Gov. Roy Cooper and DHHS Sec. Kody Kinsley (center) receive an update on Mission Hospital’s recovery efforts from Hurricane Helene in October. (Pool photo/Paul Barker-Governor’s Office)
As the Cooper administration transitions to the Stein administration, leadership changes are happening across state cabinets as well.
NC Newsline sat down with outgoing NC Department of Health and Human Services Secretary Kody Kinsley just before the holidays to discuss his remarkable three years at the helm of one of the largest state agencies, overseeing a staff of 18,000 and an annual budget of $38 billion.
Kinsley, who came to leadership during the COVID-19 pandemic, discussed how DHHS has rolled out Medicaid expansion, substantially increased behavioral health care services, and created a first-in-the-nation medical debt relief model that will benefit nearly 2 million North Carolinians. Kinsley also offers a candid assessment of the work that lies ahead in public health as Devdutta Sangvai is poised to take over the NCDHHS this January. Sangvai is a professor of family medicine, pediatrics and psychiatry at Duke University School of Medicine. He previously worked at Duke Regional Hospital as president and at Duke University Health System.
Some answers with Kinsley have been edited for brevity and clarity. Click here to listen to our full radio interview.
NC Newsline:
Well, this is sort of a farewell conversation as you prepare to take your leave from three years leading this amazingly diverse agency that serves so many people in need in our state. I wonder if you have any overall takeaways on your time shaping this vast and important state agency.
Sec. Kody Kinsley:
Well, first and foremost, I’m just so grateful to Governor Cooper, one, for having the opportunity to lead this organization to be able to work side by side with some of the most talented and passionate public servants I’ve had the pleasure of working with for my whole career, but also being able to work closely with him to see him up close such a man of great integrity and passion.
And, you know, his focus has been really revolutionizing how we do healthcare in North Carolina, how we invest and make people healthier. And that’s what I’m proud of.
You know, I think everybody feels in this moment right now how frustrating the healthcare system can be. I think we’re unfortunately seeing that frustration peak in ways that are incredibly dangerous and incredibly unproductive. And that breaks my heart.
But at the same time, look at North Carolina in the last three years alone.
We have expanded Medicaid. We’ve got 600,000 people on the rolls. We’ve put about a billion dollars into behavioral health. We were able to provide relief of four billion dollars in medical debt for two million North Carolinians. We’re able to raise the bar on charity care and our Medicaid program paying for food, transportation, housing is actually lowering the cost of the healthcare system.
We are doing in North Carolina what every state in the nation wants, which is how do we make this thing actually work. And how do we just make it so people don’t have to worry so much about how to navigate it.
So, I am very proud of what we’ve done. I’m very proud of my team. And we’ve got an incredibly strong foundation that will pay dividends for decades to come.
NC Newsline:
You ticked off a lot of the topics I want to ask you about. But I guess one more general question is, are we doing enough as a society to serve people in need? Obviously, you’ve listed some of the amazing accomplishments and we’ll get into them a greater detail, but it still seems that there are not a lot of people who are struggling in our state, who are not participating or not lucky enough to be a part of the economic boom that’s affected so many people. And I wonder if there’s just the social safety net that we’ve constructed both here and perhaps nationally, we still have a long way to go to just making them sort of meet minimum standards of adequacy.
Sec. Kody Kinsley:
Let me come at this from two directions. One, yes, too many families in North Carolina sit down at the kitchen table at the end of the weekly pay period. And after they’ve paid their rent and after they’ve paid their power bill, maybe they don’t even get that far, trying to figure out how to put food on the table, trying to figure out how to take care of health care for their family members, let alone there be a crisis.
Very few people have more than $400 in their savings account. That’s not working for so many people.
We can have a really tight employment market, but if so many folks are struggling to get ahead, then that’s not working. We need to reward their work in a way that is more meaningful. And that’s really stressful, that stress-inducing, and we see the negative health outcomes because of it. And so, it is every reason why we have to do more there.
But on the other hand, when we look at just how much money we spend on health in this state and in this country, gosh, we blow the second largest-spending country out of the water by a factor of two, right?
So, we are putting a lot of money in, but we are not getting the results that we want.
We see a flattening or decreasing life span. We see maternal mortality issues. We see a lot of other diseases that other countries aren’t worrying about. And so it continues to offer an opportunity.
The opportunity being how do we solve the stress and the challenges that those families have by using our dollars more wisely? That’s where these have been big, monumental steps forward in expanding access to care and spending our dollars more wisely by investing in food, but we’ve got to continue to push forward here.
And the places where my mind goes is, how do we break even further out of the kind of healthcare disease spend, right? We got to get away from sick care and actually go to healthcare.
And how do we start to spend on things like child welfare? High quality early education. We’ve got to continue to double down. North Carolina was a leader on that in the nation for a very long time and we’re slipping, and we’ve got to continue to double down.
How do we try to help ensure individuals can age with grace in our state, right? The demography of our state is changing. We’re not going to be able to continue to provide concentrated care of folks in facilities with the right staffing levels.
We’ve got to make sure we can curb chronic diseases. I mean, that’s why I invested in GLP1s, even though that was controversial nationally because I wanted to lower the cost on that. And then another area I think is a big investment area versus staying focused on rural. North Carolina is the second largest rural population in the country. We got to make sure our folks in rural North Carolina can thrive just as much as our folks in urban communities with access to all the things that help them be healthy and well.
NC Newsline:
One of the things you’ve already alluded to it, we know one of the driving factors perhaps that led to ultimately the expansion of Medicaid in the state was the fact that we were seeing so many rural hospitals closing.
And it finally, I think, maybe inspired some very conservative lawmakers who might ordinarily opposed it to get on board with Medicaid expansion. But tell us, how did we get 600,000 enrollees? Seems like it was just the other day that we expanded the program. And I guess it’s a testament to how desperately needed this expansion was.
Sec. Kody Kinsley:
Yeah, first and foremost, you know, the fact that we’ve gotten to 600,000 is exactly that. People needed this, they’ve needed this for a long time. And so the fact that we’re able to get them on so quickly is a testament to fulfilling that need. But it’s also a testament to the fact that during COVID, when we weren’t redetermining people for Medicaid because of the public health emergency, we made the smart decision at the department to invest in our technology and to completely rewire the way that it works. So it would work faster.
I’ve got 40% of people that are going through applications right now, never having to talk to a person. It is automatically happening for them. That’s never happened before. That’s a new thing we’ve been able to do. That also reduces the workload in our county employees so they can spend their time on SNAP benefits and other things that help families.
Right now, our processing time is around 30 days. That’s well below the federal average that is required. We’ve partnered with civic organizations and faith-based leaders who really have the trust in communities to go out and break down those myths and break through those barriers to try to get folks in the front door, our navigators and ambassadors that we’ve funded have been out on the ground going after folks.
And let’s remember, because of all these technology changes, because we were smart in our policy, day one, December 1st of last year, we put over 280,000 people on the rolls. They had to do nothing. They just got a card in the mail and say, guess what? You have insurance, you have comprehensive coverage and never a copay of more than $4. It’s the best Christmas gift anybody could ever get.
And I hope it also helps folks know that roughly 3 million people that we have on Medicaid, a third of the folks in North Carolina, that their government works for them and that the public servants that are here are working day in and day out round the clock to make this thing work better for them.
NC Newsline:
One concern I guess a lot of people still have about Medicaid expansion is that there’s still this sort of rumble from the new administration that’s coming in in Washington and some of the new Congress that they might actually try to repeal it or take something away. And we know that Medicaid expansion in North Carolina is dependent on federal dollars coming in. I wonder is that something you’re concerned about that we should be concerned about? Or are you hopeful that’s just campaign talk?
Sec. Kody Kinsley:
Well, I think now is the time for us to tell the story. I think people need to remember that the vast majority, more than 80% of people that have come on to Medicaid as part of expansion are by definition people that are working. These are folks that are working for small businesses, many in rural North Carolina childcare facilities who are doing critical work to our economy, critical work to their families, but these employers can’t afford to give them health insurance.
We want those employees to be healthy so they can continue to do that work.
We also know that we’re putting those folks on a Medicaid program that has been leading the nation at saving money.
Our pilots, our healthy opportunity pilots have shown that when we pay for food, transportation and housing, we meet their social needs, we reduce their hospital visits and we’ve been saving $85 per person per month in spite of the cost.
This is not about more money, this is about putting money into the right place and seeing the return. And, you know, I’m also, you know, as a person who served in both the Obama administration and the Trump administration and who has worked hard with anybody across any aisle or in any branch of government to get stuff done and I don’t really believe healthcare is so much a red issue or a blue issue as much as it is a green issue.
It is highly incentivized by money and interests and we have to continue to work together to find these win-win wins that we have been charting the path on in North Carolina.
NC Newsline:
Another mostly related issue that you’d spend a lot of time on and had some really exciting success, you alluded to previously is the issue of medical debt really. And what I understand, other states are now saying, wait a minute, how’d you guys build this off in North Carolina? How did it work? And what have you actually gotten done there? It sounds like an amazing boon to a lot of people who had a pretty big heavy weight on their shoulders.
Sec. Kody Kinsley:
I always like to start here by defining the problem. You know, medical debt is not like any other debt, right? You don’t buy a heart attack, you know, you have one, you show up at the ED, you don’t check the price list on the way in to decide where you can get cheaper care.
You’re like, ‘Save my life, please’ if you’re even talking. And then you leave and you end up with debt that you never wanted and what we find is that folks hold that debt and hospitals hold that debt, they collect between one and three pennies on the dollar as the debt ages.
Also, hospitals spend a lot of money trying to collect the debt. People can’t pay it, but they carry the emotional and financial burden of it. Maybe they can’t buy a car. Maybe they can’t stay in their home because their credit is ruined. And also, even if it’s $100, they’re scared to go to the primary care doctor for a checkup because they know the first question that person will ask is, can you pay your bill from last time?
And if you’re not getting your checkup for what you think is indigestion and that turns into another heart attack, then where are you? You’re back in that debt.
And by leveraging federal dollars to invite hospitals to change their approaches on this, we had all 99 hospitals say yes. And we’re seeing it. We’ve seen Atrium now, Carmel, ECU Health, others that are stepping up, complying with the policy, forgiving debt, changing their charity care limits.
But I think what is most exciting is that they’re changing their relationship with the patients that they serve and love and care about. That’s why they’re in this. They’re changing the relationship from one of collection to one of care. And that puts us on the healing path that we need to be out.
NC Newsline:
Will this work going forward? Are we going to be able to avoid imposing this kind of debt on people in the future?
Sec. Kody Kinsley:
That is what is particularly breakthrough about North Carolina’s plan. We use no state dollars to get debt relieved.
And hospitals have to raise the minimum thresholds for the charity care policies that they offer all across the state. So, there’s now a consistent level. Hospitals have the responsibility of getting you onto the charity care program as opposed to waiting for you to apply, which is free care if you can’t afford it
If you’re up to think you’re up to 350% of the federal poverty limit or below, then depending on household size, the sliding scale, then your care is free or there’s a percent reduction up to it.
But so many people have been eligible for that, but have never applied. They didn’t know they could.
Now, if they are on SNAP benefits, we’ve already checked their income. I don’t need the hospital do that again. Why do that work? They can sign a thing saying I’m on SNAP benefits. They’re in charity care.
Hospitals are putting in place the technology, like what we use for Medicaid eligibility to automatically pull people’s income information. So that way, when you’re being admitted to the hospital, they’re like, hey, look, we’ve pulled your income information. You’re eligible, we’re gonna put you in. So again, this is how we make the healthcare system work easily for folks.
NC Newsline:
One thing I would be remiss about if I didn’t ask you about is the work you’ve been doing in Western North Carolina. This is the issue of the day in our state, so much devastation out there. I know it’s caused problems in every area of society, from education to childcare, to healthcare, and to, of course, debt. But I take it, HHS, the department you lead, has had its hands full and been very busy in the recovery effort in the Western part of our state.
Sec. Kody Kinsley:
Yeah, you know, that night when the hurricane was bearing down on Western North Carolina, our team was at the emergency operations center, working around the clock.
We were in contact with all of our acute care hospitals, our skilled nursing facilities, our adult care homes. We made sure that they had contingency plans in place, and then as soon as the weather cleared, we were ensuring that we can make contact with them. If we couldn’t, we were working through our law enforcement partners to go out and to check on these facilities. And then within 24 hours, we were delivering water and food and gasoline by helicopter or truck. And then it turned into oxygen tanks. And then we had staff that were setting up healthcare facilities in portions of communities that had been cut off. And then we worked hard to continue to stabilize access to food and water and shelter, of course, sheltering.
But then as things started to regain stability, we worked hard with the business community to make sure they could reopen. You know, when you’ve had water turned off, you don’t have access to sewer, you can’t open a restaurant.
We actually got the FDA to approve, first in the nation, a clever way to kind of work around public health requirements for operating restaurants so that they could reopen. Think about it, it’s like a little bit, we framed it as working as a food truck, essentially, right?
Like we got to have hand-washing stations, you got to have a port-a-potty outside, you can share the port-a-potty with the other restaurant, but you can serve. It’s important for our businesses to reopen. It’s also important for those community members to have access.
We did the same thing with hotels. And, you know, in moments like these, you see the heroes really come out, local community folks step up, reach out into their neighborhoods and help each other, and it was beautiful.
It’s a long way to go. I mean, we’ve got to continue to do work there, and I’m very hopeful that the federal government will step up, make the investment that we need to see in Western North Carolina.
It’s a space that I know is incredibly important to me. I lived in Brevard for a long time. I’ll be in Ashe County for the holidays, and so many people in North Carolina have such a deep love of that space.
NC Newsline:
Another really challenging issue that I know you spent time on, has to deal with the whole broad issue of people with intellectual and developmental disabilities and mental health needs. We know that there’s a process going on and that’s been driven by advocacy groups, and also by people who are in the department to move us to a realm in which people can get the services, whether they need to be in an institution or they can be in the community. We’re making headway in that direction, but it’s a big, heavy lift. Talk to us about the progress made there, the lawsuit settlement that’s still being monitored and complied with.
Sec. Kody Kinsley:
Yeah, I think one of the happiest days that I’ve ever had in this role was actually about a month ago, the North Carolina Council of Developmental Disabilities afforded me the great honor of giving me an award for the Kerri Eaker Mountain Mover Award.
Kerri Eaker was an amazing advocate who had fought so hard for her family, fought so hard for community-based services for individuals with disabilities and we lost her recently. And we have done such important work with the disability community.
Any two people, regardless of having any different ability, you’re gonna have differences.
Our job at the department has been to try to find the middle space to move the system forward in the midst of many different views on how to do that. At the same time, working with the General Assembly to get the funding that we need to make those transformations.
And so I’m really proud of progress we’ve made. One that you pointed out specifically is the Transitions to Community Living Initiative, which is really focused on individuals with serious mental illness who had historically ended up in adult care homes because there was just no where else for them to go.
We’ve now been able to house individuals instead of ending up in adult care homes. We’ve been able to essentially shut the front door on adult care homes through a really good diversion process so that people can more easily reroute into those community-based livings. We’ve changed services so that more services are available in the community so people can really thrive.
And what’s great about that for those individuals who do well live longer are happier in those spaces as they move into those spaces is it also helps everybody else living in those communities to know folks with different abilities, maybe mental illness or something else, and it helps us break down stigma, which is the real thing that we’re fighting here.
And so we got the United States Department of Justice to agree with us that we had made sufficient progress and have dismissed almost half of the lawsuit that we have with them. There’s still some more work to do. I mean, we have a lot more work to do in this space and I’m excited by our work and know that we’ll continue to get it done.
NC Newsline:
We hear about massive waiting lists that still exist to get these services that people need and people waiting years because there just aren’t available resources to serve them. Is there a hope that we’ll get to a point where that’s no longer an issue in our state?
Sec. Kody Kinsley:
I actually think that we are closer to that than people may realize. And that may be hard for some people to believe, but here’s why. As part of our managed care transformation and launch and our launch of standard plans and tailored plans, North Carolina negotiated with the federal government to get a service array called 1915(i).
These services can pay for respite care in home care and other supports for individuals that doesn’t normally pay for and Medicaid.
We have an opportunity to leverage 1915(i) to support people that are on the waiting list with significantly more services, even if they don’t have a waiver slot, which is what I know folks are so kind of focused on. Now, our job is to make it so that all this accounting and stuff in the background is seamless. People don’t need to know and that’s the challenge of our tailored plans, right? We’ve resourced them significantly. They’ve got to continue to lean in and make sure that we can get folks with services. Our biggest limiting factor I believe right now is actually the workforce challenges.
It’s why one of the things that we’ve done is put out a strategic workforce report outlining some of our biggest gaps. We said in our future focus plans, nursing, behavioral health providers and direct care workers are going to be really critical and that’s going to be important.
But backing up, I came home to North Carolina in 2018 with the goal of transforming behavioral health in this state. That was my mission. I started as the head of behavioral health of the department.
I got drafted into the COVID response to run operations for every good reason. And we were able, as part of the Medicaid expansion, to be able to get nearly a billion dollars for investments in behavioral health and individuals with disabilities.
We have increased the number of behavioral health urgent cares by 50%. We have done a facility-based crisis, we’ve done a crisis system, criminal justice or justice involved populations work, school-based mental health, transformations all up and down the continuum and we’ve got that capacity building as far as the places for people to go, people for folks to call, the workforce investments.
And we’re going to continue to double down on that path. And we just got to continue to work together with advocates, with consumers to continue to change.
It all goes back to the center theme, which is we’ve got to fight stigma. These are real folks who need to make their own choices with their family members about what life needs to look like for them. And we need to meet every individual wherever they are.
NC Newsline:
Obviously, we’ve got some new leaders in Washington who are raising questions about fundamental public health policies that have been pursued in this country for decades. I trust perhaps that that is a concern, that is something we don’t want to backtrack on here in North Carolina because they’ve made an awful lot of success and saved a lot of lives with common sense vaccination policies?
NCDHHS Sec. Kody Kinsley:
I was just riding in the car with a friend of mine who was in the legislature and we were talking and they mentioned to me that they were on blood pressure medications and statins, but then they weren’t going to get their flu vaccine. And I said, “Why?”
Why would you not trust the FDA in evaluating the safety of these drugs, but you don’t have concerns about those?
And this is where you mean there’s a long history in our country around vaccinations.
And here’s the bottom line, when people get sick, tragically that is a hard lesson to learn. And I hope we can continue to educate folks. North Carolina actually has a relatively high vaccination rate, especially for vaccines for kids and I’m proud of that.
I think it comes back to the trust that individuals have, nothing I say, it’s nothing anybody in my department says, it’s everything to do with individuals’ trust with their own healthcare provider, with their pharmacist, with their doctor.
And I always try to remind folks that these vaccines are the cheat sheet that your body needs to learn how to fight the virus before it gets it. And as much as you would put any other medication in your body when you get sick, they’ve been incredibly tested, incredibly used widely.
And like everything that you take, some people have a negative side effect to certain drugs. There can be side effects, but by and large, for like 99.9% of people, the side effects of any of these vaccines are far less than the real damages and dangers of the disease themselves.
NC Newsline:
Finally talk to us about advice you might have for your successor and what are your plans going forward?
Sec. Kody Kinsley:
Well, first off, I’m aiming for Secretary Emeritus, but whatever works.
So I’m excited about the future here at the department. I’m proud of my team. I’m excited for the appointee that has been named. And I know that he will make this job his own.
He’ll build his skills and capabilities around it. He’ll build the team in the direction of meeting the moment, just much like I’ve done, right?
Trying to be responsive to what needs to happen. I’ve mentioned some of the areas that I think are gonna’ be on the front burner for our department in the future. Aging, rural, especially around workforce and what that looks like, and child welfare. These are areas that have been simmering and challenged.
North Carolina’s systems in those spaces are incredibly underfunded per capita, relative to many other states. And they’re so foundational to the health and wellbeing of our state and more will need to be done there. And it’s gonna’ be complex and hard, but our staff, our team is up for it. And I know his leadership will make the difference.
For myself, my plan is to run home to my dog and cuddle with him for a little bit, to take a breather, to take a real vacation, maybe for the first time in seven years, and then to figure out how I can continue to be helpful.
I’m committed to North Carolina. This is my home. This is where my family is. And I think we have been charting a path for the nation on how to make health work for folks. I’m gonna continue to stay engaged.