HEALTH CARE
Rejuvenate our Health Care System

Making a Good System Better:
Growing Human Resources for Access to Quality Care

 [Top]

North Carolina can anticipate significant growth in the healthcare industry over the next ten years. Advancements in technology, population growth, the aging of our population will all increase the demand for healthcare services, facilities and practitioners. Fortunately, North Carolina has a thriving healthcare sector thanks in part to our excellent university system. We need to support responsible growth, address issues of the distribution of care across the state, and prepare our workforce and institutions to be healthcare leaders of the future.

The Challenge: Caregivers Overwhelmed by Demand

According to a 2004 report from the Task Force on the NC Nursing Workforce, while North Carolina has not yet witnessed the “extreme shortages of nursing personnel” reported in other states, under our current course North Carolina is “likely to experience a severe nursing shortage in the next decade.” We are facing estimated shortages of anywhere from 9,000 nurses in 2015 to as much as 18,000 by 2020.

Based on the growth in demand, shortages of specialized skills in geriatrics, oncology, dialysis, critical care, cardiology, home care and chronic illness are likely to be more critical.

 We also expect that North Carolina will face similar shortages among primary and specialty care providers. In 2005, the state had 18.9 physicians to every 10,000 people – roughly in line with the averages nationwide. However, with continued growth, that ratio is expected to drop to 17.38 physicians to every 10,000 people by 2020 and to 14.9 physicians to every 10,000 by 2030. Eleven North Carolina counties and parts of 40 other counties were considered primary care heath professional shortage areas in 2005 by the U.S. Department of Health and Human Services.

 We must act now, and this must be our first priority in healthcare, or our next-generation medical professionals will be overwhelmed by demographics and increased demand. If we don’t get this done, any improvements we make in health insurance coverage will be undermined if access to quality care is limited by provider shortages.

 My Vision: A growth industry to serve a growing population

Leaders at the UNC and ECU Schools of Medicine recently announced a proposal for adding medical students and creating regional campuses to deal with a predicted doctor shortage in North Carolina. This far reaching vision to address in part the critical need for quality medical care is an excellent first step, and must be coordinated with a strategic program to grow and retain all types of providers to serve throughout North Carolina. Above all, any plan to grow healthcare resources must account for rural health needs, include a plan to measure progress at regular intervals, and include the right mix of health provider expansion (physicians, nurses, and allied health professionals).

•  Grow the physician supply: coordinate with leaders of the North Carolina University System to increase annual production of physicians by 5-10%. This expansion plan must include an incentive structure to: ensure an adequate supply of primary care practitioners that studies show improve outcomes and lower costs; ensure an adequate supply of critical specialists; and ensure a suitable regional distribution to meet rural health needs.

• Grow the nurse supply: coordinate with leaders of the North Carolina University System and Community College System to increase annual production of nurses by 5-10%. This plan must include a review of our process for determining the number of seats available to train qualified nursing applicants. It makes no sense to restrict nursing education, especially in counties that have nursing shortages and Community Colleges ready to enroll nursing students. We must also reconsider the Board of Nursing proposed rule that part-time clinical nursing instructors be Masters Degree prepared. This additional requirement goes beyond accreditation standards, and would place an impossible burden on Community College nursing programs.

• Grow the Allied Health Professional supply: the allied health profession includes 200 key health professions, and numbers more than twice the number of doctors and nurses combined. These are the folks that do the lion’s share of basic healthcare, from dental hygiene to emergency medical technology. There are shortages of these professionals across the board, and once again, our Community College system is the key to addressing this problem over the long term. It’s time to get serious about the resources available to train allied health professionals and work with the Community College leadership to be sure we are prepared for the perfect storm of a growing and aging population.

• Keep more NC doctors in NC: even if all of the 440 medical students graduating in North Carolina this year stayed here to practice, we would still need to recruit doctors. Unfortunately, over the past 40 years, only 40% of the doctors trained here stay here to practice medicine. We must implement an incentive plan to retain at least 50% of our home-grown doctors.

• Bring more out-of-state doctors to NC: as stated, we will not be able to grow all the doctors we will need over the long term. We must review physician migration, and develop an incentive plan to increase the net physician migration into North Carolina by 5%.

The Challenge: Providing Quality Care for all North Carolinians

 [Top]

Residents in rural communities have a higher incidence of chronic disease and lower per capita incomes than urban counterparts, making access to medical services and preventative care all the more important. Yet virtually all of North Carolina’s rural hospitals face critical shortages of physicians across many specialties. When these problems go unaddressed, significant consequences can occur. Aside from having to travel further for care, many studies have found that higher mortality rates and hospitalizations correspond with a lack of primary care providers.

 My Vision: A Deliberate Approach to Rural Healthcare

New Models of Care: expanding the use of non-physician clinicians and team-based care have been shown to improve care and increase access. We must coordinate the efforts of state and local health services, local health boards, foundations, and medical schools to fund, implement and train these new models of care

Increase Rural Provider Supply must be a key component of our proposals to grow medical education and incentivize physicians to practice in North Carolina. In addition, we must examine funding in the Community Colleges’ health sciences programs to ensure local communities have the resources they need to train health professionals.

 Preventive Care Improves Health and Controls Cost

 The Challenge: from healthcare users to healthcare consumers Preventive care and disease management can have a significant impact on controlling rising healthcare costs by reducing the likelihood of illness, costly procedures and hospitalizations. Initiatives like the Asheville Project, which provided educational opportunities and personalized care for city employees with diabetes, have shown to have a significant impact on controlling costs for employers while improving the quality of life for employees. We must adapt the lessons of the Asheville Project to implement comprehensive preventive care for state employees to provide the model for the private sector. While we cannot legislate healthy behavior, we can implement a preventive healthcare policy that instills individual responsibility for preventive health and health outcomes for our state employees.

My Vision: North Carolinians as informed consumers of healthcare

• Implement a comprehensive Preventive Care Program for all state employees through the State Health Plan(SHP) that will be the model for preventive care in the private sector. This new SHP will:

• Identifying high users, educate users on chronic disease management, and have means to ensure compliance with individual preventive health plans;

• Build on the Pharmacist networks developed to support the Asheville project;

• Include provisions to extend coverage to employees’ families;

•  Review the North Carolina Standard Course of Study to ensure health and preventive care instruction is emphasized. Coordinate with education leaders to make health instruction a priority in our schools.

Health Insurance:
A Market-Based Approach that We Can Afford

  [Top]

The Challenge: Coverage for all North Carolinians at a price we can afford: I know that health insurance is a pressing concern for many of our families and businesses. While some struggle to afford health insurance and many go uninsured, others choose not to buy insurance even though they could afford it. Health insurance cost and accessibility is likely to be one of the top three issues in this year’s national election campaign. While we can’t predict the timing or shape of future federal healthcare reforms, I believe the next governor must act to implement state-based policies that enhance private sector solutions and control the growth of tax-payer funded programs. I simply do not believe that it is in our long term best interests to have government fund, run, and deliver healthcare.

 My Vision: Market-based solutions are the answer to reducing health insurance costs. The best solution for any individual or family is to have private insurance that fits their specific health needs and budget. I am against any proposal that seeks to impose universal coverage through a mandate system, excessive coverage mandates, and the expansion of taxpayer funded programs that crowd out private insurance. This is an issue of consumer choice, and infusing more choice and individual participation in healthcare is good for all of us.

• Reduce Coverage Mandates: North Carolina has 46 coverage mandates (government dictated policy benefits) resulting in 41% higher premiums and preventing you from choosing a basic plan. We must reduce coverage mandates so that you can choose a basic plan that meets your health needs and does not include benefits that you do not need, like for example, coverage for a chiropractor.

• Make the healthcare market more transparent: healthcare is perhaps the only consumer market in existence where the purchaser of goods or services has no idea what they are paying for the goods or services. We must examine and implement methods to communicate healthcare costs—the recent move by Blue Cross Blue Shield NC to publish costs on their website is a good start—so that our citizens can become involved and informed healthcare consumers in an open healthcare and healthcare insurance market.

• Open the insurance market: not only do North Carolina’s coverage mandates force you to buy a “Cadillac” health plan. You cannot go to another state and buy a cheaper, more basic plan that would provide minimum benefits and cover catastrophic injury or illness (like Idaho for instance that has just 14 state mandates). We must completely review our healthcare regulations and determine how to open the market for North Carolina’s individuals and small businesses so that North Carolinians have access to a wider range of viable health insurance companies. (large businesses are regulated by the Federal Government).

• Promote alternatives to traditional insurance: Health Savings Accounts (HSAs) and Health Reimbursement Accounts (HRAs) allow individuals to set aside pre-tax dollars or make tax-deductible payments to pay for qualified medical expenses. When combined with High-Deductible Health Plans, HSAs and HRAs often provide a good alternative to traditional insurance, and we must encourage employers and employees across the state to take advantage of the lower premiums they deliver.

• High Risk Insurance Pool (HRP): high risk insurance pools seek to provide comprehensive health insurance to people who could not get coverage, or only get it at a high premium, because of pre-existing medical conditions. In August, the General Assembly authorized the creation of the North Carolina Health Insurance Risk Pool which will begin to enroll members in January 2009. We must carefully monitor the implementation of this program to ensure that it is effective and efficient in assisting high risk individuals.

• Tax credits for small businesses: we need to review the results of the recent state law that provides a $250 per employee tax credit to small businesses for health insurance. We must consider increasing and extending this credit to encourage private insurers to take on the challenge of providing preventative care services under employee health plans to identify, address, and manage employee health issues thereby reducing long term costs of care.

• Tax fairness for individuals: currently, people who have access to health insurance through their employers pay for that insurance with pre-tax dollars. Individuals that buy insurance pay with post-tax dollars. This is patently unfair and must be changed.

• Litigation Reform: it’s important that we look at shortcomings within the civil justice system that have forced the medical community to practice unnecessary defensive medicine, thus driving up the cost of care without resulting in better health outcomes. Our current system has led many physicians to limit their practices, particularly in specialties like obstetrics. We need to further look at reforms that provide the necessary compensation to negligently injured patients without unnecessary dollars being diverted to legal fees or costs not directly related to compensating the patient.

 My Vision: a safety net for those who really need it

 [Top]

It is a fact of life that despite market reforms, some of our people will not be able to afford health insurance. According to the North Carolina Institute of Medicine, in 2005-06, 58% of the 1.5 million uninsured North Carolinians aged 0-65 live at or below twice the Federal Poverty level. While 66% of these uninsured adults are employed and the market-based reforms outlined above will bring private health insurance into the reach of many budgets, some tax-payer financed health insurance will be necessary to help the poorest of our citizens.

 Medicaid was originally intended as a safety net for the poor, but unfortunately, spending on Medicaid has gotten out of hand—up 96% since 2000. If current spending trends continue, Medicaid will make up 100% of the Department of Health and Human Services budget by 2016-17, leaving no money for other DHHS programs like Mental Health, Public Health, and Child Development. Unless we act now, before long cuts will have to be made in other areas (education, infrastructure, public safety) or we will have to raise taxes to pay our Medicaid bill.

 We have also heard a lot recently about NC Health Choice, North Carolina’s State Children’s Health Insurance Program (SCHIP), especially calls to expand coverage dramatically. Folks we’ve done this, and for the most part it has simply shifted coverage from the private to the public sector. The number of children enrolled in Medicaid/NC Health Choice increased by 31% from 2000-05. At the same time, the number of children in private plans increased by only 2.4%. If we stay on this path, our government program will continue to crowd out private insurance and the responsibility for insuring more and more of our children will shift from parents to tax payers.

 We cannot allow our safety net programs to be the first option and will need a range of solutions to help our poorest people. We must take on the tough task of reforming these tax payer funded government insurance programs so that they will be viable for the long term. If we do not get this done soon, our children will pay the cost of having to make do with much less for other state programs.

• Grow our economy: expanding the economy is the surest way to reduce the demands for Medicaid. This is where my proposals for education, economic development, and healthcare come together. State government focused on establishing the conditions for the creation and growth of businesses in North Carolina will mean more jobs, better quality jobs, and less demand for Medicaid.

• Examine Premium Assistance: our neighbors in South Carolina and Florida have implemented premium assistance programs to allow Medicaid recipients to choose their own coverage and take control of their healthcare. We need to look at these programs and determine if they are generating positive results and controlling costs.

• Review Medicaid Service Offerings: North Carolina’s Medicaid services go beyond what we should reasonably expect. While the Federal Government requires a baseline of services, North Carolina also offers 33 of 38 optional services. Only 8 other states offer more optional services through Medicaid, and North Carolina spends 70% more than the national average for optional services for “medically needy” recipients (recipients with too much income to qualify for basic Medicaid).

• Review Eligibility Standards: a significant portion of our growing Medicaid bill comes from newly eligible recipients. It is time to review the eligibility expansions of 1987 and 2000 that added 45% of North Carolina’s Medicaid recipients.

• Public-Private Partnerships that bridge the gap: many non-profit organizations across the state have stepped in to help working poor North Carolinians get access to healthcare and ultimately transition to private insurance. These programs (there are currently 10 in North Carolina) save money because they help provide access to preventive care and chronic disease management and reduce the need for emergency care. We need to understand the lessons learned from these programs and look for ways to improve these public-private partnerships to support and expand this effort.

Rejuvinating Our Health Care System | Making a Good System Better |
Preventive Care | Health Insurance: A Market Based Approach

 [Top]