COVID-19, public health

As state nears 25,000 COVID-19 cases, rural NC infection rates are the highest

On Monday, North Carolina reported 24,000 positive COVID-19 cases. Twenty percent of those infections are in the state’s two most populous counties, Mecklenburg (3,403) and Wake (1,478). The country and the state have focused a lot of attention on the virus’s rapid spread in population-dense and urban spaces. This framing, coupled with an initial lack of testing, has created the perception that rural North Carolina has not experienced COVID-19 like the rest of the country.

This is untrue.

In the North Carolina context, it appears that the rural counties have been harder hit. By examining COVID-19 infection and death rates instead of solely infection and death counts, one is able to scale impact relative to county population.  Once viewed through this context, the conclusions change.

The state rate of COVID-19 infections is 229 per 100,000, while the crude death rate is 7.5 per 100,000. Counties classified as rural by the NC Rural Center’s methodology show an infection rate of 257 per 100,000 and a death rate of 8 per 100,000. For comparisons sake, urban/ suburban counties have an infection rate of 204 per 100,000 and a death rate of 7 per 100,000.[1]

While these rate differences are not extreme, several hot spots in rural North Carolina are cause for concern. Duplin and Wayne counties lead the state with 1,121 and 837 COVID-19 cases per 100,000 people.

In terms of crude death rate (deaths per 100,000), Northampton and Vance counties lead the state with 62 and 40 deaths per 100,000, respectively.

These are all rural counties, but the trend does not stop there.[2] The 15 counties with the highest COVID-19 infection rate are rural, and 18 of 20 counties with the highest COVID-19 death rates are also designated as rural.[3]

There are several reasons that rural North Carolina is ill-positioned to respond to a pandemic. After North Carolina refused to expand Medicaid, seven rural hospitals closed, leaving 17 counties without a state-licensed facility.[4]

These same rural counties generally have higher rates of uninsured, making it less likely that people get treated for any disease, let alone COVID-19. Duplin, Greene, Swain, Sampson, Graham and Robeson counties lead the state in the percentage of county population uninsured, further complicating efforts to reduce the cases and spread of COVID-19 infections.[5]

A potential contributor to NC COVID-19 infections in rural North Carolina are occupational trends — how people work in community. In places where economies without a significant number of highly skilled jobs, meat processing plants offer many residents the opportunity to earn a steady income and stability. However, in a pandemic, the close nature of meat processing work creates a liability for the workers, their families and entire communities.

While one would offer caution in arguing that a scientific relationship exists between communities with meat processing plants and COVID-19 infection rates, policymakers should be aware of potential impact.

Last week, NCDHHS announced that 13 counties had meat processing plants with COVID-19 outbreaks.[6] Twelve of the 13 counties are considered rural.

After mapping these communities and the percentage of the county workforce employed in production jobs, four rural county clusters emerge as plausible connections between the concentration of meat processing plants and higher rates of infection per 100,000.

Cluster 1 — Duplin, Sampson, Wayne, Wilson, Lenoir, and Greene
Cluster 2 — Bertie, Northampton, and Halifax
Cluster 3 — Chatham and Lee
Cluster 4 — Wilkes, Surry, and Yadkin. [7]

As the number of COVID-19 cases climb toward 25,000, let us not lose focus on the particular pain rural communities in North Carolina are experiencing. All it takes is a deeper look.

William Munn is a policy analyst with the North Carolina Justice Center’s Health Advocacy Project.

[1] Internal analysis from NCDHHS COVID-19 Dashboard data

[2] Internal analysis from NCDHHS COVID-19 Dashboard data

[3] NCDHHS Dashboard

[4] “A triple disaster: Uninsured, living far from a hospital, and sick with COVID-19”, Lisa Sorg, NC Policy Watch – https://bit.ly/2V1uTaY

[5] Small Area Health Insurance Estimates – https://www.census.gov/data-tools/demo/sahie/#/

6] “N.C. has 23 meat processing plants with COVID-19 outbreaks, more than 1,300 cases” WBTV 3 – https://www.wbtv.com/2020/05/12/nc-has-meat-processing-plants-with-covid-outbreaks-more-than-cases/

[7] Internal analysis from NCDHHS COVID-19 Dashboard data

 

Commentary, COVID-19

Report: uninsured rate will soar in states that have not expanded Medicaid

Percentage of newly unemployed to lose insurance in states like NC will be almost twice the rate of Medicaid expansion states

Between March 15 and April 25, more than 30 million American workers lost their jobs during the economic slowdown caused by COVID-19. [1]

More than a million of those workers are from North Carolina, and while talks of reopening businesses ramp up, there is much uncertainty around how quickly many employees will be rehired or find new jobs. With the occupational environment in a state of flux, some economists predict that the jobless rate could reach 30%. [2] Since most health insurance coverage is tied to employment, such stark job losses are having an enormous impact on North Carolinians’ ability to access health care.

Earlier this month, the Urban Institute and the Robert Wood Johnson Foundation published a report highlighting this issue in very precise and quantitative terms. [3] The authors employed a model that predicted the loss of employer-sponsored health insurance under three national unemployment rate scenarios: 15%, 20% and 25%. While many of the newly unemployed will become eligible for Medicaid or Marketplace coverage with federal subsidies (financial help),  a number of Americans will become uninsured.

In states that have refused to expand Medicaid, the percentage of newly unemployed becoming uninsured is much higher than states that chose to expand Medicaid. The model revealed that in expansion states of the 11.6 million losing employer-sponsored health insurance, 2.6 million or 23% would find themselves uninsured.

In non-expansion states like North Carolina, of the 6 million who have lost employer-sponsored health insurance, 2.4 million, or 40%, could find themselves uninsured. The visualization below illustrates how states measure up when considering ESI loss population eligible for Medicaid and those from the same group now projected to be uninsured.

The decision to refuse to expand Medicaid in North Carolina has had numerous negative implications such as rural hospital closures, the burden of needless uncompensated care, an over-reliance on emergency rooms as primary care facilities, as well as preventing more than 500,000 people from access to quality health coverage. [4]
With the loss of more than 1 million jobs and an estimated 550,000 employer-sponsored health insurance plans, one would think that Senate Leader Phil Berger would consider Medicaid expansion as good policy for North Carolinians. While Berger’s press conference yesterday certainly does not engender confidence that he will change his mind, it is possible that this report’s findings showing North Carolina adding 240,000 to the coverage gap might do so. [5]

Read the report here.

[1] U.S. Department of Labor. News Release: Unemployment Insurance Weekly Claims. Washington: U.S. Department of Labor; 2020. https://www.dol.gov/ui/data.pdf.

[2] Matthews S. U.S. unemployment rate may soar to 30%, Fed’s Bullard says. Bloomberg. March 22, 2020. https://www.bloomberg.com/news/articles/2020-03-22/fed-s- bullard-says-u-s-jobless-rate-may-soar-to-30-in-2q.

[3] How the COVID-19 Recession Could Affect Health Insurance Coverage – https://www.urban.org/research/publication/how-covid-19-recession-could-affect-health-insurance-coverage/view/full_report

[4] Ku L, Bruen B, Brantley E. The Economic and Employment Benefits of Expanding Medicaid in North Carolina: June 2019 Update. Washington, DC: Center for Health Policy Research, The George Washington University; 2019. http://www.ncpolicywatch.com/wp-content/uploads/2019/06/Expanding-Medicaid-in-North-Carolina-final.pdf.

[5]  Under 20 percent unemployment scenario

William Munn is Policy Analyst with the N.C. Justice Center’s Health Advocacy Project.

Commentary, COVID-19

Report: African Americans are contracting and dying from COVID-19 at higher rates. We know why.

[Editor’s note: The following is the executive summary from an important new report on the impacts of the COVID-19 pandemic that was released last week by the North Carolina Justice Center’s Health Advocacy Project. Click here to explore the full report.]

African Americans are disproportionately contracting and dying from COVID-19.

  • Data from states such as Michigan, Illinois, New York, Alabama and Louisiana show that the percentage of African Americans who have been diagnosed with and died from COVID-19 is considerably higher than their representation as a percentage of the population.
  • If current trends hold, 162 African Americans will die from COVID-19 in North Carolina—70 more than would be expected to die based solely on the state’s demographic makeup.

Historical discriminatory policies and practices, as well as the nation’s failure to value its “essential workers,” have put African Americans at greater risk.

  • African Americans are more likely than white Americans to work jobs — even multiple jobs — that do not offer health insurance. Many of these workers fall into the “coverage gap,” meaning they earn too much to qualify for Medicaid and too little to qualify for financial assistance under the Affordable Care Act.
  • African Americans are overrepresented in occupations now deemed essential to the well-being of the nation, such as food service, food production, home health care and nursing home care. These jobs put the people who work them at higher risk for contracting the coronavirus.
  • Neighborhoods and counties with high populations of people of color have fewer health care providers and grocery stores, as well as lower air and water quality due to the legacy of environmental discrimination. As a result, African Americans have a higher rate of conditions that make COVID-19 more deadly, such as diabetes, chronic lung disease and hypertension.

State lawmakers should immediately approve Medicaid expansion, which would reduce African American deaths from COVID-19 and long-term measures to improve the health of African American individuals and communities.

  • Approving Medicaid expansion is the most impactful step North Carolina lawmakers can take to both protect African Americans from the lethal effects of COVID-19 and improve the health and resiliency of African American communities, making them better able to combat this and future outbreaks.
  • Expanding Medicaid would provide a much-needed financial boost to rural hospitals, which currently face high costs for uncompensated care, and improve the health outcomes of rural communities.

Click here to explore the full report.

NC Budget and Tax Center

New data: Economy continues to leave rural areas behind

While much attention is being paid to the September national and state unemployment rates of 3.3 percent and 3.5 percent, one risks overlooking serious regional challenges that undermine the broader prosperity of North Carolina as a whole. September’s local and metropolitan labor market report revealed that 77 counties in North Carolina with unemployment rates the same or higher than September 2018, 51 counties with rates higher than the state unadjusted average, and 42 counties that have lost jobs since December of 2007.

Rural, eastern North Carolina is over-represented in this group of economically distressed communities. In fact, 26 of the 42 counties that have lost jobs since the beginning of the Great Recession are from these county groupings. The northeastern part of the state is host to a group of counties – Vance, Warren, Halifax, Edgecombe, Wilson, and Hyde – whose unemployment rates are all nearly 2 percentage points higher than the state’s September average. Also, counties on the state’s southeastern border with South Carolina – including Richmond, Scotland, Hoke, Cumberland, Robeson, Bladen, Columbus, and Brunswick counties – all have jobless rates at least one percentage point higher than the state average.  

In addition to the state’s highest regional concentration of high unemployment, eastern NC counties make up 26 of the 42 counties that have lost jobs since the beginning of the Great Recession. Three of the four are “Double whammy” counties: those that have jobs since December of 2007 and year-over-year are in the eastern part of the state. Martin, Vance, and Washington counties have lost nearly 6,500 jobs since the beginning of the Great Recession, a loss of 18 percent of the nearly 36,000 jobs combined from 12 years ago.

As the end of 2019 approaches there is no question that after 12 years the state has not recovered equitably. Too much of rural North Carolina is mired in economic distress that is not happening in many urban spaces. This imbalance leaves the entire state, and particularly rural communities, exposed to collective harm caused by natural disasters and economic downturns.

Will Munn is a Policy Analyst at the N.C. Budget and Tax Center.

Falling Behind in NC, NC Budget and Tax Center

Starved of capital, small businesses in rural NC are fading away

Roanoke Riverwalk along Plymouth, NC photo credit: J Stephen Conn via Flickr

Along the Roanoke River, economic developers and policymakers in Martin County were not strategically planning a pitch to land Amazon’s HQ, nor were they particularly confident that they could lure Apple to the quaint streets of Williamston. Local leaders have long embraced the fact that their economies depended not on the big splash of major retailers, but the formation, retention, and expansion of small businesses. It is in this context that the NC Rural Center’s report on Small Business Dynamism in North Carolina, detailing the long term decline of business formation in rural North Carolina, is particularly distressing.

In an effort to grasp the implications of a slower recovery in rural North Carolina, the report reveals that “dynamism” — defined as economic vitality spurred by new firm creation, increased employment growth, wage growth, and labor mobility — has faded steadily outside of urban and suburban counties. According to the NC Rural Center, between 2005 and 2015 rural counties have lost 4,289, or 7 percent, of their very small firms. These, according to the center’s definition, are firms with less than 10 employees — the heart and soul of economies like Martin County. This is starkly different than the increase urban counties saw during the same 10 years. The six core metro counties added 5,534 (+9%) firms with fewer than 10 employees. After the Great Recession, small businesses grew rapidly in urban counties, seeing an increase of 3,180 (+5%) firms with 10 employees or less, while rural counties lost 2,657 (-5%).

While the report argues that there are a number of potential reasons for the decline of businesses with fewer than 10 employees in rural NC, it identifies access to capital as a primary contributor. Access to capital is a vital part of any firm’s ability to “get started, keep going, and grow,” but particularly so for small firms. In an effort to explain the increasing scarcity of commercial lending, the report points to the loss of local bank branches (252 from 2010 to 2015), which hit rural North Carolina especially hard. The net reduction of five rural bank branch closures for every one urban closure has created a desperate shortage of commercial loan officers in places least positioned to withstand such a shock. These officers are best situated to understand the nuances of the local market and work directly with rural small business communities to provide financing tailored to fit their needs.

Predictably, lending declines emerged. The report revealed that from 2005 to 2010, rural small business lending decreased by 53 percent, or $1.4 billion dollars, in North Carolina. In the five years after the Great Recession (2010 -2015), urban counties only saw a 1 percent decrease in small business lending. However, rural counties continued to experience steep declines, a loss of $218 million dollars, or 17 percent. Rural Eastern N.C. business communities faced the economic shocks brought by hurricanes Matthew (2016) and Florence (2018), starved of capital for the past decade. Innovative minds in rural Western N.C. are finding it difficult to finance the transition of old manufacturing operations to ventures suited for their community and a 21st-century economy.

This report offers undeniable evidence that a “tax cut only” policy will not provide the support necessary to reverse the trends that are undermining the formation, growth, and retention of small businesses throughout rural North Carolina. Special attention needs to be devoted to solving the challenges around access to capital so that the state’s brightest minds and ideas can prosper in their beloved communities.

Read the report here.