Let’s Look Before We Leap Into Using Emergency Public Health Authority to Respond to the Coronavirus

Given what we now know about how easily the new Coronavirus spreads and the fact that it’s spreading in several countries including South Korea and Iran it’s only a matter of time before it starts circulating here in Arizona.

That means state and county health staff and our elected officials will be making decisions about what kinds of public health measures to take when it gets here.   

We urge them to exercise two kinds of caution: use public health interventions that are reasonable and necessary and avoid taking actions that will do more community harm than good.  There’s a balance to be struck in public health.  Every decision needs to weigh the costs versus benefits.

Let’s start with what we know.

The new Coronavirus seems scary.  It’s highly communicable, but it’s probably not as lethal as the news might lead you to believe.

Nearly every flu season, Arizona reports less than 20,000 cases of influenza.  But the actual number of persons infected is much higher, with 5-20% of the population being infected per season. The reason?  Most people with the flu don’t seek healthcare.  Many that do seek care don’t get tested.  Lots of people have mild or even no symptoms yet may still spread it to others.  We probably find out about only one case out of 50.

The same thing is almost certainly happening with this new Coronavirus. Mild infection is common.  Completely asymptomatic infection has been documented, including transmission of the virus from someone who had no symptoms.  Few people in the mild category are likely seeking care or testing.  Even if they seek it, they might not get it. It’s reasonable to assume that something like the 1-in-50 rule is happening right now with this novel Coronavirus.

That means two things.

First, this virus is more contagious than the reported number of cases would indicate.  That’s not good, because most of the actions now being taken to try to prevent spread are likely to eventually fail and it’ll become a global pandemic.  

It also means that it’s less lethal than current reports imply.  The cases we know about are the sickest ones.  What looks like a 2% mortality rate (when you multiply by ~50 times the number of people infected) drops to a 0.04% mortality rate.  That puts it right in the range of influenza, which kills approximately 20,000 in the US in an average year.

We believe that we should handle the illness like we do influenza when the Coronavirus begins circulating here. 

During the 2009 flu pandemic, the guidance from the CDC was to close schools when a student was diagnosed with the new virus.  Within a few days, there were three schools closed in Maricopa County, and the number of pending cases made it obvious that the virus was Valley-wide. It was spreading, well, like influenza.

It made no sense to close schools based upon where testing happened to have been done when it was almost certainly in many schools.  The choice became either close every school, or none.

If we had made the decision to close Valley schools out of an abundance of caution, we would have closed all schools. Out of an abundance of caution is public health speak for this may be more than necessary, but because we don’t know for sure, we’re going to take extra precautions.

We decided to err on a different side of caution. Arizona and Maricopa County were among the first jurisdictions in the country to push back against the CDC recommendations to close schools with an H1N1 case, and we reopened all our schools during the first week of the pandemic.  We decided that the economic and social disruption caused by closing schools would do more harm than good.  That proved to be the right choice.

When the virus arrives, it will surely be seizing headlines.  Even so, some local jurisdictions will likely take the initiative and ease up on control-measures sooner than the CDC is willing to. They’ll push back against the federal and maybe even state guidance in order to protect their communities against unnecessary economic and social damage.

Sometimes the control measures can do more harm than the disease you’re trying to prevent. 

We urge the public health system and our elected officials to carefully consider community disruptions before they implement control measures out of an abundance of caution.

Bob England, MD is the former Director of the Maricopa County Department of Public Health and currently serves as the Interim Director of the Pima County Health Department.  Will Humble is the former Director of the Arizona Department of Health Services and currently serves as the Executive Director of the Arizona Public Health Association.

High Prescription Drug Costs are an Increasing Priority for Voters

So, What’s Being Done to Lower Them?

If you’ve been watching the news and listening to the grievances that the American people have about the cost of healthcare, one thing you’ll consistently hear is that American’s are increasingly concerned about the high cost of the their medications, especially folks that get their medications through Medicare.

The reason why people are so concerned is real: over the first 6 months of 2019, more than 3,400 drugs saw increased prices, at an average rate of 10% per drug.  More than 40 drugs saw price increases of more than 100% including a 879% increase in the cost of Prozac.  The price of insulin has nearly tripled since 2002, and increased by 64% between 2014 and 2019.

Under the current process, Medicare contracts with private plans, which are given the sole authority to negotiate drug prices directly with pharmaceutical companies. But if Medicare could do the negotiating, they’d have a lot more leverage.  The fact that Medicare can’t negotiate on our behalf is a big reason why U.S. drug prices are nearly four times higher than the average prices in similar countries.

So, the question is, is anything being done to lower costs? The answer is yes, and no.

Last December the US House of Representatives passed a bipartisan bill known as H.R.3 (called the Lower Drug Costs Now Act) which is essentially a policy intervention that would end the ban on Medicare negotiating with pharmaceutical companies for drug prices.  H.R. 3 would not only lower the cost of drugs for Medicare and Medicare beneficiaries, but everyone would benefit because manufacturers would be required to offer the lower negotiated prices to group and individual health insurance plans too.

According to the nonpartisan Congressional Budget Office, H.R. 3 would lower drug prices by an average of 55% and save Medicare $456 billion over 10 years.

And, it’s a popular solution.  An October 2019 Kaiser Family Foundation poll found that 88% percent of respondents supported allowing the federal government to negotiate lower Medicare drug prices, including 85% of Republicans.

The problem is that the US Senate has thus far refused to bring H.R. 3 to the floor of the Senate for consideration (Senator Mitch McConnell makes that decision).  In other words, Senators haven’t even had the opportunity to consider the law- and as a result- Medicare is still forbidden from negotiating drug prices on our behalf.

Some say that’s because the Senate leadership is held captive by the drug manufacturers lobby and is therefore unwilling to bring the solution up for consideration. 

Just something to keep in mind as we as voters think about who to vote for in the Arizona Senate race.

This Week’s Action at the Legislature

This was the final week for bills to be heard in their chamber of origin in their assigned committee. Those that didn’t get heard this week are essentially dead.  However, they can always be resurrected as a Strike All amendment later in the session.

Here’s the summary file with the summary of the action this far and below is a little description about this week’s action (it was a busy week). 

Good Bills

SB1493 Pharmacists; Dispensing Hormonal Contraceptives – AzPHA Supports.  This good bill passed the Senate this week.  It was amended slightly to make it clear that county health department staff (doctors) can write the Standing Order in addition to the ADHS.  This is a good bill that’s consistent with our Resolution Supporting Universal Access to Contraception 

SB 1167 Graduate Medical Education – AzPHA Supports.  Passed the full Senate this week.

SB 1086Long Term Care Surveyors- AzPHA Supports.  Passed Senate Appropriations this week.

HB 1571 Newborn Screening Fund – AzPHA Supports.  This got a pass recommendation from the Senate Health Committee this week. 

SB1028  Public Health Surveillance – AzPHA Supports. This bill was on the agenda in Senate Health this week but for some reason was held and is now essentially dead.

HB 2244 Dental; Native Americans –  AzPHA Supports. Passed House Appropriations this week and House Health back in January.

HB2608  Overdose Prevention & Harm Reduction – AzPHA Supports.  Got a pass recommendation from the House Health Committee (8-0) last week and passed House Rules this week.

HB 2549 Adult Protective Services Audit – AzPHA Supports.  Passed both House Health and House Appropriations Committees this week.

HB 2784 Medical Marijuana Research – AzPHA Supports.  The bill is consistent with our Resolution on this topic and passed the House Health Committee Thursday.

HB 2550 ADHS Licensing SurveyorsAzPHA Supports. The bill is consistent with our Resolution on this topic and passed the House Health Committee Thursday

Bad Bills

HB 2453  Exemption, Food Code Wineries – AzPHA OpposesPassed the full house this week.

HB 2739 Liquor Omnibus- AzPHA Opposes.  Passed the commerce committee and Rules is next.

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Here’s the List of Bills that We’re for and Against & their Status

This is the last week for bills to be heard in Committee in their Chamber of Origin.  The Bills that didn’t get heard in time have a strike-through on them. Of course, they could come back as a strike all amendment, but for now the lined-out Bills look dead.

Tobacco Control

HB2636 &SB1400  Tobacco Retail Licensing – AzPHA Supports

This bill (sponsored by Representative Blackman) would facilitate a licensing system for stores that wish to sell tobacco products including e-cigarettes.  It also references the amendment to federal FDA law that raises the tobacco sale age to 21.  This bill would be helpful to ensure compliance with the new federal age standard. The licensing system would be coordinated by the ADHS and begin on January 1, 2022.

HB2637   Tobacco Definition –  AzPHA Supports

This bill (sponsored by Representative Blackman) will define electronic cigarettes as a tobacco product for the all purposes of state law (although I don’t think that this would extend for tax purposes although I’m not sure yet).

HB2173   Smoke Free AZ Act Amendments –  AzPHA Supports

This bill sponsored by Representative Kavanagh would amend the voter approved Smoke Free Arizona Act to include electronic cigarettes.  Because this amends a voter approved initiative it will need a super-majority vote in the legislature.

Immunizations

HB2050 Immunizations; Parental Control – AzPHA Opposes

This (Fillmore) bill would essentially get rid of the current system by which schools track whether students are vaccinated or not.  Currently, parents decide whether to vaccinate their children and schools can’t require students to receive the recommended immunizations OR refuse to admit or otherwise penalize a student because the student has not received the recommended immunizations as long as the parent signs a personal exemption. Bad bill.

HB2486  Immunization Requirements – AzPHA Opposes

This bill would basically do away with the FDA vaccine approval process and replace it with criteria set by this law for the purposes of implementing vaccination requirements.  The FDA has a rigorous approval protocol that includes all the core elements to determine whether they are safe and effective.  The data are reviewed by independent panels and approved using rigorous protocols.

This bill adds a series of additional requirements that, unless met, mean that a vaccine is eliminated from any vaccination requirement. It’s basically an IED to get completely rid of all vaccination requirements.  Bad bill.

SB 1267  School Immunization Rate Reporting – AzPHA Supports

This common-sense Carter bill would require schools to post the immunization rates on their school website.

Oral Health

HB 2244 Dental; Native Americans –  AzPHA Supports

This bill would require AHCCCS to seek federal authorization to reimburse IHS and tribal facilities to cover the cost of adult dental services that are eligible for a federal medical assistance percentage of 100%.  Authorizes AHCCCS to seek CMS approval to reimburse Indian health care dental providers that receive 100% FMAP for the cost of dental services. Passed House Health 9-0 in late January.

HB2423, SB1170 & HB2727  AHCCCS Dental for Pregnant Women –  AzPHA Supports

These bills from Rep. Butler & Sen Carter would expand oral health coverage for pregnant women enrolled in AHCCCS to include preventive and other services.  This is a terrific bill for public health because a mom’s oral health status is directly linked to birth outcomes.  A new systematic review found a clear relationship between periodontal disease and pre-term birth, and low birth weight.  HB 2727 Received a unanimous pass recommendation from House Health Committee.

HB2535 Preventive Dental Care (AHCCCS) – AzPHA Supports

This bill from Representative Shah would boost the adult oral health coverage for Medicaid members to include two regular cleanings, fluoride 15 treatment, and one set of X-rays annually.  We are in support of this common-sense bill.

Maternal & Child Health

SB1472   Maternal Health; Postpartum Visits – AzPHA Supports

This is a terrific bill from Senator Carter that would direct AHCCCS to require their contracted health plans to increase post-partum visits by new moms and increases the appropriation that would be required to pay for this important initiative.  There are a ton of important physical and behavioral health reasons to implement this important initiative.  Passed the Senate Health Committee.

SB 1493  Pharmacists; Dispensing Hormonal Contraceptives – AzPHA Supports

This is a bill we support which would allow a pharmacist to dispense a self-administered hormonal contraceptive to a person 18 or over pursuant to a standing order.  There are checks and balances in this statute to ensure that best practices are used.  This is a net public health benefit as teen births are the number one cause of inter-generational poverty and the bad health outcomes that result.  Passed the full Senate.

HB2670 Doulas; Voluntary Certification – AzPHA Supports

This bill would establish a voluntary certification process for a person to “practice as a certified community doula.” The ADHS would write the rules and run the program.  There’s good evidence that doulas can improve birth outcomes while reducing delivery costs. Here’s an Issue Brief that provides documentation. This Bill passed the House Health Committee 9-0 on 2/6.

HB 1571Newborn Screening Fund – AzPHA Supports.

Increases the newborn screening fees from to $117 for both screening tests (one is at birth and the second is at about 2 weeks after birth.  The Arizona State Public Health Laboratory currently screens every newborn in Arizona for 31 different conditions.  The new combined fee will provide more efficiency in collections and also provide additional resources for 2 new recommended tests.   This got a pass recommendation from the Senate Health Committee Thursday. 

Here’s a link to our weekly bill tracking spreadsheet thanks to our crack group of policy interns this year. Interesting to note that the bills that would further erode vaccination coverage haven’t been scheduled for a hearing next week. That doesn’t mean they’re kaput, but it’s a good sign.

Social Determinants

HB2104 Child Care Assistance and Training – AzPHA Supports

This bill would let ADES waive work requirements for people enrolled full time in an accredited educational institution in order to continue to provide supplemental child care assistance subsidies for the dependent child.  Unanimously passed House Health Committee.

Disease Control

SB 1028   Public Health Surveillance – AzPHA Supports

Adds “an emerging public health threat to the list of things that can trigger ADHS enhanced surveillance orders and compliance with mandatory public health interventions.  The idea is that the bill would provide enhanced surveillance authority for emerging public health threats that aren’t yet a full public health emergency- along the lines of doing enhanced surveillance when persons were getting severe lung illnesses from the bootleg vaping products that contained vitamin e acetate.  Received a pass recommendation from the Senate Health Committee.

Workforce

SB 1167 Graduate Medical Education – AzPHA Supports

This important bill from Sen Carter would set up a program to reimburse primary care residency programs and qualifying Community Health Centers.  This bill is important because it addresses the shortages that we face in rural and under-served areas by setting up residency programs that will have a long-term positive impact on access to care (especially primary care) in these areas. Passed the full Senate.

HB 2296     Native American AHEC – AzPHA Supports

This bill would create a sixth Area Health Education Center (AHEC) that will focus on the Indian Health System. AHECs are committed to expanding the health care workforce, while maximizing diversity and facilitating distribution, especially in rural and under-served communities and offer creative, hands-on and innovative health career curriculum for pre-college level students.  It passed the House Education Committee.

Vulnerable Populations

 HB2608   Overdose Prevention & Harm Reduction – AzPHA Supports

This bill would facilitate evidence best practices that slow the spread of blood-borne pathogens and engage injection drug users in treatment.  It’s currently a felony to provide syringes to injection drug users via a syringe access program even though these programs are evidence-based programs that reduce the spread of Hepatitis C, HIV and other blood-borne pathogens and engage injection drug users in treatment. 

We have supported bills like this for the last several years, but they have yet to be successful.  This Bill got a pass recommendation from the House Health Committee (8-0). On to the Rules Committee then the House floor.

HB 2549 Adult Protective Services Audit – AzPHA Supports

A recent report from the Developmental Disabilities Planning Council has identified several critical shortcomings in the performance of the Adult Protective Services program at the Arizona Department of Economic Security. This bill would charge the Auditor General’s Office with contracting for an independent evaluation of APS’ performance- an evaluation that is sorely needed.  It includes a $300K appropriation to conduct the review.  Passed the House Health Committee last week.

SB 1086 Licensing Surveyors –  AzPHA Supports

Appropriates $3M & 44 staff positions in FY 2021 for additional (ADHS) long-term care facility surveyors.  Normally, these services would be paid for via a licensing fee.  In this case, the bill contemplates a general fund appropriation.  The genesis of this bill is as a result of the 2019 Auditor General’s Report that found the ADHS is not adequately following up on complaints at skilled nursing facilities in Arizona. Passed Senate Health 8-0 in late January.

HB 2031   School Marshals – AzPHA Opposes

Lawmakers just introduced a new bill that would bring guns into Arizona schools.  HB 2031 would create a school marshal program that would allow school employees across Arizona to carry concealed firearms on school grounds, during school hours.  There is no evidence in the literature that we could find to demonstrate that this is an evidence-based intervention to prevent violence and injury in schools so we are opposing the measure.

SB 1164    Severe Threat Order of Protection – AzPHA Supports

This bill would create a new kind of severe threat order of protection (with judicial review) and place new requirements for persons for who the orders have been issued including prohibiting the person from buying or having a firearm during the order’s duration.

SB 1169 School Health Program – AzPHA Supports

This bill from Sen Carter would support the costs of placing nurses and psychologists in Arizona public schools. The bill includes a detailed list of application standards for schools.

SB 1397 Health Insurance; Pre-existing conditions – Neutral 

This bill provides a partial backstop in case the US Supreme Court strikes down the Affordable Care Act. It would prohibit health insurers from offering health insurance plans that exclude people with pre- existing conditions from coverage.

It is silent on whether people with pre-existing conditions could be charged higher premiums, which is why we’re neutral on the bill.  We’d like to see it amended so that it includes Community Pricing. The bill got a pass recommendation from the Senate Finance Committee last week (9-0). Hopefully it’ll eventually be amended to include community pricing.

HB 2788 Pre-existing Conditions; Essential Benefits

This bill from Rep. Butler would provide a backstop in case the US Supreme Court strikes down the Affordable Care Act. It would prohibit health insurers from offering health insurance plans that exclude people with pre-existing conditions from coverage and would not allow insurers to charge more for people with pre-existing conditions. It would also require coverage for the 10 essential health benefits outlined in the ACA.

Nutrition & Food Safety

SB1221   SNAP; benefit match – AzPHA Supports

This bill would direct an appropriation of $800K to the ADES to develop the infrastructure to create a produce incentive program within SNAP (food stamps) and to help enrollees to buy Arizona grown fruits and vegetables.Passed Senate Finance Committee.

HB 2739 Liquor Omnibus

Exempts alcoholic beverages that are commercially produced by a licensed producer from laws and rules relating to the Department of Health Services and Pure Food Control (the state food code). Passed the commerce committee and Rules is next.

HB 2453  Exemption, Food Code Wineries

Arizona law already exempts certain food or drinks from the state food code requirements that are: a) Not potentially hazardous; b) Offered at a child care facility and limited to prepackaged food that is not potentially hazardous and whole fruits and vegetables; and c) Offered at locations that sell only commercially prepackaged food or drink that is not potentially hazardous. (A.R.S. § 36-136). 

This bill would extend the exemptions to liquor, wine or beer that is produced and served on the premises.  In other words- bars that only serve booze and pre-packaged foods would no longer require a food establishment license.  Counties would no longer have any authority over making sure bar bathrooms are sanitary or how glassware is washed and sanitized.  Also, the bathrooms would be unregulated.  Passed the full House this week.

White House Releases the Executive Budget Proposal

Big Cuts Proposed for Public Health & Social Determinants

The White House staff released the Executive Branch’s proposed budget for FY 21 last week.  I won’t spend a lot of time on it here because it will have little influence on what actually comes out of Congress because of the fact that different parties control the House and Senate. 

The basics of the proposal include a 9% cut to the HHS including a $693M cut to CDC and a $742 cut to HRSA. The overview of the 9% HHS cut says that it includes reductions on the Medicaid side of CMS. I couldn’t find any of those cuts in the CMS line items except for a general $3.6B cut to state budget authority (with no detail) a $24B cut to various federal hospital insurance trust funds. 

The proposed budget says that “$1 out of every $7 spent in Medicaid, were considered an improper payment”. I had never seen that statistic before. They also say that their budget cut to Medicaid is due to the fact that the Administration will “… strengthen CMS’ ability to address weaknesses in provider screening, enrollment, and identification, as well as beneficiary eligibility determinations in Medicaid“. Maybe they expect to capture the cuts there?  Ok, then.

They also propose an 8% cut to USDA programs (especially SNAP).  They book those savings due to “…  SNAP work requirements and apply them consistently to able-bodied adults ages 18 to 65, unless they qualify for specific exemptions. Under the proposal, adults would be required to work, participate in job training, or volunteer at least 20 hours a week in order to receive SNAP benefits“.

USDA will get big increases in other areas like farm subsidies. The proposed budget says: “To help farmers survive the market shocks (read tariffs), the Administration has provided $28 billion in trade mitigation assistance and $5.7 billion in supplemental and ad hoc disaster assistance to farmers.” 

In fact, a third of farm income last year came from Government payments and crop insurance last year, and they don’t expect that to change.  

New AzPHA Preventing Firearm Violence Evidence Resources

Member Action Items for this Week

HB 2784 Medical Marijuana Research – AzPHA Supports

This bill will make it explicit that the medical marijuana fund could be used for research regarding medical marijuana.  The bill is consistent with our Resolution on this topic and we encourage you to sign up in support of the bill.  It’ll be heard in the House Health Committee this Thursday.

HB 2550 ADHS Licensing Surveyors

Appropriates $3M & 44 staff positions in FY 2021 for additional (ADHS) long-term care facility surveyors.  Normally, these services would be paid for via a licensing fee.  In this case, the bill contemplates a general fund appropriation.  The genesis of this bill is as a result of the 2019 Auditor General’s Report that found the ADHS is not adequately following up on complaints at skilled nursing facilities in Arizona. This will be heard in House Health Committee Thursday and we encourage you to sign up in support of the bill.

HB1028   Public Health Surveillance –  AzPHA Supports

Adds “an emerging public health threat to the list of things that can trigger ADHS enhanced surveillance orders and compliance with mandatory public health interventions.  The idea is that the bill would provide enhanced surveillance authority for emerging public health threats that aren’t yet a full public health emergency- along the lines of doing enhanced surveillance when persons were getting severe lung illnesses from the bootleg vaping products that contained vitamin e acetate. This will be heard in the Senate Health Committee Thursday and we encourage you to sign up in support of the bill. 

Here’s a link to our weekly bill tracking spreadsheet thanks to our crack group of policy interns this year. Interesting to note that the bills that would further erode vaccination coverage haven’t been scheduled for a hearing next week. That doesn’t mean they’re kaput, but it’s a good sign.

Coronavirus Intervention Activities & Editorial Notes

Intervention Activities

As you know, Maricopa County Department of Public Health confirmed one case of 2019 Novel Coronavirus infection in a person from a couple of weeks ago. The person came to the Valley from Wuhan and had a mild illness that didn’t require hospitalization (a good sign). The person is still isolated at home with daily monitoring and regular testing to determine if the virus is still present in the nose and mouth.

Close contacts are being monitored daily for fever and symptoms, but so far there’s no evidence of community spread.  All the county health departments are set to contact travelers from China and provide them with monitoring instructions for 14 days after their last exposure (because Maricopa is the urban hub of the state they will be the primary spot where any action will be from travelers). Here are a few notes from Maricopa about some particulars: 

  • Maricopa County residents who have traveled to China recently and are concerned about 2019 Novel Coronavirus are supposed to call 602-747-7099;

  • Anyone with respiratory symptoms who is concerned about 2019 Novel Coronavirus should contact their healthcare provider BEFORE seeking care to avoid spread to others; and

  • Healthcare providers in Maricopa County who see patients with travel history to China in the 14 days before illness onset AND respiratory symptoms should contact Public Health at 602-747-7111

Anybody can go to the Maricopa.gov/Coronavirus website and look at their social media (Twitter @maricopahealth and @saludmaricopa, Facebook in English and in Spanish) for local updates including: Current case counts; FAQs in English, Spanish, and Mandarin;  Detailed healthcare provider guidance; Template letter for schools to inform families about the low risk; and Actions to prevent stigmatization and bullying.

MCDPH will also continue to work with healthcare providers to facilitate testing of people who meet CDC criteria, monitor those who are risk of developing illness, and isolate those who are potentially contagious.

Editorial Remarks

So far, the evidence suggests that this new virus is easily transmitted person to person.  While the symptoms can be severe in some folks, they’re commonly quite mild (like the single AZ case). It looks like the virus can be transmitted from asymptomatic persons, which means that standard practices like screening and isolation will be of limited effectiveness as interventions over the long run (the data are still a little unclear whether asymptomatic folks are infectious).

When you put these characteristics together along with the patterns for similar illnesses- it suggests that the number of undiagnosed and unreported cases (driven by a lot of people with truly mild infection) will turn out to be at least 10 times higher than what’s currently being reported in the Chinese surveillance data. 

While 2019-nCoV currently shows ~2% mortality the denominator is likely much much larger.  In reality, mortality is likely closer to something like 0.2% or even 0.02% (because the denominator is likely much larger than what is being reported by China). 

In other words, it looks like this new virus will be a high-incidence and fairly low virulence infection. 

So, as public health professionals, we need to keep our evidence hat squarely on our heads…  and as the virus spreads across the globe (as it will likely do in the coming weeks and months) frame our intervention plans consistent with what we do for similar viruses (e.g. influenza).

Right now, with just sporadic travel cases being reported and tracked and with some uncertainty still out there about the virulence of this virus, it makes sense to conduct the interventions that are underway at our county health departments and at other levels of government.

The CDC action is now quarantining repatriated citizens for 14 days – the first time they’ve used quarantine authority since smallpox.    Interventions like that when there are a handful of contacts is of course do-able and will have essentially no societal disruption.  It will also buy valuable time- time that we will use to better characterize the etiology of the new virus. 

However, when the wave eventually hits – as it will likely do in either weeks or months – we need to think carefully and make sure that our interventions are consistent with our standardized and existing public health practice principles.  By that, I mean the kinds of interventions we conduct and encourage for influenza type illnesses.

Encouraging actual suspect cases to self-isolate is a no-brainer.  But, when the wave comes, should we invoke public health authority beyond that?

Interventions like isolation and quarantine (once the wave hits) would cause major disruptions to society and place public health in the crosshairs of needing to justify why such dramatic interventions are needed – when we don’t implement them for things like influenza.  Also, there’s a real danger to future public health authority if you “cry wolf” too soon about a disease that may turn out to be a tragedy for a few, but no big deal for the vast majority.  

Just something for the back of your mind as we do what we need to do in the coming days.  Let’s continue be cautious at first, but not over-hype it, and be prepared to back off sooner than later if the data continues to suggest that this will indeed be a high-incidence and fairly low virulence infection. 

Member Action Items for this Week

HB2423, SB1170 & HB2727 Dental for Pregnant Women

SB 1170 is scheduled for a hearing before the Senate Appropriations Committee Tuesday 02/11/2020 at 2 PM and the mirror bill HB2727 will be heard in the House Health and Human Services Committee the next day (Thursday 2/13 at 9AM).  Please sign on in support of both bills and come to the hearing rooms at the Capitol to show your support.   

Please email appropriations committee members, letting them know how you feel about SB1170, which will provide comprehensive dental care to pregnant adults. See their email addresses: lalston@azleg.gov; SBOWIE@azleg.gov; hcarter@azleg.gov; dgowan@azleg.gov; SKERR@azleg.gov; vleach@azleg.gov; dlivingston@azleg.gov; LOTONDO@azleg.gov; mugenti-rita@azleg.gov

These bills would expand oral health coverage for pregnant women enrolled in AHCCCS to include preventive and other services.  This is a terrific bill for public health because a mom’s oral health status is directly linked to birth outcomes.  A new systematic review found a clear relationship between periodontal disease and pre-term birth, and low birth weight.

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SB1493 Pharmacists; Dispensing Hormonal Contraceptives

This good bill (SB1493) is scheduled to be heard in the Senate Health and Human Services Committee on Wednesday morning at 9 am. Please go into the AZLEG system and express your support for this bill.  It would allow a pharmacist to dispense a self-administered hormonal contraceptive to a person 18 or over pursuant to a standing order.

There are checks and balances in this statute to ensure that best practices are used.  This is a net public health benefit as teen births are the number one cause of inter-generational poverty and the bad health outcomes that result.

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HB 2549 Adult Protective Services Audit

HB 2549 is scheduled to be heard will be heard in the House Health and Human Services Committee on Thursday 2/13 at 9 am.  Please sign on in support of this bill and come to the hearing rooms at the Capitol to show your support.

A recent report from the Developmental Disabilities Planning Council has identified several critical shortcomings in the performance of the Adult Protective Services program at the Arizona Department of Economic Security. This bill would charge the Auditor General’s Office with contracting for an independent evaluation of APS’ performance- an evaluation that is sorely needed.  It includes a $300K appropriation to do the review.

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HB2486  Immunization Requirements – AzPHA Opposes

While HB2486 isn’t scheduled for a hearing next week, we’re asking our members to go into the AZLEG system and express their opposition to this bad bill.  It would basically do away with the FDA vaccine approval process and replace it with criteria set by this law for the purposes of implementing vaccination requirements.  

This bill adds a series of additional requirements that, unless met, mean that a vaccine is eliminated from any vaccination requirement. It’s basically an IED to get completely rid of all vaccination requirements.  Bad bill.

Here’s a Summary of Last Week’s Committees Hearings

Bills that Passed House Health Committee this week:

HB 2608  Overdose Prevention & Harm Reduction – AzPHA Supports

This bill would facilitate evidence best practices that slow the spread of blood-borne pathogens and engage injection drug users in treatment.  It’s currently a felony to provide syringes to injection drug users via a syringe access program even though these programs are evidence-based programs that reduce the spread of Hepatitis C, HIV and other blood-borne pathogens and engage injection drug users in treatment. 

We have supported bills like this for the last several years, but they have yet to be successful.  This Bill got a pass recommendation from the House Health Committee (8-0). On to the Rules Committee then the House floor.

HB2670 Doulas; Voluntary CertificationAzPHA Supports

This bill would establish a voluntary certification process for a person to “practice as a certified community doula.” The ADHS would write the rules and run the program.  There’s good evidence that doulas can improve birth outcomes while reducing delivery costs. Here’s an Issue Brief that provides documentation. This Bill passed the House Health Committee 9-0 on 2/6.

SB1397 Health Insurance; Pre-existing conditions – Neutral 

This bill provides a partial backstop in case the US Supreme Court strikes down the Affordable Care Act. It would prohibit health insurers from offering health insurance plans that exclude people with pre- existing conditions from coverage.

It is silent on whether people with pre-existing conditions could be charged higher premiums, which is why we’re neutral on the bill.  We’d like to see it amended so that it includes Community Pricing.  The bill got a pass recommendation from the Senate Finance Committee last week (9-0). Hopefully it’ll eventually be amended to include community pricing.

Here’s the List of Bills that We’re For and Against

Below is a summary of the short list of bills that we’re following closely. Our public health policy interns from the UA College of Public Health (Dylan Miller, Caitlin Tillis & Desiree Jones) have also put together a tracking tool in spreadhseet format that you can download. 

Tobacco Control

HB2636 & SB1400  Tobacco Retail Licensing – AzPHA Supports

This bill (sponsored by Representative Blackman) would facilitate a licensing system for stores that wish to sell tobacco products including e-cigarettes.  It also references the amendment to federal FDA law that raises the tobacco sale age to 21.  This bill would be helpful to ensure compliance with the new federal age standard. The licensing system would be coordinated by the ADHS and begin on January 1, 2022.

HB2637   Tobacco Definition –  AzPHA Supports

This bill (sponsored by Representative Blackman) will define electronic cigarettes as a tobacco product for the all purposes of state law (although I don’t think that this would extend for tax purposes although I’m not sure yet).

HB2173   Smoke Free AZ Act Amendments –  AzPHA Supports

This bill sponsored by Representative Kavanagh would amend the voter approved Smoke Free Arizona Act to include electronic cigarettes.  Because this amends a voter approved initiative it will need a supermajority vote in the legislature.

Immunizations

HB2050 Immunizations; Parental Control – AzPHA Opposes

This (Fillmore) bill would essentially get rid of the current system by which schools track whether students are vaccinated or not.  Currently, parents decide whether to vaccinate their children and schools can’t require students to receive the recommended immunizations OR refuse to admit or otherwise penalize a student because the student has not received the recommended immunizations as long as the parent signs a personal exemption. Bad bill.

HB2486  Immunization Requirements – AzPHA Opposes

This bill would basically do away with the FDA vaccine approval process and replace it with criteria set by this law for the purposes of implementing vaccination requirements.  The FDA has a rigorous approval protocol that includes all the core elements to determine whether they are safe and effective.  The data are reviewed by independent panels and approved using rigorous protocols.

This bill adds a series of additional requirements that, unless met, mean that a vaccine is eliminated from any vaccination requirement. It’s basically an IED to get completely rid of all vaccination requirements.  Bad bill.

SB 1267  School Immunization Rate Reporting – AzPHA Supports

This common-sense Carter bill would require schools to post the immunization rates on their school website.

Oral Health

HB 2244 Dental; Native Americans –  AzPHA Supports

This bill would require AHCCCS to seek federal authorization to reimburse IHS and tribal facilities to cover the cost of adult dental services that are eligible for a federal medical assistance percentage of 100%.  Authorizes AHCCCS to seek CMS approval to reimburse Indian health care dental providers that receive 100% FMAP for the cost of dental services. Passed House Health 9-0 in late January.

HB2423, SB1170 & HB2727  AHCCCS Dental for Pregnant Women –  AzPHA Supports

These bills from Rep. Butler & Sen Carter would expand oral health coverage for pregnant women enrolled in AHCCCS to include preventive and other services.  This is a terrific bill for public health because a mom’s oral health status is directly linked to birth outcomes.  A new systematic review found a clear relationship between periodontal disease and pre-term birth, and low birth weight.

HB2535 Preventive Dental Care (AHCCCS) – AzPHA Supports

This bill from Representative Shah would boost the adult oral health coverage for Medicaid members to include two regular cleanings, fluoride 15 treatment, and one set of X-rays annually.  We are in support of this common-sense bill.

Maternal & Child Health

SB1472   Maternal Health; Postpartum Visits – AzPHA Supports

This is a terrific bill from Senator Carter that would direct AHCCCS to require their contracted health plans to increase post-partum visits by new moms and increases the appropriation that would be required to pay for this important initiative.  There are a ton of important physical and behavioral health reasons to implement this important initiative.

SB1493 Pharmacists; Dispensing Hormonal Contraceptives – AzPHA Supports

This is a bill we support from Sen. Ugenti Rita which would allow a pharmacist to dispense a self-administered hormonal contraceptive to a person 18 or over pursuant to a standing order.  There are checks and balances in this statute to ensure that best practices are used.  This is a net public health benefit as teen births are the number one cause of inter-generational poverty and the bad health outcomes that result. 

HB2670 Doulas; Voluntary CertificationAzPHA Supports

This bill would establish a voluntary certification process for a person to “practice as a certified community doula.” The Department of Health Services would write the rules and run the program.   There is good evidence that doulas can improve birth outcomes while reducing delivery costs. Here’s an Issue Brief that provides documentation. This Bill passed the House Health Committee 9-0 on 2/6.

Social Determinants

HB2104 Child Care Assistance and Training –  AzPHA Supports

This bill would let ADES waive work requirements for people enrolled full time in an accredited educational institution in order to continue to provide supplemental child care assistance subsidies for the dependent child. 

Disease Control

SB 1028   Public Health Surveillance –  AzPHA Supports

Adds “an emerging public health threat to the list of things that can trigger ADHS enhanced surveillance orders and compliance with mandatory public health interventions.  The idea is that the bill would provide enhanced surveillance authority for emerging public health threats that aren’t yet a full public health emergency- along the lines of doing enhanced surveillance when persons were getting severe lung illnesses from the bootleg vaping products that contained vitamin e acetate.

Workforce

SB 1167 Graduate Medical Education – AzPHA Supports

This important bill from Sen Carter would set up a program to reimburse primary care residency programs and qualifying Community Health Centers.  This bill is important because it addresses the shortages that we face in rural and under-served areas by setting up residency programs that will have a long-term positive impact on access to care (especially primary care) in these areas. 

HB 2296 Native American AHEC – AzPHA Supports

This bill would create a sixth Area Health Education Center (AHEC) that will focus on the Indian Health System. AHECs are committed to expanding the health care workforce, while maximizing diversity and facilitating distribution, especially in rural and under-served communities and offer creative, hands-on and innovative health career curriculum for pre-college level students.

Vulnerable Populations

HB 2608  Overdose Prevention & Harm Reduction – AzPHA Supports

This bill would facilitate evidence best best practices that slow the spread of blood-borne pathogens and engage injection drug users in treatment.  It’s currently a felony to provide syringes to injection drug users via a syringe access program even though these programs are evidence-based programs that reduce the spread of Hepatitis C, HIV and other blood-borne pathogens and engage injection drug users in treatment.  We have supported bills like this for the last several years, but they have yet to be successful.

HB 2549 Adult Protective Services Audit – AzPHA Supports

A recent report from the Developmental Disabilities Planning Council has identified several critical shortcomings in the performance of the Adult Protective Services program at the Arizona Department of Economic Security. This bill would charge the Auditor General’s Office with contracting for an independent evaluation of APS’ performance- an evaluation that is sorely needed.  It includes a $300K appropriation to conduct the review.

SB 1086 Licensing Surveyors –  AzPHA Supports

Appropriates $3M & 44 staff positions in FY 2021 for additional (ADHS) long-term care facility surveyors.  Normally, these services would be paid for via a licensing fee.  In this case, the bill contemplates a general fund appropriation.  The genesis of this bill is as a result of the 2019 Auditor General’s Report that found the ADHS is not adequately following up on complaints at skilled nursing facilities in Arizona. Passed Senate Health 8-0 in late January.

HB 2031   School Marshals – AzPHA Opposes

Lawmakers just introduced a new bill that would bring guns into Arizona schools.  HB 2031 would create a school marshal program that would allow school employees across Arizona to carry concealed firearms on school grounds, during school hours.  There is no evidence in the literature that we could find to demonstrate that this is an evidence-based intervention to prevent violence and injury in schools so we are opposing the measure.

SB 1164    Severe Threat Order of Protection – AzPHA Supports

This bill would create a new kind of severe threat order of protection (with judicial review) and place new requirements for persons for who the orders have been issued including prohibiting the person from buying or having a firearm during the order’s duration.

SB 1169 School Health Program – AzPHA Supports

This bill from Sen Carter would support the costs of placing nurses and psychologists in Arizona public schools. The bill includes a detailed list of application standards for schools.

SB1397 Health Insurance; Pre-existing conditions _AzPHA Neutral

This bill provides a partial backstop in case the US Supreme Court strikes down the Affordable Care Act. It would prohibit health insurers from offering health insurance plans that exclude people with pre- existing conditions from coverage. It is silent on whether people with pre-existing conditions could be charged higher premiums, which is why we’re neutral on the bill.  We’d like to see it amended so that it includes Community Pricing.

HB 2788 Pre-existing Conditions; Essential Benefits

This bill from Rep. Butler would provide a backstop in case the US Supreme Court strikes down the Affordable Care Act. It would prohibit health insurers from offering health insurance plans that exclude people with pre-existing conditions from coverage and would not allow insurers to charge more for people with pre-existing conditions. It would also require coverage for the 10 essential health benefits outlined in the ACA.

Nutrition

SB1221   SNAP; benefit match – AzPHA Supports

This bill would direct an appropriation of $800K to the ADES to develop the infrastructure to create a produce incentive program within SNAP (food stamps) and to help enrollees to buy Arizona grown fruits and vegetables. 

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