Will Humble Prevention, Social Determinants, Wills Blog

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

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

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

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

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

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

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

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

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

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

A welcome public health intervention indeed.

Will Humble Uncategorized, Wills Blog

US House Approves HR3: A Prescription for Lower  Drug Prices

Allowing Medicare to Negotiate with Drug Makers can Dramatically Lower Costs

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

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

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

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

Will Humble Tobacco, Wills Blog

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Will Humble Tobacco, Wills Blog

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

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

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

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

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

Will Humble Uncategorized, Wills Blog

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

Allowing Medicare to Negotiate with Drug Makers will Dramatically Lower Costs

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

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

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

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

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

Will Humble Affordable Care Act, Public Health, Wills Blog

University of Arizona Creating a Primary Care Tuition Waiver Program!

Great news. The UA Colleges of Medicine in Tucson and Phoenix are creating a new tuition waiver program for medical students specializing in primary care fields that agree to work in rural under-served areas in Arizona.  Up to 94 students who attend the UA Colleges of Medicine in Phoenix or Tucson can receive free tuition if they agree to practice in a rural area for at least 2 years after they graduate.

Kudos to the UA Administration for making the decision to spend a big chunk of the $8M that had appropriated to the medical schools in last year’s state budget for this innovative and badly needed intervention. 

In addition to the $8M appropriation to those medical schools, last year’s budget included an additional $750,000 for the State Loan Repayment Program (to make a total of $1.75M/year) and $12.5M more for Graduate Medical Education ($7M rural and $4.5M urban).

The new UA tuition waiver program will be a new resource to help carry some of the additional load already carried by the state’s loan repayment program.  That program was enhanced back in 2015 with the success of Senate Bill 1194 which enhanced Arizona’s State Loan Repayment Program by expanding the types of providers who can receive loan repayment assistance, increasing the award amounts for the initial and succeeding commitment years, and removing the 4-year service cap.  

The list of practitioners that can qualify for the state loan repayment program now include primary care physicians, dentists, advanced practice providers like nurse practitioners, physician assistants, nurse midwives, mental health providers, pharmacists and geriatrics. 

The AZ loan repayment program makes up to $65,000 available (for a 2-year commitment) for physicians and dentists.  Advanced practice providers can qualify for up to $50,000.  The incentives even get better as providers stay longer in the program. 

For each year of continued service in the under-served area after the first two years, physicians and dentists can receive up to $35,000.  Actually the loan repayment funds are worth even more than these figures because it is loan relief that isn’t counted as income for tax purposes.

Will Humble Affordable Care Act, Medicaid, Prevention, Wills Blog

AZ Center for Rural Health Workforce Reports

The UA Center for Rural Health (AzCRH) recently release healthcare workforce data briefs on Maternal Health and the Obstetrician and Gynecologist Physician Workforce in Arizona.  Access to timely and high-quality women’s health and primary care services is an essential component of a supporting maternal health. In the report, you’ll see that Greenlee and La Paz counties are maternal care deserts and Cochise, Graham Pinal, and Santa Cruz counties have limited access to maternal care.

Women in rural Arizona face barriers to maternal health care including a lower ratio of Ob-gyn providers per population. In general, women in rural areas have additional barriers like longer drive-times and fewer facilities offering obstetric services. 

Reports like this are important as they can be used to inform and influence both elected officials in the legislature and appointed officials in state agencies and universities.  Thoughtfully used- this kind of data can help inform legislative and administrative policy initiatives that can help improve the system of care for women (like the new tuition waiver program mentioned above).

Will Humble Early Childhood, Maternal Health, Nutrition, Prevention, Wills Blog

Good News about Childhood Obesity in new MMWR Report

We got some good news from the childhood obesity public health front this week!  This week’s Morbidity and Mortality Weekly Report  found that the obesity rate among WIC participants aged 2–4 years went down in most states between 2010 and 2016 in most states including Arizona.  Arizona’s rate went from 15% in 2010 to 12% in 2016.  The study  looked at kids between 2 and 4 years old that participate in WIC between 2010 and 2016  obesity.  Very encouraging.

Here’s an news article that summarizes the Arizona results.

A big factor was undoubtedly a public health policy initiative from back in 2009 which revised the content of the foods that qualify under the program- to better align with nutrition research and practice guidelines of the American Academy of Pediatrics.  The revised food packages included a broader range of healthy food options and promotes fruit, vegetable, and whole wheat product purchases; support breastfeeding; and gave states more flexibility to accommodate cultural food preferences.

The study was among WIC participants- but WIC interventions are likely not the only intervention at play here.  Other state initiatives were under way in Arizona during the 2010 – 2016 study period, including:

  • Working with the county health departments to implement the Health in Arizona Policy Initiative. This initiative focused on school health, worksite wellness, healthy community design, procurement of healthy foods (like having healthy alternatives in vending machines), preventive clinical care, and inclusion of children with special health care needs.

  • The implementation of the CDC public health prevention grant in 2013, which, like the Health in Arizona Policy Initiative, which made healthy living easier by supporting healthy environments in workplaces, schools, early childhood education/child care, and in the community. Arizona was one of 32 states to be awarded enhanced funding that year and received $2M per year for 5- years. That grant resulted in a host of statewide interventions.

  • Arizona’s county health departments implemented Health Impact Assessments, action plans, and initiatives during the study period aimed at increasing healthy eating and active living by using tools like the Arizona Health in Policy and Practice Resources and the Urban Land Institute’s Community Plan, both of which help local officials to focus on a holistic approach to land use planning, zoning, transportation, economic development, real estate development and finance.

  • School Health Advisory Councils were started in 2012 which helped schools to identify and incorporate best practices for obesity prevention including standards that promote healthy eating and physical activity, like focusing on serving fruits and vegetables, limiting sugary beverages, and providing more opportunities for physical activity, and reducing screen time- like the ADHS’ 2010 nationally-recognized Empower program does.

  • State level legislative policy also may have been a factor. Back in 2013 we were able to pass ARS 33-1551 which addresses liability concerns of schools when opening outdoor facilities to the public outside of the school day- making it easier for schools to open playgrounds to the public so children have more places to play and be physically active.


WIC at a Glance

As a federal grant program inside the USDA, WIC is administered by states, territories, and Indian Tribal Organizations to provide supplemental nutritious foods, breastfeeding support, health care referrals, and nutrition education for low-income children aged <5 years and pregnant, postpartum, or breastfeeding women. WIC PC is a biennial census in even years of all participants certified to receive WIC benefits.

To be eligible for WIC, participants must live in the states in which they apply, have gross household income ≤185% of the federal poverty guidelines or be eligible for other programs (e.g., Supplemental Nutrition Assistance Program, Medicaid, and Temporary Assistance for Needy Families), and be at nutrition risk. Children’s weight and height are measured by WIC staff members during certification and recertification clinical visits.

Will Humble Federal Budget, Wills Blog

Congress Passes Temporary Continuing Resolution- Keeping the Federal Government Open until December 20

This year’s federal fiscal year started October 1, but there’s still not a budget for this year.  At least there’s a new continuing resolution.  Last week the US House and Senate passed a continuing resolution that temporarily funds the federal government through December 20.  It’s called the Further Continuing Appropriations Act, 2020 and Further Health Extenders Act of 2019, and it continued current funding levels through December 20, 2019.

The previous continuing resolution had expired last Thursday.  Here’s a section-by-section summary of the bill can be found funding bill and here’s the full text.  Public health programs will continue to be funded at the current level, for now. Congress now has 3 weeks to continue work on FY20 (current year) budget negotiations.

Will Humble Affordable Care Act, Health Insurance, Public Health, Wills Blog

Is the AZ Attorney General Contemplating Legislation to Protect Health Insurance Coverage for Folks with Pre-existing Conditions?

I was surprised to see an article in the AZ Capitol Times this week  reporting that Attorney General Brnovich along with Senator Mesnard abd Rep. Weninger and  are contemplating putting together a bill  that would provide a backstop for folks with pre-existing conditions to continue to be able to buy health insurance in case the Affordable Care is stricken down by the US Supreme Court in 2020 – which by the way is a real possibility. 

Arizona, via Brnovich, has signed on to the lawsuit trying to overturn the ACA in its entirety.

In December 2018 a judge in Texas (O’Connor) ruled that the Affordable Care Act is unconstitutional now that the individual mandate has effectively been eliminated (by the large tax cut bill last year). In July of this year, the 5th US Circuit Court of Appeals heard the Texas v Azar case. That ruling could come out any day now.

Whatever the 5th Circuit rules, the ACA will probably once again be in front of the US Supreme Court- perhaps as early as this spring.

Protections at Risk

At risk if the ACA is overturned are core health insurance coverage provisions like expanded Medicaid eligibility from 100% to 133% of the poverty level, coverage for childless adults under 100% of federal poverty (made possible via the AZ hospital assessment), subsidized Marketplace Plans, and a host of health insurance reforms like protections for folks with pre-existing conditions. 

The idea floated by Brnovich et.al. really focused on one of the insurance regulation measures in the ACA – the pre-existing conditions exclusions- which is one of the consumer protection components in the ACA that prevent insurance companies from: 

1) denying someone health insurance because they have a preexisting condition -called the “guaranteed issue” requirement;

2) refusing to cover individual services that people need to treat a pre-existing condition- called “pre-existing condition exclusions”; and

3) charging a higher premium based on a person’s health status – called the “community rating” provision.

Prior to the ACA, standards to protect people with preexisting conditions were determined at the state level.  Most states including AZ had very limited protections. Before the ACA, many insurers maintained lists of up to 400 different conditions that disqualified applicants from insurance or resulted in higher premiums.  35% of people who tried to buy insurance on their own were either turned down by an insurer, charged a higher premium, or had a benefit excluded from coverage because of their preexisting health problem.

Several states already have their own state laws that incorporate some or all the ACA insurance market protections. Could it be that Senator Mesnard, Rep. Weninger and Attorney General Brnovich want to do the same? 

And if so, what about the other things like expanded Medicaid eligibility from 100% to 133% of the poverty level (FPL), coverage for childless adults under 100% FPL (made possible via the AZ hospital assessment), and subsidized Marketplace Plans? 


Background on the 2012 Ruling Upholding the ACA

In the 2012 Ruling that upheld the ACA, Chief Justice Roberts wrote that: “… the Affordable Care Act’s requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax… because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.” 

Roberts rejected the Obama Administration’s argument that the federal government’s authority to regulate interstate commerce provides the authority needed for the ACA to be constitutional (the Court struck down that argument 5-4).  Fortunately, the court held (5-4) that the ACA was constitutional based on the federal government’s taxing authority (and that tax has now been eliminated).

Supreme Court Forecast

Because of the makeup of the 5th Circuit Court of Appeals they will likely uphold O’Connor’s decision to invalidate the ACA…   and the case will probably end up with the US Supreme Court, which has a different cast of characters than it did when the ACA was originally upheld back in 2012 by a 5-4 vote.

Since the 2012 decision upholding the ACA, Gorsuch has replaced Scalia.  Kavanaugh replaced Kennedy.  Both Scalia and Kennedy voted to overturn the ACA- so not much on that score has changed.

Chief Justice Roberts voted with the majority that upheld the law. His argument rested on the ACA’s link to the financial penalties for not having health insurance. But remember, those financial penalties f were removed from the IRS tax codes in last year’s federal tax overhaul, pulling out the structure that Roberts used in his argument.

The bottom line is that the ACA, including its protections for folks with pre-existing conditions, and all of the coverage through Medicaid and the subsidized Marketplace plans are in jeopardy if Roberts views the ACA as fundamentally different now that the financial penalties are gone.

Basically, the fate of the US’ health care system and all the protections that it provides will likely rests with one person, Chief Justice John Roberts.

And while it’s nice that AG Brnovich is contemplating doing something about the pre-existing condition exclusions- it’s really just focusing on a fraction of the chaos that would result from the overturning the ACA.

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