Health Mettler Institute

By Taylor Knopf

In his State of the State address Monday, Gov. Roy Cooper said the “youth mental health crisis cannot be ignored,” adding that he would soon “propose a plan that makes historic investments in the whole-person health.” 

On Wednesday, Cooper announced his plan to invest $1 billion in mental health and substance use services in North Carolina. The money will come from the $1.8 billion sign-on bonus the Biden administration has extended to get holdout states such as North Carolina to expand Medicaid coverage. 

“The highest priority for that bonus must be making smart investments in our mental health and substance use system across the entire continuum of care,” the governor’s plan reads.

In the wake of the pandemic, North Carolina is contending with a growing mental health and substance use crisis.

More and more people are waiting longer at emergency departments to go to a psychiatric hospital. Drug overdose deaths increased by 72 percent over the pandemic. Crippling workforce shortages in health care mean that psychiatric beds sit empty as the state struggles to fill vacant positions. People with disabilities have lost their direct service providers to higher-paying jobs. And teenagers are reporting high levels of depression and suicidal thoughts. 

“Clinics closing, people can’t find care […], folks waiting in emergency departments, staff levels at record lows… Folks, it is only going to get worse,” NC Department of Health and Human Services Secretary Kody Kinsley said in February at the annual Legislative Breakfast on Mental Health, where he gave an update on the state of North Carolina’s mental health needs. “And I do not want to stand here next year and tell you how much worse it is. I want to sit here in front of you and say, ‘Here’s all the extra things we’re able to do because of Medicaid expansion.’” 

Kinsley has repeatedly said Medicaid expansion is the best investment for the state’s mental health system, as more people with behavioral health needs will be able to afford care. 

“But after decades of no one being able to pay, we need to jumpstart our system of care,” Kinsley said Wednesday. “This plan does just that. It helps us invest wisely to make a system of care that prevents crises, serves people where and when they need it most, and helps increase health and decrease costs over people’s lifespans.”

“Not only is the system not working, it’s inefficient,” Kinsley added. “This plan allows us to save costs over time, by building better places and ways for folks to get preventative care and recovery supports.” 

Support from state lawmakers

After nearly a decade of debate, leaders of the North Carolina House and Senate announced in early March that they have reached an agreement on Medicaid expansion. 

Cooper’s plan to invest part of the sign-on bonus will require legislative action from the Republican-led General Assembly. Members of both chambers have suggested that there is support from their colleagues to spend $1 billion on mental health services. 

“I don’t think there’s anybody in our caucus that doesn’t have someone they know, or someone in their family, that has experienced a mental health or drug issue,” said Sen. Jim Burgin (R-Angier), who has emerged as a leader on behavioral health issues for Senate Republicans. 

On Wednesday, a spokesperson for Sen. Phil Berger, the Republican from Eden who leads the state Senate, said, “The governor has not informed Senate leadership of his preferred spending plan for the sign-on bonus, but there is certainly some shared concern for mental health and substance abuse issues.”

In the House, Rep. Wayne Sasser (R-Albemarle) told the audience gathered at the breakfast event in February that he feels “motivated” to have more than a billion dollars to spend on whatever the state would like as part of the expansion deal.

“And we want to spend a billion of that on mental health,” Sasser added.

How to spend the $1 billion

The governor’s proposal for spending the $1 billion is broken down into three parts: to make behavioral health services more available when people need them, to build a stronger system for people in crisis and those with complex needs, and to better track data to ensure access and health outcomes.

• Medicaid rate increases — $225 million

First on the list, with the largest price tag of $225 million over three years, is ​​raising Medicaid rates for behavioral health services. Providers of mental health services have said for years that they need higher reimbursement rates to be able to continue working. Even private insurance plans often pay as little as 80 percent of what Medicare — a government program — pays to mental health providers. 

The governor’s plan would cover three years of rate increases, noting that “ongoing funding would be needed to sustain rate increases beyond that.”

• Improve access in schools/communities — $175 million

“Youth suicides doubled in the last decade,” the governor’s report reads. “Suicide is the second leading cause of death for youth in North Carolina ages 10-18.” As more young people report persistent feelings of sadness and hopelessness, there’s been a push for more mental health interventions in schools. 

The governor’s plan suggests $175 million be spent to integrate mental health care in primary care offices, increase school-based telehealth, link schools to community resources and extend mental health education in schools. 

In an effort to provide teachers with more support, North Carolina recently expanded its Psychiatry Access Line to 130 public schools to offer mental health training and consultation. The state also recently awarded grants to five Certified Community Behavioral Health Clinics, and the governor’s plan seeks to expand that community clinic model further to help people with more serious mental illness.

• Behavioral health and justice systems — $150 million

Nationally, it’s estimated that more than 40 percent of people in jails have a mental illness, and more than 60 percent have a substance use disorder. Sometimes, people are arrested for a crime but are not mentally competent to stand trial. They must go through treatment to restore their mental capacity to take part in their court proceeding. Cooper’s plan includes more funds for this kind of treatment in local detention centers and communities. Until recently, the only facilities that could treat these patients were state-run psychiatric hospitals at the price tag of $1,400 per day, according to Kinsley. 

Kinsley added that justice-involved patients stay in state psychiatric hospitals on average twice as long as other patients, holding up beds and creating longer wait times for patients sitting in emergency departments. In December, Mecklenburg County launched the first pilot program with the state to do capacity restoration treatment in the county’s jail. Kinsley said his department approached four counties about starting this pilot, and only Mecklenburg agreed. Other counties are welcome to join, he added.

Cooper’s plan includes investments in programs that divert people with mental health and substance use issues from jail and into treatment and programs that help them live in the community again after they have been released. The plan also calls for “decision aids” and educational resources for judges who often direct people to either jail or a form of treatment. 

The governor’s plan has several policy recommendations too. He suggests that lawmakers review the state’s involuntary commitment laws to avoid unnecessary institutionalization, as many people go to the hospital willingly for help and end up under an involuntary commitment order, a costly level of treatment that temporarily takes away a patient’s ability to make their own health decisions. His plan recommends a “study of policy options, such as a Medicaid 1115 waiver, that support reentry health services for certain incarcerated individuals 90 days prior to release.”

• Behavioral health crisis support — $200 million

“All too often, the front door to behavioral health care is our crisis system, because people don’t seek care or can’t access it until they reach a crisis point,” the governor’s report reads. 

The plan includes upgrades to the state’s 988 crisis lifeline to include offering telehealth visits and incorporating a “warmline” where peer support specialists — people with lived experience of mental illness — answer the phone. The governor’s policy recommendations include reducing access to lethal means for suicide and implementing safe firearm storage practices. 

The state recently partnered with health organizations to launch 15 mobile mental health clinics, and Cooper’s plan seeks to add even more to cover the many rural counties that still do not have one. The plan would add facility-based crisis and drop-in centers so people experiencing mental health distress can avoid going to the emergency room for an initial evaluation. The plan calls for investment in housing for people with serious mental illness, who often have nowhere to go after being discharged from a hospital.

The governor’s plan includes the creation of a statewide transportation service to drive mental health patients under an involuntary commitment order, or those seeking voluntary treatment, to a psychiatric hospital. Currently, mental health patients are transported by sheriff’s deputies — often in handcuffs — which patients and their families find traumatizing. Meanwhile, sheriffs have said they no longer want this role. 

• Address foster care issues — $100 million

There have been multiple reports of children in foster care living in hospital emergency departments and child welfare offices. The governor’s report confirms that this is the case for more than 50 children each week, and Kinsley noted that some of these children have been moved up to 50 times. 

“North Carolina still has the lowest per child spending and child welfare among other states who have decentralized systems, and overall we are 36th in the nation —  at the bottom of funding per child,” Kinsley told the audience at the breakfast event in February. “You get what you pay for.”