Will Humble Affordable Care Act, Wills Blog

Quick ACA Lawsuit Update

The Supreme Court will decide soon whether to grant an expedited appeal in the Texas v. Azar case. Defenders of the Affordable Care Act have asked the court to grant an exception and hear the case in 2020 (before the election). SCOTUS has asked the plaintiffs (who are trying to overturn the ACA) to respond to the request for an appeal last week.

The 5th Circuit Court of Appeals ruled in late 2019 that the ACA’s Individual Mandate is unconstitutional but pushed the case back to the lower court to determine which elements of the law are tied to the individual mandate. If an expedited appeal is granted, the Supreme Court would hear the case before the term ends in June of this year. More info here and don’t forget about the ACA Social Media Toolkit.

Will Humble Early Childhood, Injury Prevention, Prevention, Public Health Law, State Legislature, Wills Blog

Child Fatality Review Report Sets Off Suicide Alarm Bells

The death of any child is a tragedy – for the family and for the community. Everybody wants to prevent childhood deaths. Making policy interventions to prevent childhood deaths requires information in order to develop effective policy interventions.  That’s where the Arizona Child Fatality Review State Team comes in.

More than 25 years ago the state legislature passed a law establishing the Arizona Child Fatality Review Program (A.R.S. § 36-342, 36-3501-4).  It’s a great example of establishing public policy designed to build data and evidence so policy makers can use evidence to build future interventions.

The State Team includes representatives from the Academy of Pediatrics and from the ADES Divisions of Developmental Disabilities and Children and Family Services, as well as from law enforcement and the ADHS. The team’s role is to review all childhood deaths in AZ and produce an annual report to the Governor and legislature with a summary of findings and recommendations based on promising and proven strategies regarding the prevention of child deaths.

The 2019 report was published last week- and as usual it provides a host of data and recommendations that are directly tied to evidence.

In past years this focus has raised the awareness about child drowning and the importance of putting babies to sleep on their backs or making sure all children are always secured in car seats.  Those interventions have made a real difference- and Sudden Unexpected Infant Deaths (SUID) decreased 29% from 2017 (n=84) to 2018 (n=60) and accounted for 7% of all child deaths in Arizona.

The 2019 report sets off the public health alarm bells when it comes to child suicide.

There was a 28% increase in suicide deaths from the previous year (which itself had a 32% increase over the year previous)… so child suicide deaths have gone up about 50% in the last 2 years.  64 kids died by suicide in 2018.  About 40% of the suicides were from a firearm.  Over the last six years, the child suicide mortality rate has gone up more than 100% going from 1.5/100,000 in 2012 to 3.9/100,000 in 2018.

Here are the Suicide Prevention Recommendations from the Report

  • Support funding and training to schools, communities, clinical and behavioral health services providers on the prevention of suicide.  

  • Educate parents, teachers, and caregivers on the risk factors for suicide. These factors include substance use, delinquency, depression and poor impulse control.

  • Provide information for educators, parents and caregivers on how to seek help for children at risk after the first red flag.

  • Continue to expand and enforce anti-bullying policies in schools.

  • Expand resources for teens that are likely to be mourning the suicide death of a friend or family member.

  • Strengthen services available to children and adolescents that address adverse childhood experiences and practice trauma informed care.

  • Completely remove firearms from homes where individuals are experiencing mental health problems such as, depression, substance use, or suicidal ideation.

  • Urge parents to monitor their child’s social media for any talk about suicide and take immediate action if there is evidence of suicidal ideation. 

  • Encourage social media organizations to develop opportunities to flag information that might indicate suicidal thinking and respond with crisis information resources. 

  • Support funding and access for quality behavioral health and substance use assessment and treatment services for youth and their families, especially in rural communities.

  • Promote and expand universal screening for suicide risk by all health care providers at each visit.

  • Store all medications in a locked cabinet and discard unused medications safely and properly when they are no longer being taken.

Here are some of the results in the other categories of child fatalities:

  • Sudden Unexpected Infant Deaths (SUID) decreased 29% from 2017 (n=84) to 2018 (n=60) and accounted for 7% of all child deaths in Arizona.

  • Deaths from prematurity increased 24% from 2017 (n=180) to 2018 (n=224).

  • Accidental injury deaths decreased 9% from 2017 (n=187) to 2018 (n=170) and comprised 20% of all child deaths.

  • The number of firearm deaths was unchanged from 2017 (n=43) to 2018 (n=43) and accounted for 5% of all child deaths.

  • Child fatalities due to abuse/neglect decreased 5% from 2017 (n=79) to 2018 (n=75) and accounted for 9% of all child deaths in Arizona.

  • Motor vehicle crash (MVC) deaths increased 13% from 2017 (n= 65) to 2018 (n= 74) and accounted for 9% of all child deaths in 2018.

  • Homicides decreased 18% from 2017 (n=38) to 2018 (n=31) and accounted for 4% of all child deaths.

  • Drowning deaths decreased 20% from 2017 (n=35) to 2018 (n=28) and accounted for 3% of all child deaths.

The full report covers each of these areas including some recommendations for policy and program interventions in each area.  Sometimes the recommendations are more related to increasing awareness but many are more policy based.

Lots of work went into this report- so if you’re somebody in a position to influence either lawmakers or agency officials to implement preventative policies in these areas- please get familiar with this   important research product – it will really help inform your advocacy efforts.

Will Humble Behavioral Health, Injury Prevention, Wills Blog

Suicide Prevention Training for Schools

In 2019, the Arizona State legislature passed Senate Bill 1468 mandating all public school staff who interact with students in grades 6 through 12 be trained in an evidence-based, best practice suicide prevention training at least once every three years.  The statute tasks AHCCCS with picking evidence-based, best practice suicide prevention training materials.  AzPHA Board member and Treasurer Kelli Donley Williams is the point person at AHCCCS that’s been working on this.

The law takes effect in the 2020-2021 school year and school districts are being encouraged to write policies describing how they will implement and track the training.

AHCCCS and the Arizona Department of Education have already selected the school suicide prevention training options. School administrators can choose from among these materials as they work toward meeting the statute’s requirements.  Here’s a list of the evidence-based programs:

  • Question, Persuade, Refer (QPR).

  • Applied Suicide Intervention Skills Training (ASIST).

  • At-Risk for High School Educators (available online).

  • Youth Mental Health First Aid.

  • Suicide Alertness for Everyone (safeTALK).

  • ACT on FACTS (available online).

  • More than Sad – Suicide Prevention Education for Teachers and other School Personnel.

  • Be a Link! Suicide Prevention Gatekeeper Training.

The qualifying programs were selected using the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Suicide Prevention Toolkit for High Schools, the Suicide Prevention Resource Center for additional gateway trainings, and peer-reviewed articles addressing cultural considerations, particularly for tribal nations, in suicide prevention.

Will Humble Behavioral Health, Wills Blog

Behavioral Health Services in Schools

One of the evidence-based strategies to prevent suicide among children is to provide easily accessible behavioral health services for students in the school setting.

Schools in Arizona have historically been approved settings for Medicaid-covered behavioral health services… but Arizona has recently been moving forward to make it more robust.  

Last legislative session, an additional $3M was appropriated to expand behavioral health services in schools with $1M going to a partnership with the Arizona Department of Education to provide mental health training to schools and school districts.  

The remaining funds are being matched with Federal Funds to generate $10M in Medicaid funding to AHCCCS health plans to bring behavioral health providers into the school setting and pay for Medicaid-covered behavioral health services in schools.  Examples of some of these projects include:

  • Project AWARE: In collaboration with the Arizona Department of Education, AHCCCS is working with three school districts to implement Mental Health First Aid training.

  • The Safe Arizona Schools Plan which pays for in mental and behavioral health resources at schools. With $1M in funding, the Arizona Department of Education and AHCCCS signed an agreement to partner efforts in expanding access to behavioral health training in schools statewide. 

  • Arizona Medicaid School-Based Claiming Program: Arizona participates in two Medicaid reimbursement programs for school-based services, the Direct Service Claiming program and the Medicaid Administrative Claiming program both of which help certain school districts by reimbursing them for their costs to provide Medicaid covered services to eligible students.

At this week’s  State Medicaid Advisory Committee (SMAC) meeting, Director Snyder confirmed that AHCCCS is planning to file a state plan amendment later this year which would allow schools to bill for eligible services provided to AHCCCS participants. More info on this opportunity here and here.  

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 willhumble@azpha.org. 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 coordinator@uspstf.net.

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.

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