Will Humble Air Quality, Environmental Health, Wills Blog

What’s with the New EPA Coal Burning Plant Rule?

There’s a good chance you heard that the EPA changed their coal power plant environmental regulations this week. Here’s a quick summary of what those changes are.

The story starts in 2013 when the EPA (under the Obama Administration) issued regulations that applied to new coal fired electricity generation plants.  The rules were called “New Source Performance Standard” or “NSPS.”

The NSPS required that any new generation units fueled by natural gas meet a limit of 1,000 pounds of CO2 per megawatt-hour and allowing new coal plants to emit 1,100 pounds of CO2 emissions per megawatt-hour of electricity generated.  The coal industry didn’t like the rule because the most advanced coal-fired power plants emit 1,700 pounds per megawatt-hour.
The EPA then issued a 2nd rulemaking in 2015 with the “Existing Source Performance Standard” or “ESPS” Rules.  The ESPS rule aimed to reduce overall emissions of CO2 from the nation’s power sector by 32% from 2012 to 2030. Under the 2015 rules, existing coal plants would have had to comply with a 1,300 pounds of carbon per megawatt hour standard (this irritated the industry because the best plants can only achieve 1,700 lbs per megawatt hour).

The U.S. Chamber Litigation Center filed a lawsuit challenging the EPA’s 2015 rules and the US Supreme Court issued a stay on the rules which halted implementation of those 2015 ESPS rules. 

This week the EPA repealed and replaced the ESPS rules (for existing plants) with what they call the Affordable Clean Energy (ACE) rule- which essentially gives states three years to create their own plans to cut emissions at existing plants mainly by encouraging coal-fired power plants to improve their efficiency. The old carbon standards were eliminated. 

The new rules set some guidelines for states to develop performance standards for power plants that boost the amount of power produced per ton of carbon. The original draft proposal would have allowed new coal plants to skip the federal permitting process and use the new “ACE” process, but that was dropped from the final ACE rule.

Arizona has 5 coal burning plants: the Apache Generating Station (Cochise County), the Cholla Power Plant (Navajo County), the Coronado Generating Station (Apache County), the Navajo Generating Station (Apache County & closing later this year), and the Springerville Generating Station in Apache County.  Under the new rules issued this week, these facilities will now be subject to state regulation via the new ACE standards- presumably by ADEQ.

Over the long run, the percentage of energy generation that comes from coal in the US will continue to decline because coal power generation  is simply more expensive than natural gas and solar and wind sources.

To look at the cost of generation for the various approaches you can visit this US Energy Information Administration Document which compares the capital, operational and transmission costs for various forms of energy generation-  and you’ll see that coal is way more expensive than natural gas, wind, and solar technologies. 

Will Humble Prevention, Public Health, Public Health Law, Wills Blog

Arizona Policies, Resources and Recent Investments are Addressing Rural Healthcare Workforce Shortages

Healthcare workforce shortages often contribute to health disparities in rural AZ.  That’s because rural communities tend to have fewer physicians, nurses, specialists, and other healthcare workers…  and at the same time face higher rates of chronic disease, mental illness, and obesity than urban areas. Having enough healthcare personnel in shortage areas can contribute to those health disparities. 

Additionally, health care providers working in shortage areas can experience isolation from their peers and burnout from seeing a greater number of patients and working longer hours than those in non-shortage areas.

A critical element to ensuring an adequate healthcare workforce is to improve the reach of provider recruitment programs, which can build a strong and diverse healthcare workforce that represents the population served. 

This year was particularly successful at the Legislature as they approved an additional $750K for the state loan repayment program (bringing the total budget to $2.75M) as well as more resources for rural Graduate Medical Education ($1.6M for rural Graduate Medical Education -$5.5M w the federal match)  – which can be use to bolster graduate training in rural AZ (this GME training is really important because it’s a key factor in where a provider practices over the course of her or his career- improving rural networks). There was also an additional $750K that was invested in the North Country GME program.

Arizona Primary Care Office

Arizona is fortunate to have an effective Primary Care Office program at the ADHS’ Bureau of Women and Children’s Health along with public policies that have been passed in the state legislature that help to improve the state program’s effectiveness. 

Our in-AZ resources to improve workforce capacity and access to care in rural and underserved AZ include the Arizona State Loan Repayment Programs, J-1 Visa Waiver Program, and at the national level, the National Health Service Corps and Nurse Corps.

Our state Primary Care Office also manages data collection regarding healthcare provider shortage areas (HPSAs) and information like Primary Care Area Statistical Profiles as well as maps and a host of additional data resources.

UA Center for Rural Health

We also have terrific programs at the UA Center for Rural Health which has rural health programs like the Rural Hospital Flexibility Program (AzFlex), the Small Rural Hospital Improvement Program (AzSHIP), Arizona First Responders Initiative (FR-CARA), The Rural Health Professions Program (RHPP), Workforce Data & Analysis (CRHWorks), Arizona Rural Recruitment and Retention Network (Az3RNet), Students Helping Arizona Register Everyone (SHARE), the Prescription Drug Overdose Program, and Health Insurance Assistance.

Arizona Area Health Education Centers

Arizona also has a unique system of AZ Area Health Education Centers that are established under state law (voter approved) “… enhance access to quality healthcare, particularly primary and preventive care, by improving the supply and distribution of healthcare professionals through educational partnerships between academic and community organizations in rural and urban medical underserved areas.” 

The Program has a state office at the UA and several local AHECs that promote community and educational partnerships to enhance access to quality health care with an emphasis on the needs of rural and urban underserved communities and populations. Their missions also include educational programs in partnership with academic institutions, communities, health care agencies, and other organizations that promote the health of Arizona residents.

Arizona Rural Health Association

We’re also fortunate to have the Arizona Rural Health Association (AzRHA) in our state doing advocacy for rural health.  The AzRHA was established in 1994 as an independent organization after serving as the Advisory Committee of the University of Arizona Rural Health Office (RHO) for many years. While AzRHA continues to serve as the RHO advisory body, its functions have been expanded to cover many areas involving advocacy for rural healthcare programs.

Access to healthcare is an essential component of health and wellness. By providing financial incentives for clinicians to practice and train in rural areas and by collecting data on provider shortages and using that data to make policy adjustments, Arizona is increasingly poised to make measurable improvements in rural networks as a result of this year’s legislative session decisions.

Will Humble EMS, Wills Blog

U of A Study Examines Emergency Department Use During the Recession

AzPHA member Patrick Wightman from the UA Center for Population Science and Discovery recently published an Issue Brief examining the impact that the freeze on “childless adult” enrollment in AHCCCS during the Great Recession had on the use of hospital and emergency department services. 

Because Arizona conducted a natural experiment by freezing Medicaid enrollment among childless adult, and the fact that data are available to measure the effect of those policy changes, Patrick was able to compare people’s behavior with health insurance to their behavior without it.  The fact that the freeze lasted years allowed him to examine any impact of pent-up demand following the lifting of enrollment freeze.

Here’s a link to the entire Issue Brief , which includes the entire results including several useful graphs, but here’s the Summary from the Issue Brief.

“While the trends presented here are descriptive, they occur in the framework of two significant “natural experiments”, the first drastically restricting low-income individuals’ access to public health insurance, and the second once again expanding that access.  Because these policy changes happen at the state and federal levels, beyond the control of beneficiaries, it can be inferred that, in large part, they are the cause of the beneficiaries’ behavior, in this case their health care utilization.

In this context, the patterns shown here provide strong evidence that health care utilization, at least in the form of ED visits and hospitalizations, follows the availability of health care, in the form of health insurance.  While this finding is not unanticipated in the case of hospital visits, in the case of ED visits it is perhaps somewhat surprising, at least to the extent that ED visits represent “legitimate” medical emergencies.”

Will Humble Assurance & Licensure, Opioids, Wills Blog

In the News

Opioid Use Disorder Treatment Medications

Earlier this week AHCCCS announced that they’ve accepted the recommendations of their Pharmacy and Therapeutics Committee and will be adding an additional buprenorphine medication (sublingual) to their preferred formulary list and a streamlined prior authorization process for a long acting injectable medication (effective 10/1). Here’s the story from the Republic and the Cap Times.

Hacienda Healthcare Enforcement Action

The ADHS issued a Notice of Intent to Revoke the license of a Hacienda Healthcare on Friday (here’s the story from the Republic). Apparently, a patient at the facility had larvae on a stoma, prompting the investigation. As you’ll recall, the facility previously had not been required to have a license – until SB1211 was passed and signed. The Governor signed the law with an emergency implementation clause (making it immediately effective) on 4/24/19.

A survey was conducted on 4/23 & 4/24 (that found no deficiencies) and the facility was apparently issued a license on 4/26. According to the news report staff from 3 state agencies (ADHS, AHCCCS, and ADES) are monitoring the facility and working on an investigation.

Will Humble Disease Control, Wills Blog

WHO Declines to Call Ebola Outbreak a Global Public Health Emergency

The now months-long Ebola outbreak in the Democratic Republic of the Congo (which spread to Uganda this week) is an emergency for the DRC and its neighbors, but according to the WHO this week, it doesn’t constitute a global health emergency.

The core of the decision was that the additional powers that come with an emergency declaration aren’t needed and, if used, may cause more harm than good.  One of those powers would allow the WHO to disclose information about a disease event to other countries without the consent of the outbreak country.  Emergency powers also give the WHO director-general authority to issue temporary recommendations regarding trade and travel.  However, the WHO’s recommendations on travel and trade have sometimes been ignored during other declarations.

On the other hand, declaring an emergency can be quite helpful in raising cash to fund public health and treatment interventions, and not declaring an emergency may miss opportunities to get additional resources to the outbreak areas.

More than 2,100 cases and 1,400 deaths have been reported in the DRC, making this the second largest Ebola outbreak on record.  It’s still 10% the size of the 2014-2016 West African outbreak, but has been difficult to control because of political and civil unrest in the DRC -despite the fact that there is now a vaccine that wasn’t available until the end of the 2016 outbreak.

Merck is making an additional 450,000 doses of the experimental Ebola vaccine for the DRC- but it takes a year from start to finish to make the vaccine. More than 130,000 DRC people have been vaccinated so far.

Will Humble State Legislature, Wills Blog

Legislative Session Session PowerPoint

Here’s a Summary of the 2019 Legislative Session (PPT) and the Summary of the Legislative Session as a (PDF). It’s been updated a bit since last week as the Governor signed the medical marijuana bill this week (which will require testing of medical marijuana, gives the ADHS additional dispensary enforcement authority, allows MM data to be used for research purposes, and makes the MM cards good for 2 years (effectively reducing the card fees by half).

Will Humble Behavioral Health, Early Childhood, Injury Prevention, Maternal Health, Wills Blog

Many States Using State Earned Income Tax Credits as a Prevention Strategy for ACEs

Is it Arizona’s Turn?

It’s no secret that exposure during childhood to negative events called adverse childhood experiences increase a person’s likelihood of having long-term chronic or behavioral health issues like heart disease, violence, suicide, and substance use.  ACEs like child abuse, neglect, parent incarceration, substance use, or separation are often clustered.

Policymakers in many states are looking for ways to prevent ACEs… which includes strategies to strengthen protective factors like social connectedness, access to healthcare and community resources, enhancing parental skills to promote healthy child development, and providing quality care and early education, and reduce risk factors before they occur. Arizona took a step forward this year by passing a budget bill that will draw down more than $60M in additional funds to support affordable childcare in Arizona.

Leading evidence-based policies to prevent ACEs before they occur are usually linked in some way to strengthening economic supports to help working families out of poverty and reduce parental stress. One well known economic support is the federal Earned Income Tax Credit. 

Many states are recognizing that they can also play a role through their state-based tax codes – and implementing Earned Income Tax Credits at the state level. Arizona hasn’t done so yet.

Here’s how they work. The Earned Income Tax Credit is a refundable income tax credit that can be used to reduce the tax burden for low- to moderate-income working people.  The federal government along with 29 states have established them at the local level. Arizona doesn’t.

Economic support from Earned Income Tax Credits is associated with improved infant and maternal health, better school performance for children, and increased college enrollment. Research suggests they reduce risk factors for child abuse and neglect ACEs by offsetting the costs of raising a child among working families.

This webpage from the National Conference of State Legislatures has a host of information about which states have state based Earned Income Tax Credits and how they work. They’re usually based on a reference to the federal EITC.

State Earned Income Tax Credits are a promising economic support for working families that help to raise more than six million people—half of them children—above the poverty line each year.

Arizona lawmakers have long had a zeal for reducing taxes.  Perhaps next year they should look at taxes from a new angle- using tax policy to support an evidence-based policy a state based earned income tax credit- that will that prevent negative childhood events and bad public health outcomes.

Will Humble Maternal Health, Wills Blog

Report Suggests Paternal Parental Work Flexibility Improves Maternal Outcomes

A new report published this week from the National Bureau of Economic Research found increasing a father’s work flexibility after a baby is born reduces the risk of the mother having physical postpartum health complications and also improves her mental health.

Workplace flexibility has long been key factor in improving postpartum outcomes but less has been known about how a father’s work hours flexibility influences outcomes.  The paper this week examined father’s work flexibility and the affect that it has on intra-household responsibilities and the effect that that flexibility has on maternal outcomes. 

The paper examined the effect that work flexibility has in the months immediately following childbirth. The authors found that a dad’s access to workplace flexibility improves maternal health. They modeled household demand for paternal presence at home in the context of a Swedish reform that granted new fathers more flexibility to take intermittent parental leave during the postpartum period.  

Increasing the father’s work hours flexibility reduces the risk of the mother experiencing physical postpartum health complications and improved her mental health. The abstract concludes that “Our results suggest that mothers bear the burden from a lack of workplace flexibility–not only directly through greater career costs of family formation, as previously documented–but also indirectly, as fathers’ inability to respond to domestic shocks exacerbates the maternal health costs of childbearing.”

Interesting research in the context of what kinds of public health policy interventions are effective at improving maternal postpartum health, don’t you think?

Will Humble Family Planning, Wills Blog

Title X Family Planning Article

Andrew Howard from the Arizona Capitol Times wrote this informative story about the outcome of a 2017 state budget provision requiring the ADHS to apply for Title X family planning grant.  Many people believe that the requirement was included in the budget in hopes that the ADHS would get Title X funds (as they’re prohibited from contracting with Planned Parenthood).

I won’t say anymore about the story…  except that it’s a quick informative read about the outcome of a key public health policy decision here in AZ.  

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