Author: NC Oral Health Collaborative

On April 8, 2002, Ray Krone was released from prison after serving 10 years for a murder he did not commit.

A decade earlier, a woman’s body was found at the bar Krone frequented. Officers identified Krone as a person of interest, and they took a Styrofoam impression of his teeth to see if they matched bite marks on the victim’s neck.

Krone had distinctly crooked teeth, so after an American Board of Forensic Odontology-certified diplomate testified that Krone’s teeth were a match and he was convicted of the murder, he was dubbed the “Snaggle Tooth Killer.”

Years later, DNA evidence proved that Krone was not involved in the murder – the bite marks were not his.

Bite-mark analysis is used in courtrooms across America, and unfortunately, it is responsible for hundreds of years in wrongful convictions.

“There has been no scientific research that has adequately established basic premises in bite mark comparison work, including whether an examiner can even, with sufficient accuracy, identify a mark as a human-created bite, much less opine on whether a particular set of dentition produced that bite,” said Brandon Garrett, director of the Wilson Center for Science and Justice and the L. Neill Williams, Jr. Professor of Law at Duke University.

The Innocence Project has documented more than 30 instances of people wrongfully indicted or imprisoned in part due to the use of bite-mark analysis.

In total, more than 424 combined years of wrongful incarceration have been served as a result of these convictions.

In fact, bite-mark analysis is so unreliable that it has even been used to convict in cases where bites were later proven to be from animals, not humans.

Garrett mentioned a case in Mississippi in 1995 where Kennedy Brewer was given the death penalty after a bite-mark analysis linked him to marks left on a victim’s body. Years later, a reexamination led to the discovery that the 19 bite marks were actually the result of insect bites, not a human’s teeth. Brewer still served 15 years before his exoneration.

As it stands today, there is little, if any, scientific evidence in support of bite-mark analysis. Beyond that, dentists who serve as forensic odontologists do not have to demonstrate a level of proficiency in the matter at hand: linking marks on a human’s skin to the teeth in someone’s mouth.

“Local courts have even permitted local pediatric dentists and persons with no prior background in forensic work to testify,” said Garrett, adding that even odontologists with decades of experience have made testimony resulting in wrongful convictions. “It is not clear that experience over many years in a technique with unknown reliability makes one better than a novice; the technique may be so unreliable that experience is irrelevant.”

Time to Reconsider Bite-Mark Analysis

The issue of bite-mark analysis is a question of equity and social justice. As NCOHC and our partners work to increase access and equity in oral health care, it is worth considering this social injustice that so closely involves the dental community.

The number of dentists who serve as expert witnesses in the courtroom is small – and the number who provide bite-mark testimony is even smaller. Nevertheless, the impact, especially on those who have been wrongly convicted, is immeasurable.

Learn more: Brandon Garrett recently spoke in depth about bite mark analysis, other social justice issues that stem from forensic sciences, and his book, “Autopsy of a Crime Lab: Exposing the Flaws in Forensics” on the podcast Pod Save the People.

NCOHC is a program of the Foundation for Health Leadership & Innovation. To get involved, find out more information, and to stay up to date, head over to NC4Change to sign up for our newsletter and see what events and other opportunities are on the horizon.

Changes may be coming to help pregnant women in North Carolina access the care they deserve.

Have you heard of Medicaid for Pregnant Women (MPW)? For those in North Carolina with incomes up to 196 percent of the federal poverty level, people can access Medicaid services for the duration of a pregnancy through the MPW program, and they retain access to medical services for 60 days postpartum (after birth).

While the MPW program offers important services at a time when people need reliable access to care, the range of benefits and time constraints are simply not enough.

For example, oral health services unfortunately don’t extend into the postpartum period at all.

Pregnancy is a busy time for anyone. It is especially busy when you have limited access to resources—financial and otherwise. Between preparing a home for a new baby, attending pregnancy classes, going to regular checkups, and more, things like dental care can easily go by the wayside.

Just as it is during the rest of a person’s life, but especially during pregnancy, oral health care is not a luxury. It is absolutely essential.

Hormone imbalances that result from pregnancy make expecting mothers especially susceptible to tooth decay and gum disease, as does vomiting from morning sickness—stomach acid is not friendly to your mouth.

And the negative impacts of poor oral health stem beyond the parent-to-be. For example, research into the oral-systemic connection has found that gum disease is related to low birthweight in newborns.

Fortunately, there is hope for an expansion of services, allowing women to retain all MPW benefits for a full 12 months postpartum. While an extension of benefits even longer than one year would certainly be even better for new mothers—the first year after birth isn’t a particularly relaxing period of time—a 12-month expansion would mark a big step in the right direction.

Earlier in 2021, Senators Jim Burgin, Joyce Krawiec, and Kevin Corbin filed Senate Bill 530, extending MPW benefits 12 months postpartum. While that bill has stalled in committee, its contents appear to be up for negotiation in the 2021 budget.

An early version of the 2021 budget included the full 12-month postpartum MPW expansion. The most recent update cut that section of the bill, but that does not mean all hope is lost.

There are legislators in the majority party who appear to have taken on this issue, and as negotiations continue, NCOHC will keep a close eye on MPW expansion in the state budget.

Stay up-to-date by joining us as a North Carolinian for Change, and take a moment to learn more about the policy options on the horizon. One of NCOHC’s fantastic interns during the 2021 summer, Hannah Archer, wrote this policy brief outlining MPW expansion and policy implications.

NCOHC is a program of the Foundation for Health Leadership & Innovation. To get involved, find out more information, and to stay up to date, head over to NC4Change to sign up for our newsletter and see what events and other opportunities are on the horizon.

Let’s talk about annual maximums.

The difference between an annual maximum and a deductible is arguably the most significant distinction between a typical dental insurance plan and a typical medical insurance plan, especially when it comes to your wallet.

It is important to note that many of the aspects of dental and medical coverage discussed in this article do not pertain to Medicaid insurance. Medicaid insurance operates differently (even though in North Carolina it does cover medical and dental, for children AND adults). We will discuss Medicaid specifically in a future post.

Additionally, this blog post should not be taken as medical or dental advice. When considering personal care and the cost of that care, consult your provider and insurance company to ensure that you fully understand all costs associated with different treatment options.

A traditional medical insurance plan usually includes what’s known as a deductible. If your deductible is $1,000, for example, once you reach $1,000 in out-of-pocket medical expenses (meaning dollars that you, not your insurance company, pay for covered medical procedures), your insurance company pays 100 percent of in-plan procedures for the rest of your annual insurance period.

Dental insurance generally works in the opposite manner. Most dental plans have “annual maximums,” not deductibles. With a maximum of $1,000, once you reach $1,000 in expenses that the insurance company has paid, you as the individual are responsible for 100 percent of your oral health care costs for the remainder of the contract year.

If you were to enroll in a dental insurance plan today, it may look something like this:

Services	Coverage
Type 1, Preventive Oral exams (1 per 6-month period) Cleanings (1 per 6-month period) Bitewing x-rays (1 per 12-month period)	100% covered by insurer, up to contract year maximum
Type 2, Basic services Fillings Full mouth x-rays Periodontal maintenance Injection of antibiotic drugs	80% covered by insurer, up to contract year maximum
Type 3, Major Services Endodontics Anesthesia Simple and Surgical Extractions Oral Surgery Periodontics and Periodontal Surgery Crowns Inlays/Onlays Dentures Bridges	50% covered by insurer, up to contract year maximum
Annual Contract Year Maximum	$1,000

 

On first glance, the tiered system of dental insurance clearly incentivizes regular preventive care. This is good, because nearly all dental disease can be entirely prevented, and regular visits to an oral health care provider are important steps in warding off cavities and gum disease.

On the other hand, however, what happens when you do experience more serious dental issues? Take a scenario where an old cavity filling fails, a new cavity forms underneath the failed filling, and you now need a root canal.

A single root canal on average will cost between $700 and $1,400, depending on the tooth requiring treatment and varying by location and provider. Once you receive a root canal you will also need a crown — an additional $800 – $1,500, depending on the crown material.

Say you end up right in the middle of those cost ranges: $1,050 for the root canal and $1,150 for the crown. Both are Type 3 procedures under the hypothetical insurance coverage above, meaning the insurance company will pay for 50 percent and you will be responsible for the other 50 percent. For both procedures, the total cost would be $2,200.

But don’t forget the annual maximum. The insurance company only pays $1,000 (assuming no other costs have been paid by the insurance company prior to your root canal) and you would be responsible for the additional $1,200. And if you need any other work done for the rest of the contract year, you will pay 100 percent of the cost.

That is a large out of pocket cost for someone who has insurance!

Unfortunately, the solution is not as simple as increasing the amount an insurance company pays for. More extensive policies would cost more and would quickly become more expensive than would make sense for most individuals who do not experience severe oral disease.

Dental insurance poses a complex question — how do we keep insurance costs low enough to incentivize people to: 1) get insurance; and 2) use that insurance to receive regular care, without leaving those with more severe needs hanging out to dry?

On the other hand, how do we create a structure where people with severe needs can see those needs met without crippling bills, while simultaneously keeping costs low for preventive care?

Neglect absolutely leads to tooth decay, gum disease, and eventually more expensive treatments. Some may argue that you reap what you sow, but those of us at NCOHC believe that everyone, with no exceptions, should be able to access quality, affordable oral health care.

It is also important to consider the fact that people can end up with severe dental needs by no fault of their own. In a case like mine, your loyal NCOHC blog author, you could end up on the wrong end of a golf club in high school and need years of surgeries and restorative work to get your two front teeth back.

My case is an example of the stark difference between dental and medical insurance. I was fortunate enough to have great medical insurance through my mother’s state employee health plan, which at the time included a clause for “accidental dental” needs (an uncommon clause in medical insurance). All of my countless dental visits for root canals, bone grafts, restorative work, surgeries, implants… (the list goes on and on) were entirely covered by medical insurance once we reached our deductible.

Our luck was rare. If all of that work had instead been covered by dental insurance, which would be the common scenario, we would have paid tens of thousands of dollars after reaching our $1,000 annual maximum.

At NCOHC, we are curious about your thoughts as a reader. We truly believe that solutions to the biggest problems will be discovered through collaboration, and we want you to be a part of it! Have an idea, a thought, or a question about the future of dental insurance? Click here and let us know!

NCOHC is a program of the Foundation for Health Leadership & Innovation. To get involved, find out more information, and to stay up to date, head over to NC4Change to sign up for our newsletter and see what events and other opportunities are on the horizon.

Dr. Rhonda Stephens, the North Carolina Department of Health and Human Services, Division of Public Health Oral Health Section’s Dental Public Health Residency Director, recently became the newest Dental Public Health Diplomate in North Carolina. A dedicated public health specialist, Dr. Stephens is well-known in the world of North Carolina dental public health for her dedication to improving the oral health status of all North Carolinians.

We sat down with Dr. Stephens to discuss her role in the Oral Health Section, access to care, and what it means to be a Dental Public Health Diplomate.

What do you do in your current position in the Department of Health and Human Services Oral Health Section?

This may be a long answer because my role has shifted quite a bit. I started off with the general title of a Public Health Dentist Supervisor, but I had many responsibilities under that: supervising some of our public health dental hygienists in the field, supervising our four program managers who are responsible for developing the programs that we implement in the field, and managing our grants.

In the last year or so I have shifted to doing all of that, except no longer supervising field staff, and I took on additional roles and responsibilities with our Dental Public Health Residency training program. I am now the Residency Director and will continue managing grants, in addition to temporarily still supervising our program managers.

Why did you choose a career in public health?

That’s a story that I tell quite often. I practiced in Federally Qualified Health Centers for 11 years as a dental director. That’s a safety-net setting, right, and we’re typically seeing the most vulnerable of the most vulnerable. It felt like a revolving door of the same issues day in and day out, and that I was only making an impact one person at a time, if that.

I think by about 2012 I felt like there had to be a better way — a way to impact change on a broader scale. So, I went back for my Master’s in Public Health while I worked part-time clinically, and then I knew from there that I wanted to move on to a more administrative role in dentistry.

You recently became an American Board of Dental Public Health Diplomate. What is a diplomate, and why did you pursue this distinction?

Each of the specialties in dentistry — like orthodontics, oral maxillofacial surgery, dental public health — all of these specialties require specialty training, and then there’s the opportunity to become certified as diplomates.

You can get any specialty training and opt not to become certified. For me, being certified was more of a personal professional desire, to get that final stamp or seal of approval. It’s a standardized test just like any standardized test, and it says that you have met the requirements established by the particular specialty board.

In dental public health, you can easily be just as qualified of a dental public health practitioner by having gone through a residency and not getting certified; but I wanted to be at the top of my professional game, having that seal of official approval.

Broadly, outside of my job, there isn’t yet a clear understanding among employers — whether its government employers, institutions, nonprofits — about the significance or the value of having the certification. But I wanted to be at that level so when employers do start to value the certification, I’m already there.

My job as the Dental Public Health Residency Director is the only role within our program that requires the certification. I’m fortunate that we have the residency, otherwise there honestly wouldn’t be a role for me to step into. It would just be an extra certification that I just happen to have.

Could you tell me a bit more about the role that dental public health plays within the broader network of dental professionals?

I’ll admit, many of our colleagues in dentistry don’t understand what it means exactly. Public health is very different than understanding how to provide clinical care to a patient. You’re focused on prevention first and foremost. Prevention at a community or population level.

So, some of the things that a clinician, a dental clinician, might do for a patient one-on-one in a clinical setting, aren’t actually effective at a population level. Going through the specialty training for dental public health helps you to understand that.

It’s a little-known specialty, like I said even within our own dental community. Then, more broadly, the general public really has no idea what dental public health specialists do. But we’re here, behind the scenes, working to help people prevent diseases that warrant them going in for emergency and urgent care.

I don’t know the raw numbers, but North Carolina in general seems to be a Mecca for dental public health specialists. We have quite a few who have played a major role in dental public health in North Carolina and beyond at some point. I think North Carolina is unique in a lot of aspects when it comes to dental public health.

NCOHC is a program of the Foundation for Health Leadership & Innovation. To get involved, find out more information, and to stay up to date, head over to NC4Change to sign up for our newsletter and see what events and other opportunities are on the horizon.

We are thrilled to introduce the newest member of the NCOHC team! Crystal Adams, a lifelong advocate for access and equity in oral health care, will join us as our Associate Director.

Crystal is a career educator, transitioning to NCOHC from her position as department head of Catawba Valley Community College’s (CVCC) dental hygiene program. Over the course of her career at CVCC, Crystal launched a dental assisting program, a Community Dental Health Coordinator program, and a school-based program allowing dental hygiene students to care for middle school-aged children in Alexander County.

Crystal brings with her a wealth of knowledge and experience in education, paired with years of statewide advocacy and representation on committees like the North Carolina Dental Society Council on Prevention and Oral Health. She is also the former president of the North Carolina Dental Hygienists’ Association (NCDHA).

We recently sat down with Crystal to talk about her career and experience in oral health, and her vision for increasing access and equity in North Carolina.

Can you tell us a bit about your career path in the dental field?

I started in dentistry as a dental assistant. My passion kept getting stronger and stronger, and I felt like I wanted to grow, so I went back to dental hygiene school. After working as a dental assistant for four years and a hygienist for almost ten years, I felt like there was something inside of me that I could share.

I love people — I love helping people. I started working in education to share my passion about oral health care. I wanted to help new graduates prepare for the dental field, and I felt like my experience as a dental assistant and a dental hygienist allowed me to go in and share my technical skills, as well as my personal knowledge working with patients.

I feel like everything begins with education, no matter what. And, with NCOHC, I am excited to work on initiatives and programs to ensure that dental literacy is continued, to help people see that they need that overall health, and that their teeth are part of their bodies!

Why did you choose a career in dentistry in the first place?

I always knew that I wanted to go into the health field. I did not have any dental care until I was 16 years old. Luckily, my family had great genes, so I was one of those lucky people who didn’t have a lot of dental issues.

Now, when I look back, I see that my personal story can help people. Especially when people come in and say, “Oh my gosh, I haven’t been to the dentist. I focused on my family, I focused on my children, and now I’m here and my mouth is a mess.” I have that personal story to share.

What is your vision for North Carolina’s oral health future?

I was born and raised in North Carolina, and I want to see my neighbors, my friends, my family throughout the state get the care that they need. My vision starts with a quality workforce. First, making sure that our stakeholders and partners are on board so that we’re all working toward the same goal. Everybody’s goal in dentistry is hopefully to help our residents in North Carolina to improve their oral health.

I envision collaboration with our stakeholders to ensure that we have a quality workforce delivering equitable oral health care to the residents of North Carolina. Working on the programs that I did at CVCC, I feel like a lot ties into the initiatives, vision, and mission of the North Carolina Oral Health Collaborative.

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

Hannah Archer is an MPH student at UNC-Chapel Hill with a passion for public health dentistry. This summer, she worked with us at NCOHC to develop a policy brief on postpartum health benefits, while continuing to develop a research project to study the value of online resources for oral health care.

Could you tell me a bit about your career/education path prior to pursuing your current degree?

I studied Education and Biology in undergrad and was always interested in healthcare. I knew I wanted to pursue a career in dentistry, but wanted to learn more about the social components that play a role in oral health outcomes prior to starting dental school. So, I decided to apply to the Master of Public Health program at UNC Gillings. While here, I fell in love with oral health policy, and learned about NCOHC during a class I took on Dental Public Health. In August, I will begin my final year of my MPH, and recently applied to dental school in the hopes of attending dental school following my MPH.

Where are you in school, what are you studying, and why did you choose that program?

I am at the UNC Gillings School of Global Public Health studying to receive my Master of Public Health with a concentration in Health Policy. I chose this program because of the incredible opportunities at UNC, ranging from the incredible faculty, diverse peers, community-based learning experiences, and connections to organizations with a dedicated mission to improve public health.

What’s one fun fact about yourself?

I played tennis in college.

Where did you first hear about the North Carolina Oral Health Collaborative, and why did you want to pursue an internship with NCOHC?

I first heard about NCOHC when Dr. Zachary Brian spoke in two different health policy courses I was taking at UNC Gillings. His presentations were incredibly interesting and encapsulating. Even with an already established interest in oral public health, Dr. Brian made me feel inspired and driven to advocate for change. Later in the semester, I established a research project with a UNC Adams School of Dentistry professor and had the fortune to also partner with NCOHC. Given the extensive work and incredible opportunities I had over the past year to work with NCOHC, I knew there was no other place I wanted to pursue an internship and I feel incredibly fortunate to be here.

What about public health dentistry is intriguing to you?

While I aspire to have a career in dentistry and to spend time in clinical settings, I appreciate the broader focus of dental public health. I want to make an impact on dentistry at both the individual and population level. I particularly appreciate the focus of dental public health on increasing equal access to oral health care for all individuals. Through my position at NCOHC, I have seen just how significant the disparities in oral health outcomes are across the state and I aspire to make significant changes in my professional career.

Tell me a little about what you have worked on as an NCOHC intern. What do you hope to take away from the work you have been doing?

My internship revolves around two primary projects. In my first project, I am learning about public health communication by establishing a website to provide oral health information to providers and patients across North Carolina. The website includes oral health education for various populations, including pregnant mothers, children, individuals with intellectual and developmental disabilities, adults, and older adults. In the next stages of this project, I hope to provide this website to a majority of safety net clinics across NC without dental services.

In my second project, I am writing a policy advocacy paper on Senate Bill S530 that was presented to the NC General Assembly in April. The bill proposes to increase postpartum Medicaid coverage from 0 days to 1 year for North Carolina mothers.. In my policy brief, I am advocating to pass this bill so that postpartum mothers can receive both medical and dental Medicaid benefits. Through my research, I am learning a lot about the legislative process and the necessary components of advocacy (i.e., stakeholder support, lobbying, grassroots mobilization, etc.) necessary to pass a bill like this. In addition, I am learning about the social determinants of health that influence poor oral health in mothers and children, along with the significant health implications a bill like this could have.

If you could tell North Carolinians one thing you have learned that you think is important for everyone to know, what would that be?

Oral health starts before birth. I did not realize what a profound impact a mother’s oral health can have on their child, and that a child should be going to the dentist as early as one year of age. Unfortunately, the presence of oral health care and education is severely lacking in North Carolina, and this is something I hope to advocate for and address in my future dental public health career.

What’s next for you?

I just completed my applications to dental school. I hope to hear back from schools in December and I intend to pursue a residency in dental public health (and potentially pediatrics) following dental school.

A landmark piece of dentistry legislation became law in North Carolina on Friday, July 23, 2021. Senate Bill 146, sponsored by Senator Jim Perry, with a House counterpart sponsored by Representative Donny Lambeth, is a broad-reaching piece of oral health legislation that will allow North Carolina to take several steps toward a more accessible, equitable oral health care future.

There are four main parts of the legislation:

1. It codifies teledentistry in North Carolina law.
2. It allows dental hygienists with proper training and qualifications to administer local anesthesia.
3. It further aligns two existing regulatory provisions that allow dental hygienists to more efficiently work in community-based settings.
4. For the first time, it formally recognizes Federally Qualified Health Centers (FQHCs) in North Carolina statute.

All parts of the legislation went into effect when the bill was signed into law on July 23, except for the section allowing hygienists to administer local anesthesia. That portion of the bill is set to take effect on October 1, 2021.

Teledentistry is Codified in North Carolina Law

Teledentistry is an important tool in the dental professional’s toolbox. In addition to being an invaluable asset during the COVID-19 pandemic, remote care technology is a great way to expand access to patient evaluations, consultations, assessments, and education to those who may have trouble getting into a brick-and-mortar dental office.

While teledentistry has never been “illegal” in North Carolina, there have not been set standards defining its use.

Senate Bill 146 defines teledentistry, lays out the various ways it can be used, and sets standards for informed consent during remote patient encounters. It also establishes patient protections, authorizing the North Carolina State Board of Dental Examiners (NCSBDE) to take disciplinary action against dentists who allow fee-splitting or who limit a patient’s ability to file complaints or grievances when receiving teledental services.

Dental Hygienists Will Be Able to Administer Local Anesthesia

North Carolina joins 45 other states and Washington, D.C. in taking this important step.

Currently in North Carolina, dentists are the only oral health professionals authorized to administer local dental anesthesia. . Especially in public health settings — where providers routinely see high numbers of patients — the time it takes to administer local anesthesia and wait for it to take effect can create a bottleneck, limiting the dental team’s efficiency.

By allowing appropriately credentialed hygienists to perform this duty, dental teams can take steps to increase efficiency, reduce care costs, and ultimately expand their reach in treating additional patients. As mentioned above, this provision of the legislation will take effect on October 1, 2021.

To learn more about training requirements, refer to North Carolina General Statute 90-225.2. Licensed hygienists and hygienists with out-of-state certification can refer to NC General Statute 90-225.3 to find out how to become certified. Both laws can be found here.

Rules Pertaining to Public Health Hygienists and Limited Supervision Hygienists are Further Aligned

The regulatory rules within Dental Hygiene Subchapters 16W (defining what it means to be a public health hygienist) and 16Z (outlining eligibility to practice hygiene outside of direct supervision by a dentist) contained similar provisions, with a grey area where eligibility requirements were unclear. Senate Bill 146 aims to further align these provisions and the eligibility requirements that hygienists must meet to practice in limited supervision capacities.

For background, a 2020 update to Subchapter 16W allowed public health hygienists to perform preventive procedures in non-traditional settings under a written standing order from a dentist, rather than with a dentist having previously examined the patient.

Senate Bill 146 lays the groundwork for the same eligibility criteria to apply for hygienists practicing outside of direct supervision under Subchapters 16W or 16Z. For true alignment, a modification to rule 16W .0104 will need to be made.

If you would like more information to clarify 16W, 16Z, and the changes made by this recent legislation, NCOHC will be hosting informational sessions in the coming months.

Federally Qualified Health Centers are Recognized in Statute as Public Health Providers

Senate Bill 146’s passage marks the first time that Federally Qualified Health Centers (FQHCs) have been formally recognized in North Carolina law within the Dental Practice Act. While this may seem insignificant, it solves key barriers that many faced when trying to expand access to care.

When Rule 21 NCAC 16W .0104 was updated to allow public health hygienists to perform preventive procedures outside of direct supervision and based on a written standing order, FQHCs found themselves unable to efficiently take advantage of the change. Many FQHCs offer school-based oral health care services, but since their designation wasn’t clear, they were limited by legislative barriers in order to use the rule change to expand the services they offered most effectively.

Senate Bill 146 resolves this issue, identifying FQHCs as an integral component of the public health safety net.

There are many improvements for oral health access and equity contained within Senate Bill 146, and NCOHC will continue to break down all the ins and outs that you need to know. Stay up to date by joining us as a North Carolinian for Change today!