The State of Mental Healthcare in North Carolina

Source: Mohammed Hassan / Pixabay

I recently presented a talk at a conference for North Carolina behavioral healthcare professionals about how North Carolina, like many states, is in the midst of a crisis in its mental healthcare system. The state ranks last in the nation for access to quality behavioral health care, with about two out of five North Carolinians living in an area with no access to mental health professionals. The number of mental health emergency room visits has been rising in recent years, straining a system already relying heavily on emergency services before the pandemic.

But, I was also able to discuss how, in December, North Carolina’s expanded access to Medicaid under the Affordable Care Act was tied to a $30 billion spending plan with substantial investments in mental health services. According to North Carolina Senator Jim Burgin, “[O]ne of the attractions to Medicaid expansion for all of us was this once in a generation or maybe even once in a lifetime opportunity to say, ‘Mental health is a big deal.’”

A few of the areas impacted by the spending plan are described below.

Alternatives to the Emergency Room

A visit to the emergency room (ER) for a mental health crisis is a traumatic experience for many, in large part because ERs are not set up to treat mental health crises. ERs across the state have been overwhelmed by mental health patients in recent years. These patients often end up waiting days or weeks for an inpatient psychiatric facility bed to become available.

Once a bed becomes available, patients are often transported in handcuffs and driven by law enforcement officers in marked police vehicles. That happened to me, and I’ve written about that experience in an earlier article. So I’m very pleased to see that the spending plan also includes $20 million over two years to fund a non-law enforcement pilot program for transporting patients for voluntary and involuntary psychiatric admissions.

Another effect of the scarcity of beds is that when one is available, the patient may not be grouped with other patients with similar conditions. That also happened to me when I was hospitalized for depression and anxiety associated with my bipolar I disorder. At least half of the other patients on my ward were there for drug and alcohol abuse. One of my roommates came in detoxing and was so erratic and disruptive that it made it harder to sleep than it already was. It also makes it hard to have meaningful group therapy sessions – about the only thing that cut across all conditions was a need to better manage stress.

The expansion of Medicaid to about 600,000 low-income North Carolinians who previously didn’t have health insurance is the first big step to get people into primary care offices instead of ERs.

Mental Healthcare as Primary Care

Due to a lack of psychiatrists in the state, primary care providers are seeing increased numbers of patients with mental health issues. These primary care providers frequently feel out of their comfort zone treating mental illnesses.

State lawmakers provided $2 million per year in recurring dollars for the Psychiatry Access Line (NC-PAL), a partnership between DHHS and the Department of Psychiatry & Behavioral Sciences at Duke University. Any health care provider can pick up the phone and speak to behavioral health experts.

The state spending plan also includes $5 million to advance a collaborative care model in which common mental illnesses are treated in primary care settings. “Behavioral health has been thought of as a specialty-level service,” said Secretary of NC DHHS Kody Kinsley. “It’s not. It’s primary care. Everybody needs access to it.”

Source: Franz P. Sauerteig / Pixabay

Alternative Crisis Response

As mentioned, I’ve been handcuffed in the back of a police vehicle due to a mental health crisis. I wasn’t violent, threatening to hurt myself, or noncompliant. It was just the policy.

My experience could have gone better, but it also could have gone much worse. And if I weren’t white, it could have gone much, much, worse. Police are five times more likely to shoot and kill unarmed Black men over age 54 than unarmed white men the same age. Police are also more likely to shoot and kill unarmed Black men who exhibit signs of mental illness compared to white men with similar behaviors.

So I’m very pleased that lawmakers allocated $80 million over two years for new mobile crisis teams and for crisis and respite facilities.

Workforce Investments

Lawmakers included hundreds of millions in ongoing funding to increase reimbursement rates for several health care positions, including:

• Skilled nursing facility workers ($71 million)
• Personal care service providers ($50 million)
• Direct care workers for people on a Medicaid program that serves people with intellectual and developmental disabilities ($55 million)

The spending plan includes one-time funding of $40 million over two years for sign-on and retention bonuses for employees of state mental health facilities. The budget also includes $18 million over two years to establish a workforce training center that would provide no-cost training to public sector behavioral health providers, and to administer grants to community colleges to enhance behavioral health workforce training programs.

Access in Rural Communities

To fill the need for psychiatrists in rural communities, funding was established to pay mental health specialists up to $100,000 to work in economically distressed Tier One and Tier Two counties. New psychiatrists can also have part of their medical school debt relieved if they agree to work in rural communities for five years, under a $50 million expansion to the N.C. Loan Repayment program.

Lawmakers also included $20 million for grants over two years to rural health care providers for telehealth start-up equipment, which will improve access for patients with transportation or other barriers to in-person medical care. I have been very happy to see telehealth services become more widely used. There were many times when I was severely depressed when I just wouldn’t have gone to appointments because it was too daunting to leave the house.

The expansion of Medicaid will also increase the number of rural patients with health insurance, which will help financially sustain rural health practices.

Conclusion

According to NCDHHS Secretary Kody Kinsley, “This is a historic moment that will change North Carolina for the better, improving the health of our people and the health of our economy … It is the most significant investment in health care in North Carolina’s history.” And in so doing, North Carolina has taken a significant step toward turning crisis to hope when it comes to its mental healthcare system.