Legislative Session Musings

It’s been a bit since I did an update on the legislative session- in part because I’ve been so consumed with the administrative advocacy regarding the pandemic.

Luckily for us, Tara Plese, Member and Chief External Affairs Officer for the  from the Arizona Alliance for Community Health Centers (and AzPHA member) just sent out a good legislative session summary to their members and she have me permission to plagiarize large portions of her work. Here goes:

____________________

On Tuesday, the legislative session officially hit the 100-day mark. Technically, that should signal that the end is near, as House and Senate rules say the Legislature must finish its work by the Saturday following the 100th day of the session. But the Arizona Legislature can extend the deadline. Rules also allow the Senate President and Speaker of the House to extend the session for an additional seven days (which they did on Tuesday).

From here on, the session can only be extended by a majority vote of both chambers, but there is no limit on the number of extensions the body can approve. After the 120th day, legislative per diem gets cut in half, although the decrease in pay has never been a motivation for members to work more quickly.

So, what is is holding up the process? Money, of course. Lawmakers will not adjourn until they have reached consensus on a budget. Those negotiations are still ongoing behind closed doors, as leadership in both chambers attempt to craft a deal that will get 31 votes in the House, 16 in the Senate and a signature from the Governor. At this point, it’s anyone’s guess as to how long that might take.

Budget and Tax Cut Negotiations

At the height of the pandemic, no one could have predicted that Arizona would be flush with cash when it came time to finalize the budget for the next fiscal year. Between the $16 billion from the latest federal relief package ($12.2 billion of which is allocated to the state government), the $38 billion from previous federal relief payouts from the CARES Act, and an increase in tax revenue during the pandemic from “Wayfair” (legislation enacted in 2019 requiring online sellers and marketplace facilitators to file and pay transaction privilege tax), Arizona is looking at a $1 billion surplus- in addition to the $1 billion that’s already in the state’s “rainy day” fund. With all those dollars at play, budget negotiations are more complex than years past.

While Republicans have agreed that a major tax cut is a top priority, they have yet to agree on specifics. Based on what has been publicly shared, preliminary proposals could result anywhere from $450 million to more than $1 billion in tax cuts when fully implemented.

Leadership in the House is pushing for a flat income tax of 2.5% over the next three years while Sen. J.D. Mesnard is lobbying for an alternate income tax intended to lessen the potential impact of recently passed Prop. 208 (education funding) on businesses that file taxes under the individual tax code. A third proposal under consideration is a reduction to commercial property tax.

Senate Republicans met to discuss the budget in a closed caucus yesterday, but leadership didn’t allow senators to take budget documents out of the room. ting told our reporter they didn’t get much out of it and predicted the Legislature will be here for another month.

The main difference between the two chambers is that the House is much further along on a tax plan. The Senate budget has remained, relatively, unchanged. The Senate appears to be more fixated on their election audit.

The House voted unanimously to rush a bill conforming Arizona’s tax code to changes made at the IRS under the Covid-19 relief bills passed last year and in March. After languishing in the House for more than a month, S1752 (conformity; internal revenue code) passed the House Appropriations Committee unanimously in the morning, and quickly moved through rules and COW before finally getting 60 votes on the House floor.

The generally routine step of aligning the state and federal income tax codes was more complicated and significant this year due to the need to conform to three federal Covid-19 relief measures. Conformity means Arizonans will not owe state taxes on their federal Covid-19 stimulus checks or on federally tax-exempt unemployment payments.

High profile bills

Most of the remaining bills before the Legislature are ones that have been the subject of extremely heated debates throughout the session. Tensions have heightened over the past several weeks, and the open display of raw tensions during floor debates has been remarkable—even by the standards of a state Legislature.

However, the Legislature passed a proposal to impose a new restriction on a woman’s right to terminate a pregnancy by making it a crime to abort a child because of a fetal genetic defect. Strongly opposed by Democrats in both chambers, SB1457 (abortion; unborn child; genetic abnormality), which now goes to Gov. Doug Ducey, says any medical professional who performs or aids an abortion in those cases can be sentenced to up to a year in state prison. Ducey has not said whether he will sign or veto the measure sponsored by Republican Sen. Nancy Barto.

Also the subject of intense debate this week was SB1485 (early voting list; eligibility), sponsored by Republican Sen. Michelle Ugenti-Rita, which would purge infrequent voters from Arizona’s early voting list. The measure unexpectedly failed when GOP Sen. Kelly Townsend flipped to a “no” vote, vowing to vote against all election bills until the audit of 2020 election results is complete. It remains unclear what that could mean for a handful of other partisan election bills, as Republicans hold a razor-thin margin in both chambers.

Adding an interesting layer to all of this is the court ruling issued this afternoon ordering the Senate and its audit team to comply with all laws governing the right to a secret ballot and the confidentiality of voter registration data, and to provide copies of all relevant policies and procedures to the court (the audit team has not yet made those documents public).

You may have heard about a number of controversial bills and actions on the floor in both the House and Senate. To say it has been a difficult week is a bit of an understatement.

Movement on bills and action “on the floor” has slowed as the work on the budget continues. Any bills will money on them are stalled until the work on the budget is nearing completion. We may not see the bill itself pass but may see the funding in the budget.

Bill Update

Our Public Health policy Committee and team of interns have been tracking over 100 bills this session- and we’ve signed up in support or against many of them. Here’s the spreadsheet with the tracking status of each. It also includes a hot link for you to click on which will take you to the actual bill.

A few bills of public health interest have passed and been signed by the Governor including:

SB 1181 Doula Certification. Good bill that charges ADHS with developing rules for the voluntary certification of Doula’s. This will help build the workforce and potentially build a path for reimbursement. Doulas have been shown to improve birth outcomes and reduce costs in Medicaid programs.

SB 1011 Maternal Mental Health Advisory Committee. Good bill which will require a state panel to examine post partum mental health and make policy recommendations.

SB 1016 Naturopath Scope of Practice. This bill expands the scope of practice for Naturopaths in various ways including the ability to sign epi pen standing orders.

SB 1094 AHCCCS Substance Abuse. This bill officially moves the FIRST Grant from ADHS to AHCCCS.

______________

Bills that are waiting for final approval that we’re supporting include:

SB 1250 Overdose Prevention. We’ve been helping to get this bill over the line for several years. It will (if it passes and is signed) improve substance abuse treatment, improve prevention for bloodborne pathogens. Among other things it will decriminalize syringe service programs.

SB 1486 Drug Paraphernalia. This good bill would decriminalize the possession of fentanyl test strips. Fentanyl is the dominant cause of opioid deaths now and this bill would help people to detect it.

SB 1680 Newborn Screening Testing. This good bill would require the state lab to add all tests recommended to their newborn testing screening testing panel.

Convenience is the Name of the Game

Getting to Herd Immunity Is Going to Require More Innovative & Spontaneous Ways to Get Vaccinated

Each week the federal government updates their 3-week vaccine allocation forecast and informs state health departments how many doses of the various vaccines are available for the following week. State health departments then make decisions about how to allocate the vaccines among the county health departments, clinics, health centers, and in some states like ours, large university-run mass vaccination sites.

From the beginning, Director Christ has been reserving the lion’s share of the Pfizer vaccine for their showcase state-sponsored &  university run mega-sites like the former State Farm stadium site. Moderna has been largely going to county health departments for community-based vaccine efforts (see breakdown).

The large stadium type sites were efficient (at least for wealthier demographics) back when the demand for vaccine was huge and people were willing to tolerate the state’s computer site and fight their way to the large vaccination site which was likely far from their home. It worked, because people were willing to put the level of effort it took to get vaccinated at a mega-site.

Fortunately, county health departments have been wise enough to prioritize more community-based sites, mobile sites, special events and other locations that are much better at getting vaccine to more difficult to reach populations.

Meanwhile, the federal government has recognized that many state health departments (like ours) weren’t being very effective at vaccine into hard to reach communities, and they began to ship vaccine directly to pharmacies and community health centers, which helped a lot.

As supplies increased along with manufacturing capacity (and as the more motivated persons have become vaccinated) we now find ourselves in a different world.

The new name of the game for reaching folks that have yet to be vaccinated (younger persons and those left behind in lower income areas) is convenience. If we’re going to get closer to herd immunity we’re going to have to change how vaccine is prioritized by the ADHS and move allocations away from the inconvenient mega-sites that are far away from people’s homes toward local sites and places that don’t require an appointment.

Indeed, last week the 7 state-financed PODs only administered an average total of  14,900 vaccines per day (104,500 for the week). That’s an average of less than 2,000 shots per large site per day.

Arizona’s ranking in vaccines administered per capita now ranks in the bottom half of states (about 31st). As other states have transitioned to a much more community-based and no-appointment needed sites the ADHS has been doubling-down on the very large mega-sites with high overhead costs (including expensive rent) that have been attracting less and less interest.

This week, ADHS allocated 179,000 doses of Pfizer vaccine to their financed sites despite the fact that last week they only administered a total of 104,000. At that pace, state financed POD freezers will continue to fill up and vaccine will continue to go unused that could have otherwise been used at a county community-based site, in community health centers or in pharmacies.

Note: state financed PODs have only administered 86% of their allocated vaccine vs. counties which have administered 100%.

Let’s hope that the ADHS senior leadership recognizes that the mega-site business model is no longer efficient and that they need to increase allocations to counties, community health centers, pharmacies, clinics and doctors offices.

A shift in the state’s business model for getting vaccine out has been in order for some time now. If they’re going to keep the large state-financed and university-run sites then they need to make them no-appointment needed sites immediately.

It’s Crunch Time for AZ’s Clean Energy Rules

Earlier this week, the Administrative Law Judge presiding over the formal rulemaking for rules issued her recommended opinion and order. If adopted by the Arizona Corporation Commission, the Order would approve Arizona’s landmark Clean Energy Rules which will move our state toward a carbon free electricity generation standard by 2050. The Clean Energy Rules will be on the Agenda of their May 4/5 meeting.

If the Commissioners “substantively” modify the ALJ’s Order at their May 4/5 meeting by amending it, then the Commission would have to do a supplemental rulemaking which would kick the can down the road by several months.

The most likely outcome is that the Commission will vote on an amendment to the proposed rule which will kick off a supplemental rulemaking, further delaying the Rule and making it more likely that the legislature or governor will find a way to scuttle the rule (the governor has made no secret about his hostility to the clean energy rules). 

AzPHA Member Action Item:

Submit written comments supporting the proposed rule

The Corporation Commission will be discussing and considering amendments to the proposed clean energy rules and the  recommended opinion and order at their meeting on May 4/5th. They are accepting comments this week through Thursday, April 29th.  I submitted this letter into the record on behalf of AzPHA. You can use my language or submit your own stuff in support of the proposed rule and opposing additional amendments.

To submit your comments go to azcc.gov, select the tab “Cases and Open Meetings,” and select “Make a Public Comment in a Docket.” This leads to a fillable form that can be submitted electronically. The clean energy rules are under Docket No. RU-00000A-l8-0284.

I did what’s called an “eFile” written comment by selecting the “Cases and Open Meetings,” and selecting “eFile in a Case” and uploading this letter.

Dr. Joe Gerald’s Weekly Epi & Hospital Report Shows Slowly Increasing Cases & Hospitalizations

Arizona Stubbornly Remains in Moderate to Substantial Spread

Arizona case rates remain “stuck” at the threshold differentiating substantial and moderate risk because of the more transmissible variant becoming dominant in AZ (e.g., B.1.1.7) and because of the policy decisions by the governor and ADHS director to eliminate all required mitigation measures and again prohibiting counties from having mask mandates. Last week Covid-19 cases increased 6% from the previous week. The highest rates are among those 15 – 24 years and 25 – 64 years of age, 116 and 81 cases per 100K residents per week, respectively.

Hospitalizations also continue to increase. As of April 22nd, 594 (7%) of Arizona’s 8605 general ward beds were occupied by Covid-19 patients, a 4% increase from the previous week’s 569 occupied beds. COVID ICU bed use is increasing more substantially than general ward beds. Eleven percent (11%) of Arizona’s 1727 ICU beds are occupied with Covid-19 patients, a 21% increase from the prior week’s count of 154 patients

In terms of vaccinations, Arizona continues to rank in the bottom half of states (30th of the 50 states) with 34% of Arizona’s adult population fully vaccinated and another 15% having received one dose (49% with ≥1 dose). Arizona also ranks in the bottom half of states when it comes to vaccinating seniors, with 78% of the ≥65 population having received ≥1 dose.

Here is Dr. Gerald’s full report this week

CDC’s & FDA Again Recommend the Johnson & Johnson Vaccine

FDA & CDC Lift the “Pause” Almost Immediately after today’s advisory committee for immunization proactices meeting

The ACIP had a very good meeting all day today discussing the risks and benefits of the Johnson & Johnson vaccine. Today’s meeting was far more comprehensive than last week’s meeting. The materials that were presented were in-depth and included information about both the risks and unique benefits of the Johnson & Johnson vaccine. Most of the presentations are on the ACIP website at this location.

Because the J&J vaccine has simpler cold chain storage requirements and the fact that it is one-dose vaccine make it uniquely useful for certain difficult to reach populations. Also, many people prefer the J&J vaccine because they complete their full vaccination card with just one dose.

The FDA and CDC followed up almost immediately by lifting the “pause” in the administration of the J&J vaccine almost immediately. Remember, this vaccine was never in jeopardy of losing it’s Emergency Use Authorization status. The issue over the last couple of weeks has to do with the recommendation that follows EUA.

CDC and FDA determined the following:

  • Use of the Janssen COVID-19 Vaccine should be resumed in the United States.

  • The FDA and CDC have confidence that this vaccine is safe and effective in preventing COVID-19.

  • The FDA has determined that the available data show that the vaccine’s known and potential benefits outweigh its known and potential risks in individuals 18 years of age and older.

  • At this time, the available data suggest that the chance of TTS occurring is very low, but the FDA and CDC will remain vigilant in continuing to investigate this risk.

  • Health care providers administering the vaccine and vaccine recipients or caregivers should review the Janssen COVID-19 Vaccine Fact Sheet for Healthcare Providers Administering Vaccine (Vaccination Providers) and Fact Sheet for Recipients and Caregivers, which have been revised to include information about the risk of this syndrome, which has occurred in a very small number of people who have received the Janssen COVID-19 Vaccine.

The CDC will put putting our a Morbidity and Mortality Weekly Report out shortly that will cover all the public health bases.

Good meeting and good result today.

Federal Retail Pharmacy Vaccination Program Expanded Again

Two weeks ago the White House announced that the Federal Retail Pharmacy Program for COVID-19 Vaccination is expanding from 17,000 participating pharmacies to nearly 40,000 stores by tomorrow. This achievement will make it so a vaccine site will be within five miles of 90% of all Americans. The participating pharmacies in the Federal Retail Pharmacy Program are in communities across the country – including 45% in the highest-need neighborhoods.

This is a very important program because these pharmacies get shipments directly from the federal government and don’t rely on meager allocations from the ADHS, who has been prioritizing allocations toward the state financed and university run mega-sites.

I just checked on www.vaccinefinder.org and found numerous convenient appointment that are available at several pharmacies near my house. 

House Bill Undermines Clean Energy Rules and Arizona’s Public Health

Below is the editorial in the Arizona Capitol Times submitted by Elizabeth Walton is the Executive Director for the American Lung Association in Arizona & Will Humble.

As organizations committed to improving and protecting a healthy Arizona, the American Lung Association and Arizona Public Health Association are deeply disappointed that the Arizona State Legislature is attempting to roll back protections for Arizonans’ health and clean energy.

The Arizona Corporation Commission set a health-protective policy to move our state toward a carbon-free electricity standard by 2050. These Energy Rules prioritize cleaner energy with more reliance on our most abundant natural resource – solar. This makes both public health and economic sense and is long overdue.

Just last year, the American Lung Association’s State of the Air report showed that 85% of all Arizonans live in a county impacted by poor air quality. It also noted that Phoenix was in the Top Ten for most ozone days, most particle pollution days and for unhealthy annual levels of particle pollution. These levels of pollution combined with warming temperatures have detrimental effects on public health.

Breathing such pollutants contribute to increased risk of severe asthma attacks, shortness of breath, cardiovascular and developmental harm, lung cancer and even premature death.

Communities of color and low-income families have too often faced the increased brunt of these burdens due to significantly higher exposure levels.

Two-thirds of voters agree that investments in clean energy should benefit the communities of color most impacted by pollution.

Arizonans know that we face some of the most difficult air pollution challenges in the country. A Lung Association poll released after the election showed voters view the Arizona Corporation Commission Energy Rules favorably.

A full 70% of voters support the requirement for Arizona utilities to get 100% of energy from carbon free sources by 2050. Over 80% support greater investment in energy efficiency, and 79% believe Arizona should use more solar power.

The ACC Energy Rules reflect the priority of voters because they provide solutions for a healthier more resilient future for Arizona.

And yet, many members of the Legislature think that they know better than voters and are attempting to undermine the clean energy rules.

HB2248 is designed to strip the ACC’s authority to adopt clean energy policies that protect health, reduce air pollution, and save on electricity costs. While it seemed the bill was stalled, HB2248 passed out of Senate Appropriations and could be on Gov. Doug Ducey’s desk shortly.

Members of the ACC are elected directly by the voters of Arizona to ensure reliable, affordable, and safe utility services. They deliberated long and hard and are committed to implementing clean energy requirements that safeguard health, protect rate payers and secure dependable power now and for generations to come.

Let’s let the Arizona Corporation Commission do their job and operate as an independent agency as constitutionally mandated. They have spoken and are in the process of finalizing clean energy rules.

We urge you to make it clear We urge you to tell your state representatives senators that clean energy is a priority and ask them to let the Arizona Corporation Commission to do the work that we elected them to do.

AstraZeneca Reports Promising Findings In COVID-19 Vaccine Trial

Last week AstraZeneca released the info about their Phase III trial of its COVID-19 vaccine candidate and found that the 2 dose series is 79% effective at preventing symptomatic COVID-19 and 100% efficacy at preventing severe disease and hospitalization.

Vaccine efficacy was consistent across ethnicity and age. Notably, in participants aged 65 years and over, vaccine efficacy was 80%. AstraZeneca will continue to analyze the data and prepare for the primary analysis to be submitted to FDA for Emergency Use Authorization in the coming weeks.

It is pretty disappointing that this vaccine has not been authorized yet. It is unclear why they still have not submitted an application to the FDA for emergency use.

Dynamics of SARS-CoV-2 neutralising antibody responses and duration of immunity: a longitudinal study

Greater disease severity was independently associated with persistent antibody level, and patients with milder disease appeared to have more rapid antibody waning. 

By contrast, T-cell responses seem to have no clear correlation with the different patterns of antibody dynamics. Patients from all groups, including the negative group, showed sustained T-cell immunity 6 months after initial infection.

By modelling the rate of antibody waning in different groups, we were able to establish prediction models to estimate the longevity of responses in individuals in the three groups showing different  antibody waning rates.

In conclusion, our study showed that antibody dynamics vary greatly among individual patients with COVID-19, in peak antibody level and rate of waning and longevity of antibodies. We found an association between persistent antibodies and severe COVID-19 clinical symptoms and higher levels of pro-inflammatory cytokines and chemokines.

Dynamics of SARS-CoV-2 neutralising antibody responses and duration of immunity: a longitudinal study

What Is Herd Immunity for COVID-19 & How Will We Know We’ve Achieved It?

Herd immunity has become a popular and important concept to help us understand our progress in combating the Covid-19 pandemic. If herd immunity is one of our goals, it’s important to understand what it is, when we will reach it, and what that will do for us.

The concept of herd-immunity makes common sense: once enough people have acquired immunity – whether acquired from vaccination or a prior infection – they’re no longer susceptible to catching it again, or at least it is very unlikely due to partial immunity. Unvaccinated persons in “the herd” will be less likely to be grazing, sneezing, and eating next to a herd-mate who can pass the disease along.

Can someone who is living in a place that has achieved “herd immunity” still get sick? Yes, because herd-immunity is a population level construct. It doesn’t apply to an individual. Someone may be less likely to contact an infectious person if they’re living in a place that has achieved herd immunity, but if they aren’t immunized, they can catch the virus (and spread it to other unvaccinated persons).

Ok, So What Does Herd Immunity Mean in a Practical Sense?

No doubt you’ve heard many statements like “experts believe we will reach herd immunity at around 70%”. What does this mean? It depends. Herd-immunity doesn’t have an agreed upon definition. It doesn’t mean that there are no cases of COVID-19 in the community. If that were the case, everyone would have to be immune, so we would require 100% of everyone to be immune and stay that way.

We think herd immunity means that disease transmission starts going down on its own (without interventions in place) because there’s enough immunity in the herd to block just enough secondary (and tertiary, etc.) transmission that it burns out the continued spread.

We can understand this by talking about R-values. We’ve all learned that if the effective R value is greater than 1, the disease is spreading exponentially. If it is less than 1 it’s declining, (also exponentially).

Ideally, policy makers would keep non-pharmaceutical interventions like mask wearing and limited indoor capacity in crowded bars, nightclubs, and restaurants until the R values are less than 1. They would then slowly relax those measures and continue to monitor the R value to make sure it stays below 1 before relaxing more measures. This would help us ease into a soft-landing that mimics the benefits of herd-immunity before we fully achieve it.

Eventually, you reach a spot where you no longer have any non-pharmaceutical interventions in place and the R value is still below 1 (cases per capita continue to fall).

Voila, you have achieved herd immunity!

How Will We Know When Arizona Achieves Herd Immunity?

Our governor and health director have already eliminated every single required mitigation measure except for vaccinating people. So, in a sense, we are at a baseline place where there are already no required mitigation measures. Yet, some people are continuing to respect distancing, wear masks in public, and are altering their routines to avoid crowded places.

Some businesses are still voluntarily following CDC recommended mitigation measures, but we’re getting close to the place where there are very few interventions in place.

For example, the DBacks home games will be played at 50% capacity beginning this week (they are not really limiting attendance because they almost never sell more than 50% of their seats). 

To reach herd-immunity, we need to have case counts that are still decreasing (with an R less than 1) even after we have full stadiums, crowded bars, full classrooms, and we’ve all taken our masks off.

Right now, Arizona’s Rt (reproduction rate) is about 1.2 indicating that cases are steadily rising. The only intervention in place is vaccination, so we will likely continue to see an increase in cases until we hit the vaccination tipping point and we begin to see a decline – and herd immunity.

Will people still get sick after we reach herd immunity? Yes, absolutely! Herd-immunity only means that cases stop growing. It doesn’t mean COVID-19 has been extinguished. Who will be most likely to get sick? Well, obviously the unvaccinated folks will.

Herd immunity isn’t permanent. Antibodies and cell mediated immunity can wane over time – regardless of whether they are acquired naturally or from vaccination. When this happens, the amount of immunity in a population can decline. Novel variants can also make herd-immunity harder to reach if antibodies aren’t cross-protective.

Diseases also have an opportunity to become endemic meaning that they are always around and never fully die out. Enough disease sticks around in susceptible folks (or herd-mates) until a few lose their immunity and get sick. So, herd immunity needs to be thought about year-after-year. The only alternative is to eliminate a disease completely, which is unlikely for this coronavirus. We already have four endemic coronaviruses, and SARS-CoV2 is trying to become the fifth.

The original ASU forecasting models suggested that we will achieve herd immunity when about 75% of the people in Arizona have either been vaccinated or had been infected with the virus and recovered.

The ASU Biodesiign Institute recently modified their model because the new (and more transmissible) British B.1.1.7 variant is now the dominant strain in Arizona. Their new estimate is that we will need to get to 80-85% of Arizonans immunized or infected before we get to “herd immunity” under our definition.

Our promise to you is that we’ll continue to look at the data objectively and let you know when we think we’ve hit a threshold of a sustained downward trajectory in community spread in an environment where there is hardly any mitigation underway (except for vaccinations).

But remember, new variants could change the calculus, and we could again be placed into an environment where spread is rising again. The likelihood of that happening depends largely on how quickly the rest of the world achieves herd immunity. The longer that takes, the more likely it is that a new variant will throw a monkey wrench at us.

Tim Lant, Ph.D.

Will Humble, MPH

Posts navigation