Commentary, public health

N.C. House budget underestimates funding needed for Medicaid

Budgeting for anticipated expenses is a key element to fiscal responsibility, just as ensuring that the tax code is adequate to meet those expenses and the needs in communities.

Unfortunately, the N.C. House of Representatives’ budget has failed to pursue this approach in the area of providing quality, affordable health insurance to low-income North Carolinians with disabilities, the elderly, children, and pregnant women.

The budget proposal they approved earlier this month introduced a Medicaid rebase nearly $40 million lower than the Governor’s budget. It also includes a management flexibility cut of $15 million that may result in the need for reductions in administrative oversight at a critical moment in the transformation of the Medicaid system in our state. Last year, the General Assembly underfunded the rebase by nearly $28 million.

While rebase adjustments are only cost estimates based on anticipated changes to enrollment, utilization, costs, rates, and more, there is no advantage to underestimating these costs and, in fact, it compromises the budget process altogether by failing to show the true expenses the state should be meeting.

In years past, inadequate rebase allocations have meant that the General Assembly has to come up with funds at a later date in order to make up the difference, leading to challenges when balancing the state’s budget with available revenue. This is because Medicaid is an entitlement program, meaning that people who apply and meet eligibility criteria are entitled to receive services.

November will also mark the start of North Carolina’s shift to Medicaid managed care, which will involve paying private insurance companies on a per member per month basis to manage the physical and behavioral health needs of those enrollees. While the thinking is that Medicaid transformation will create savings for the state, this expected net savings will take place over time, and it would therefore be prudent for state lawmakers to carefully allocate funds to this area.

Of course, there are also limitations in the state budget thanks to tax cuts introduced since 2013, which have severely limited North Carolina’s ability to generate revenue and invest in our state.

This year alone, the tax cuts that took effect in January resulted in $900 million loss to expected revenue for the upcoming fiscal year, and a current proposal in the Senate would be another blow to the state’s dwindling revenue, worsening the structural deficit.

Suzy Khachaturyan is a Policy Analyst at the Budget and Tax Center, a project of the North Carolina Justice Center.

News, public health

With the numbers of unvaccinated children on the rise, some pediatricians take a get tough approach

Here’s a startling statistic: North Carolina’s vaccination rate for toddlers has dropped by almost ten percent in the last few years. The data published in a story by North Carolina Health News on Wednesday, comes as the Centers for Disease Control and Prevention report a record number of measles cases hitting the U.S. this year.

Here’s more from reporter Sarah Ovaska-Few’s story:

Some pediatric practices around the state are sending a strong message to parents and guardians hesitant to vaccinate – immunize or find another doctor.

That’s the tactic that Scott St. Clair and his colleagues at Boone’s Blue Ridge Pediatric & Adolescent Medicine took in early 2015 when announcing the practice would no longer treat patients whose parents and guardians choose not to vaccinate for non-medical reasons.

The decision came after doctors at the Blue Ridge practice treated seven cases of pertussis, or whooping cough, the prior fall. They were concerned that having these sick patients in their waiting rooms put other children, unable to be vaccinated because of age or medical reasons, at great risk, St. Clair said.

Whooping cough, with an effective vaccine against it widely available since the 1940s, can be dangerous or even fatal for newborns who typically don’t get their first dose of immunization until two months of age.

“We felt like we were putting other families at risk,” St. Clair said.

The N.C. Pediatric Society doesn’t keep track of how many practices have adopted policies like that of the Boone clinic. But doctors around the state are looking for ways to make clear the life-saving importance of childhood immunizations, including policies that decline to treat unvaccinated children, said Elizabeth Hudgins, the N.C. Pediatric Society’s executive director.

“Vaccines are one of the greatest accomplishments of modern medicine,” Hudgins said.  “High immunization rates are how we protect communities.”

More skipping the shots

The numbers of unvaccinated or partially vaccinated children appear to be rising in the state, with data from the Centers for Disease Control and Prevention showing a concerning drop in overall vaccination rates for very young children.

More than 80 percent of North Carolina’s toddlers were up to date in 2014 on a series of seven vaccines recommended by the CDC and the American Academy of Pediatrics, a rate that exceeded national numbers by nine percentage points.

But North Carolina’s coverage rate dropped to 70.9 percent just three years later in 2017, according to the most recent data collected for the CDC’s annual National Immunization Survey of toddlers 19 to 35 months old. The survey is conducted by telephone, with researchers later confirming reports about immunizations with medical providers.

Source: NC Health News

North Carolina is now just slightly above the national average (70.9 percent of North Carolina toddlers versus 70.4 percent nationwide) for the combined seven-series of immunizations. The series of seven vaccines includes protections against diphtheria, tetanus and acellular pertussis (DTaP); polio; measles, mumps and rubella (MMR); hepatitis B; Hib (Haemophilus influenza B, which can cause bacterial meningitis); varicella (commonly known as chickenpox); and pneumococcal diseases (PSV).

The number of children without any vaccines is still small – 1.3 percent of U.S. toddlers born in 2015 – but much higher than it was in 2001, when only 0.3 percent of surveyed children reporting having no vaccines, according to a 2018 report from the CDC.

Zack Moore, N.C. Department of Health and Human Services’ state epidemiologist and a pediatrician by training, emphasized that the overall numbers of vaccination are high in North Carolina —a sign the majority of children are protected from preventable disease. But he also is concerned about the drop over the last three years.

Statewide numbers can mask a larger problem, he said, with pockets through the state with high numbers of unvaccinated children especially susceptible to outbreaks.

“People don’t get sick statewide, they get sick in their own individual communities,” Moore said.

Read the full story here at NC Health News, and be sure to check out their interactive map of North Carolina that details the county vaccination rates for kindergarteners in 2017-18.

Education, Environment, Legislature, public health

Bill would require schools, day cares to test for lead in drinking water

A new bill would appropriate $8 million in non-recurring funds for public schools and some day cares to test for lead in their drinking water, as well as providing alternate water supplies for buildings that exceed federal action levels for the chemical.

House Bill 386 would require all public schools, including public charters, and those day cares located in commercial buildings to test for lead in water used for drinking, including fountains and drink stations.

Schools and day cares where lead levels are 5 parts per billion or higher — the federal action level for drinking water — would then have to immediately shut off fixtures where the elevated concentrations were detected. In addition, the bill lays out requirements for public notification — no more than 48 hours to all parents, faculty and staff in the affected school, as well as those governing alternate water supplies.

Lead is a neurotoxin that can harm the central nervous system, particularly in children, whose brains are developing. Chronic exposure to elevated lead levels can lower IQ, cause learning disabilities, behavioral problems, nerve damage and possibly Alzheimer’s disease, Parkinson’s disease and schizophrenia, according to the peer-reviewed journal Environmental Health.

Last year, two school districts in North Carolina reported elevated lead levels at some of their facilities. In the Charlotte-Mecklenburg school district, 27 schools tested above the action level. 

In Guilford County, three schools — Allen Jay Elementary, Frazier Elementary and Southeast Guilford Middle — all had lead in drinking water above the EPA’s action level for schools: 20 ppb. HB 386 would require schools and daycares to adhere to a more stringent federal standard set for drinking water.

The district did replace the plumbing responsible for the lead but waited four months to notify principals and parents of the findings.

Elevated lead levels are often the result of old plumbing, which has leached the chemical into drinking water. Aging schools and commercial buildings that haven’t been renovated can be affected.

Data on the age of North Carolina public schools wasn’t immediate available, but the National Center for Education Statistics reported that about a third of all public schools in the US had plumbing systems in their permanent buildings that were rated either fair or poor.

The bill establishes water testing deadlines for schools, depending on the age of the building and when the plumbing had last (or ever) been completely removed and replaced. Schools whose plumbing is new or has been renovated after Dec. 31, 1990, are exempt, as are schools that already monitor for lead.

Schools constructed on or before Dec. 31, 1960, must test by June 30, 2021. Those constructed between Jan. 1, 1961, and Dec. 31, 1990, must test by June 30, 2022.

The $8 million appropriation would provide matching funds for districts based on need.

 

Commentary, Environment, public health

Duke University is killing regional light rail, while air pollution from cars kills people.

Archival photo of the Personal Rapid Transit, a tram line at Duke Medical Center, from Duke Today. The PRT operated from 1979 to 2009.

The irony is not lost on me, or many people, that the heart of the Duke Medical Center district — a congested stretch of Erwin Road, between Fulton and Trent streets — is hazardous to public health.

Put aside for the moment, the imminent physical peril that threatens bicyclists on those thoroughfares or pedestrians attempting to cross the streets, even if the walk sign assures them it’s safe to do so. The longer-term damage stems from the thousands of cars that pass by, that stack up 10 deep at the stoplights, that circle the dizzying mazes inside parking garages in search of a free space, that idle at valet parking or patient drop-off.

Air pollution from those thousands of tailpipes contribute to some of the very diseases and disorders that Duke doctors, nurses and researchers are trying to cure: asthma, heart disease, cancer, reduced lung function and premature death. MIT researchers estimated that in 2005 air pollution-related mortality shortened the average victim’s lifespan by 12 years.

There is a partial solution to this air pollution problem, or there was. Go Triangle’s 18-mile light rail line connecting NC Central University to downtown Durham, Duke University, Duke Medical Center, Chapel Hill and UNC Hospitals was supposed to dislodge people from their polluting cars and move them en masse to major education and employment centers with a lighter carbon footprint.

Now, though, Duke University, which for years supported the light-rail project, has suddenly refused to sign a cooperative agreement with GoTriangle that would allow the line to be built. Duke had planned to donate land for the rail line — in fact, the project aligns with university’s own climate change goals — but now university president Vincent Price is backing out.

In a letter to GoTriangle, Price cites as reasons construction vibrations and traffic disruptions, electrical frequency interference and possible power outages. (This is some weak sauce. Hospitals in major cities, like Johns Hopkins in Baltimore, connect to rail lines and subways.)

Here’s another example of why this rationale is disingenuous. Duke University and its Medical Center operated a rail line for 30 years. The cars rode on a “cushion of air” and were “propelled forward with the help of magnets.”
From a 2017 article in Duke Today:

For almost three decades, Personal Rapid Transit whisked patients, staff and visitors between the expanding hospital’s facilities at Duke South, Duke North and Parking Garage No. 2. It was taken out of service in 2009 and most of it was demolished to make way for the Duke Cancer Center and Duke Medicine Pavilion.

Surely the rail line’s demolition, in tandem with the construction and expansion of the Medical Center caused vibrations. Did new utility lines have to be run? Why yes.  And what of the magnets? Were MRI machines going haywire? Apparently not.

Mass transit is also key to offsetting the global damage from climate change. Transportation accounts for nearly a third of greenhouse gas emissions in North Carolina, according to the state’s recently published GHG inventory. Since the Trump administration is proposing to relax vehicle emissions standards, North Carolina’s decrease in tailpipe emissions — 12 percent from 2007 to 2015 — is in jeopardy.

Duke University’s own Climate Action Plan, published last November, advocates for enhanced public transit access, including “regional light rail, efficient bus routes, etc. that connect employees to Duke University.”

Nothing short of becoming its own city seems to align with Duke’s vision of civic duty. The university already strong-armed Durham into changing the route of the Bull City Connector, a free campus-to-downtown bus that ran every 15 to 20 minutes. The service was especially popular among low-income Durham residents — and moderate-income townies like myself.

But Duke argued that the timetable was insufficient for its employees and students. Thus, the university demanded that the BCC save time by bypassing the main transit center, the hub where people could transfer to the fare-free system. Durham caved to that demand, over much opposition from the Black community and its allies. Yet even that major route alteration didn’t satisfy Duke. The university withdrew funding for the route, and now it’s in jeopardy. And it still doesn’t stop at the main transit center.

Instead, Duke started a shuttle service — wait for it — with a stop next to the transit center that runs nearly the identical route as the BCC. But you must have a Duke ID to board the cocoon. Unencumbered by the hoi polloi, riders can be whisked to their destinations on a cushion of airs, propelled not forward, but backward — to a regressive, shortsighted, punitive transit policy. It’s bad not just for the patients, students and workers at Duke, but also the residents of Durham, and ultimately, the planet.

Commentary, Courts & the Law, Education, Environment, Higher Ed, News, public health

The week’s Top Stories on Policy Watch

1. In some North Carolina counties, traditional schools are being squeezed by charters

School buses prepare for another school year

There has been much written about the impact charter school growth has had on some of North Carolina’s larger, urban school districts.

But the impact might be greater on some of the state’s smaller, rural school districts where the loss of students, and the funding that follows them, are felt more profoundly.

Take Granville County Public Schools (GCS), a district of about 7,600 on the Virginia border.

This month the school board approved a plan to close an elementary school and to consolidate two middle schools, the result of lagging enrollment. [Read more…]

2. When will Republicans’ patience with President Trump run out?

 

Republicans, we need to talk.

Not about the shutdown. I get the ceasefire, I get that the air traffic slowdowns may have finally spooked the president and D.C. Republicans, even if only for a temporary respite.

This is about the bigger picture, not about short-term, beltway battles and shutdowns that may or may not be on the minds of Americans when they go to the polls in 2020 – although I don’t imagine the passage of time will sweeten the memory for Americans who worked weeks without paychecks.

This is about the future of the GOP platform, that grand-old-promise to shrink government, reduce inefficiencies, cut taxes, and preserve the American dream. [Read more…]

3. “The spill was an instant disaster”: Reflections on the five-year anniversary of the Dan River coal ash breach

Until that winter’s day, the 4-foot section of corrugated metal pipe, 48 inches in diameter, had done its job. It swallowed storm water, said to be uncontaminated, that drained from Duke Energy property, chugged the water through its gullet that ran beneath an unlined coal ash basin, and then spewed it into the Dan River near Eden.

But on Feb. 2, 2014, the pipe could take no more.

For more than 50 years, Duke Energy had dumped millions of tons of coal ash into an open, unlined pit at its power plant on the Dan River. On that calm, cloudy Sunday afternoon, as pre-gamers chilled beers and fried chicken wings for their Super Bowl parties, the pipe collapsed. Hazardous material from the basin rushed through the breach, which released at least 39,000 tons of ash and up to 27 million gallons of contaminated water into the Dan River.

At 2 o’clock, a security guard making the rounds had noticed the water level in the 27-acre ash pond had dropped.

At 6:30 p.m., thousands of North Carolinians watched the Seattle Seahawks, led by former NC State quarterback Russell Wilson, win the coin toss to start Super Bowl 48 against the Denver Broncos. Two minutes later, as the Seahawks kicked off, Duke Energy officials were investigating the pipe breach and preparing an EM43 report, used to document emergencies in North Carolina. [Read more…] Read more