

Horsch declined to comment on whether Berger supported the bill.

Last week during the Public Health Leaders’ Conference, the first time the participants had gathered in person since March 2019, a road map for a better public health system was being drawn.

“I know these last two and a half years have felt like 20 and a half,” Kody Kinsley, secretary of the Department of Health and Human Services, told the crowd of about several hundred. “I know that your teams are tired. I’m so glad that we’re having the occasion to gather and be together, I hope that you will invest in time with each other.

“You all have been on the frontlines in so many ways you have been battle worn and tried and tired.” 

Big ticket promise

There was enthusiasm for new projects, but also recognition that even if a Medicaid expansion bill were introduced in the state Senate, there still could be some obstacles in the path of a possibility that’s been on the table since 2013.

“Over the last decade, we’ve been leaving about $4 billion on the table each year,” Kinsley said, citing the sum that would have flowed from federal to state coffers if the legislature had chosen to expand. 

This put the state behind the curve at the start of the pandemic, he argued, with North Carolina having as many as 1.2 million people lacking health insurance and a usual source of care. 

“You figure you have a million people who have no connection with a primary care provider, no experience in the health care system, the only place they know to go for care is the emergency department,” Kinsley said. “I always like to point out to people that when you tell someone who doesn’t have health insurance they should get tested, it’s free, you know, that’s not real, they don’t experience the healthcare system as free.”

Kinsley pointed out that expansion would do more than cover the costs of care for about 550,000 additional uninsured people. It also would help free up state dollars, the secretary added, particularly dollars that could be put toward behavioral health programs.

In addition, the Biden administration has dangled a one-time bonus to states that haven’t expanded as an inducement. North Carolina’s share of that money would be $1.5 billion.

“We could, essentially in one year, pull five and a half billion dollars down that would be so transformative to North Carolina for health care,” he said. 

Renewing the workforce

Recent reports on the record numbers of people dying from opioid overdoses highlighted the enormous public health needs that continued to simmer below the surface, even as they’ve been eclipsed by the more than 24,627 deaths from the pandemic. 

“We’ve got HIV up against us,” said Evelyn Foust, who leads the communicable disease branch of DHHS’s Division of Public Health. “I think just getting access to primary care is a huge challenge. And then, one more time we got into those real health equities we know are there.”

At the conference, where many of the attendees had heads full of gray hair, one of the biggest concerns was the driving need to recruit, train and retain the next generation of public health workers amid an exodus of older workers. 

Even before the pandemic, more than half of public health workers nationwide were over the age of 45, according to statistics from the National Association of County and City Health Officials. That was before the stress of the pandemic. 

In just the first year of the pandemic alone, more than half of public health leaders responding to a national survey said they experienced harassment and workplace violence, driving departures of experienced staff. 

“Constrained by poor infrastructure, politics, and the backlash of the public they aimed to protect, public health officials described grappling with personal and professional disillusionment, torn between what they felt they should do and their limited ability to pursue it,” wrote researchers from the Johns Hopkins Bloomberg School of Public Health. “For some, the conflict was untenable.”

Part of North Carolina’s response to helping recruit and retain new workers includes providing flexibility for people who have had to juggle multiple demands over the past two years.

“We can accommodate brilliance in the workplace while recognizing that people have child care issues, and they have issues in taking care of their adult families,” Foust said. “We can accommodate that, and still get really outstanding stuff done.”

Gov. Roy Cooper’s recent proposed budget has $45 million in health care workforce enhancement, and a new pipeline of $10 million specifically to beef up local health departments. 

Kinsley also talked about how public health workers need to take a rest. 

“This is a time to take some time off to pivot,” he said. “I want folks to invest in themselves. You’ve got to put your oxygen mask on before assisting others and take a breath. But then, you know, let’s be intentional about transitioning.”

Unsexy infrastructure

Early in the pandemic, former DHHS secretary Mandy Cohen talked about how the state was collecting information on hospital admissions and completed COVID tests via faxes sent to Raleigh by hospitals, medical labs and testing centers. Even as the pandemic raged, public health officials started streamlining communications, installing updated software and creating databases.