AzPHA Urges No Vote On Phoenix Proposition 105

A light rail extension on Central Avenue in South Phoenix will have a long-lasting, positive impact on community health in South Phoenix.  That’s not just an opinion, that comes from a scientific and detailed 2015 Health Impact Assessment by the Maricopa County Department of Public Health and the Arizona Alliance for Livable Communities.

The South Central Neighborhoods Transit Health Impact Assessment concludes that a thoughtfully planned transportation plan that includes a light rail extension in South Phoenix will result in positive long-term health outcomes for residents, including lowering rates of chronic disease, improving pregnancy outcomes, and reducing violent deaths.

The City of Phoenix’s current transportation plan has been developed over a decade and approved by voters 3 times.  The public has been heavily engaged in this planning effort which has included more than 500 public meetings held to gather input.

Proposition 105 will dismiss this planning and prohibit Phoenix from investing in any kind of rail project – including light rail, commuter rail, or other potential train connections despite the fact that light rail extension have a long-lasting positive public health impact and reinforce the positive aspects of the community.

The Existing Transportation Plan is Good

Four years ago, Phoenix voters passed Proposition 104, a comprehensive transportation plan that included input from public health stakeholders.  The plan incorporated evidence-based provisions to improve many facets of transportation – including things to make transportation easier for folks with disabilities and improving opportunities for physical activity with more walkable and bike-able transportation options.

The voter approved plan extended Phoenix’s existing 4/10ths of a cent transportation sales tax (originally passed in 2000) and increased it by 3/10ths of a cent to:

  • Greatly enhancing Dial-a-Ride for persons with disabilities;

  • Add 1,150 new bike lanes;

  • Add 170 miles of new sidewalks;

  • Increase bus frequency by 70%;

  • Increase transit hours of operation by 20%;

  • Invest $280 million for new roads and bridges;

  • Repair 750 miles of asphalt streets; and

  • Increase investments in light rail.

Phoenix’s existing Plan is well-balanced to provide various services based on differing community needs, contributing to improved transportation flexibility options and improving social determinants of health related to transportation.

For example, the existing transportation plan includes substantial investment in new transportation options in South Phoenix including a light rail extension.  That’s important because South Phoenix households are four times more likely to not have a car compared to other households throughout the Valley. 

The existing plan also enhances public transit services to South Phoenix and provides families with convenient access to key destinations such as work and school. In fact, over 70% of South Phoenix residents voted in favor of the current transportation plan. 

For all these reasons the Arizona Public Health Association urges Phoenicians to VOTE NO on Proposition 105.  Our health depends on it.

Thank you for a Successful FY 18-19!

We’ve had a terrific FY-19 as an organization.  Our membership has grown more than 30% in the last two years and we’ve been increasingly becoming a force for positive public health policy development.  We also have a growing list of Organizational Membership supporters- which you can view on our Supporters Page: https://azpha.org/oursupporters 

Here’s a link to our end of FY-19 MEMBERSHIP REPORT and some current membership SUMMARY CHARTS.  As a refresher- here’s a link to our PowerPoint Summary of the 2019 Legislative Session (PDF)

Maternal Morbidity & Mortality in AZ to be Examined

The US has the highest maternal mortality rate of any developed country.  Sadly, it’s getting worse each year.  About 800 American women die and 65,000 almost die during pregnancy or childbirth. The number of deaths in AZ jumped from around 10 in 2015 to about 30 in 2016 (the last year for which ADHS has data posted- the numbers are cell-suppressed to protect confidentiality). 

Nationally, back women die from pregnancy-related causes at three to four times the rate of white women, even after controlling for social determinants. Women in rural areas also have higher maternal mortality rates than urban women.  Here’s a story that highlights some of the issues in an easy to read way.

Evidence-based policy making is a key.  Twenty-nine states (including Arizona) have committees that review maternal deaths and make public policy recommendations.  Arizona took a big step forward this last legislative session with the passage of SB 1040 Maternal Mortality Report which 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.

Syringe Services: A Proven Public Health Intervention that Saves Lives

Arizona Law is Having Chilling Effect

The opioid epidemic is one of the greatest public health crises of our time.  The roots that caused the epidemic are deep and the public health interventions that will be needed to ease the crisis are many.  Those interventions include dramatic changes to prescribing practices, things like the distribution of naloxone, more robust treatment options including Medically Assisted Treatment, and harm reduction and engagement strategies like Syringe Services.

We need all those tools working together in order to mount an effective response.  Last year’s Arizona Opioid Epidemic Act was an important new law that is addressing many of those factors- but not all.  A real outlier is that the Act didn’t make an important change that is needed in Arizona – decriminalizing syringe service programs. As this excellent report by Stephanie Innes in the Republic this week shows, needle exchange efforts in Arizona have been impaired because some of the things that syringe service programs do are considered felonies under state law.

Syringe services programs are community-based prevention efforts that offer a range of interventions. They provide access to and disposal of sterile syringes and injection equipment, linkage to substance use disorder treatment, and naloxone distribution.  People who use syringe service programs gain access to other vital services including vaccination, testing, and linkage to care and treatment for infectious diseases including viral hepatitis and HIV. 

Nearly 30 years of research shows that comprehensive syringe service programs are safe, effective, and reduce overall health costs. They play an important role in reducing the transmission of viral hepatitis, HIV, and other infections and are a major component of the Ending the HIV Epidemic: A Plan for America initiative. The U.S. Surgeon General determined that syringe service programs don’t increase the illegal use of drugs by injection. Studies also show that they protect the public and first responders by providing safe needle disposal.

Sadly, syringe service programs in Arizona are illegal because syringes are considered drug paraphernalia under Arizona law (a class 6 felony). While arrests, indictments and convictions of workers that operate syringe service programs are rare- the fact that syringe service programs are illegal has a marked chilling effect on the ability of organizations and individuals to operate and fund these important programs. 

After all- it’s pretty hard to get a grant award if you need to disclose to the funder that you intend to commit felonies with the money!

A cohort of public health organizations led by Sonoran Prevention Works have been trying for the last few years to simply decriminalize syringe service programs.  Pretty simple, right?

Sadly, the effort has been unsuccessful. 

In 2018 HB 2389 Syringe access programs; authorization passed the full House of Representatives, was dramatically weakened by a poor amendment in the Senate but ultimately failed to come out of a Conference Committee.  This year, HB 2148 Syringe Services Programs failed to even make it to the House Floor for a vote.

Public health stakeholders will continue to try to get our Legislature to pass a bill that will decriminalize this important evidence-based public health practice.

By the way, the CDC has released materials that health departments can use to provide information on the critical role of SSPs in prevention and treatment, including:

  • A summary of information on the safety and effectiveness of SSPs in reducing viral hepatitis and HIV;

  • A fact sheet outlining the various ways syringe service programs can prevent transmission of blood-borne infections and link people to care, reduce and treat substance use, and enhance public safety;

  • A fact sheet for health departments and community partners that defines syringe service programs and their public health impacts; and

  • Frequently asked questions and answers about syringe service programs.

All of these materials are available to you online on the CDC’s Syringe Services Programs website.

Here’s a statement from the CDC on the subject: “It is our hope that by sharing these materials with you, we will engage the full strength of the nation’s public health and community infrastructure to reduce the toll of opioids and infectious diseases in our communities. We have the tools. We have the science. We can work together to improve the health and security of current and future generations.”

Federal Court Decision Allows Implementation of the New Title X Family Planning Rules

The new regulations eliminate Title X’s long-standing requirement for non-directive pregnancy options counseling and requires a “bright line” of physical and financial separation between the provision of family planning and abortion services

Title X is a super important public health program that provides folks with comprehensive family planning and related preventive health services. It’s designed to prioritize the needs of low-income families or uninsured people. Its overall purpose is to promote positive birth outcomes and healthy families by allowing individuals to decide the number and spacing of children.

The services provided by Title X grantees (the funding comes from the federal government) include family planning and contraception, education and counseling, breast and pelvic exams, breast and cervical cancer screening, screenings and treatment for sexually transmitted infections and HIV.  It also focuses on counseling, referrals to other health care resources, pregnancy diagnosis, and pregnancy counseling. Title X funding does not pay for abortions.

Back in March of this year, the US Department of Health & Human Services published in the Federal Register a final rule making changes to the federal regulations governing the Title X national family planning program. The final rules dramatically change the existing Title X family planning program nationally and in AZ.  The changes include:

  • Eliminating Title X’s long-standing legal and ethical requirement for non-directive pregnancy options counseling; and

  • Requiring a “bright line” of physical and financial separation between the provision of family planning and abortion services.

Numerous provider groups, state attorneys general and non-profit organizations sued and sought an injunction after the new Rules were announced in March (seeking an injunction to stop the rule from taking effect while the courts decide the legality of the rule). 

Legal History of the Case

Multiple federal district court judges blocked the new restrictive rules from going into effect. On June 20, 2019, a three-judge panel of the Ninth Circuit Court of Appeals granted the Trump Administration’s request to lift the preliminary injunctions, allowing the new Title X rules to be enforced. In early July, the 9th Circuit court ordered the cases be reheard en banc (meaning by all the judges on the 9th circuit versus a three-judge panel).

On July 11, the en banc court refused to block the new Title X rules from taking effect, rejecting 20 states, the District of Columbia, and reproductive right advocates request to impose an emergency stay (indefinitely or temporarily suspend or stop proceedings).

So, what’s the bottom line then?  For now- the new April Title X Rules that eliminate Title X’s long-standing legal and ethical requirement for non-directive pregnancy options counseling, and requiring a “bright line” of physical and financial separation between the provision of family planning and abortion services stand.  There have been mixed signals from HHS whether Title X grantees will be contractually required to immediately comply with the new rules or not. 

Earlier last week, published accounts suggested that HHS would be requiring immediate compliance with the new rules by their Title X contractors (including the Arizona Family Health Partnership).  Later in the week, journalists quoted anonymous HHS sources suggesting that Title X grantees wouldn’t be immediately required to adjust their business processes. Late Saturday night grantees got a letter saying the HHS “does not intend to bring enforcement actions against clinics (grantees) that are making good faith efforts to comply” with the new rules. Perhaps grantees (including the Arizona Family Health Partnership) will hear something more specific this week.

Most likely there will be an appeal and rehearing of the challenge to the April Rules in the coming weeks.

A big thanks to AzPHA members Hannah Fleming, Leila Barraza and James Hodge for helping to straighten out this complicated legal case!

Sign on to this Letter to Support Policies that Encourage Vaccination

We invite you to express your support for immunization requirements for public school attendance, vaccine education and informed use of appropriate vaccine exemptions by signing a letter of support to the Governor. The letter includes the Arizona Medical Association Resolution adopted in 2015. Practicing physicians, nurses and pharmacists from across the State of Arizona believe vaccine education is essential to the health of our children and our communities.

CLICK HERE and add your name to the growing list of Arizonans that believe that we must protect Arizona children against vaccine preventable diseases and protect community immunity that protects the most vulnerable among us.  Here’s a copy of the letter you’d be signing on to:

Dear Governor Ducey,

We, the undersigned, want to express our full support for this resolution adopted by the Arizona Medical Association (ArMA):

“ArMA supports adopting requirements that parents (or guardians) who do not wish to have their children vaccinated receive public health-approved counseling that provides scientifically accurate information about the childhood diseases, the available vaccines, the potential adverse outcomes from catching diseases, the risks unvaccinated children pose to children who cannot be vaccinated for medical reasons, the risks of vaccine side effects, and the procedures that are implemented to exclude unvaccinated children if an outbreak of disease occurs in the area administered by the local or state public health agency.

ArMA also supports adopting requirements that parents annually sign an affirmative statement that acknowledges the risks they are accepting for their own children and the children of others by claiming a personal exemption from mandatory vaccination requirements.”

As residents of Arizona, we actively support and encourage you to work with the Arizona Department of Health Services (ADHS), all County Health Departments, and longstanding partners of The Arizona Partnership for Immunization (TAPI) to maintain high levels of immunization coverage rates in our schools and our communities…to keep your constituents safer and healthier.

Respectfully,

A.D. Jacobson, M.D.
Steering Committee Chair
The Arizona Partnership for Immunization

WHO Declares the DRC Ebola Outbreak a Public Health Emergency

Decision will Amplify Intervention Efforts

The WHO declared the Ebola virus disease outbreak in the Democratic Republic of the Congo a Public Health Emergency of International Concern this week. The declaration follows several decisions in the last few months to not make that call. 

The WHO cited recent developments in the outbreak in making its recommendation, including the first confirmed case in Goma (a city of almost 2M and a major transportation hub).  The outbreak has been underway for more than a year now and there have been insufficient resources including funding to fight the outbreak – impairing the effectiveness of the public health interventions. 

Policy interventions for controlling Ebola are dicey because of the need to protect livelihoods of the people most affected by the outbreak by keeping transport routes and borders open. Interventions that effect travel and trade can have negative economic consequences, but not implementing some restrictions can impair the public health response.

The WHO made the following recommendations that relate to the declaration:

Strengthen community awareness, engagement, and participation, including at points of entry to identify and address cultural norms and beliefs that are barriers to the response.

Improve cross-border screening and screening at main internal roads to ensure that no contacts are missed and enhance screening through improved sharing of information with surveillance teams.

Enhance coordination with the UN and partners to reduce security threats to enable public health operations.

Strengthen surveillance and reduce the time between detection and isolation and implementing interventions.

Optimal vaccine strategies that have maximum impact on curtailing the outbreak should be implemented rapidly (they are using a ring-vaccination strategy).

The public health tools are available to eliminate the transmission of Ebola in the DRC. The challenge is really getting the resources deployed and implementing the proven intervention methods. Plus, and important new tool- an Ebola vaccination- is now available (it was not widely available during the 2014 West African epidemic). Security concerns, local and regional infrastructure, cultural practices and access to care are all important factors that need to be addressed in order to stop the on-gong transmission of the virus.

In an example of what the Declaration can do- the Congolese government this week tasked the military and policy with enforcing hand-washing and fever checks in Kivu Province.

AHCCCS to Begin Covering Pre-Exposure Prophylaxis for HIV

Last month the United States Preventive Services Task Force (USPSTF) listed Preexposure Prophylaxis for the Prevention of HIV Infection (PrEP) as a Category A Preventive Health Service.  That’s an important designation because it means that PrEP will now be included (at no cost to consumers) in all Qualified Health Plans during the next contract year. The final recommendation statement can also be found in the June 11 issue of JAMA.

The task force found convincing evidence that PrEP is of substantial benefit in decreasing the risk of HIV infection in persons at high risk of HIV acquisition.  They conclude that PrEP is associated with small harms, including kidney and gastrointestinal adverse effects and that (with high certainty) the benefit of PrEP (with oral tenofovir disoproxil fumarate–based therapy) is substantial.

Pre-exposure prophylaxis (or PrEP) lowers the chances of getting infected with HIV even if the person otherwise engages in risky sexual behavior.  PrEP can stop HIV from taking hold and spreading through the body and is highly effective for preventing HIV if used as prescribed (but it is much less effective when not taken consistently).  Daily PrEP reduces the risk of getting HIV from sex by more than 90%. Among people who inject drugs, it reduces the risk by more than 70%.

This week AHCCCS announced that they’ll be covering PrEP medications as a benefit for their members beginning on October 1, 2019…  a solid public health move that will lower the transmission of HIV in Arizona. The move will likely produce a positive return on investment also, as preventing HIV is much less expensive than treating persons infected with the virus. PrEP (Truvada) will be on their preferred drug list without Prior Authorization starting 10/1/19.

Maricopa County Seeking Hepatitis A Intervention Strike Team Volunteers 

AHCCCS Policy Change Assisting the Response

Maricopa County is part of a statewide hepatitis A outbreak mostly affecting folks experiencing homelessness, substance use and/or recent incarceration. 229 people have been reported with the disease and more than 80% have been hospitalized. The Maricopa County Department of Public Health is working with community partners to vaccinate the people at highest risk…  both to protect them from getting sick and to stop the disease from spreading further.  

The public health response consists of: 1) vaccinating everyone in the county jail system for the next 8 months; 2) deploying vaccination and service strike teams (with other organizations); and 3) partnering with cities and parks to go to homeless encampments and offer vaccination in Strike Teams.

They’re recruiting volunteer healthcare providers and screeners (no healthcare experience needed) for the vaccine outreach events. If you’re interested in volunteering, please contact PHVolunteer@maricopa.gov.

In addition, AHCCCS now covers medically necessary covered immunizations for people 19 years of age and up when the vaccines are administered by AHCCCS registered providers through county health departments. Immunizations are covered even if the AHCCCS registered provider isn’t in the member’s health plan network. The list of covered vaccinations includes (but isn’t necessarily limited to) Hepatitis A & B and Measles.

Policy changes like this make a big difference in the effectiveness of public health interventions like the ones associated with this Hep A outbreak – and they also sets up a system that will be better able to prevent future outbreaks.

Federal 5th Circuit Court Signals New Threat to the ACA

Health Care Increasingly Looking Like a Major Campaign Topic for 2020

Background on the 2012 Ruling Upholding the ACA

In the 2012 Ruling that upheld the ACA, Chief Justice Roberts wrote that: “… the Affordable Care Act’s requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a taxbecause the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.” 

Roberts rejected the Obama Administration’s argument that the federal government’s authority to regulate interstate commerce provides the authority needed for the ACA to be constitutional (the Court struck down that argument 5-4).  Fortunately, the court held (5-4) that the ACA was constitutional based on the federal government’s taxing authority.

The Texas v Azar Challenge

Last week the 5th US Circuit Court of Appeals heard the Texas v Azar case which, once again, challenges the constitutionality of the Affordable care Act. Arizona is a party to the case and is supporting the suit (to overturn the ACA).

This latest challenge essentially argues that the ACA is no longer constitutional because the tax penalty for not having health insurance has been eliminated. 

All the media reports that I found about the questions they were asking and the statements they were making suggest that the appellate court may rule that the ACA is unconstitutional (now that the tax penalties for not having insurance are gone) – which would send the case up to the Supreme Court.

Protections at Risk

In addition to the coverage that the ACA provides through Medicaid expansion and the availability of Marketplace Plans with subsidies, the ACA has a ton of health insurance reform measures including preventing commercial health insurance companies from:

1) denying someone health insurance because they have a preexisting condition -called the “guaranteed issue” requirement;

2) refusing to cover individual services that people need to treat a pre-existing condition- called “pre-existing condition exclusions”; and

3) charging a higher premium based on a person’s health status – called the “community rating” provision.

Supreme Court Forecast

Because of the makeup of the 5th Circuit Court of Appeals (and the signals they sent through their questions at the hearing this week) the Court will likely uphold O’Connor’s decision to invalidate the ACA and the case will probably end up with the US Supreme Court…  which has a different cast of characters than it did when the ACA was originally upheld back in 2012 by a 5-4 vote.

Since the 2012 decision upholding the ACA, Gorsuch has replaced Scalia and Kavanaugh has replaced Kennedy.  Both Scalia and Kennedy voted to overturn the ACA- so not much on that score has changed.

Chief Justice Roberts voted with the majority that upheld the law. His argument rested on the ACA’s link to the financial penalties for not having health insurance. But remember, the financial penalties for not having health insurance were removed from the IRS tax codes in last year’s federal tax overhaul, pulling out the structure that Roberts used in his argument.

The bottom line is that the ACA, including its protections for folks with pre-existing conditions, may very well be in jeopardy if Roberts views the ACA as fundamentally different now that the financial penalties are gone.

Healthcare’s Link to the 2020 Election

If a decision comes from the 5th Circuit in the next couple of months (as is likely) the US Supreme Court could be hearing the case during their October 2019 – April 2020 schedule…  making access to healthcare a sentinel issue in the November 2020 election.

Pre-existing exclusion exemptions, community rating, guarantee issue of health insurance, the availability of Marketplace plans with subsidies, and Medicaid expansion will all be front and center with the electorate. All very personal issues.

Social science suggests that people feel a loss of a benefit much more acutely than a missed opportunity.  In other words, it’s a lot harder to take something away than to not give it in the first place. 

With the American people now accustomed to the benefits that the ACA provides, there could be a backlash against those that take those benefits away.  Just sayin’.

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