- Just ahead on Black Issues Forum, behind every policy debate are real people.

Parents skipping medication, workers delaying doctor visits and communities holding on as hospitals disappear.

We take a look at how policy decisions at the top are shaping the health of North Carolina families and the fight to keep care within reach for everyone.

Coming up next, stay with us.

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[upbeat music] ♪ - Welcome to Black Issues Forum.

I'm Kenia Thompson.

Health care can be one of the most personal and pressing issues in our lives.

From the cost of prescriptions to the accessibility of clinics to the policies that determine who gets care and who goes without, it all shapes how healthy our communities can truly be.

In North Carolina, we're seeing both progress and pressure.

Awareness about needs is growing, but rural hospitals are struggling to stay open.

Medicaid reimbursement cuts and uncertainty over Affordable Care Act protections continue to stir anxiety among health care providers.

And as the government shut down looms, community clinics that serve our most vulnerable residents brace for the potential fallout.

Joining me to break it all down is Scot McCray.

He's the Chief Executive Officer at Advanced Community Health and North Carolina Senator Natalie Murdock, who's been vocal about state and federal health care policies that impact working families.

Thank you so much both for being here.

- Thanks for having us.

- Scot, I want to start with you.

I want you to kind of give us an understanding of what community centers do within their communities.

- So community health centers are actually enjoying 60 years.

So that's six decades formed back when there was a lot of social movement and there was a lot of social justice acts that were happening.

So those administrations, former in D.C.

are now we're now seeing the dividends six decades later.

The original community health centers were actually formed in the deep south, in Mississippi, in the north in New York.

So you had these opposing landscapes that both had the same issues where it was lack of health care for families that needed it the most and the affordability and access for those high quality primary care programs, especially for women and kids.

So today, full circle community health centers are a network of 1500 unique organizations across the nation.

Here in North Carolina, we are one of 43 organizations.

In North Carolina, we actually serve nearly one quarter of the residents and that really goes across the nation as well.

So 750,000, 750,000 unique residents here.

So that's pretty much like one in six, maybe.

- Across all counties?

- Across all counties, all 100 counties.

That's locations that are urbanized, semi urbanized and deeply rural as well.

So we all have the same mission intact to provide access, provide quality and to ensure that we are delivering care at the highest quality level.

The thing that's distinctly different about community health centers than your private practices or hospital based practices that we have to see the uninsured.

We have to see the uninsured.

We each enjoy a very modest federal grant every year that helps subsidizes that care.

I know at Advanced Community Health, we've been around for 53 years and on average, we double that amount of subsidy.

So we're actually providing about eight to ten million dollars a year in write-offs in uninsured care.

Some states actually have a letter of agreement that provides some additional subsidy in the state of North Carolina.

There is zero reimbursement for your uninsured folks.

We also have a sliding fee scale.

This means that underinsured folks or uninsured folks that qualify based upon family size and income actually pay a nominal fee or fit into a different slide lane.

So our nominal fee is $40.

And that $40 visit is no different than anybody else that has Medicaid or Medicare or commercial insurance.

So we're really there as the safety net bridge for a lot of folks to get access.

- And so when we look at the cost of health care, especially here in North Carolina, I was surprised to learn that we have one of the highest, if not the highest rates of health care here.

What contributes to that?

- Yes, it actually was not until I became a legislator that I found out we do have some of the highest health care rates in the entire nation.

And but also to kind of take it up a notch, the U.S.

in general, we pay a lot compared to other countries.

There are other countries that do a better job with prescriptions is a really big one.

I was thrilled when the former administration got insulin down to around $35.

So you don't have the ability here in the states to do a lot of negotiation, except if it's very specific programs.

But overall, we have a lot of private industry that are driving up a lot of these costs.

And you also have a lot of specialists.

And I say this as someone who doing much better was hospitalized at five days at Big Duke, as we call it, and walked away with a bill of over two thousand dollars.

And I'm not I'm going to break that up myself, you know, so I see firsthand.

But I saw a number of specialists.

I had an MRI.

I had x-rays.

I've now picked up an additional specialist.

So it does make those higher costs go up.

So particularly in North Carolina, we have very high quality care, but it doesn't mean that everybody will have access to it.

And it means it will not be cheap.

You have the huge systems, the UNC Health, Duke Health, Rex, these really big systems are huge and sprawling and they are going to cost a lot of money.

What's unfortunate here in North Carolina is those in leadership and the House and Senate have different ideas of how to lower those costs, but cannot agree.

So we have not had any substantive legislation this year that will work to lower those costs.

That's compounded by the big ugly bill at the federal level, which will cause over eight hundred thousand people here in North Carolina.

Their health insurance premiums will go up.

And we also are fighting for Medicaid.

When we finally expanded Medicaid, it will help with the cost because when more people are getting health care, that makes the cost go down for everyone because it's your folks that are really sick, that go back for a lot of visits.

That also drives up the cost.

But we weren't even able to fully see the benefits of expanding Medicaid.

It's going to take a few years to see that.

But also what's holding back on Medicaid expansion did not help with the cost of our care.

- There's not a retraction of that expansion that happened, though, is there?

Not quite.

But at the federal government, it is it is coming.

It is coming as a result of the cuts and the big ugly bill.

And that's the big part of what we have, that federal government shut down.

You could have millions of people across this nation that will lose their health care.

So that is what.

So at the federal and state level, we are we are fighting over how to get health care right and potentially not serving those that need the health care the most.

- And for those that may be confused, it is a big, beautiful bill.

But I know what you mean.

I understand what I understand what you're saying.

I just want to clarify that for viewers in case there's any confusion there.

That's all.

Scot, it has.

Have you seen any impact so far on community health centers as far as government shutdown or cutbacks that are looming?

- Tremendous.

I mean, even prior to the government shutdown, the new administration took over January one and we immediately saw a few things that happened, how we drew down our funding, yes, which has always been lock and step for years.

You know, we have budget cycles that we run through as community health centers.

A lot of nonprofits that receive federal funding have the same budget type cycles.

Those budgets are approved for X. You draw your money down on the same cadence.

Immediately there was the Dodge movement, the Doge movement, right?

And and then there was layers and layers and layers of proof to us that you actually need this money, which actually stymied and put a real stop in services for many weeks because funds were just halted.

The other thing that we're starting to see is some of the mechanisms in place that really hurt us long term.

You really can't forecast and grow business the way that you need to.

The Medicaid reimbursement, the things that are happening from the tax subsidy level at the federal level trickles down to the state level here.

Three percent cuts for primary care we're facing.

That impact to us is going to be roughly about three quarters of a million dollars a year, depending on the size and the payer mix that you have.

Hospital systems that provide a lot of safety net care as well.

Charity care.

They're facing 10 percent deductions.

Right.

So we're really starting to see the mechanisms and some of the things that are being put in place as barriers that really impact not only the day to day business, but how people access care.

It's hurting patients and it's hurting constituents, whether it be, again, across this landscape in North Carolina, rural and semi-urban landscapes.

Everybody's reeling from just how do I get services and how do my communities get services back into them and how do we access those.

- You touched on Medicaid a bit.

So how does Medicaid funding work with community health centers?

- So the Medicaid funding works because that is our best payer.

So the offset of us having to see uninsured is that we get enhanced PPS rates called a prospective payment system rate.

So that rate is much higher than your private practices or your hospital based practices.

However, Medicaid is not the best payer for most folks.

Medicaid patients just by origin have a tremendous amount of complexities.

A lot of times we call them social drivers.

Right?

What's happening in your environment will impact how you navigate the health system.

Right?

And outside of the physical aspect of that, whether you're a diabetic or hypertensive, there's a lot of social environmental things that we have to deal with either lack of training, lack of housing, job insecurity, food insecurity, all these things that impact overall wellness.

So Medicaid for us is something that's very important for us to actually maintain the access again to how people actually navigate the system.

So when you start talking about Medicaid cuts and how it's being attacked now, you're attacking an entire cohort of Americans, but specifically in North Carolina.

I think the face of Medicaid has been tremendously skewed.

- Yes.

- It's been skewed to look like only brown and black faces or non-working people.

I had this conversation not too long ago with it with on another show.

And I said, you know, we went out of our way to be the backdrop for the one year anniversary of Medicaid expansion.

And what we found out is that the cohort that benefited most from Medicaid expansion in the state of North Carolina was white men, white men of a certain age.

So I think it doesn't we definitely don't want to just point the finger and say, see, but the totality of the impact you have to look at it balanced and say, this is a very good program if utilized correctly and we have utilized it correctly.

I think that the efforts of Senator Murdock and others to actually get Medicaid expansion over the line, right.

So tremendous, tremendous guts and tremendous foresight.

But now you're staring down this barrel of what happens when people start to fall out of the realms of Medicaid.

They're right back into uninsured status.

The cost of a visit, our $40 visit, for an earache, back pain, for the management of care, again, $40.

That same patient now doesn't have Medicaid, right?

They don't come to us.

25% of all visits to the ED are what they call ambulatory care sensitive conditions, things that shouldn't be there, back pain, toothache.

So that cost is $1,500.

I'm uninsured.

The state and taxpayers end up carrying it.

So we're just kicking the can down the road.

- Yeah.

I want to bring Senator back into the conversation.

Democrats introduced the working families tax cut.

Explain a little bit about what that legislation does and how does it connect to all of this?

- Yeah, essentially, it's the tax cut that allows North Carolinians to keep more money in their pocket.

So at the federal level, you have something called the earned income tax credit.

Essentially, every year in the House and the Senate, Democrats have proposed some version of that.

Now it's the working families tax credit or tax cut to say to help offset some of these costs.

So it's not directly only for medical care, but the inspiration of it is if you have more money in your pocket, whatever those additional costs are, extra medical visits, needing transportation, all the social determinants of health issues that folks may have of how do they even get to the doctor, how do they pay these out of pocket costs.

The goal of that is for them to keep more money.

But we have not been able to move forward with that at the state level.

And it's meant to complement a federal program that's there.

But it depends on, you know, who files your taxes, if you know that you're eligible.

So we really wanted to have that program here at the state level so that people can keep more money in their pocket.

It's not modeled the exact same way, but even states like New York, particularly now with inflation, groceries, gas, the cost of everything is going up.

So states are saying we've got to figure out a way to essentially provide a bit of a stimulus to get more money in the pockets of people.

But states like New York have actually already moved forward with getting money back into people's pockets this year alone to provide them with some economic relief.

- We're also seeing a lot of Medicaid cuts.

I went down this chart and the list of things that were being cut and seems minimal, right?

Three percent here, two percent here.

But when you add all of that together and I say minimum very lightly, it's a major impact, especially I think in rural areas.

- Yes.

- How are how how are what is the psychology behind the cuts?

Number one.

And how are we being impacted?

- Yes.

And so with the federal legislation has really forced the hand of the state to say if we're having federal level cuts, we don't know what the future of Medicaid is here in North Carolina.

We've skipped over the state does not have a budget at this time.

And so we have not fully funded Medicaid currently.

There's something called the Medicaid rebates.

Essentially, it's being able to pay all the bills for Medicaid.

We have a gap of some 200 million dollars that has not been settled.

Again, the cost of everything is going to go up.

We have this federal uncertainty.

So essentially, nonpartisan staff let us know on the high end we would need around eight hundred and ninety million dollars on the low end six hundred something million.

So we have not hit that six hundred and eighty million dollar goal.

We've gone back to session month after month and to the House's credit, the House actually proposed a clean bill that would just fully fund Medicaid.

The Senate did not take it up.

We weren't even in the building to receive the legislation.

So that's why you have the DHS secretary who has imposed a 3 percent cut when you're looking at probably the largest program we even enact here in the state.

DHS is the largest agency we manage.

You can't pull the rug from underneath providers at the ninth hour to say, hey, you know, the money's run out.

Now the cuts going to be 10 percent.

So with a 3 percent cut, it allows providers to get prepared.

But it also brings people to the table and it worked.

You saw House Republicans and Senate Republicans say, hey, we need to have a meeting because the DHS secretary said reimbursements were going to go down 3 percent.

But you have to subsidize health care.

You can't expect low income folks who don't have the means, community providers to just bear all that cost.

You have to have the state and the federal government working together to get these costs down.

- You mentioned that you see a large number of uninsured.

We're talking a lot of talk that might be kind of just over the head, over people's heads.

And frankly, they don't want to understand.

They just want health care.

So how does this impact the day to day person that's looking for care, quality care?

- Well, people still have to start making decisions that they don't want to make.

Right.

If I'm a part of the tax subsidy and I'm one of the one million plus people in North Carolina that are part of the marketplace, 90 percent of those folks actually qualify for subsidy.

90 percent.

Wow.

So January 1, when the tax subsidies go away, you're going to have 90 percent of those people that are going to be making decisions at their dining room table and their kitchen tables, right, with their spouses and or others saying and their children, do we put food on the table?

Do we pay these bills?

Do we keep our health insurance going?

Right.

You can't have a quote unquote healthy America or great America if people aren't gainfully employed in some fashion.

Right?

Health care in this state is probably the number one, if not the number one industry in some form or fashion, even if you roll up research under that.

Right?

So what we've done is we've taken Medicaid, which was a huge infusion of cash to this state.

And when you have more patients coming in that qualify, that means you have more practices that will thrive and grow.

So that means you just don't have more doctors.

You have more front desk.

You have more M.A.s.

You have more certified nurses.

You have more phlebotomists.

You have more folks that do billing and coding.

So you're actually pushing people into the workforce that are now gainfully employed.

The economic engine that is health care.

We have taken shot to that again because we have politicized it.

We've made it ammunition, right, for one side or the other.

So the cuts that you see are tremendous because these providers in the community center, they're not going to make decisions whether we see less Medicaid.

They're going to say we're not seeing Medicaid.

Right?

Because we're getting reimbursed less.

Yeah.

So we have to have some shut off valve to say enough is enough.

Right?

I think the biggest thing is also is to start putting health care in the right lanes.

Who does primary care well?

Who can do it most affordable and incentivize community health centers and other practices like community health centers to actually see more primary care period because the cost of primary care at the hospital level is tremendous as a feeder for specialties and other diagnostics.

- Let's bring in undocumented folks into the conversation.

They are a large population of services that are rendered out that don't potentially get paid for.

How does this fall into in line with this this conversation in this issue with health care costs?

- Yeah, there's a huge overlap, not only with health care costs, but with safety.

I mean, we're having this huge debate around immigration.

And this is the first time in recent history that those who are undocumented are not safe, not only in health care centers, but not even in churches.

That is unprecedented.

And the irony of it is it was George W. Bush that signed a federal law saying that those who are undocumented had a right to health care.

So this is something that not even 20 years ago, less than that, we were able to agree on.

If you are sick, we want to get you care.

And back to folks that are on death's door that go straight to the hospital.

That costs more than getting you to a primary care physician.

So I've seen it.

I did a small closed door conversation with some undocumented folks actually just last week.

And they're fearful.

Why would they want to go not only go to the doctor, they are these health care workers.

Duke University immediately had people calling out as soon as the ICE raids picked up, fearful of going to work.

These are people that keep our economy going, meaning they also work in these health care systems.

So not only we would have more folks waiting until they're on death's door to go to the emergency room, but how can they work?

How can they provide for their families if they're sick?

And we need to just agree that health care is a basic human right.

Let's take care of you and not focus on your status.

That's constantly changing because of the federal government.

That's not their fault.

They are here.

They're sick and we just need to provide them with the care.

- When we look at community health centers and emergency rooms and a visit made by an undocumented person who carries those costs?

- Taxpayers.

Taxpayers at the end of the day, a $1500 on average, $1200 to $1500 ED visit for world class health care in North Carolina.

Undocumented folks will pay at the pump, as we say, right?

They don't really want any trouble, right?

Hospitals have the responsibility to treat and street, which is the terminology we use in health care for EDs.

If you walk into the ED, we have a legal responsibility to take care of you and make sure that you fall back into some follow up care.

But at the end of the day, from the primary care side, undocumented are part of our patient base, right?

What we see, and I'm an old public health school, I'm an old school public health guy, is that we don't want to see prevention go unchecked.

So that's still a big part of what we do in all of our services, whether it's family medicine, dentistry, pediatrics, internal medicine, our pharmacy program and behavioral health, which is continuing to grow as a problem or the lack of access to behavioral health.

But I say all that to say is that we have a responsibility as well as a primary care network nationally, but especially in North Carolina, to continue to provide service for undocumented.

Now, if we want to go by the letter of the law and be able to maneuver and be flexible, what I would challenge anyone to say is, let's not create barriers for undocumented folks to get care when they can pay for it, right?

If there are provisions within the Public Health 330 Act, Section 330, that actually creates community health centers that says you have to have ID, you have to be an American citizen to be qualified for the sliding fee scale.

Great.

But let's not have ICE showing up in parking lots and waiting outside in the bushes.

Right?

Let's not make it very antagonistic and very almost unsafe to get care for your families, especially children.

- And it's not helpful to providers, who wants to work in that kind of environment to say I'm fearful of treating my patients because ICE could be parked out in the parking lot.

So it's not helpful for the providers either.

- In this last five minutes, I want to touch on rural areas and the access to care there.

You know, we've seen hospitals thrive with support.

We've seen hospitals clearly on the verge of shutting down.

What is the status of medical provisions in rural areas right now?

- That is a huge provision in the federal bill, which again is why we're having this federal government standoff.

And in my district in Chatham County, we could lose our hospital in Siler City.

So you're talking about a mom who could have delivery to be 10, 15 minutes away from that UNC property versus 40 minutes to an hour.

You know, so you're definitely going to have those folks that need health care the most.

We have health care deserts where it is only those community health centers.

They don't have the big flagship hospitals.

We have a huge rural population.

I think we're number four in the nation.

So when we talk about rural health care, it is those community health care centers that are standing in the gap.

But there are times where you have, you know, really, really sick, some sort of unique illness where you need care that you may not have access to.

And a lot of it is going to be because of the lack of this federal funding.

Hospitals aren't making tons of money.

A lot of them are running negative balances.

And so they need that federal supplement so that they're even able to keep the lights on, especially in rural areas where it's harder to find providers.

Then you also have folks that are driving farther to get care and it could impact how sick they are even when they finally arrive to the hospital.

- Community health centers in rural areas?

- Community health centers in rural areas are essential.

We have a rural county in our service area, which is Franklin County.

Our service area is Wake and Franklin County.

We just expanded our square footage.

We just tripled our square footage to be very comprehensive because we know that, again, the distance, the mileage, all the things that are the barriers in rural terrain are clear and evident.

And we haven't cracked the code on that yet.

Part of it again is what you said, workforce development piece.

The workforce development piece is key.

We cannot sustain and recruit at a high enough clip doctors and APPs and other support staff into rural areas.

So those are conversations that from a systematic view, I always challenge my hospital partners to say, why don't we think about some innovative rebranding or operations methodologies to actually share the cost, lower expenses, to figure out what things we can put under the FQHC umbrella, the federally qualified health center umbrella to actually lower costs and you do what you do best and we do what we do best.

Because primary care is something that is essential to actually getting people into specialists and the continuity.

So I think there's a way for us to sustain the rural health banner.

But at the end of the day, we have to be mindful of what those residents need most, which is affordable and access.

- About two minutes left for Affordable Care Act.

What can we do to ensure that we don't lose it?

Can voters do anything at this point?

- Voters, they can vote.

They can vote for congressional members, legislators that care about their health care.

Again, this is the primary issue that has brought the federal government to its knees and don't want to skip over.

It is not because we're out of money.

It is to give tax breaks to those that don't need them.

Even here in North Carolina, those that are considered low income pay more taxes than those that make over 200 plus thousand a year.

So at the federal level, it is literally to provide tax cuts to millionaires and we need to just provide the health care.

But you are talking of millions of people.

And again, here in North Carolina, over 800,000 people on ACA that will see their premiums not only go up, for some of them it's going to double and triple.

So people will have higher health care costs.

They're going to have higher gas bills, higher prices at the grocery store.

Something's going to give and people are going to get thicker because they're going to start cutting some of this stuff out.

They're going to start saying, you know, I can't afford that copay because I got to feed my child because they're also cutting off WIC and SNAP.

So we really are approaching the perfect storm.

But particularly as black people, we are in community.

We will always lift up each other and we'll figure out a way to make it through.

But those in D.C.

need to come to the table and figure this out.

- Senator Natalie Murdock, Scot McCray, thank you both so much for being here and having this conversation.

- Thank you.

- Thanks.

- And I thank you for watching.

If you want more content like this, we invite you to engage with us on Instagram using the hashtag #BlackIssuesForum.

You can also find our full episodes on PBSNC.org/BlackIssuesForum and on the PBS Video app.

I'm Kenia Thompson.

I'll see you next time.

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