NC Healthcare Reform: Family Voices

Previous health assessments of North Carolina parents, individuals, and families concluded that the intentional efforts to enhance the quality of healthcare will eliminate health care disparities for residents across the state. It remains to be seen if the apparent benign, yet still persistent gaps in healthcare continue under the new managed care system. One can only hope that the transition North Carolina Medicaid is about to make will address the majority of these issues. There is no cure-all program for the long-standing history of deliberate behaviors undermining equity in health care for low-income, disabled and minority North Carolinians. In a best-case scenario, a more effective change will occur when healthcare providers choose to give equal consideration to all patients.

North Carolina is moving towards the transformation of public health care into a regulated managed care system. The conversion is thought to take five years with the most significant changes occurring within the first year (July 2019 – June 2020). The central focus for the Department of Health and Human Services is to increase the quality of health care for North Carolinians by implementing whole-person centered care for both medical and non-medical related needs. The proposed transformation of the current public health care system looks good on paper, although there are certain aspects of data management and incentives that lend themselves to opportunistic gaps.

Many holes found in healthcare services are associated with the lack of appropriate health care for disabled citizens. There is an array of misdiagnosis and dummying down of communications under the presence of an intellectual disability or the apparent lack of ability to communicate with patients having intellectual impairments.  Also, it is  not uncommon for additional diagnosis to be included in medical records and implementation of treatment plans without full disclosure to the patient or patient caregiver. The comradery between medical supervisors and staff sometimes lends itself to ignoring the fact that the use of such strategies is availed at the whim of the provider. There are a host of unconventional methodologies that skirt realistic healthcare outcomes.  Will these instances be counted among the disparities thought to improve under the new healthcare plan? 

An even more frightening possibility is the potential for an increase in unconventional practices to achieve Pre Paid Health Plan (PHP) goals and incentives.

On the surface, we see the history of North Carolina’s commitment to measuring and improving the quality of outcomes for Medicaid and North Carolina Health Choice beneficiaries. It is by this history that the gauge for documenting the results of the upcoming transformation is set. And though improvements have been made in the quality of public healthcare, there is an undercurrent of deceptive practices which are scarcely noted. One such method is the perpetuation of the global disparity to treat low-income individuals and families as though they are not worthy of receiving better quality healthcare. As a means to correct this disparity, some areas create dual assessability clinics where private insurance care and  Medicaid care are available within the same building. There are no apparent differences between the two sides until patient check-in where the discriminative divide is more visible. In some instances, assumption muddles the line of discrimination, and the disparity goes relatively unnoticed. Under the covering of privilege, the gap is evidenced by the shameless whispers to privately insured patients who unwittingly wander into the Medicaid side of the clinic. 

There are quite a few instances where shameless whispers take place. These occurrences are part of an unwritten standard procedure. Determining factors for ignition of such systems are often based on socioeconomic status and/or marital status. 

“It is standard practice to leave out specific information while reporting to parents such as yourself based on the assumption of the parent’s inability to understand medical terminology. We do not want to alarm the parent unnecessarily. We commonly share what is pertinent and easily understood. It takes way too much time to come up with layman’s terms, otherwise. ”

“It’s a good thing you are married. If you were unmarried, the assumption would be that your baby is unwanted. Unmarried women are not given the option of being admitted into the hospital for services when miscarrying. They are only offered a D&C and sent home. Since you are married, it is assumed that your baby is wanted, and you are given the option of being admitted into the hospital and receiving full services during your miscarriage.”

Even though there is some knowledge of these standards, little has been done to correct this disparity.

Over the years a cliché of overviews and reports on health disparities point the finger of blame towards marginalized citizens. There are no indicators of the countless times low-income patients sought help and help was not there. Numerous out-patient phone calls requesting assistance are endlessly forwarded to voicemail. Prescriptions expire long before refills run out. Inquiries from pharmacies seeking refills or having questions about medications also go unanswered. For low-income, minority and disabled citizens getting assistance with straightforward needs often require additional doctor appointments. Having to make extra appointments is costly. Basic needs are not being met. Utterly defeated, disabled minority and low-income citizens are left to contend with medically-related tasks becoming too difficult to achieve. 

The question of whether public healthcare is providing quality care does not centrally rest upon the differences in the level of education and experience of health care providers or their bed-side manner. Many of these practices are permitted in low-income clinics, and medical staff usually coin such instances as acceptable when asked about the integrity of their actions. This sort of training is often downplayed and seldom ever addressed outside of the initial complaint.

As if there were not already enough to bare, another layer to the disparity  are reports by individuals and families being told by their pharmacist that Medicaid will not pay for higher cost prescriptions. Though approval for payment of these medications has been verified by the doctor's office, the pharmacist makes no motion to fill the order.

Changing the method of distributing healthcare in North Carolina is only a drop in the bucket. 

In the 2018 County Health Ranking Report for North Carolina, collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, identifies that the emergence of health disparities is when some groups of people have more access to opportunities and resources over their lifetime and across generations. They further recognize to achieve health equity means to reduce and ultimately eliminate unjust and avoidable differences related to health conditions, and resources needed for optimal health of marginalized groups. How is this accomplished? By creating an environment where all people are treated fairly. 

The age-old adage, “It takes a village,” can definitely be applied here. Who makes up the village: families, individuals, providers, educators, employers, political officials, and the institutions that govern? Bring all sides to the table facilitating partnerships, addressing the hard questions, and facing debilitating issues head-on to develop concrete solutions that will ensure equity in earning power, education, access to comparable housing, safer neighborhoods, better childcare programs, and all other necessary resources for productive outcomes. 

The desired outcome is for all North Carolinians to have not adequate, but equal access to knowledge and resources needed to make better choices. Changing our overall systems to decrease healthcare disparity will pave the way towards gaining and maintaining seamless whole-person health, wellness, and life-long care.  

The Robert Wood Johnson Foundation (RWJF) has collaborated with the University of Wisconsin Population Health Institute (UWPHI) to bring their program to cities, counties, and states across the nation. Significant changes in healthcare outcomes for lower-income Blacks have already been documented in several cities and counties. Kansas City officials identified a gap in life expectancy between the city’s Black and White populations. They took investigated data and came up with a plan that reduced the disparity in life expectancy from an 8-year gap to 6.9 years. Spartanburg County, SC, examined their data and found they had the worst teen birth rate in the state. Using a village approach, they came up with a plan that decreased teen birth rates by 50% from 2010 to 2016 for all 15 – 19-year-olds. Though the disparity of teen birthrates still exists, Spartanburg has managed to close the gap between teen births of Black and White females (in 2016, 23.3 per 1,000 and  23.9 per 1,000 respectively). 

Columbia George Region, OR/WA, Richmond VA, Chelsea MA, and Santa Monica CA to name a few, are communities that share in the belief of good health for all.

It is our hope that the North Carolina Healthcare reform will utilize these strategies and other best practices.  We want healthcare that eliminates stereotypes and the stigmas of ableism, classism and racism. A system that is equitable, respectful and collaborative.

This paper is written collectively by a group of parents, individuals and families in North Carolina who wish to remain anonymous because of possible retaliation in services.


PHP (Pre Paid Health Plan) Quality Performance and Accountability Concept Paper

2018 NC Health Equity Report - NC State Center for Health Statistics