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.

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.

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