There’s a good reason President Lyndon B. Johnson traveled to Independence, Missouri on July 30, 1965, to sign the legislation that created Medicaid — he wanted to present the first membership card to former President Harry S. Truman. 

Truman had long been a backer of socialized medicine, inheriting the position from his Oval Office predecessor Franklin Delano Roosevelt, who established a number of social safety net programs during his 12 years as chief executive.

Calling the $24 billion state budget passed by North Carolina’s Republican-led legislature “an astonishing failure,” Gov. Roy Cooper, D-Rocky Mount, vetoed it June 28. 

North Carolina Gov. Roy Cooper has a budget. The N.C. House of Representatives has a budget. The N.C. Senate has a budget. But as of now, the state of North Carolina does not. 

Four-time freshman legislator and recently re-elected Rep. Joe Sam Queen, D-Waynesville, launched into this year’s legislative session by hosting a trio of town hall meetings across his district, but if the ones held in Jackson and Swain counties were anything like the one in Waynesville on Feb. 16, there’s just one thing on people’s minds — expanding Medicaid. 

Major changes are coming to North Carolina’s Medicaid program, and the regional organizations that manage those dollars for behavioral health needs are wasting no time in getting prepared to respond. 

After wading through more than 300 legislative goals presented by more than 500 commissioners throughout the state, the North Carolina Association of County Commissioners has agreed on five top priorities to present to legislators during the 2015 General Assembly.

Macon County Commissioner Ronnie Beale, president of the NCACC, gave his fellow commissioners an update on the recent Legislative Goals Conference during the board’s retreat last week. 

Hospitals in North Carolina face a catch-22 of the worst kind: the $600 million kind, the kind they have no control over, the kind that involves politics.

Hospitals in North Carolina are seeing a financial hit they can ill-afford after state lawmakers in the General Assembly turned down the federal government’s offer to expand Medicaid last year. It would have added 500,000 uninsured poor to Medicaid rolls.

Republican lawmakers in North Carolina are standing by their controversial decision last year to deny Medicaid expansion to 500,000 low-income people who otherwise lacked health coverage.

Some Democrats in the General Assembly are pushing to revisit Medicaid expansion, however. The legislative season had barely gotten underway last week when a group of Democratic lawmakers introduced a bill that would reverse course on Medicaid expansion.

An elderly man was swindled out of $5,500 by a Department of Social Services employee in Swain County, according to an investigation by the Bryson City police department.

As nursing home bills for his wife mounted, the man had sought help from DSS worker Nicole Warren in hopes of qualifying for Medicaid.

Warren has been charged with three counts of obtaining property under false pretenses and one count of felony conversion, or theft, by the Bryson City Police

Warren had told the man — who wants to stay anonymous and whom authorities refused to name — that he and his wife had too much money in the bank to qualify.

It isn’t uncommon to ask Medicaid applicants with too much money to “spend down” their assets on valid household expenses before they can qualify. In this case, however, Warren proposed some rather unorthodox solutions.

According to Bryson City Det. Sgt. Diane Wike, Warren first asked the man to give her a $3,000 loan. He felt pressured to relent.

“He felt like if he didn’t give her the loan, he might not get the Medicaid for the wife,” said Wike.

Later, Warren asked him to “spend down” a further $2,500. While he proposed making a donation to St. Jude hospital, Warren suggested an alternative charity: the N.C. Social Services Association. She told him to make out a check and she would make sure the organization got it. Instead, Warren tried unsuccessfully to cash it herself, an attempt that was caught on bank surveillance.

Warren went back to the man, insisting that he make the donation in cash instead, according to police reports. The elderly man eventually conceded but demanded a receipt. Warren wrote a handwritten receipt in which she scribbled her name illegibly.

He then asked for an affirmation on letterhead, which Warren wrote using the official DSS letterhead.

“She didn’t sign her name to that one,” said Wike.

Warren also asked for the man to transfer property deeds to her name, but he refused.

The man reported Warren to DSS in late May, and the attorney for DSS in turn reported it to the Bryson City Police Department in mid-June.

Wike said Warren confessed almost instantly.

“Her explanation was that she got in a bind and needed money,” said Wike. “She had a clean record. She’s never been charged with anything.”“

Tammy Cagle, the Swain County DSS director, did not return calls, and Justin Greene, the attorney for Swain County DSS, said that he could not comment on any “ongoing personnel issues or certain issues involving law enforcement.”

Abuse of the elderly

This particular case undoubtedly qualifies as elder abuse, according to Kim Gardner, elder abuse program coordinator for the 30th Judicial District Domestic Violence-Sexual Assault Alliance.

“It’s financial exploitation,” said Gardner. “She used her power and influence to obtain $5,500 from this man fraudulently.”

Gardner suspected the Bryson City Police did not include specific elder abuse charges in Warren’s indictments because its penalties are less severe. There is no mandatory jail time though probation can be given.

“That’s probably why they went with the stronger charges,” said Gardner, adding that she’d like to see the charges changed. “We need more teeth in the elder abuse laws.”

To qualify as elder abuse, the victim must be over 60. Though Gardner warned the elderly to be cautious with their money, she doesn’t think they should be afraid to ask for assistance at DSS.

“I know a lot of people have negative thoughts about DSS from time to time,” said Gardner. “[But this is] an unusual occurrence. They’re there to help people.”

A pivotal moment arrives every time a pregnancy test turns positive at public health departments across the state.

The new mother could walk out the doors, overwhelmed and underprepared, never to return again. She could receive little or no prenatal care before delivery. She could possibly die.

Or, she could pay absolutely nothing for prenatal care, delivery and 60 days of postpartum care. Not to mention, childbirth and parenting classes, one year of Medicaid for her newborn child, family planning services, and even emotional support and advice throughout the pregnancy.

It’s a moment that nurses at Haywood and Jackson County health departments don’t take lightly.

“That’s where we grab them,” said Vicki James, maternal care coordinator for Haywood for the past 11 years.

“We really have the nurse literally come knock on my door as they get their positive pregnancy test,” said Courtney McLaughlin, Jackson’s maternity care coordinator. “As soon as we get them, we connect them to all these services.”

North Carolina has come a long way in providing support to low-income women, bringing them closer to the reality of an uncomplicated pregnancy and a healthy baby.

Moreover, Medicaid for Pregnant Woman extends generous financial aid to women who don’t usually qualify for regular Medicaid.

Yet a study released this month by Amnesty International, a human rights group, shows a major gap still exists in care given to pregnant women across the state.

The report states 15.7 percent of women in North Carolina still receive delayed or no prenatal care, equivalent to about one in six women. That number jumps to nearly one in four among women of color.

Amnesty International claims that women who do not get prenatal care are three to four times more likely to die than women who do.

With 11.4 mothers dying per 100,000 live births, North Carolina ranks 37th in the nation for maternal mortality. In comparison, Maine, the top-ranked state, has 1.2 mothers dying for every 100,000 live births.

The reasons for the disparity are manifold, but major culprits include lack of health insurance, lack of access, and lack of education and awareness.

Nevertheless, lawmakers in Raleigh have already made significant cuts to the Baby Love program, which provides nursing and social work to low-income women. They are considering doing away with the program altogether — an idea that causes deep worry for health officials across the state.

“We’re not sure where these clients will go if that program ceases to exist,” said Debbie Sprouse, adult health supervisor in Haywood County.

Logical disconnects

Julie Guffey, a 28-year-old Waynesville resident, says she can’t fathom why those who need prenatal care aren’t receiving it. Guffey qualified for Medicaid for Pregnant Women when she gave birth to twin girls almost a decade ago and easily obtained it again after learning she was pregnant late last year.

Medicaid for Pregnant Women covers all pregnancy-related costs, even those that result from complications. It also provides one year of Medicaid coverage for the newborn child automatically.

Guffey says the entire application process is very simple, and the care she’s received has been excellent. Nurses have sent her home with thick educational packets to prepare her again for pregnancy, and she’s taken advantage of free birthing classes at Haywood Regional Medical Center in the past.

“If the services are available, and if you qualify for Medicaid, I don’t see why they don’t use it,” said Guffey. “Anyone who’s not getting prenatal care, it’s their own fault.”

It is relatively easy for low-income women to receive Medicaid for Pregnant Women, commonly called “Pink” Medicaid because its ID card had been pink at one point.

Income requirements are significantly more relaxed than those that exist for regular Medicaid.

For example, a family of four must make no more than $594 each month to qualify for Medicaid for families, while they can qualify for Pink Medicaid if they make up to $3,400 each month. Unborn children are included in the family count.

But even such a generous eligibility requirement can leave those who need financial aid floundering. Pregnancies in Western North Carolina can run up bills from $4,000 to $8,000. Ultrasounds cost $500 and up, and most women need at least two per pregnancy.

Having health insurance doesn’t necessarily shelter expecting mothers from the burden of financial worries. It’s not uncommon for policies to exclude prenatal care and to consider pregnancy a pre-existing condition.

Katie Martin, a 35-year-old Waynesville mother of two, said she paid nearly $2,500 in pregnancy-related costs, despite having state health insurance.

Martin says she’s not sure many of her friends could meet the Medicaid cutoff requirement even though they’d struggle to pay for prenatal care.

Because her own pregnancy was completely normal and she didn’t take any drugs during delivery, Martin was shocked when she set her eyes on such steep bills.

“I can’t even imagine if we had issues, how expensive the delivery would be,” Martin said.

Some of her bills had to be paid upfront, but Martin was able to set up a payment plan for the rest.

“Her birth is paid for now,” said Martin of her 1-year-old daughter, laughing. Of course, countless other expenses have piled up since then.

“From conception on, they cost a whole lot more than you would think,” Martin said.

Countless barriers to care

Charlene Carswell, prenatal clinic coordinator, understands that no matter how much she and her co-workers preach, some women will always insist that they don’t need prenatal care.

They’ll say “My sister didn’t have a low birth weight baby, and she smoked a pack a day,” said Carswell.

Others adamantly argue that no one received prenatal care a hundred years ago, so there’s no need for it now.

But late or no prenatal care can be detrimental to both the mother and the baby. It can lead to preterm births, dangerously low birth weights, gestational diabetes, and babies that haven’t fully developed.

Many of the women who don’t receive prenatal care do not have health insurance. Even those who have Medicaid may have trouble tracking down doctors who accept it.

Women who can’t afford medical care often put off early prenatal care to save up for the costs that’ll greet them in the third trimester. They pick and choose which tests they’ll get done and which they’ll skip. Even though it’s recommended that pregnant women get a check-up at least once a month, they’ll pass on those as well.

“They say ‘If I’m going to have to pay for the delivery, I’ll save for the delivery, not monthly visits to doctors,’” said Tania Connaughton-Espino, Latina program manager for the North Carolina Healthy Start Foundation, a nonprofit devoted to reducing infant death and illness.

Since Pink Medicaid applications can take up to 45 days to be approved, some patients who qualify for the aid skip out on appointments until it is formally approved.

Other barriers include lack of access to treatment, whether it’s not owning a car to drive to the health department or not being able to take off from work to make an appointment. Mothers might also not be able to line up childcare for their other kids while they are visiting the doctor.

And sometimes, it can be hard to even get an appointment with the recession sending waves of newly uninsured people to local health departments.

According to Connaughton-Espino’s experience, some women just might not see why prenatal care is necessary. They wonder why they’ve given up several hours of work time to wait for a 15 minute appointment with a nurse who measures their belly and takes their temperature.

“We just need to makes sure that moms understand that they can make that appointment important for them and ask questions,” said Connaughton-Espino.

According to Connaughton-Espino, the best route to a solution is through education. Some expecting mothers just don’t know when they’re supposed to take a prenatal vitamin or how often they should visit the doctor.

A whole other category of women who are not receiving prenatal care are undocumented workers. Because citizenship is a requirement for Pink Medicaid, illegal immigrants who are expecting often are left behind.

They do have the option of applying for presumptive eligibility Medicaid, which provides care until an application is formally approved or denied. However, this kind of Medicaid promises only a maximum of two months of care. It allows only minimal contact with a doctor and does not cover the cost of delivery.

At most public health departments, undocumented workers pay on a sliding scale based on their income. Even though the cost of care might be within reach, undocumented immigrants are afraid to even show up on the health department’s doorstep.

“They fear that they’re going to be arrested or shipped back to Mexico,” said Adrienne Maurin, a licensed therapist at Jackson County’s health department.

“Some of them come in later for care, some decline testing doctors recommend,” said McLaughlin, who tries to schedule ultrasounds and any other major tests within the few weeks that undocumented workers gets Medicaid coverage.

Children of undocumented workers who are born in the U.S. automatically get American citizenship, but they might still receive inadequate care because of their mother’s illegal status.

Carswell doesn’t think that that’s fair.

“It’s not the baby’s fault, whoever is pregnant,” said Carswell. “You just have to have good prenatal care.”