The 2010s & Public Health Policy: A “Top 10” Retrospective

As we transition into the 2020s next week, I thought I’d put on my 10- year public health thinking cap and reminisce about some of the top public health policy topics of the 2010s in Arizona.  Here you go… 

  • The Recession. I still have PTSD from being responsible for a state agency during the recession. We made so many horrible budget cuts those years including a childless adult enrollment freeze in the behavioral health medicaid system. That was gut wrenching and it had untold bad outcomes for so many.

  • The 1 cent 3-year sales tax.  Remember the special election for the one cent sales tax? I can’t imagine what would have happened to vulnerable Arizonans if that hadn’t been pushed by Governor Brewer and put on the ballot.  It passed with a yes vote of something like 64% to 36%.  Who says Arizonans are a bunch of stingy tightwads?

  • Medicaid restoration and expansion.  A bipartisan group of legislators and hard work by a host of Stakeholders (including AzPHA) and leadership from Governor Brewer pushed Medicaid restoration and expansion over the line. Critical to the passage was consent by the hospital industry to pay an annual assessment that captures the state funding portion that was needed to make this a reality. It was perhaps among the most significant and long lasting health care achievements of the 10’s in Arizona.  

  • AZ Supreme Court upholds the hospital assessment funds that pay for Medicaid restoration and expansion. The careful writing of the statutory language that funded Medicaid expansion pays off- and the fees charged by AHCCCS to hospitals stands.

  • Medical Marijuana.  Voters narrowly approved medical marijuana and the ADHS did the best they could to build a responsible system. As we transition to the 20’s we’re poised to have retail marijuana stores. Conservatives could potentially head off such a move if they would approve meaningful criminal justice reform of our marijuana laws. Odds are that we’ll have retail marijuana stores by the early 2020s.

  • Senator McCain stands with Senate Democrats voting against
    a bill that would have repealed the Affordable Care Act with the “skinny repeal” which would have radically jeopardized access
    to care. 

  • Behavioral health system interventions were implemented for Medicaid members needing behavioral health services. The decade began with interventions that resulted in a settlement of the Arnold v Sarn suit by tying performance measures to evidence-based SAMHSA fidelity models and additional financial investments in the system. Later in the decade, Medicaid managed care contracts are overhauled integrating physical and behavioral care for most Medicaid members in AZ.

  • The roots of the Opioid Epidemic lie in the 2000s decade, but the epidemic really accelerates in the 2010s- with opioid deaths passing the number from car crashes in AZ early in the decade. Various interventions happen through the mid part of the decade, culminating in the bipartisan Arizona Opioid Epidemic Act at the end of the decade.

  • CPS Carved out of ADES to be the new DCS.  The “NI” discoveries and a deep dive into ADES reveals that the CPS system needs and overhaul and the new agency is created with a more specific mission. No doubt the 2020s will continue to have stories about bad outcomes. The root of many of the core issues go back to dramatic cuts to preventive service programs that happened in the Recession and decisions made by elected officials to use federal prevention funds for other purposes (see Morrison Institute work on this) as well as not pay a small match for federal child care subsidy funds that were easily available.

  • Social Determinants increasingly recognized as drivers of outcomes during the decade.  Policy makers and agency directors increasingly look toward interventions that address social determinants.  The 2020s will likely build on those successes.

Health Insurance, Marketplace Diversity and Competition

Guest Blog by Pele Peacock Fischer

Public health policy has never been simple, and for decades Arizona policymakers have worked to identify ways to ensure residents have health insurance options and access to quality health care. Their efforts are further complicated by the questions arising from ongoing litigation over the Affordable Care Act and divisive political dynamics that have painted compromise and bipartisan cooperation as a negative thing.

The Arizona Public Health Association (AzPHA) celebrates small victories in the quest for more health coverage even while we fight for the ideal solutions.  We try not lose sight of the perfect outcomes while we acknowledge the small steps and partial improvements that will get us there.  We try not to let the perfect be the enemy of the good.

One example of this is last year’s SB 1085, which expanded association health insurance plans to more Arizona residents and businesses. These plans are a relatively new option, authorized under a rule from the U.S. Department of Labor in August 2018. AzPHA – and other leaders in public health policy – expressed concern that this expansion could hinder Arizonans who don’t understand that the plans don’t necessarily cover essential health benefits (or pre-existing conditions) and may charge differently depending on gender and age. 

We’ll continue to advocate for improvements to these health plans and more consumer protections and policy transparency to ensure Arizonans understand the details of their insurance coverage, but we also acknowledge the steps this bill took toward increased health insurance access in Arizona including:

1) More insurance coverage options for small businesses that may not qualify for other affordable health plan options; and

2) Expanded coverage for those who may not otherwise have any, since some families and small businesses are not able to – or choose not to – pay for high-cost insurance plans.

Health association plans provide options for the small percentage of individuals and small businesses that do need more options than those provided by the ACA.

And while these association health plans do not threaten existing ACA-compliant insurance plans, they do increase competition and keep insurance prices low for all Arizonans.

There is a long way to go to ensure Arizonans have high-quality, affordable health coverage and access to care.  AzPHA is committed to playing a part in every discussion that will lead us to that goal, and to informing policymakers about the good and bad of every option that may get us there.

Bicameral surprise billing legislation announced

Senate Health Committee Chairman Lamar Alexander (R-Tennessee) and House Energy and Commerce Committee Chairman Frank Pallone Jr. (D-New Jersey) along with Ranking Member Greg Walden (R-Oregon) released a bipartisan and bicameral legislation Sunday that addresses surprise billing. A surprise bill occurs when a patient is unexpectedly billed for an out-of-network provider who is not covered by the patient’s insurance.

Among the numerous provisions, the bill would:

  • prohibit balance billing under certain circumstances. Patients would be required to pay only the in-network cost-sharing amount for out-of-network emergency care (including air ambulance services), for certain ancillary services provided by out-of-network providers at in-network facilities, and for out-of-network care provided at in-network facilities without the patient’s informed consent.

  • require insurers to reimburse providers for all claims subject to the balance billing prohibition at the median in-network negotiated rate for the service in that geographic area where the service was delivered at a minimum.

  • allow both providers and insurers the right to contest claims paid at or above $750 using baseball-style, binding arbitration.

  • require notice and disclosure of balanced bill with at least 72-hour notice to receiving out-of-network care.

  • restrict certain contracting terms between providers and health plans. Specifically, they would enable health plans to unfairly tier providers, steer patients to particular providers, and contract with only certain providers or “cherry-pick” within a hospital system.

  • require providers and health plans to give patients good faith estimates of their expected out-of-pocket costs within two days of a request.

  • set timelines for billing. The bill would require providers to give patients an itemized list of services received not later than 15 calendar days after discharge. In addition, providers would have 20 calendar days after discharge to bill the health plan; health plans would have 20 calendar days to adjudicate the bill; and providers would have no more than 20 days to send the adjudicated bill to the patient. Patients would have no obligation to pay any bills received more than 60 calendar days after receiving care, subject to some extenuating circumstances identified by the Secretary of the Department of Health and Human Services.

Tobacco Buy Age Moving to 21!

Last week Congress passed and the executive signed a budget bill that will raise the federal age of sale of all tobacco products to 21.  The provision will apply in Arizona, accomplishing what we’ve been trying to do here in AZ for the last few years.

The policy change is included in an end of year package that funds the federal government for the remainder of FY2020, as well as a number of other policy changes.  The tobacco 21 provision is accomplished by amending the Tobacco Control Act of 2009, which established at that time a federal age of sale of 18. 

The provision is slated to take effect sometime in the second half of 2020.  The Secretary of HHS is supposed to publish a final rule amending FDA regulations to include the age of 21 within 180 days of enactment of the law and is to take effect 90 days after the publication of that final rule. 

FDA’s existing enforcement authorities as granted by the Tobacco Control Act will be applicable to the raising of the age of sale to 21 which currently involve joint federal and state enforcement arrangements.  The law will also require that age verification requirements extend to those up to the age of 30 from the previous requirement of the age of 26.

The new federal age of sale:

  • Doesn’t preempt state and local tobacco control laws

  • Is applicable to all tobacco products; and

  • Doesn’t exempt any population from the age of sale provision.

In addition to raising the federal age of sale to 21, the law amends existing provisions of the Public Health Service Act related to the Synar Program. The Synar Program was established in 1992 and required states to pass a law prohibiting the sale of tobacco products to individuals under the age of 18, and to enforce the law.

If a states don’t comply with Synar, funding from SAMSHA (Federal Substance Abuse Prevention and Treatment Block Grant Funding) would be withheld.

The current legislation amends the Synar Program in the following ways:

  • Removes the existing requirement that states have minimum age of sales laws to receive substance abuse funding.

  • Raises the age at which states must ensure tobacco retailers are not selling to individuals from under the age of 18 to 21 to receive substance abuse funding.

  • Includes alternative penalties if a state is not in compliance in order to continue to receive substance abuse funding.

  • Includes a transitional or grace period in which HHS can use discretion to enforce State compliance.

  • Includes funding for states to implement this provision.

The Secretary of HHS has 180 days to publish updated regulations or guidance to ensure compliance.

This is a big public health accomplishment.  Tobacco remains the biggest cause of preventable death in the US.  Because human brains aren’t fully mature until the early 20s, young people are easily addicted to nicotine- hard-wiring their brains and making it much more difficult to quit tobacco later in life.

A special shout-out to AzPHA members Brian Hummell from the American Cancer Society Cancer Action Network and Nicole Olmstead from the American Heart Association for helping me get this right.

5th Circuit Court of Appeals Rules on the Affordable Care Act Case 

Affordable Care Act Remains in Limbo

The U.S. Court of Appeals for the 5th Circuit ruled on the Texas v Azar case last week.  The 5th Circuit was hearing an appeal on a Texas District Court ruling earlier this year that found that the ACA is unconstitutional in it’s entirety now that the tax penalties for not having health insurance (the individual mandate) has been eliminated (by the big tax cut bill a couple of years ago).

The 5th Circuit agreed with the lower district court that the individual mandate of the Affordable Care Act is unconstitutional. In the 2012 US Supreme Court case (NFIB v. Sebelius) the U.S. Supreme Court found that the ACA is constitutional because of Congresses taxing authorit When Congress zeroed out the ACA’s “shared responsibility payment” in 2017, the tax power was negated, invalidating the mandate itself.

Although the lower court previously concluded that the elimination of the individual mandate rendered the entire ACA unconstitutional, the 5th Circuit majority decision this week did not agree.

The 5th Circuit rebuked federal district court Judge Reed O’Connor for his over-reaching analyses, remanding the case back to his court for “a more searching inquiry” of which ACA provisions are severable from the individual mandate.

As the process of reviewing the severability of ACA provisions may take months, questions have already surfaced regarding potential immediate appeals to the U.S. Supreme Court.

Read the decision here.

A big shout out to AzPHA members at the Western Region Office of the Network for Public Health Law for their analysis of last week’s ruling.  Here’s a bit about the Center and how they can help you with public health legal questions that you might have.  Their work is always well-researched and there’s not charge for their services.

The Center for Public Health Law and Policy explores fascinating and emerging global and domestic issues in public health law, policy, and ethics. Varied topical interest areas include emergency legal preparedness, vaccinations, health care reform, injury prevention, and constitutional rights and protections. The center brings students together with leading scholars, practitioners, and policymakers to address critical challenges at the intersection of law, ethics, policy, and the public’s health.

Its diverse group of scholars and partners seeks to promote the role of law as a tool for improving the public’s health by conducting targeted legal and policy research, developing innovative tools and educational materials, generating extensive scholarship, and collaborating with public health and medical leaders.

The center also hosts the Western Region Office of the Network for Public Health Law, supported primarily by the Robert Wood Johnson Foundation. The Network provides technical assistance to practitioners and attorneys nationally, and allows students the opportunity to research, develop, and implement public health law solutions.

AHCCCS Working on an “Whole Person Care Initiative” to Focus on Additional Factors That Impact Wellness

The social determinants of health including socio-economic status, housing, community stressors, behaviors, and physical environment contribute more to health outcomes than access to health care. 

Last week, AHCCCS announced that they’re going to be exploring more opportunities to support whole person health care by engaging stakeholders who have expressed interest in augmenting our ability to address:

  • Transitional housing, particularly for individuals leaving a correctional facility; those being discharged from a behavioral health inpatient stay; and individuals experiencing chronic homelessness;

  • Non-medical transportation with a focus on access to healthy food and employment navigation services; and

  • Social isolation that can impact individuals who receive Arizona Long Term Care System (ALTCS) services in their own homes including, but not limited to, peer support programs.

AHCCCS says they’ll be partnering with Health Current (Arizona’s Health Information Exchange) to explore technology to facilitate screening for social risk factors and referring their members to community resources.

In 2020, AHCCCS anticipates that Health Current will evaluate solutions seeking a single, statewide, electronic, closed-loop referral platform. Their goal is to find a technology allowing health care providers to screen patients for social risk factors using existing systems, submit electronic referrals to local agencies, and measure social service outcomes.

Over the next few months, AHCCCS will be collaborating with their contracted MCOs and other external stakeholders to craft this Whole Person Care Initiative.

Information will be posted on the AHCCCS website where users can subscribe to email updates and submit ideas and feedback.

A welcome public health intervention indeed.

US House Approves HR3: A Prescription for Lower  Drug Prices

Allowing Medicare to Negotiate with Drug Makers can Dramatically Lower Costs

The U.S. House of Representatives approved H.R. 3 this week- an important and common-sense consumer protection bill that would lower the cost of prescription drugs by allowing the HHS Secretary to to directly negotiate drug prices for up to 250 of the highest-priced drugs (including insulin).

As it stands right now (and as it’s been for decades) pharmaceutical companies set the prices that Medicare has to pay and prohibits Medicare from negotiating with drug makers. The fact that Medicare can’t negotiate prices raises costs to both Medicare patients and everybody that contributes to the Medicare fund through their payroll taxes.

The bill now moves on to the Senate where it has an uncertain future. If it were ultimately successful, it could have a dramatic effect – lowering the costs to consumers by lowering costs for coverage in both Medicare and private health insurance.

Under the process laid out in the bill, the secretary of health and human services could negotiate the price of as many as 250 drugs each year. The negotiation process would prioritize drugs with the greatest savings potential—those that rank highest by spending, have no generic or bio-similar competitor, and have a large pricing gap between the United States and peer nations.

State Legislatures Increasingly Taking Action to Restrict Flavored E-Cigarette Sales

E-cigarette use among young people has been increasing at an alarming rate across the US and in Arizona.  In fact, e-cigarette use among middle and high school students has grown by 900% among middle and high school students from 2011 to 2015. 

That’s not a typo.  It’s 900%.  Even the FDA has stated that e-cigarette use among young people has “hit epidemic proportions.” The latest 2019 findings from the National Youth Tobacco Surveyindicate that over 5 million middle- and high-school-aged youth reported using e-cigarettes in 2019.

Last year’s Arizona Youth Survey found that e-cig use was up dramatically across all three age groups:

  • 8th -graders: 21% reported using e-cigarettes in 2016- that’s up to 28% now

  • 10th-graders: 29.4% 2016, now it’s 39%

  • 12th-graders: 35% 2016, now it’s nearly half- at 46%.

Regulating the sale of flavored e-cigarettes is an important strategy to reduce youth e-cigarette use and the nicotine addiction that comes with their use.  According to FDA, 96% of youth who started using e-cigarettes started with a flavored product.

During last year’s legislative session, Senator Heather Carter proposed HB 2357 which would have done several good things including classifying vaping products in the same category as tobacco, including vaping products in the Smoke Free Arizona Act, and explicitly allowing cities and towns to impose their own stricter regulations (including having a 21 year old buy age).   Sadly, that bill didn’t pass.

Senator Carter also proposed SB 1363 last session, which would have moved the tobacco and e-cigarette buy age to 21.  Sadly, that bill never even received a hearing.

So far, our Governor doesn’t appear to be supportive of banning the sale of flavored e-cigs in AZ.  He’s quoted in this article in the Arizona Capitol Times as saying “What I don’t want to do is take someone who is addicted (to nicotine), restrict them from finding a product and push them to the black market, so we’re going to have a measured approach.”

The FDA has been sending mixed signals whether they intend to use their authority to better regulate or eliminate the sale of flavored e-cigarettes- but several states are taking clear action. 

Here’s a quick summary of what other states have been doing. 

Massachusetts has a bill named  H 4196 which would prohibit the sale, marketing, or advertisement of any flavored tobacco product or flavor enhancer in any retail establishment, online, or through other means to any consumer in the commonwealth, except if sold by a smoking bar. The bill passed the legislature and was sent to the governor for his signature.

Massachusetts has another proposed bill called (H 3778) that would prohibit the sale of flavored tobacco products (including e-cigs)m in locations accessible to minors.

California is considering companion bills (AB 739 and SB 38) that would prohibit tobacco retailers from selling flavored tobacco products.

Illinois has companion bills (HB 3883 and SB 2275) that would prohibit establishments from selling or distributing any flavored tobacco products. Other Illinois bills are include (SB 2274 and HB 3887) which would prohibit tobacco retailers from selling flavored tobacco products and  solutions or substances intended for use with e-cigarettes.

A proposed bill in New York (S 6809) would prohibit the sale and distribution of flavored tobacco products and accessories.

DC proposed a bill (B23-0453) that would prevent the sale or distribution of flavored electronic smoking devices.

The Ohio legislature is considering a bill (HB 346) prohibiting manufacturers, producers, distributors, wholesalers, or retailers of cigarettes, other tobacco products, alternative nicotine products, or papers used to roll cigarettes from selling or giving away flavored electronic smoking devices or flavored vapor products that have not received approval from the FDA.

A proposed bill in Washington (HB 1932) would restrict a retailer or distributor from selling flavored vapor products.

The Pennsylvania legislature is considering a bill (HB 1994) that would make it a criminal offense to sell, furnish, purchase for resale, manufacture, advertise, or market flavored vapor products. In addition, the bill would restrict the placement of vending machines containing flavored vapor products in locations accessible to purchasers.

Evidence Review: Does Flavor Banning Work to Decrease Youth Tobacco Use?

We’re all about using evidence-based interventions to address Arizona’s current and emerging public health challenges.  With the legislative session coming up- we’ll likely have some opportunities to weigh in and discuss the evidence base for interventions to address the vaping epidemic among young people.

I did some literature search recently and found some evidence and some examples of interventions that other states have implemented to get a handle on their vaping epidemics.

For example, a recent study found some evidence that restricting the sale of flavored tobacco products, including e-cigarettes. The study compared two similar cities in Massachusetts, one that had enacted a policy restricting flavored tobacco sales to specific retail establishments and another with no policy.

The results after six months showed a decrease in use of both flavored and non-flavored tobacco in the city that had passed the policy, whereas the city without a policy saw an increase in tobacco use, in general. See the article here.

The Arizona Public Health Association Urges Arizona’s Congressional Delegation to Vote Yes on HR3 Tomorrow to Lower Prescription Drug Prices

Allowing Medicare to Negotiate with Drug Makers will Dramatically Lower Costs

Tomorrow (Thursday December 12) the U.S. House of Representatives will be voting on H.R. 3- an important and common-sense consumer protection bill that will lower the cost of prescription drugs by allowing the HHS Secretary to to directly negotiate drug prices for up to 250 of the highest-priced drugs (including insulin).

As it stands right now (and as it’s been for decades) pharmaceutical companies are free to set the prices that Medicare has to pay and prohibits Medicare from negotiating with drug makers. The fact that Medicare can’t negotiate prices raises costs to both Medicare patients and everybody that contributes to the Medicare fund through their payroll taxes.

If the bill is ultimately successful, it could have a dramatic effect by lowering the costs to consumers by lowering costs for coverage in both Medicare and private health insurance.

Under the process laid out in the bill, the secretary of health and human services could negotiate the price of as many as 250 drugs each year. The negotiation process would prioritize drugs with the greatest savings potential—those that rank highest by spending, have no generic or biosimilar competitor, and have a large pricing gap between the United States and peer nations.

Let’s hope the members of our Delegation in Congress have our back and vote YES on HR 3 this week!