Final 2019 Legislative Summary

The 2019 Legislative Session is in the books.  There were several good things that came out of Session this year.  Of course, there were also some missed opportunities that would have improved public health.  There were also a few close calls on bills that would have done some damage to public health.

The session ended Monday night when the House and Senate agreed on a series of budget bills.  Once those were passed and sent to the Governor, Legislators voted to adjourn for the year.

The budget highlights included funding to protect Arizona’s Kids Care program, some additional investment in the state loan repayment program and graduate medical education, some funding for prenatal care equipment in rural Arizona, needed funding for providers that serve folks with disabilities, and an appropriation of federal funds to draw down federal funds from the Child Care Block Grant. Disappointments in the budget included a failure to fund preventative oral health coverage for pregnant women and investing in the state’s 211 information hotline.

Here’s the subset of the budget that was passed related to public health and human services and a link to the health budget reconciliation bill and the Budget Bill Summary: https://apps.azleg.gov/BillStatus/GetDocumentPdf/471479

Medicaid

  • Fully funds KidsCare and eliminates the risk of an enrollment freeze by paying the increased state match requirements that are coming up.  The language also eliminates the former trigger language that would have frozen KidsCare when the federal match requirement changes again.

  • Makes last year’s one-time $13M increase for providers that serve persons with developmental disabilities ongoing (because of the Prop 206 minimum wage increase) and an additional $13M in provider funding (rate increases) for the upcoming fiscal year.  There’s an additional $4M in provider rate increases for Prop. 206 impacted services for January 1, 2020 (this funding is for half a fiscal year to address the January 1, 2020 minimum wage increase). 

  • Provides new Prop 206 (minimum wage increase) funding for Elderly Long-Term Care (for persons with developmental disabilities) of $4.8M.

 

Child Care Subsidies

  • Appropriates $56M Childcare Block Grant funding (this is entirely federal funding- but the feds still require a state appropriation to draw down the funds). Will go a long way toward reducing the wait list for child care subsidies and will help improve reimbursement rates.

Miscellaneous Health Items

  • Appropriates an additional $750,000 for the State Loan Repayment Program (in addition to the current $1M/year).

  • Appropriates $1.6M for rural Graduate Medical Education ($5.5M w fed match) and $1.3M for urban GME ($4.4M w fed match)

  • $750,000 for North Country Graduate Medical Education

  • $1M for rural prenatal equipment

  • Provides $10M to the Housing Trust Fund for programs related to homelessness

  • $700K for Colorado City primary care clinic

  • $1.5M for Benson and Northern Cochise critical access hospitals

  • Continues $3M annual appropriation for TGEN for 3 years

  • Increases Alzheimer’s funding by $2M ($1M base)

  • Provides an additional $15M for an Arizona Department of Education school safety grant program for School Resource Officers, behavioral health counselors and social workers

  • Provides $1.6M for Veteran’s Suicide Prevention (includes $450K for trauma training)  

  • $8.0 million for the UofA Health Sciences Center

 

Arizona State Hospital

  • Provides $2.8M in pay raises for AZ State Hospital staff

  • Provides $300K for AZ State Hospital for a temporary staffing contract increase

I’m still in the process of putting together a PowerPoint that will summarize the legislative session.  Below is a summary of the various bills related to public health that passed followed by some of the missed opportunities and the close calls.

 

Bills Passed and Signed

Injury Prevention

SB 1468 Suicide Prevention Training

This new law will require school districts, charter schools, and Arizona teacher training programs to include suicide awareness and prevention training in their continuing education curricula.  It’ll require AHCCCS to make suicide awareness and prevention training available (fortunately some evidence- based tools curricula already exist).

Starting in the 2020 school year, school districts and charter schools would need to provide training in suicide awareness and prevention to school personnel in grades 6 to 12.  The bill also establishes requirements for suicide awareness and prevention training and specifically says that the training use evidenced-based training materials and instruct participants on how to identify the warning signs of suicidal behavior in adolescents and teens.

HB 2488 Veteran Suicide Annual Report

Requires ADHS (starting this year) to complete an annual report on veteran suicides in Arizona that includes the number and rate of veterans who died by suicide, trends, an analysis of the years of potential life lost, a comparison of Arizona’s resident veteran suicide rate to those of the nation, and the relative risk of suicide by race or ethnicity, age group, gender and region. 

The report is also supposed to analyze patterns of drugs, or combinations of drugs, that were used by Arizona’s resident veterans when drug poisoning was the mechanism of suicide. The idea is to create the surveillance and data linkages needed to inform suicide prevention strategies based upon medical risk factors that significantly correlate to suicide.

HB 2318 Hands Free Cell Requirement 

This bill was a long time coming- but were on the precipice of having this good public policy finally happen. It will prohibit using a hand-held cell phone while driving.  There are some common-sense exemptions for example if the person is using it hands free etc.  It’ll change driving behaviors and save lives.

Violations are a civil money penalty (no driving points) with the first offense being between $75- $150 and the 2nd offense between $150 and $250.  The bill would provide a state overlay so the cell phone use laws would no longer be different from jurisdiction to jurisdiction. Warnings for a year and a half – and then the penalties kick in.

Licensing Requirements

SB 1247 Residential Care Institutions

This good bill will require more robust staffing background checks for facilities that provide services for children and will remove the “deemed status” designation for child residential behavioral health facilities.   

Under the old law, facilities in this category (e.g. Southwest Key) can be accredited by a third party (e.g. Council on Accreditation) and avoid annual surprise inspections by the ADHS.  This intervention will provide more oversight to ensure background checks are done and that the facilities are compliant with state regulations. 

SB 1211 Intermediate Care Facilities

Like SB 1247, this bill closes a licensing loophole. This good bill will require more robust staffing background checks for facilities that provide services to people with disabilities at intermediate care facilities.  These facilities would also require a license to operate from the Arizona Department of Health Services beginning on January 1, 2020.  Under current law these facilities (Hacienda de los Angeles and similar facilities run by the ADES are exempt from state licensing requirements).

HB 1494 Medical Marijuana Testing

This bill will require medical marijuana dispensaries to test their product for potency and contaminants.  It will also require the ADHS to develop testing standards and laboratory certification criteria to implement the requirements. Still needs to be signed by the Governor.

Maternal & Child Health

SB 1040 Maternal Mortality Report

The new law will establish an Advisory Committee on Maternal Fatalities and Morbidity. It requires ADHS and the Committee to hold a public hearing to receive public input regarding the recommended improvements to information collection concerning the incidence and causes of maternal fatalities and severe maternal morbidity and complete a report (including recommendations) by the end of this year.

SB 1456 Vision Screening

This bill would require schools to provide vision screening services to students in grades prescribed by future ADHS rules, kids being considered for special education services, and students who are not reading at grade level by the third grade. Appropriates $100,000 from the state General Fund to the ADHS for the tracking and follow up.  

Access to Care

SB 1089 Telemedicine

Any healthcare service covered in-person by a commercial insurer will also be covered when provided through telemedicine. Currently, Arizona law limits telemedicine coverage to a handful of medical services.

SB 1109 Short Term Limited Health Plans

This authorizes the sale of short- term limited health plans in Arizona for terms up to 3 years.  The previous limit was 1 year.  These plans don’t cover pre-existing conditions and have limited consumer protection because they aren’t required to cover the essential health services under the ACA and can drop enrollees.  We urged a not vote because of the poor consumer protections.

SB 1085 Association Health Plans

This new law basically provides a regulatory structure at the state level for Association Health Plans – serving to make them more available in Arizona. A primary concern for folks interested in public health and consumer protection is that this category of health plan won’t need to cover the essential health benefits and can charge differently depending on gender and age. 

Missed Opportunities:

SB 1354 Graduate Medical Information & Student Loan Repayment

The final budget did make some investments that were included in this bill, but not all.  This bill would have done a great deal both in the short-term by boosting the primary care loan repayment program and really enhancing graduate medical education residencies over the coming years (important because where a practitioner does her or his residency greatly influences where they ultimately practice).

HB 2718 Syringe Services Programs

This bill would have decriminalized syringe access programs, currently a class 6 felony. To qualify, programs need to list their services including disposal of used needles and hypodermic syringes, injection supplies at no cost, and access to kits that contain an opioid antagonist or referrals to programs that provide access to an opioid antagonist.

SB 1088 Dental Care During Pregnancy

This bill would have expanded AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding. Good oral health is well established to improve birth outcomes including reducing pre-term birth while also preventing the transmission of caries from mom to infant after birth. 

SB 1174 Tribal Area Health Education Center

Health Education System consists of five area health education centers each representing a geographic area with specified populations that currently lack services by the health care professions.  

SB 1355 Native American Dental Care

This bill would have required AHCCCS to seek federal authorization to reimburse the Indian health services and tribal facilities to cover the cost of adult dental services.

SB 1245 Vital Records- Death Certificates

This bill would have made it clear that both state and county Registrars can provide certified copies of death certificates to licensed funeral home directors upon request.  There’s been some confusion about this authority and this bill would clear it up.

SB1399  School Health Pilot Program

This bill would have charged the AZ Department of Education with conducting a 3-year physical and health education professional development pilot program to improve the ability of physical and health educators in this state to provide high quality physical and health education to students in this state, improving student health and reducing Arizona health care cost containment 10 system and other health-related costs.

Others:

SB 1363  Tobacco Product Sales (Tobacco 21) (Carter)

HB 2162  Vaccine Personal Exemptions (Hernandez)

HB 2352 School Nurse and Immunization Postings (Butler)

HB 2172  Rear Facing Car Seats (Bolding)

HB 2246  Motorcycle Helmets (Friese)

SB 1219  Domestic Violence Offenses & Firearm Transfer

HB 2247  Bump Stocks (Friese)

HB 2248  Firearm Sales (Friese)

HB 2161  Order of Protection (Hernandez)

SB 1119 Tanning Studios (Mendez)

HB 2347  Medicaid Buy-in (Butler)

HB 2351  Medical Services Study Committee (Butler)

Bills that Didn’t Pass that We Opposed:

HB 2471 Informed Consent

This bill would add a requirement that physicians provide to parents and guardians the full vaccine package insert and excipient summary for each vaccine that will be administered.  Physicians already provide a Vaccine Information Summary to parents and guardians for each vaccine administered, which is noted in the medical record.  This new requirement would mandate provision of the 12-15 page insert, which is not presented in a format that incorporates health literacy principles.

HB  2472 Vaccinations- Antibody Titer

These bills would mandate that doctors inform parents and guardians that antibody titer tests (which involve a venous draw) are an option in lieu of receiving a vaccination and that there are exemptions available for the state requirements for attending school.

HB 2470 Vaccination Religious Exemptions

This bill would add an additional exemption to the school vaccine requirements into state law.  Currently there are medical and personal exemptions.  The bill doesn’t include any verification of the religious exemption from a religious leader, just a declaration from the parent that they are opposed to vaccines on religious grounds. 

Final 2019 Legislative Summary

The 2019 Legislative Session is in the books.  There were several good things that came out of Session this year.  Of course, there were also some missed opportunities that would have improved public health.  There were also a few close calls on bills that would have done some damage to public health.

The session ended Monday night when the House and Senate agreed on a series of budget bills.  Once those were passed and sent to the Governor, Legislators voted to adjourn for the year.

The budget highlights included funding to protect Arizona’s Kids Care program, some additional investment in the state loan repayment program and graduate medical education, some funding for prenatal care equipment in rural Arizona, needed funding for providers that serve folks with disabilities, and an appropriation of federal funds to draw down federal funds from the Child Care Block Grant. Disappointments in the budget included a failure to fund preventative oral health coverage for pregnant women and investing in the state’s 211 information hotline.

Here’s the subset of the budget that was passed related to public health and human services and a link to the health budget reconciliation bill:

 

Medicaid

  • Fully funds KidsCare and eliminates the risk of an enrollment freeze by paying the increased state match requirements that are coming up.  The language also eliminates the former trigger language that would have frozen KidsCare when the federal match requirement changes again.

  • Makes last year’s one-time $13M increase for providers that serve persons with developmental disabilities ongoing (because of the Prop 206 minimum wage increase) and an additional $13M in provider funding (rate increases) for the upcoming fiscal year.  There’s an additional $4M in provider rate increases for Prop. 206 impacted services for January 1, 2020 (this funding is for half a fiscal year to address the January 1, 2020 minimum wage increase). 

  • Provides new Prop 206 (minimum wage increase) funding for Elderly Long-Term Care (for persons with developmental disabilities) of $4.8M.

 

Child Care Subsidies

  • Appropriates $56M Childcare Block Grant funding (this is entirely federal funding- but the feds still require a state appropriation to draw down the funds). Will go a long way toward reducing the wait list for child care subsidies and will help improve reimbursement rates.


Miscellaneous Health Items

  • Appropriates an additional $750,000 for the State Loan Repayment Program (in addition to the current $1M/year).

  • Appropriates $1.6M for rural Graduate Medical Education ($5.5M w fed match) and $1.3M for urban GME ($4.4M w fed match)

  • $750,000 for North Country Graduate Medical Education

  • $1M for rural prenatal equipment

  • Provides $10M to the Housing Trust Fund for programs related to homelessness

  • $700K for Colorado City primary care clinic

  • $1.5M for Benson and Northern Cochise critical access hospitals

  • Continues $3M annual appropriation for TGEN for 3 years

  • Increases Alzheimer’s funding by $2M ($1M base)

  • Provides an additional $15M for an Arizona Department of Education school safety grant program for School Resource Officers, behavioral health counselors and social workers

  • Provides $1.6M for Veteran’s Suicide Prevention (includes $450K for trauma training)  

  • $8.0 million for the UofA Health Sciences Center

 

Arizona State Hospital

  • Provides $2.8M in pay raises for AZ State Hospital staff

  • Provides $300K for AZ State Hospital for a temporary staffing contract increase

I’m still in the process of putting together a PowerPoint that will summarize the legislative session.  Below is a summary of the various bills related to public health that passed followed by some of the missed opportunities and the close calls.

 

Bills Passed and Signed

 

Injury Prevention


SB 1468 Suicide Prevention Training

This new law will require school districts, charter schools, and Arizona teacher training programs to include suicide awareness and prevention training in their continuing education curricula.  It’ll require AHCCCS to make suicide awareness and prevention training available (fortunately some evidence- based tools curricula already exist).

Starting in the 2020 school year, school districts and charter schools would need to provide training in suicide awareness and prevention to school personnel in grades 6 to 12.  The bill also establishes requirements for suicide awareness and prevention training and specifically says that the training use evidenced-based training materials and instruct participants on how to identify the warning signs of suicidal behavior in adolescents and teens.

HB 2488 Veteran Suicide Annual Report

Requires ADHS (starting this year) to complete an annual report on veteran suicides in Arizona that includes the number and rate of veterans who died by suicide, trends, an analysis of the years of potential life lost, a comparison of Arizona’s resident veteran suicide rate to those of the nation, and the relative risk of suicide by race or ethnicity, age group, gender and region. 

The report is also supposed to analyze patterns of drugs, or combinations of drugs, that were used by Arizona’s resident veterans when drug poisoning was the mechanism of suicide. The idea is to create the surveillance and data linkages needed to inform suicide prevention strategies based upon medical risk factors that significantly correlate to suicide.

HB 2318 Hands Free Cell Requirement 

This bill was a long time coming- but were on the precipice of having this good public policy finally happen. It will prohibit using a hand-held cell phone while driving.  There are some common-sense exemptions for example if the person is using it hands free etc.  It’ll change driving behaviors and save lives.

Violations are a civil money penalty (no driving points) with the first offense being between $75- $150 and the 2nd offense between $150 and $250.  The bill would provide a state overlay so the cell phone use laws would no longer be different from jurisdiction to jurisdiction. Warnings for a year and a half – and then the penalties kick in.

Licensing Requirements

SB 1247 Residential Care Institutions

This good bill will require more robust staffing background checks for facilities that provide services for children and will remove the “deemed status” designation for child residential behavioral health facilities.   

Under the old law, facilities in this category (e.g. Southwest Key) can be accredited by a third party (e.g. Council on Accreditation) and avoid annual surprise inspections by the ADHS.  This intervention will provide more oversight to ensure background checks are done and that the facilities are compliant with state regulations. 

SB 1211 Intermediate Care Facilities

Like SB 1247, this bill closes a licensing loophole. This good bill will require more robust staffing background checks for facilities that provide services to people with disabilities at intermediate care facilities.  These facilities would also require a license to operate from the Arizona Department of Health Services beginning on January 1, 2020.  Under current law these facilities (Hacienda de los Angeles and similar facilities run by the ADES are exempt from state licensing requirements).

HB 1494 Medical Marijuana Testing

This bill will require medical marijuana dispensaries to test their product for potency and contaminants.  It will also require the ADHS to develop testing standards and laboratory certification criteria to implement the requirements. Still needs to be signed by the Governor.

Maternal & Child Health

SB 1040 Maternal Mortality Report

The new law will establish an Advisory Committee on Maternal Fatalities and Morbidity. It requires ADHS and the Committee to hold a public hearing to receive public input regarding the recommended improvements to information collection concerning the incidence and causes of maternal fatalities and severe maternal morbidity and complete a report (including recommendations) by the end of this year.

SB 1456 Vision Screening

This bill would require schools to provide vision screening services to students in grades prescribed by future ADHS rules, kids being considered for special education services, and students who are not reading at grade level by the third grade. Appropriates $100,000 from the state General Fund to the ADHS for the tracking and follow up.  

Access to Care

SB 1089 Telemedicine

Any healthcare service covered in-person by a commercial insurer will also be covered when provided through telemedicine. Currently, Arizona law limits telemedicine coverage to a handful of medical services.

SB 1109 Short Term Limited Health Plans

This authorizes the sale of short- term limited health plans in Arizona for terms up to 3 years.  The previous limit was 1 year.  These plans don’t cover pre-existing conditions and have limited consumer protection because they aren’t required to cover the essential health services under the ACA and can drop enrollees.  We urged a not vote because of the poor consumer protections.

SB 1085 Association Health Plans

This bill was passed by the House this week and is awaiting the Governor’s signature.  He’s sure to sign it. It basically provides a regulatory structure at the state level to regulate AHPs in AZ – serving to make them more available in Arizona. A primary concern for folks interested in public health and consumer protection is that AHPs don’t need to cover the essential health benefits, they can charge differently depending on gender and age. 

Missed Opportunities:


SB 1354 Graduate Medical Information & Student Loan Repayment

The final budget did make some investments that were included in this bill, but not all.  This bill would have done a great deal both in the short-term by boosting the primary care loan repayment program and really enhancing graduate medical education residencies over the coming years (important because where a practitioner does her or his residency greatly influences where they ultimately practice).

HB 2718 Syringe Services Programs

This bill would have decriminalized syringe access programs, currently a class 6 felony. To qualify, programs need to list their services including disposal of used needles and hypodermic syringes, injection supplies at no cost, and access to kits that contain an opioid antagonist or referrals to programs that provide access to an opioid antagonist.

SB 1088 Dental Care During Pregnancy

This bill would have expanded AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding. Good oral health is well established to improve birth outcomes including reducing pre-term birth while also preventing the transmission of caries from mom to infant after birth. 

SB 1174 Tribal Area Health Education Center

Health Education System consists of five area health education centers each representing a geographic area with specified populations that currently lack services by the health care professions.  

SB 1355 Native American Dental Care

This bill would have required AHCCCS to seek federal authorization to reimburse the Indian health services and tribal facilities to cover the cost of adult dental services.

SB 1245 Vital Records- Death Certificates

This bill would have made it clear that both state and county Registrars can provide certified copies of death certificates to licensed funeral home directors upon request.  There’s been some confusion about this authority and this bill would clear it up.

SB1399  School Health Pilot Program

This bill would have charged the AZ Department of Education with conducting a 3-year physical and health education professional development pilot program to improve the ability of physical and health educators in this state to provide high quality physical and health education to students in this state, improving student health and reducing Arizona health care cost containment 10 system and other health-related costs.

Others:

SB 1363  Tobacco Product Sales (Tobacco 21) (Carter)

HB 2162  Vaccine Personal Exemptions (Hernandez)

HB 2352 School Nurse and Immunization Postings (Butler)

HB 2172  Rear Facing Car Seats (Bolding)

HB 2246  Motorcycle Helmets (Friese)

SB 1219  Domestic Violence Offenses & Firearm Transfer

HB 2247  Bump Stocks (Friese)

HB 2248  Firearm Sales (Friese)

HB 2161  Order of Protection (Hernandez)

SB 1119 Tanning Studios (Mendez)

HB 2347  Medicaid Buy-in (Butler)

HB 2351  Medical Services Study Committee (Butler)

 

Bills that Didn’t Pass that We Opposed:

HB 2471 Informed Consent

This bill would add a requirement that physicians provide to parents and guardians the full vaccine package insert and excipient summary for each vaccine that will be administered.  Physicians already provide a Vaccine Information Summary to parents and guardians for each vaccine administered, which is noted in the medical record.  This new requirement would mandate provision of the 12-15 page insert, which is not presented in a format that incorporates health literacy principles.

HB  2472 Vaccinations- Antibody Titer

These bills would mandate that doctors inform parents and guardians that antibody titer tests (which involve a venous draw) are an option in lieu of receiving a vaccination and that there are exemptions available for the state requirements for attending school.

HB 2470 Vaccination Religious Exemptions

This bill would add an additional exemption to the school vaccine requirements into state law.  Currently there are medical and personal exemptions.  The bill doesn’t include any verification of the religious exemption from a religious leader, just a declaration from the parent that they are opposed to vaccines on religious grounds. 

Legislative Budget Negotiations Underway & Several Public Health Initiatives in the Mix

All signs are that the Legislature is focusing on building a budget for next fiscal year.  The Republican leadership in the House and Senate met with representatives from the Governor’s Office over the weekend to come up with a budget proposal.  Here’s a link to the proposed budget worksheet.

It’s still unclear whether they have a plan that’ll pass. Several issues stand in the way – including a dispute about the statute of limitations for sexual assault victims and other specific priorities that some lawmakers are linking to their support of a budget.  Committee hearings on the spending plan won’t occur until Wednesday at the earliest (if they happen this week at all).

Some of our priorities are included in the weekend proposal (e.g. KidsCare funding & an appropriation for federal funds for child care subsidies), but several other priorities aren’t included (increases in the AZ primary care and loan repayment program and for additional primary care residencies).  Also not included is preventative dental services for pregnant Medicaid members.

Now would be a really good time for you to use any relationships you have with legislators to let them know that you support the encouraging portions of the initial proposal (e.g. KidsCare) but you believe more needs to be done to support access to care in rural and underserved areas by investing in the state’s loan repayment program and through increased residency opportunities (GME), as well as preventative dental care for pregnant Medicaid members.

Here’s the subset of the budget proposal related to public health and human services:

Medicaid

  • Fully funds KidsCare and eliminates the risk of an enrollment freeze by paying the increased state match requirements that are coming up (FY20 = $1.6M, FY21 = $9.4M, FY22 = $9.4M) 

  • Makes last year’s one-time $13M increase for providers that serve persons with developmental disabilities (because of the Prop 206 minimum wage increase) ongoing.  The proposal also includes a $6.7M cap rate increase for the current year for those providers.  Proposes an additional $13M in provider funding for the upcoming fiscal year.

  • Provides new Prop 206 (minimum wage increase) funding for Elderly Long-Term Care (for persons with developmental disabilities) of $4.8M

Child Care Subsidies

  • Appropriates $56M Childcare Block Grant funding (this is entirely federal funding- but the feds still require a state appropriation to draw down the funds)

Arizona State Hospital

  • Provides $2.8M in pay raises for AZ State Hospital staff 

  • Provides $300K for AZ State Hospital for a temporary staffing contract increase

Miscellaneous Health Items

  • Increases Alzheimer’s funding by $2M ($1M base)

  • Proposes $1M for rural prenatal equipment

  • Proposes $700K for Colorado City primary care clinic

  • Proposes $1.5M for Benson and Northern Cochise critical access hospitals

  • Continues $3M annual appropriation for TGEN for 3 years

  • Provides $10M to the Housing Trust Fund for programs related to homelessness

  • Provides an additional $15M for an Arizona Department of Education school safety grant program for School Resource Officers, behavioral health counselors and social workers

  • Provides $1.6M for Veteran’s Suicide Prevention (includes $450K for trauma training)  

This part of the legislative session is very fluid and things can move quickly or completely stall out at any time.  

Now would be a really good time for you to use any relationships you have with legislators to let them know that you support the encouraging portions of the initial proposal (e.g. KidsCare) but you believe more needs to be done to support access to care in rural and underserved areas by investing in the state’s loan repayment program and through increased residency opportunities (GME), as well as preventative dental care for pregnant Medicaid members.

To find your Senator and Representative go to: https://www.azleg.gov/findmylegislator/

Arizona Research will Change EMS Brain Injury Care

Traumatic brain injury is involved in about 1/3 of all injury-related deaths… it’s clearly a public health issue.  That’s why back in 2013 Arizona created the Excellence in Pre-hospital Injury Care (EPIC) project- which has been aimed at improving brain injury outcomes in AZ. 

Back in 2013 the National Institutes of Health chose AZ as the only state to evaluate the national standards for pre-hospital emergency care of brain injury (under a grant application led by AZPHA member Ben Bobrow, MD). 

EPIC has been a unique partnership between state government, the U of A and more than 130 fire departments and ground/air ambulance companies.  Together they implemented a series of pre-hospital traumatic brain injury treatment interventions and measured the effectiveness of the results.

The interventions included: 1) prevention of hypoxia by early oxygen administration; 2) airway interventions to optimize oxygenation; 3) prevention of hyperventilation; and 4) quickly treating low blood pressure by infusing fluids.

Participating EMS agencies sent treatment information to the ADHS and the UA College of Medicine for tracking and evaluation. An early donation from the Ramsey Justice Foundation made it possible for the agencies to receive special breathing devices to implement the new protocol and assist in the treatment patients at no cost.

More than 5 years of work by literally hundreds of Arizonans resulted in the publication of the results this week in JAMA Surgery entitled Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines with Patient Survival Following Traumatic Brain Injury.

Remarkably, the team found that implementation of the protocol doubled the chances of survival among persons with a critical traumatic brain injury and improved neurological outcomes. Doubling the chances of survival is no small thing for a public health intervention, so this is really a landmark study.

This Arizona study will change the way EMS providers treat traumatic brain injury in the field around the globe. That shows the importance of publishing. When hard work like this with dramatic results is published in reputable journals- people take note. It won’t be long before the Arizona protocol becomes a global EMS standard for traumatic brain injury care. For more info go to www.epic.arizona.edu.

A huge public health thank you to the entire research team including Dan Spaite, MD; Ben Bobrow, MD; Sam Keim, MD, MS; Bruce Barnhart, RN, CEP; Vatsal Chikani, MPH; Joshua Gaither, MD; Duane Sherrill, PhD; Kurt Denninghoff, MD; Terry Mullins, MPH, MBA; P. David Adelson, MD; Amber Rice, MD, MS; Chad Viscusi, MD; and Chengcheng Hu, PhD.

Washington Passes Medicaid Buy-In Law

This week Washington Governor passed the nation’s first Medicaid buy-in law.  The new law will offer a new health insurance option to people who make too much money to qualify for Medicaid but not enough to afford private health coverage. 

Washington’s new law directs their state Medicaid agency to contract directly with at least one private health insurer to offer a “qualified health coverage” plan that meets Affordable Care Act standards on the state’s marketplace. It will expand subsidies to people making up to 500% of the federal poverty line, or $62,450 a year, for a single person.

The tiered public plans are expected to be up to 10% cheaper than comparable private insurance, in part because of savings from a cap on rates paid to providers. The WA public plans are set to be available to all residents regardless of income by 2021.  Here’s more info in a Time Magazine article from this week.

In addition to Washington, legislation to study or start a public option or Medicaid buy-in program is currently pending in Colorado, Connecticut, Maine, Massachusetts, Minnesota, Missouri, New Hampshire, New Jersey and Oregon.

The basic idea is to leverage the buying power of state Medicaid programs to negotiate better premium rates that offer a lower-cost alternative to the health-care marketplace and spur competition which would lower premiums overall.

Washington State Eliminates the Personal Exemption for MMR

Washington’s Governor also signed a new law this week that will eliminate the “personal exemption” that parents can sign to exempt their kids from school and pre-school vaccination attendance requirements. 

Interestingly, the new law just eliminates the personal exemption for the MMR (measles, mumps, rubella) vaccine.  The personal exemption option will still be available for the other school-required vaccines.  The new law will be effective before the start of this year’s school season.

Washington lawmakers overcame strong lobbying by anti-vaccine groups who mobilized hundreds of supporters, who telephoned and sent emails to lawmakers, and turned out in large numbers for the hearings.

As is often the case, a protracted outbreak created the political will to pass the measure.  Earlier this year Washington declared a  state of emergency after officials reported 25 measles cases. The cases continued to climb – and so far 78 measles cases have been confirmed in Washington and neighboring Oregon.

As is the case in AZ, Washington has seen a consistent increase in the number of kids whose parents have exempted them from vaccination school enrollment requirements.  In fact, Washington’s exemption rate for Kindergarteners is 4.7%.  Arizona’s exemption rate is even worse than Washington’s- as the exemption rates for Kindergarten went up this year to 5.9%.

It’s only a matter of time before Arizona has a Washington/Oregon style outbreak.  Most likely it’ll be in a place like Yavapai County- which has the state’s lowest immunization rates.  There’s a good chance it’ll start when an unvaccinated Arizonan returns from Europe with measles and spreads it within their community.

AzPHA Letter to AHCCCS Urging them to Consider Adding Additional Opioid Use Disorder Medications

AzPHA sent the following letter to AHCCCS’ Pharmacy & Therapeutics Committee (which meets next Thursday), urging them to consider expanding the MAT Preferred Drug List for treating AHCCCS members with an opioid use disorder.  This work fits under the Administrative Advocacy portion of our mission.

I write on behalf of the Arizona Public Health Association – one of Arizona’s oldest and largest membership organizations dedicated to improving the health of Arizona citizens and communities. An affiliate of the American Public Health Association, our members include health care professionals, state and county health employees, health educators, community advocates, doctors, nurses and students.

Thank you for the opportunity to comment on the Pharmacy & Therapeutics Committee’s recommendation regarding the Preferred Drug List for Medication-Assisted Treatment (MAT) for opioid use disorder.

As Governor Ducey correctly declared, opioid addiction and abuse constitutes a public health emergency in Arizona.  While the Arizona Opioid Epidemic Act passed last year included several evidence-based interventions that will have an impact on the public health crisis over time, we believe that additional measures are necessary to improve MAT options for clinicians and patients.  In the area of medication options, we believe that more should be done to improve the therapeutic options available to clinicians as they treat patients for opioid use disorder. 

Buprenorphine products have demonstrated clinical efficacy in treating individuals with opioid addiction. There are now several FDA approved medications which each work differently and exist in several forms, strengths, and routes of administration.  Physicians treating AHCCCS members with opioid use disorder should be able to take advantage of the growing number of therapeutic options and be able to select the optimal medication in consultation with their patient.

The current PDL for AHCCCS members provides one buprenorphine treatment option: Suboxone film. While this medication may be the best currently available FDA approved option for many patients, evidence suggests that other patients may respond more positively to some of the other alternatives that are now FDA approved.

While “non-preferred” MAT options can be obtained by physicians via pre-authorization for Medicaid members, the process represents an unnecessary barrier to treatment. Time is of the essence when treating patients with opioid use disorder, and delays between when an individual decides to seek treatment and begins his/her regimen can reduce the likelihood of treatment success.

In summary, we ask that the Pharmacy & Therapeutics Committee recommend that AHCCCS open the Preferred Drug List to additional FDA-approved MAT medications.  When evaluating the list of FDA approved medications for the Preferred Drug List, we urge the Committee and AHCCCS to take into consideration the various FDA approved forms, strengths, and routes of administration as well as individual medication risks for diversion and accidental poisoning. 

Using those criteria, we believe the Committee can responsibly recommend an expansion of the MAT Preferred Drug List for treating AHCCCS members with an opioid use disorder that would improve outcomes for Medicaid members with an opioid use disorder.

We commend the Governor, our state legislators, and the staff at the ADHS and AHCCCS for recognizing the public-health threat posed by opioid abuse and taking concrete steps to implement evidence-based interventions to save lives.  Expanding options for MAT would be an additional concrete step toward that end.

Legislative Update

Not a ton news since last week. I’m beginning to sound like a broken record.

On the e-cigarette and smoking front, the good bill (HB 2357) remains in limbo- as it’s passed the full Senate and got through it’s Conference Committee- but wasn’t called to the floor of the House for a vote again this week.

The competing- not so good bill- SB 1147 passed on a voice vote through the Committee of the Whole in the House- but didn’t make it to a floor vote this week. 

Other than that, legislators are mostly focused on the budget negotiations.  There are a few items we’ll need to ask you to press for in the next couple of weeks with the legislators in your district including:

1) preventative and comprehensive oral health services for pregnant Medicaid members;

2) increased investment in funding for the state loan repayment program and health profession residencies (especially for primary care); and

3) funding Kids Care.

In addition, there’s an important $65M appropriation of federal funds that needs to be made to provide additional subsidies for child care services for folks that qualify- along with a needed increase in reimbursement rates. No state dollars are needed- simply an appropriation of the federal funds that have been allocated to AZ.

A Tale of 2 Vape Bills

This week featured a dual between bills that say their goals are to address the vaping epidemic.  One does and one doesn’t.

The Good Bill

This week the Senate approved (29-0) a bill from Senator Carter (a strike amendment HB 2357) that would classify vaping products in the same category as tobacco.

That means vape pens and the like would be subject to the same laws and rules that govern sales and where you can use them (e.g. vaping would be covered under the Smoke Free Arizona Act). It would also continue to allow cities and towns to impose their own stricter regulations.   HB 2357 would continue to keep the sale age at 18 (rather than 21 which would be ideal) but it would still allow communities to adopt and keep their own ordinances which have raised the age for the purchase of tobacco and vaping products to 21.

After passing the Senate unanimously (as the e-cig version) it went to a Conference Committee a couple of days ago and passed through unanimously. Looks like it’ll be up for a floor vote on Monday in the House.

Now would be a great time to get with your 2 Representatives and let them know you support 2357 because it’s a common-sense bill that defines e-cigarettes as a tobacco product and would remove vaping from public spaces, workplaces and schools.

The Not Good Bill

The tobacco bill dualing for attention is SB 1147 (a different striker bill) which I blogged about last week.  It would set the minimum age statewide for tobacco possession at 21 but it would override lots of other local ordinances about how tobacco and vaping products could be sold and would allow only “reasonable” zoning regulations about where sales can take place.

Another bad thing about SB 1147 is that e-cigs would be in a separate legal category from tobacco meaning it would specifically exempt vaping products from the Smoke Free Arizona Act (vaping didn’t exist when the Smoke Free AZ Act passed in 2006).

This one will likely see a House floor vote next week too.  If it passes it would also need a conference committee because the original Senate version was completely different (about city development). If it gets through the conference committee- it would need another Senate floor vote.

Legislative Update

Not a ton news since last week. The main thing that happened this week is that the Governor signed a good bill on suicide prevention (more info below). He also signed a bill that will make Association Health Plans more available in AZ. Info on that below too.  Last week’s  Legislative Update covers things pretty well so far.

Other than that, we’re moving full force into the budget negotiations process now. By all accounts it looks to be a more deliberative process than in years past because of the tight party affiliation margins and the disconnect between the executive budget priorities and those of the legislature. It’s likely that we’ll have at least a few more weeks before a final budget is complete- and it might even go into June this year. 

SB 1468 Suicide Prevention Training

It will require school districts, charter schools, and Arizona teacher training programs to include suicide awareness and prevention training in their continuing education curricula.  It’ll require AHCCCS to make suicide awareness and prevention training available (fortunately some evidence- based tools curricula already exist).

Starting in the 2020 school year, school districts and charter schools would need to provide training in suicide awareness and prevention to school personnel in grades 6 to 12.  The bill also establishes requirements for suicide awareness and prevention training and specifically says that the training use evidenced-based training materials and instruct participants on how to identify the warning signs of suicidal behavior in adolescents and teens.

SB 1085 Association Health Plans (AzPHA Opposed)

This bill was passed by the House this week and is awaiting the Governor’s signature.  He’s sure to sign it. It basically provides a regulatory structure at the state level to regulate AHPs in AZ – serving to make them more available in Arizona. A primary concern for folks interested in public health and consumer protection is that AHPs don’t need to cover the essential health benefits, they can charge differently depending on gender and age. 

Additionally, we’re concerned that if an employer offers a “skinny” benefit plan that barely meets the definition of minimum value (and doesn’t include important essential health benefits) families could be prevented from benefitting from the subsidies that would otherwise be available to them on the Marketplace.

Back in August (at the direction of the President) the US Department of Labor issued a final rule that established criteria for determining when employers can join in an association and be treated as an employer sponsor of a group health plan.  The federal regulation loosens the rules for additional plans to come onto the market, allowing more small businesses including individuals who work for themselves to join these plans.  This bill will make these plans more available in AZ.

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