Will Humble Injury Prevention, Prevention, Wills Blog

Are More Suicide Prevention Interventions on the Way this Legislative Session?

There’s talk at the Legislature of creating a Suicide Fatality Review Board (much like the child fatality review board).  The idea is to review all suicides in Arizona and find trends and brainstorm prevention programming (interventions in AZ are difficult because the trends often depend on geography).  

Yavapai County has the highest rate of suicide, but this is among those 65 and older. Native American youth are most at risk for suicide, but prevention resources are often harder to access in Arizona’s rural and frontier counties where most Native Americans live.

I’ve also heard rumors that there will be a bill that will enhance the existing behavioral health services in schools- but I haven’t heard any details about what the initiative is or what it would do yet.  Stay tuned.

Will Humble State Legislature, Wills Blog

Our Legislative Session Advocacy Approach

This week marks the beginning of the 2020 legislative session.  The kickoff will be the Governor’s address to the legislature where he’ll outline what he sees as priorities.

Our Advocacy Approach

AzPHA will follow the session closely and express our support or opposition to bills based on a simple core principle…  we support bills that will have a positive impact on public health especially when they are evidence-based or evidence-informed.  We will oppose bills that are likely to have a negative impact on public health.  Our support or opposition to bills is located on the https://www.azleg.gov/ site under RTS Current Bill Positions (a summary of the system went out in last week’s update).

We have a host of Resolutions that also guide our advocacy which are posted on the members only website.  The fact that we have Resolutions on so many core public health priorities make it easy for us to be swift with our support or opposition. Our Resolutions go all the way back to the 1930s.  They are initiated by either the Board or our members and all resolutions have been voted on and approved by our members.

Our Public Health Policy Committee has a discussion board on Basecamp and that’s also where we post information, research and documents related to public health policy.  Let me know if you’d like to sign up for that Basecamp site at [email protected]. Our policy committee also has conference calls every other Monday starting tomorrow at 11 am.  The call-in number is 641.715.3580 and the Code is 389388.

Harmful Reproductive Health Education Bill

We haven’t started our full review of bills as most have not yet been proposed.  We have, however, signed up in opposition to SB1082 which would make it more difficult for schools to provide evidence-based and age appropriate reproductive health education. The bill proposes to prohibit age appropriate reproductive health education before 8th grade and would place additional administrative barriers on schools that will discourage them providing this important curriculum topic.

Here’s our statement in the RTS system on the Bill:

Teen births are the number one cause of inter-generational poverty resulting in poor health outcomes and avoidable reliance on public benefits. Evidence-based and age appropriate reproductive health education in schools reduces teen births- and is an important tool to reduce teen births and inter-generational poverty. 

This bill includes burdensome administrative requirements that will discourage school districts from providing reproductive health education and will increase teen births and the resulting poverty, poor health outcomes and reliance on public benefits.  

For example, Texas has a very restrictive reproductive health school requirement (similar to those in this Bill) and also has among the country’s highest teen birth rate.

Will Humble Prevention, Public Health, Wills Blog

US Preventive Health Services Task Force Accepting Applications to Serve

In the last 10 years a prevention model of health has woven its way into the fabric of traditional models of care. With the passage of the Affordable Care Act, the role preventive services has expanded significantly in the US health care delivery system.  Preventive health care services prevent diseases and illnesses from happening in the first place rather than treating them after they happen.

“Category A & B” preventive services recommended by the US Preventive Services Task Force are now included (at no cost to consumers) in all Qualified Health Plans offered on the marketplace. In addition, many employer-based and government-sponsored health plans have included Category A & B preventive services in the health insurance plans they offer to their respective members.

Currently, the United States Preventive Services Task Force recommends more than 50 Category A or B preventive health services.  Category A services are those that “…  there is high certainty that the net benefit is substantial”.  Category B services are those that: “… the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial”.

The Task Force operates within the Agency for Healthcare Research and Quality.  The Task Force consists of a panel of experts representing public health, primary care, family medicine, and academia.  They update the list of recommended services by reviewing best practices research conducted across a wide range of disciplines.

The Preventive Health Services Task Force is currently accepting applications to serve on the Task Force.

This is a terrific opportunity for a mid to late career public health professional to serve the public health community, improve outcomes in the US, develop further professionally, and to increase your professional network connections.

DATES:

Nominations must be received in writing or electronically by March 15th to be considered for appointment (to begin in January 2021).

NOMINATION SUBMISSIONS:

Nominations must be submitted electronically or in writing, and should include:

  • The applicant’s current curriculum vitae and contact information, including mailing address, and email address; and

  • A letter explaining how this individual meets the qualification requirements and how he or she would contribute to the USPSTF. The letter should also attest to the nominee’s willingness to serve as a member of the USPSTF.

AHRQ will later ask people under serious consideration for USPSTF membership to provide detailed information that will permit evaluation of possible significant conflicts of interest. 

Interested individuals can nominate themselves. Organizations and individuals may nominate one or more people qualified for membership on the USPSTF at any time. 

ADDRESSES:

Submit your responses either electronically or in writing to: https://uspstfnominations.ahrq.gov/register, Lydia Hill, ATTN: USPSTF Nominations, Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, 5600 Fishers Lane, Mailstop: 06E53A, Rockville, Maryland 20857.

SUPPLEMENTAL INFORMATION:

USPSTF members currently meet three times a year for two days in the Washington, DC area. A significant portion of the USPSTF’s work occurs between meetings during conference calls and via email discussions.

Member duties include prioritizing topics, designing research plans, reviewing and commenting on systematic evidence reviews of evidence, discussing and making recommendations on preventive services, reviewing stakeholder comments, drafting final recommendation documents, and participating in workgroups on specific topics and methods.

Members can expect to receive frequent emails, can expect to participate in multiple conference calls each month, and can expect to have periodic interaction with stakeholders. AHRQ estimates that members devote approximately 200 hours a year outside of in-person meetings to their USPSTF duties. The members are all volunteers and do not receive any compensation beyond support for travel to in person meetings.

FOR FURTHER INFORMATION CONTACT:Lydia Hill at [email protected].

For more information, including nominee selection, qualification requirements, and additional background information: https://www.federalregister.gov/documents/2020/01/07/2020-00019/solicitation-for-nominations-for-members-of-the-us-preventive-services-task-force-uspstf

Will Humble Prevention, Tobacco, Wills Blog

Lots Happening on the Tobacco Control Front

There has been a lot of action to better regulate tobacco products in the last couple of weeks.  Here’s my summary of what’s been happening.  Keep in mind that the FDA’s statements have sometimes in flux and statements sometimes contradict themselves within hours – but here’s where we are as of today:

Tobacco 21

  • Congress passed and the president signed a budget bill that has raised the federal age of sale of all tobacco products to 21 years old. 

  • The 21 buy-age applies as of now in Arizona.  No further legislative action (at the state level) is required in order to implement the law.

  • The law is being implemented immediately.  The FDA could have taken several months to activate the 21 buy age provision.  Astonishingly (at least to me) they elected to activate the provision immediately.

  • 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. 

  • FDA’s existing enforcement authorities apply, called the Synar provisions. If states don’t comply with Synar then funding from SAMHSA’s Substance Abuse Prevention and Treatment Block Grant is supposed to be withheld (that grant is $20M+ in AZ.

  • Synar was amended in last week’s budget to remove the existing requirement that states have minimum age of sales laws (in other words AZ doesn’t need to pass a T-21 law to keep the SAMHSA Block Grant).  

  • Funding was included in the bill for states to do the Synar compliance and enforcement activities.

Electronic Cigarettes

Last week the FDA also announced a few policy decisions related to electronic cigarettes.  Here’s that stuff:

  • The Tobacco 21 provisions apply to all tobacco products including electronic cigarettes.

  • The FDA is banning the sale of fruit, candy, mint, and dessert flavored small cartridge electronic cigarettes.  Menthol flavors will still be allowed.  The flavor ban exempts large (tank based) refilling cartridges.  Right now small cartridges are 60% of the market and the big refillable cartridges are 40%.

  • Companies that don’t cease manufacturing, distributing and selling  unauthorized flavored cartridge-based e-cigarettes (other than tobacco or menthol) within 30 days risk FDA enforcement actions.

  • All e-cigarettes will be going through an FDA review beginning in May and only those products that demonstrate “benefit for U.S. public health” will be allowed to stay in the retail market.

  • The FDA intends to prioritize enforcement by focusing on:

    • Any flavored, cartridge-based product (other than a tobacco- or menthol-flavored e-cigarettes;

    • Other e-cigarettes for which the manufacturer has failed to take (or is failing to take) adequate measures to prevent minors’ access; and

    • E-cigarettes that are targeted to minors (under 21).

Stay tuned.  As we’ve seen, federal agencies can change their minds quickly and without notice these days.

Note: These provisions don’t impact the Smoke Free Arizona Act.  We still need to get a super-majority of the legislature to approve a bill that amends that voter initiative to include e-cigarettes in order to get e-cigs out of our bars, restaurants and other places of employment.

Will Humble Public Health, Public Health Law, Wills Blog

Voice Your Opinion this Legislative Session

As the leading public health professionals in the state, it’s important that you engage in public health policy development. After all, we’re the people that have first hand knowledge about the public health implications of the decisions that our elected officials make.

The good news is that it’s easier than ever to voice your opinion. Our state legislature has a transparent way to track bills through their www.azleg.gov website. The site allows you to track when bills are being heard in committee and provides an opportunity for you to express your support, opposition, or neutrality from your home or office.  

The main URL to bookmark in your computer is http://www.azleg.gov – which is the State Legislature’s official website.  It got an overhaul last year making it easier to work with.

If you have the number for a bill you’re interested in following, simply go to the upper right corner of the http://www.azleg.gov website and punch in the numbers. Up pops the bill including its recent status, committee assignments and the like. 

The dark blue tabs provide more detailed info about the bill.  For example, the “Documents” tab displays the actual language of the bill including the most recent versions.

You’ll see that bills have committee assignments on the Bill Status pages. You can easily check the committee agendas each week on the website too.  Go to the “Committee Agenda” and pull up the agenda for the committee you’re interested in.  

Most of the bills we’ve been following and advocating for or against have been assigned to either the House Health Committee or the Senate Health and Human Services Committee.  This year the House Health Committee meets on Thursdays at 9 am. The Senate Health & Human Services Committee meets Wednesdays at 9 am.

I’m encouraging all of you to weigh in for and against bills when you believe that it’s in the best interests of public health to do so. It’s straightforward.

First you need to create an account with an e-mail address and a password. You’ll need to go down to one of the kiosks in the House or Senate to set up your account and password- but after that you’ll be able to sign in for or against bills from your home or office. If you don’t want to use your work email address you can use a personal e-mail.

Once your account is set up, you can sign in support or against any bill at the Azleg’s My Bill Positons site at https://apps.azleg.gov/RequestToSpeak/MyBillPositions 

Even if you don’t have an account, you can click on each bill and find out who has signed in for or against or neutral on the bill.  Just go to the tab over each bill that says “RTS Current Bill Positions” and you’ll see who has signed in support or against each bill. Sometimes you’ll see our name up there (AzPHA).

Will Humble Affordable Care Act, Health Insurance, Medicaid, Medical Marijuana, Opioids, Prevention, Public Health, Public Health Law, Social Determinants, Wills Blog

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.

Will Humble Uncategorized, Wills Blog

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.

Will Humble Affordable Care Act, Wills Blog

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.

Will Humble Prevention, Tobacco, Wills Blog

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.

Will Humble Affordable Care Act, Medicaid, Wills Blog

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.

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