Will Humble Medicaid, Prevention, Public Health, Return on Investment, Wills Blog

Aligning the Roles of Medicaid and Public Health

Aligning the Roles of Medicaid and Public Health

Medicaid and public health partnerships play an important role in advancing a statewide approach to improving health and reducing health disparities. Collaboration and shared priorities between agencies can play a super important role in improving outcomes.

The Association of State and Territorial Health Officials recently put together this interesting and easy to listen to 30 minute podcast that highlights opportunities to  leverage each agency’s respective roles and resources through the CDC’s 6|18 Initiative.  Here are some links to additional resources regarding these kinds of partnerships:

Will Humble Marijuana, Wills Blog

Retail Marijuana Voter Initiative: My First Impressions

A group of Medical Marijuana Dispensary operators have completed statutory language for a retail marijuana and marijuana law criminal justice reform voter initiative. I’ve been able to go through the Initiative language a couple of times now. The statutory language is 16 pages long- and there are a lot of provisions…  but below are some of my initial impressions from a public health perspective:

Good Things

  • Employers would still be able to have drug-free workplace policies and can restrict marijuana use by staff.

  • Driving while impaired (to the slightest degree) by marijuana would still be illegal.

  • The governance structure is decent. It’s with an executive branch agency- ADHS (the 2016 Initiative created would have created a self-serving commission).

  • I mostly like the criminal justice reform parts for possession of less than an ounce. Possession up to 2.5 oz is a reduced penalty. Possession of more than 2.5 oz (with some exceptions for home cultivation) appear to be left where they are as a Class 6 felony. Currently, possession of very small amounts of marijuana (w/o a MM Card) are a class felony 6. Convictions impair people’s ability to earn a living – placing stress on families because of low wages and limiting the ability of folks to support kids and families and pay child support etc. – basically impairing self-sufficiency. AZ is one of a very very few states with possession of small amounts being a felony, this Initiative would fix that.

  • I like the conviction expungement provisions for the same reasons as above- and the expungement process is reasonable and not a free-for-all.

  • The labeling and packaging requirements are reasonable.

  • The testing requirements make sense too.

  • The restrictions on advertising are pretty good.

The Bad Things

  • There are no penalties for persons over 21 that give or buy marijuana for people under 21. This is a major shortcoming. There’s no disincentive for older people to buy for people under 21. There are small penalties and low-grade misdemeanors for people under 21 that misrepresent their age to people over 21 for the purpose of buying marijuana – but no penalty for the older person whatsoever.

  • The buy age in the Initiative is 21 years old. Data suggests that the buy age should be 25 years old. Brains continue to develop up to age 24 (25 in males). Data suggest that marijuana is more harmful and is more likely to cause longer term behavioral health problems when people start using before 25 y.o. Here’s a new Surgeon General Advisory from this week on the subject.

  • The Initiative would allow the ADHS to regulate potency but prohibits the agency from limiting doses to less than 10mg. 10mg is a good “ceiling” regulation but a bad “floor” regulation. Having said that- dispensaries would still be able to produce edibles that are less than 10mg and sell them – it’s just that the ADHS can’t regulate below 10mg.

  • The excise tax is a good idea – but the funds don’t go toward public health or youth marijuana prevention programs. There’s a one-time distribution ($10M) to the ADHS from the existing medical marijuana fund for public health stuff, but nothing after that. There should be some excise tax funds going to prevention campaigns- in particular youth prevention. A lot more of the excise tax should go toward preventing the downside of the policy decision- e.g. preventing kids from using marijuana.

  • Some excise funds should go to the AZ Biomedical Research Commission to study the effects of this policy intervention.

  • The law would let people cultivate up to 6 plants or 12 per household. While there are some requirements for locking the plants away from kids in houses- enforcing that will be next to impossible and diversion to kids would happen for sure with basically no checks in the system.

  • The existing medical-marijuana dispensaries would have a corner on the market in perpetuity. This is anti-competitive and permanent. Current medical marijuana dispensaries will be allowed to apply to the ADHS for a license to run a retail marijuana store in early 2021. It’s possible that there could be a few more stores that open eventually, but not many, because the total number is limited to about 130 total (10% of the number of pharmacies in AZ). Existing medical marijuana dispensaries, with a handful of exceptions, would essentially be the only stores that exist. ADHS would regulate the program.

  • The Initiative appears to tie the hands of local authorities in setting zoning restrictions (although the League of Cities and Towns would be a better expert).

Will Humble Climate Change, Wills Blog

EPA Proposes Eliminating Methane Capture Regulations

This week the EPA proposed new rules that would reverse regulations adopted by the Obama administration requiring the natural gas industry to prevent fugitive methane gas releases. The existing rules were adopted during the previous administration as a measure to slow the emission of greenhouse gases causing climate change.

Under the proposal released this week the EPA would no longer specifically regulate the transmission and storage of the potent greenhouse gas… but treat it like a routine volatile organic compound. 

The rules proposed this week would eliminate the current requirements that require the industry to prevent methane releases at transmission and storage of methane at compressor stations, pneumatic controllers, and underground storage vessels (basically- the transmission and storage segment of the industry).  The proposed regulations would also eliminate methane emission limits from the transmission and storage segment of the industry. 

Methane (CH4) is a very powerful greenhouse gas. It absorbs much more energy than carbon dioxide (CO2) and is 30 times more potent as a greenhouse gas.  Methane has a half-life in the atmosphere of about 10 years (much less than CO2) but has a powerful impact during that time.

The U.S. oil and gas industry emits 13 million metric tons of methane from its operations each year (emissions of methane are about 2.3% of the production).  Most of these “fugitive” emissions came from leaks and equipment malfunctions in the transmission and storage of the gas- the very sector that the proposed rules deregulate. 

The climate impact of these leaks is roughly the same as the climate impact of carbon dioxide emissions from all U.S. coal-fired power plants.  [R.A. Alvarez el al., “Assessment of methane from US oil and gas supply chain”, Science (2018).]

In their comments this week – EPA officials stated that the industry has a powerful incentive to stop fugitive emissions of methane without regulation because they lose product via leaks. That argument only holds when the cost of fixing the leak is less expensive than the short-term cost of lost product.

Here’s a link to EPA’s proposed rules.  Public comment isn’t open because it’s not published in the Federal Register yet.  Once it’s published, there will be a 60-day comment period.  I’ll keep following this and put the link to the comment site in a future public health policy update.  The comments page – when available – will be at www.regulations.gov.

Editorial Note: In addition to the public health impacts from climate change caused by the obvious things like worse storms, water shortages, decreased agricultural output, impacts to assets from sea level rise (oceans are already 20cm higher then they were in WWII), and the geopolitical implications that these disruptions will cause from increased  conflicts, refugee crises and widespread social dislocation would almost certainly increase – climate change also causes a diversion of resources toward adaptation, diverting public and private resources from more efficient uses of capital.

This results in long-term decreased GDP growth and investment and capital losses. For example, the expected value of a future with 6°C of warming represents present value losses worth US$43trn—30% of the entire stock of manageable assets (the current market capitalization of all the world’s stock markets is around US$70trn).

The reason I mention this – is that as public health officials – we often focus on those direct public health impacts that are resulting and will continue to result from climate change. Convincing decision makers that aren’t partucularly interested in public health that the the climate crisis is serious and requires immediate aggressive interventions requires a variety of arguments. Here is an interesting, if dense, analyis recently published by The Economist.

Will Humble Medical Marijuana, Prevention, Wills Blog

U.S. Surgeon General’s Advisory:

Marijuana Use and the Developing Brain

The US Surgeon General (Jerome Adams MD) Issued  a concise advisory this week  that emphasizes the health risks of marijuana use in adolescence and during pregnancy. He released the Advisory in response to recent increases in access to marijuana and in its potency, along with misperceptions of safety of marijuana endanger our most precious resource, our nation’s youth.

Will Humble Vaccination, Wills Blog

AzDHS Immunization Action Plan:

Recommendations for Increasing Immunization Coverage Rates in Arizona

Immunization coverage rates in Arizona continue to fall. The ability for parents to opt their child out of vaccination is simple and is being done more frequently in Arizona. This has resulted in families and communities being at increased risk for vaccine preventable diseases. 

The ADHS recently led a stakeholder group that explored interventions and activities that could help to stop and reverse this negative trend and increase vaccine coverage rates across all Arizona communities. The group developed a report that included the following goals:

  1. Improve vaccine education to professionals who will interact with parents

  2. Implement public information campaigns to promote vaccination

  3. Evaluate the effectiveness of current vaccine education pilot in reducing exemptions

  4. Ensure private providers continue to provide childhood vaccination services

  5. Determine best practices for improving vaccination coverage

  6. Partner with the Department of Education to increase school vaccination rates and compliance

The team put together a 15-page report that includes recommendations to address each goal.  I couldn’t find a copy of the report on their website, but somebody sent me a copy. The recommendations are mostly educational or administrative- no major policy recommendations (like eliminating the personal exemption).  Take a look.  Sounds like we will be seeing more details about these goals and recommendations in the coming months.

Will Humble Affordable Care Act, Wills Blog

Group Gathering Signatures for the “Healthcare Quality Improvement Act”

A group called Healthcare Rising Arizona filed the paperwork with the AZ Secretary of State with language for a voter initiative called “Arizonans Fed Up with Failing Healthcare” that would make some changes to healthcare law and provide a backstop for consumers in case the Affordable Care Act is overturned by the US Supreme Court now that the tax penalty for not having health insurance has been removed from the ACA by the 2017 major tax law overhaul.

Here’s a link to the voter initiative language.  The folks running the campaign still need almost 238,000 valid signatures by July 2, 2020 to get on the ballot- no easy feat given the new requirements passed by the Legislature and signed by the Governor which make getting things on the ballot harder. There are 4 basic components to the measure:

Consumer Protections for Health Insurance

Some consumer protections for Arizonans in case the Supreme Court overturns the ACA now that the tax penalties for not having insurance are gone.  This initiative would prevent commercial health insurance companies in Arizona from doing the following things (if the ACA is overturned):

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.

Hospital Associated Infections

Requires private hospitals to meet national safety standards regarding hospital-acquired infections and gives the Arizona Department of Health Services the authority to impose civil penalties if hospitals fail to meet those standards.

Surprise Billing

Protects Arizona consumers against surprise medical bills from out-of-network providers and requires refunds if patients are overcharged.

Raises for Direct Care Workers

Gives direct care hospital workers a 5% wage increase each year for four years. Direct hospital care workers include nurses, aides, technicians, janitorial and housekeeping staff, social workers and non managerial administrative staff. Physicians are excluded.

The fly in the ointment on this one is that last bullet. My guess is that there wouldn’t be a whole lot of organized opposition to the measure without that last piece- requiring raises for hospital direct care workers. 

Honestly, I think the provisions that require raises for direct care workers is what will make the Initiative fail, and along with it the opportunity to provide consumer protections in the health insurance market in case the US Supreme Court overturns the ACA now that the tax penalties for not having health insurance have been eliminated.

We’ll continue to review the language and evaluate whether to take a position on this and other voter initiatives that are I the works like the retail marijuana initiative and the Voter’s Right to Know Amendment.

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