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Last week the Arizona Attorney General certified new emergency rules established by the state health department to address the ongoing opioid epidemic.  The regulations apply to the facilities that the agency regulates like skilled nursing facilities, outpatient treatment clinics, hospitals and the like. 

Basically, the new regulations require the health care facilities that they license to adopt and implement policies and procedures relating to the prescribing and administration of opioids.  There are a few webinars scheduled to help facilities understand & implement the new regulations. The ADHS also began expanded blood screening for suspected opioid overdose cases in order to better characterize the epidemic.

There seems to be no end to the damage that opioid painkillers are having in our society.  The latest sign that the epidemic is causing widespread public health damage is highlighted in this abstract published in the American Journal of Public Health where the researchers found a huge increase in the number of drivers killed while under the influence of prescription painkillers. 

The prevalence of prescription opioids detected in fatally injured drivers analyzed in the six study states increased from 1.0% in 1995 to 7.2% in 2015.  The researchers looked at drivers who died within 1 hour of a crash in California, Hawaii, Illinois, New Hampshire, Rhode Island and West Virginia. Those states routinely test for drugs in people who have died in car crashes.

It’s no secret that Arizona and the U.S. are in the midst of an unprecedented opioid epidemic. Public health professionals, healthcare providers, managed care organizations and first responders have been implementing interventions to improve prescribing practices, better manage addiction, and quickly intervene during overdoses to mitigate the epidemic- yet the crisis has worsened. Policy makers in Arizona and across the nation, including the governor, have taken note and are prioritizing resources and policy directives to mitigate the crisis. 

Our Fall AzPHA Conference and Annual Meeting (September 28) will focus on this critical public health crisis.  The conference, titled Arizona’s Opioid Epidemic: Evidence – Interventions – Policy, will present recent Arizona opioid epidemic data and will explore interventions and future policy initiatives within public health, healthcare and managed care systems, first responders, state government, and county health departments to mitigate the epidemic. 

Sign up today at www.azpha.org and take advantage of our early bird registration rates.

 

 

 SB 1080 kicks into action next week… and Arizona will finally join the 47 other states that have laws on the books restricting the use of smart phones while driving.  It’ll ban brand-new teen drivers from using their smart phone while driving for the first 6 months of their license (if they’re under 18).  Using the phone in an emergency will still be OK.  Tickets can only be issued if the driver committed another violation.  Prior to this, the only other limitation in AZ to this kind of distraction applied to school bus drivers. 

We supported SB 1080 because of the evidence that this would be an effective public health intervention.  Data in this NHTSA summary document that shows that teens are the largest age group reported as distracted at the time of fatal crashes and have the highest prevalence of cell phone use while driving.  A 2003 study of US crash data called Driver distraction and crashes: An assessment of crash databases and review of the literature found that driver distraction is a contributing factor in 8% to 13% of crashes including cell phone distractions of between 1.5 to 5%.

Between now and our Fall Conference & Annual Meeting on September 28, our Public Health Policy Committee will be discussing proposing a member Resolution at the Conference that will urge Arizona lawmakers to go further and put in place a law restricting the use of cell phones while driving for all ages of drivers- not just minors in their 1st 6 months of driving.

The Governor in his signing statement for SB 1080 suggested he might be supportive of extending the restrictions to all minors (not just minors in their 1st 6 months of driving).  In part, the signing statement said:

“…Distracted driving is a growing problem in Arizona and nationally. I generally believe that public awareness and education campaigns are a more effective remedy to prevent accidents and save lives than blanket laws that let politicians feel like they’ve checked the box, and then move on to the next issue. For that reason, I am skeptical of large-scale bans on texting while driving — I just don’t think they work. But this bill is different. The state already regulates a number of things when it comes to early driving by teens. And for good reason. For our youth, these laws can act as a teacher. In fact, I’d be in favor of a law that goes further, banning texting while driving for all minors.  Driving is a privilege for our youth, and they are still the responsibility of their parents, financially and otherwise, before the age of 18.”

This signing statement suggest that we have some executive branch support for extending the restrictions to at least all drivers under 18.  Not the full intervention (restrictions for all ages) as is in the case in most other states, but a start.

July 28, 2017

 

The Honorable John McCain

RE: Thank You

 

Dear Senator McCain:

I write on behalf of myself and the membership and Board of the Arizona Public Health Association (AzPHA) to thank you for your statesmanship.

Throughout the debate in the U.S. Senate regarding the repeal and replacement of the Patient Portability and Affordable Care Act you have been the voice of reason and a primary advocate for ensuring that this important policy decision includes a cross section of perspectives. 

Your commitment to that principle is a testament to your fidelity toward developing public policy that will work for the people of Arizona.

Thank you for your service to the people of Arizona and for your unwavering commitment the United States of America.

Sincerely,

 

Will Humble, MPH

Executive Director,

Arizona Public Health Association

Those of you that have attended our AzPHA Fall Conferences know we also have our all members Annual Meeting at the Conference.  One of the things we do at the Annual Meeting is summarize our advocacy efforts over the last year- and get some guidance from members regarding where we should focus our public health policy advocacy in the coming year.

One way we do that is to propose Resolutions for our members to ratify.  For example, at last year’s meeting we approved Resolutions in support of voluntary certification of Community Health Workers and full dental coverage for Medicaid members during their pregnancy.  Those Resolutions helped to drive the direction of our advocacy efforts last year (and in the coming legislative year).

This year we’re exploring resolutions for: 1) passing a state law to restrict the sale of tobacco to people at least 21 years old; 2) additional limitations on distracted driving (e.g. texting & driving); and 3) a statewide requirement regarding recess and time for physical activity in elementary schools. 

I’ll devote the rest of this update to the evidence for moving to a “21” standard for buying tobacco products. I’ll cover the others in later policy updates.

In a nutshell, the rationale for moving the purchase of tobacco to 21 from the current 18 has its roots in human biology. People that start smoking before 21 are much more likely to be a lifetime smoker because their (still developing) brain gets hard-wired to the craving for nicotine.  The intervention is basically designed to push back the start date for smoking so we create fewer lifetime smokers.

There’s a host of evidence to support this policy initiative in a new report from the Institute of Medicine (it’s available for free on the  Institute of Medicine’s website).  The report thoroughly evaluates the evidence base and concludes that… “Increasing the minimum age of legal access to tobacco products will prevent or delay initiation of tobacco use by adolescents and young adults, particularly those ages 15 to 17, and improve the health of Americans across the lifespan”.  The report also quantifies the immediate and long term accompanying public health outcome improvements. 

What about the FDA, can’t they do this at the national level?  Basically no, not under existing federal law and regulations. 

While Family Smoking Prevention and Tobacco Control Act of 2009 granted the FDA broad authority over tobacco products (including issuing regulations to restrict tobacco retail sales to kids and to restrict tobacco product advertising and marketing to youth) the Act prohibits the FDA from establishing a minimum tobacco sale age to people over 18.  States, however, have the authority to raise the minimum purchase age on their own.   

Several jurisdictions have done it already. New York City raised the age to 21, in 2013.  Hawaii did it in 2015, becoming the first state to go to the 21 (the Hawaii Public Health Association was instrumental in that effort). California followed suit in 2016, and New Jersey’s Governor signed a bill last week that will move the tobacco purchase age to 21.  A bill that raises the minimum age to 21 in Oregon is awaiting the signature of their governor.

In Arizona, Douglas and Cottonwood have passed local ordinances restricting the sale of tobacco to people 21 and older.

We hope to see you all at the Fall Conference and Annual Meeting on September 28 entitled: Arizona’s Opioid Epidemic: Evidence – Interventions – Policy.  We’ll be proposing the smoking age resolution at the Annual Meeting of our members. 

We expect to have our registration website up and running on www.azpha.org later this week.

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Healthcare Debate Factoids

We’re continuing to hear that the US Senate will vote on a Motion to Proceed on a bill that would eventually “repeal and replace” the Affordable Care Act as early as Tuesday afternoon.  Lots of confusion remains on which bill they’ll be voting to proceed on. 

While there are differences in the various Bills that have been floated in the Senate, every one so far would make big reductions to Medicaid funding, deprive millions of people of health insurance, and remove consumer protections while providing tax breaks to corporations and high-income households.

Thus far, all the Democrats in the Senate have been holding firm with their opposition to these bills as well as a handful of Republicans.  The President, Senate leadership and groups that want to repeal the ACA are putting pressure on Senators Capito (R-WV), Heller (R-NV), Murkowski (R-AK) and other targets to vote yes on the Motion to Proceed vote. This week will be very important for access to care! 

In an informal ruling last week, the Senate parliamentarian (an appointed person named Elizabeth MacDonough) ruled that certain provisions in one of the Senate Bill drafts doesn’t comply with the reconciliation rules- (meaning that those provisions would need 60 votes rather than 51)…. including defunding Planned Parenthood and restricting the use of tax credits for plans that cover abortion. More Senate Parliamentarian rulings are to follow, including the ‘Consumer Freedom’ amendment authored by Sen. Cruz (R-TX).

The U.S. spends far more on medical care than any other nation, yet ranks 26th in life expectancy.  That’s partly because we tend to focus on treating illnesses rather than preventing them in the first place.  Basically, we’re not adhering to wise advice that “a stitch in time saves nine”.

More than 85% of the health care costs in the U.S. are from preventable chronic conditions, yet only 3% of our health care spending is focused on prevention and public health – the key factors that prevent chronic medical conditions before they start. It’s essential that we do a more effective job preventing costly chronic medical conditions to reduce health care costs.

The Affordable Care Act included several initiatives designed to reduce health care costs. One important component was the creation of the Prevention and Public Health Fund, which provides federal, state and local public health resources to reduce long-term health costs. The fund focuses on preventing expensive chronic medical conditions by providing expanded and sustained national investment in public health programs that improve health and restrain the rate of growth in health care costs.

This investment in public health infrastructure to reduce costs is evidence-based. Research suggests that funding for community-based public health has a 5.6 to 1 return on investment. In other words, every dollar invested in evidence-based prevention programs results in a $5.6 in savings in overall health care costs.

Over the last several years, the fund has been used to support an array of evidence-based community prevention and clinical prevention programs that bolster public health infrastructure and workforce and expand public health research and tracking efforts that reduce health care costs. Resources go to programs at the local, state and federal levels to: a) better detect and respond to disease threats; b) increase vaccination rates; c) fight obesity; d) curb tobacco use; and e) increase access to preventive care services.

The fund also provides state and local resources to fight numerous health threats. Vaccination programs supported by the fund ensure access to vaccines that protect the most vulnerable among us from routine diseases like influenza and provide community-based immunity to prevent the widespread circulation of diseases like mumps and measles. The fund supports the ability to track emerging infectious disease outbreaks like Zika or Ebola, as well as foodborne illnesses.

Arizona public health jurisdictions have received more than $52.6 million through the Prevention & Public Health Fund since 2010. This $9.3 million annual investment is at work in Arizona, providing critical resources that support evidence-based, community prevention activities tailored to meet community health needs and preferences.

Evidence-based PPHF investments in Arizona include:

• Prescription painkiller (Opiate) and heroin use prevention;

• Health security funds for bioterrorism, disease outbreaks, and disasters;

• Building immunization services to prevent serious infectious disease outbreaks;

• Promoting better detection and response to disease threats;

• Lead poisoning prevention;

• Reducing tobacco use; and

• Reducing diabetes, heart disease, and obesity.

Astonishingly, the US House of Representative’s “American Health Care Act”, all introduced versions of the US Senate’s “Better Care Reconciliation Act” (and Amendments), and the President’s proposed budget would eliminate the Prevention and Public Health Fund.  

We’re urging our elected representatives in congress and their staff to reflect on the impact that Prevention and Public Health Fund resources are having in Arizona as they consider options for reforming the U.S healthcare system.  Arizona’s public health infrastructure is already stretched thin because of limited state and local investment in public health. Further reductions in capacity by reducing or eliminating the Prevention and Public Health Fund would impair Arizona’s ability to bend the health care cost curve as well as impair its ability to respond to infectious diseases, the opioid crisis, and preventable diseases and chronic conditions.

The Arizona Public Health Association partnered with the Vitalyst Foundation to develop a report that outlines the progress that Arizona is making using existing prevention and Public Health Fund resources. 

The report, entitled The Value of Prevention: How the Prevention and Public Health Fund Invests in Arizona’s Health is geared to inform policy makers and other stakeholders of the potential implications related to eliminating or restructuring the Prevention and Public Health Fund.  The report is also posted on our AzPHA home page at www.azpha.org.

Please take a gander and forward the report to folks that might be interested- especially people and organizations that you know that may be able to influence the outcome of this enormously important national debate about the future of health care and public health in our country.

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“Our Lives on the Line”, Arizona” Rally and Press Event

More than a dozen groups have joined forces to lead a national “day of action” against the plan to drastically cut back Medicaid and public health resources as part of the repeal of the Affordable Care Act. The rally and press event in Arizona is one of many being held simultaneously in numerous other cities around the country that day.

“Our Lives On the Line, Arizona” event — including a flagship rally in Washington — will set the tone for several weeks of action to persuade key lawmakers to focus on evidence-based solutions that will improve health outcomes as they debate changes to the Affordable Care Act  Here’s where you can register for the Arizona event    

 

Time:

Saturday, July 29, 2017 11:00 AM – 12:00 PM AZ Time

Host:

Our Lives on the Line

Location:

Parsons’s Center for Health and Wellness – Southwest Center for HIV/AIDs (Phoenix, AZ)

1101 N. Central Avenue
Phoenix, AZ 85004

There were 2 important actions this week regarding public health & access to care.  The U.S. Senate released their 3rd version of the Better Care Reconciliation Act (BCRA) and House released their Health and Human Services and Appropriations bill for next fiscal year

Let’s start with BCRA.

The Senate released it’s new version of BCRA this week (PDF) but it still hasn’t been evaluated by the non-partisan Congressional Budget Office…  so we won’t know the particulars of what the new version would likely do to insurance coverage and premiums until that evaluation is complete (probably next week). 

We do know that many things are the same as the previous version of the bill- especially when it comes to the troubling changes that would be made to Medicaid:  

• Like the previous version of BCRA, the new bill would still convert federal Medicaid funding to a per capita allotment (or a block grant) and limit growth in federal Medicaid spending beginning in 2020. Medicaid funding per person would go up with the Medical Consumer Price Index from 2020 – 2024 and by just the regular Consumer Price Index after that- which will likely serve to dramatically cut back Medicaid funding.

• Phases out the enhanced federal contribution for the expansion population in states like AZ from 90% in 2020 to regular state match in 2024.  That means that somewhere between 2020 and 2024 Arizona would drop the expansion population from Medicaid coverage (people from 100% to 138% of FPL).

• Marketplace plan premium tax credits would be available down to 100% of FPL in 2020 (because those folks between 100 and 138% of poverty won’t be enrolled in Medicaid anymore).

• Eliminates the individual mandate for everybody to have health insurance.

• Eliminates the requirement that larger employers provide health insurance.

• Would let insurers sell currently “non-compliant” insurance plans – meaning insurance plans with very high deductibles and limited benefits (people that buy these catastrophic plans would be eligible for a tax credit). This would serve to reduce premiums (and benefits) for people that elect these plans- but it would shrink the risk pool for people that want more robust (compliant) plans- meaning that premiums for the more comprehensive plans will go up alot.

• Repeals the mandate to have health insurance and eliminates cost sharing subsidies in 2020.

• Completely eliminates the Prevention and Public Health Fund in FY19, which is used by every state to support vital public health programs that promote health, prevent disease, and allow for rapid response to emerging public health threats.

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The House Labor, Health and Human Services and Education Subcommittee released their FY18 appropriations bill this week too. Here’s a summary of the funding proposals included in the bill:

The bill decreases the US Department of Health and Human Services’ budget by $542M below last year’s level.  It reduces CDC’s budget by almost $200M , which includes $840M in transfers from the Prevention and Public Health Fund (eliminating the fund).  Many if not most of these budget cuts would roll down to state and local health departments.

The bill reduces HRSA funding by about $400M (to $5.8B) including a complete elimination of all Title X Family Planning Funds ($300M).

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We’re encouraging AzPHA members to send messages to our Senators urging them to focus on supporting a Senate bill that: 1) protects future funding for Medicaid; 2) allows folks with pre-existing conditions to be able to continue to have access to affordable health insurance; and 3) protects the Prevention and Public Health Fund.

Senator Jeff Flake
Russell Office Building 413
Washington, D.C. 20510
(202) 224-4521
Twitter: @JeffFlake

Senator John McCain
Russell Office Building 218
Washington, DC 20510
(202) 224-2235
Twitter: @SenJohnMcCain

This week the U.S. Senate had a goal of voting on the “Better Care Reconciliation Act of 2017” – the earlier version of the bill that was passed in the House of Representatives this year.  Fortunately, the Senate decided to chill and not to take the vote this week or next.  Hopefully they’ll reflect over the July 4 break and come back with a more productive approach to improving on the ACA.

The nonpartisan Congressional Budget Office released it’s analysis of the Senate Bill (https://www.cbo.gov/publication/52849), which seems to have had a profound impact on the negotiations.  The report found that the proposal would have increased the number of people who are uninsured. It is estimated that 15 million more people would be uninsured by next year. The increase in the number of uninsured people would reach 19 million in 2020 and 22 million in 2026.

In later years, lower spending on Medicaid and substantially smaller average subsidies for coverage would lead to even more increases in the number of people without health insurance. By 2026, enrollment in Medicaid would fall by about 16% and an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under the ACA.

Another interesting development this week was a new analysis released by AHCCCS concluding that the proposal would cost our state at least $7.1 billion through 2026. Download the full report from the AHCCCS website.            

The analysis shows that the Bill increases costs for Arizona by $2.9 billion between FY 2018 and FY 2026.  It would make changes to the enhanced federal funding provided for the 320,000 Medicaid members that are childless adults with incomes up to 100% of federal poverty, as well as 82,000 adult members with incomes between 100-133% of federal poverty.   

We’re encouraging AzPHA members to send messages to our Senators urging them to focus on supporting a Senate bill that decouples the issues related to the individual health care insurance market from these dramatic changes to federal and state Medicaid programs.

Senator Jeff Flake
Russell Office Building 413
Washington, D.C. 20510
(202) 224-4521
Twitter: @JeffFlake

Senator John McCain
Russell Office Building 218
Washington, DC 20510
(202) 224-2235
Twitter: @SenJohnMcCain

This morning the U.S. Senate released draft healthcare legislation entitled the “Better Care Reconciliation Act of 2017”.  Note that it has a different name than the House version that passed a few weeks ago (American Health Care Act).  In many respects, the two bills are very similar.

They’re calling this a “discussion draft”, implying that it’s possible that the language of the bill could morph before it hits the Senate floor next week.

The non-partisan Congressional Budget Office is still working on an evaluation of the Senate version.  That evaluation will provide a better picture of the practical impacts that the bill would have if enacted, however, here’s what we know from the initial reading of the discussion draft: 

• Like the House version, BCRA would give states either a per capita cap for federal Medicaid contributions or a block grant of funds beginning in 2020. It appears that, unlike the House version, federal funds for kids the elderly and people with disabilities could not be “block granted” (an improvement).  On the down side, the inflation rate used to calculate future per capita contributions would be even lower than the inflation rate in AHCA which will result in less Medicaid spending in 2025.

• Rolls back the Medicaid expansion (to 138% of poverty), but more slowly than the House version. Would creates some kind of state innovation fund for states that didn’t expand Medicaid.

• Eliminates the individual mandate for everybody to have health insurance.

• Eliminates the requirement that larger employers provide health insurance to their employees.

• Insurance companies would still not be allowed to increase premiums or deny coverage based on preexisting conditions.

• States would be allowed to change what qualifies as an essential health benefit for Marketplace plans.

• Completely eliminates the Prevention and Public Health Fund (PPHF) in FY18, which is used by every state to support vital public health programs that promote health, prevent disease, and allow for rapid response to emerging public health threats.

The Century Foundation has a good comparison of the House and Senate Versions as well as the current law under the Affordable Care Act on their website here:  https://tcf.org/content/commentary/heart-comparison-house-senate-health-bills/   ;

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We’re encouraging AzPHA members to send messages to our Senators urging them to focus on supporting a Senate bill that: 1)  protects futue funding for Medicaid; 2) allows folks with pre-existing conditions to be able to continue to have access to affordable health insurance; and 3) protects the Prevention and Public Health Fund.

Senator John McCain

Washington, DC Office:       202.224.2235

Phoenix Office:                    602.952.2410

Senator Jeff Flake

Washington, DC Office:       202.224.4521

Phoenix Office:                    602.840.1891

There’s been a promising increase in public health policy focus in recent weeks regarding Arizona’s ongoing opioid epidemic. 

A few weeks ago the Arizona Department of Health Services (ADHS) released the 2016 Arizona Opioid Report which found that there were 790 deaths in 2016 in Arizona from opioids, a 16% increase from 2015 and a 74% increase since 2012.  More than half of the increase in the last two years have been heroin deaths (heroin increased from 11% of opioid deaths in 2007 to 39% in 2016).

Shortly after the report was released, the Governor declared a Public Health State of Emergency charging the ADHS with developing: 1) an enhanced opioid surveillance protocol; 2) new emergency regulations for prescribing opioids among licensed healthcare institutions; 3) additional provider practice guidelines; 4) Naloxone use guidelines for law enforcement; and 5) a report of findings that include possible additional legislative action by September 5, 2017.

Last week the ADHS launched an opioid website at www.azhealth.gov/opioid which houses information about the opioid epidemic including information for those required to report data, and resources for law enforcement and EMS and  clinicians as well as standing orders for naloxone dispensing.

These latest administrative actions are just the latest in a string of interventions in Arizona regarding the opioid epidemic.  In October 2016 the Governor issued an Executive Order charging AHCCCS with limiting  Initial Opioid prescriptions to 7 days.  On January 9, 2017 he signed an Executive Order that establishes a substance abuse program for people leaving prison at risk for opiate abuse.

Last legislative session, the Legislature passed HB 2493, which will set up a drug overdose review team at the ADHS (much like the child fatality review team).  It’ll be a 21-member consisting of nine heads of various government entities (or their designees) and 12 members that will:

• Develop a data collection system regarding drug overdoses;
• Conduct an annual analysis relating to drug overdose fatalities;
• Develop standards and protocols;
• Provide training and technical assistance to local Teams;
• Develop investigation protocols for law enforcement and the medical community;
• Study state and local laws, training and services, recommend policies to decrease drug overdose fatalities; and
• Educate the public regarding drug overdose fatalities.

In addition to all of these interventions, AHCCCS has received a  State Targeted Response Grant ($24M over the course of 2 years) from the Substance Abuse and Mental Health Services Association to increase access to medication assisted treatment, care coordination for high risk individuals, recovery support services and prevention activities to reduce opioid use disorders and deaths.  The project will also develop and support state, regional, and local level collaborations, build capacity and infrastructure and service enhancements in high need areas.

The proposed activities within the Arizona Opioid State Targeted Response project will: 1) create a new streamlined data-driven decision-making process to target and tailor treatment and prevention resources where they are most needed in the state; 2) expand training for prevention and treatment providers; 3) expand law enforcement access to Naloxone kits; 4) expand access to MAT and integrated treatment; and 5) expand peer support services, recovery homes and recovery supports to pregnant and parenting women. 

We’ll continue to track the policy interventions that are underway and update our AzPHA members on the latest surveillance and intervention activities.