Will Humble Assurance & Licensure, Wills Blog

CMS Updates Health and Safety Expectations

With all the news about the Hacienda Healthcare facility I thought I’d give an update about how facilities like Hacienda are regulated.  Hacienda was a special case because it was exempt from the state licensing requirements and wasn’t required to have a state license.  It did, however, need to be certified as meeting the federal standards of care.  CMS has an interest in ensuring quality care because they are the payers for many of the patients in skilled nursing facilities and the like.

In general, skilled nursing facilities are required to have a state license (and meet state licensing standards).  However, if the facility is accredited by a 3rd party like the Joint Commission or the Council on Accreditation, they can submit that certification to the ADHS and receive a license without an on-site inspection.  The Agency still has the authority to conduct complaint investigations, but will, in general not do annual surprise inspections not related to a complaint.

In addition to the state licensing standards, CMS requires that facilities that treat Medicare and Medicaid patients also be Certified as meeting their standards.  That compliance work is also done by the ADHS – under a contract between CMS and the ADHS.  CMS asks states to use what’s called the States Operations Manual when they do the certification inspections. 

So, a typical skilled nursing facility for example, would need to meet the state standards as well as the CMS expectations (in order to get paid for Medicare and Medicaid patient services).  When we (ADHS) re-wrote the healthcare institution Rules back in 2013, we did our best to synchronize the ADHS rules and CMS certification expectations.

CMS certification guidance addresses violations of health and safety regulations that cause serious harm or death to a patient and require immediate action to prevent further serious harm.  Their guidance also provides inspectors with guidance on quickly identifying and handling these urgent situations. 

This week, CMS announced that they’ve updated their guidance to states with information clarifies what information is needed to identify immediate jeopardy cases across all healthcare provider types.  The new guidance is in Appendix Q of the State Operations Manual that federal and state inspectors use.  CMS also released some new administrative tools to help inspectors make sure they have the evidence needed to meet criteria for immediate jeopardy.

Because these changes affect all Medicare- and Medicaid-certified healthcare providers, suppliers, and laboratories, CMS is providing online training on this new guidance at https://surveyortraining.cms.hhs.gov/ and are the revised guidance and administrative tools.

This was CMS’ final statement about their new guidance: “Investigators will now have a clear framework to identify serious patient health and safety problems. Today’s guidance is just the beginning of upcoming efforts to strengthen oversight of healthcare settings. Expect to hear more from us on this issue. This is part of the agency’s broader initiative of ensuring safety and quality, and we look forward to continuing to work on this priority across all our programs.”

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It’s Switchover Time at the Legislature

The week before last was the deadline for bills to be heard in their chamber of origin- and much of last week’s action was on floor votes (called Third Read).  When a bill clears the House or Senate (having a 3rd reading with a recorded vote of the body) it’s transmitted to the other body of the legislature (the switchover). At that point, it gets 1st and 2nd read and assigned to a committee (s). Then it’s up to the chair to schedule the bill.

If heard, then it gets voted on and gets thru that body. If there are no changes, it’s sent back to its original body who then transmits it to the Governor. If there are changes the bill, goes back to the originating body to decide if they accept the changes. If they do, they’ll be a final read and recorded vote before transmitting to the Governor. If they don’t agree then it goes to conference committee. It can be a “simple” conference where the choice is the House or the Senate version. Most are free conference committees in which there are 3 members per body who serve.

Conference committees usually don’t take testimony.  The meetings are open but there’s usually only announcements from the floor to know when the group meets.  If there’s finally agreement, it goes back for acceptance of the conference report and a final vote by each side before it goes to the Governor.

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Lots of action last week with lots of 3rd read floor votes in the Senate. The House isn’t as far along in finishing 3rd reads.  This week we’ll mostly be watching the 3rd Read votes.  We’d really like to get the hand free cell use bill, the syringe services bill, the GME bill and the e-cigarette smoke free AZ act bill through their chambers this week. Here’s our document with all the particulars on bills this week.

Public health can breathe a little sigh of relief now that the Governor made it clear that he doesn’t   intend to sign any bill that would lower vaccination rates. We’re already gambling with the lives of infants, people with disabilities, and immune optimized folks because of the erosion in our immunization rates and any of the 3 anti-vaccine bills this year (HB 2470, HB 2471, or HB  2472 would have done just that. 

We need public health policy decisions that improve vaccination rates, not decisions that put vulnerable people at even more risk.  With the Governor’s statements this we can now focus more of our efforts on the other (mostly good) public health policy bills out there.

 

Bills that Passed through the House or Senate

Access to Care & Healthcare Workforce

SB 1088 Dental Care During Pregnancy (Carter) – AzPHA Position: YES

Passed the Senate 27-3.  This bill would expand AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding. Good oral health is well established to improve birth outcomes including reducing pre-term birth while also preventing the transmission of caries from mom to infant after birth.  This priority bill was passed by the Senate this week and has been transferred to the House. Note that since this bull would have a needed appropriation it will need to be included in the final state budget.

SB 1089Telemedicine Insurance Coverage (Carter) – AzPHA Position: Yes

This Bill would put into law specific standards requiring non-Medicaid insurance companies to cover telemedicine.  There are criteria and standards in the law regarding contracting standards. Requires that coverage for telemedicine healthcare services if the service is covered when delivered in-person.   This bill would be good for access to care especially in rural Arizona which is why we’re supporting it. Passed 30-0.

SB 1174 Tribal Area Health Education Center

Health Education System consists of five area health education centers each representing a geographic area with specified populations that currently lack services by the health care professions.  The current regional centers include: 1) Eastern Arizona AHEC; 2) Greater Valley AHEC; 3) Northern Arizona AHEC; 4) Southeast Arizona AHEC; and 5) Western Arizona AHEC/Regional Center for Border Health.  This bill adds an area health education center that would focus on tribal areas and the Indian health care delivery system. Passed 30-0.  

SB 1355 Native American Dental Care

Passed Senate 25-5.  Requires AHCCCS to seek federal authorization to reimburse the Indian health services and tribal facilities to cover the cost of adult dental services.

** Kids Care: The Kids Care Reauthorization bills have all languished in their chamber of origin, however, we have good reason to believe that reauthorizing Kids Care including the appropriation needed to pay the state match (10%) will be negotiation in the state budget bills.

 

Licensing & Vital Records

SB 1247 Residential Care Institutions (Brophy McGee) AzPHA Position: Yes

Passed the Senate 30-0. This good bill will require more robust staffing background checks for facilities that provide services for children and will remove the “deemed status” designation for child residential behavioral health facilities.  Under current law, facilities in this category (e.g. Southwest Key) can be accredited by a third party (e.g. Council on Accreditation) and avoid annual surprise inspections by the ADHS.  This intervention will provide more oversight to ensure background checks are done and that the facilities are compliant with state regulations. 

 

SB 1211 Intermediate Care Facilities (Carter) AzPHA Position: Yes

Passed the Senate 30-0. Like SB 1247, this bill closes a licensing loophole.  This good bill will require more robust staffing background checks for facilities that provide services to people with disabilities at intermediate care facilities.  These facilities would also require a license to operate from the Arizona Department of Health Services beginning on January 1, 2020.  Under current law these facilities (Hacienda de los Angeles and similar facilities run by the ADES are exempt from state licensing requirements). 

 

SB 1245 Vital Records- Death Certificates (Brophy McGee) AzPHA Position: Yes

This bill will make it clear that both state and county Registrars can provide certified copies of death certificates to licensed funeral home directors upon request.  There’s been some confusion about this authority and this bill would clear it up.   Passed the Senate 30-0.

Tobacco & Nicotine

SB 1009 Electronic Cigarettes, Tobacco Sales (Carter) – AzPHA Position: YES

Expands the definition of tobacco products to include e-cigarettes. Among other things, it’ll make it clear that it’s illegal to sell e-cigarettes to minors. The penalty for selling to minors remains at $5K. Passed the Senate 30-0.

Surveillance & Social Determinants

HB 2125 Child Care Subsidies (Udall) – AzPHA Position: YES

Passed House 46-13.  Makes a supplemental appropriation of $56 million from the Federal Child Care and Development Fund block grant in FY2018-19 to the Department of Economic Security for child care assistance. Another bill, HB 2124 would allocate the money as follows: $26.7 million for provider rate increases, $14 million to serve children on the waiting list, and $13.1 million to increase tiered reimbursement for infants, toddlers and children in the care of DCS. HB 2436 is a similar bill. Passed 46-13 and has moved over to the Senate.

HB 2488 Veteran Suicide Annual Report (Lawrence) AzPHA Position: Yes

Requires ADHS to annually compile a report on veteran suicides beginning January 1, 2020. The data in the report would be shared across the public health system and with the VA and will hopefully include surveillance results that are actionable to prevent veteran suicides.

SB 1040 Maternal Mortality Report (Brophy-McGee) – AzPHA Position: YES

This bill would require the Child Fatality Review Team subcommittee on maternal mortality to make recommendations on improving information collection. Passed the Senate 30-0.

Bills that Still Need to Have a Final (3rd Read) First Chamber Vote

SB 1165 Texting and Driving Prohibition (Brophy McGee) – AzPHA Position: YES

This bill prohibits using a hand-held cell phone while driving.  There are some common-sense exemptions for example if the person is using it hands free etc.  Violations are a civil $ penalty (no driving points) with the first offense being between $75- $150 and the 2nd offense between $150 and $250.  The bill would provide a state overlay so the cell phone use laws would no longer be different from jurisdiction to jurisdiction. We’re signed up in support of this bill.  This bill still needs to go to Committee of the Whole and get a Senate 3rd read.

HB 2718 Syringe Services Programs (Rivero) AzPHA Position: Yes

Decriminalizes syringe access programs, currently a class 6 felony. To qualify, programs need to list their services including disposal of used needles and hypodermic syringes, injection supplies at no cost, and access to kits that contain an opioid antagonist or referrals to programs that provide access to an opioid antagonist.  Approved by the International Affairs Study Committee this week.  Did not receive a hearing in Rules yet, we’ll work with stakeholders to get it heard in Rules.

SB 1354 Graduate Medical Information & Student Loan Repayment (Carter) AzPHA Position: Yes

This bill appropriates $50M from the General Fund to AHCCCS, UA Health Science Center, ADHS and the to address the state-wide shortage of physicians and nurses.  The bill has several elements with a rural focus. Elements include $20M for Graduate Medical Education in critical-access hospitals and community health centers in rural areas and $4M for the ADHS’ health practitioners loan repayment system. Many elements will be very good for access to care in rural AZ.  Bill still needs a final vote in the Senate and of course – since it’s a money bill it’ll need to go through the budget process.

SB 1060 (Strike-all Amendment) Electronic Cigarettes. Smoke Free Arizona Act (Carter) – AzPHA Position: YES

Includes e-cigarettes in the definition of tobacco products and smoking for the purposes of the Smoke Free Arizona Act.  Allows smoking in retail stores that sell electronic smoking devices exclusively and have an independent ventilation system.  Because the Act was voter approved- this modification to the law will require a 3/4 majority of both houses.  This bill still needs to go to Committee of the Whole and get a Senate 3rd read.

SB 1456 Vision Screening- AzPHA Position: Yes

This bill would require schools to provide vision screening services to students in grades prescribed by future ADHS rules, kids being considered for special education services, and students who are not reading at grade level by the third grade. Appropriates $100,000 from the state General Fund to the ADHS for the tracking and follow up.  This bill still needs to go to Committee of the Whole and get a Senate 3rd read.

HB 2471 Informed Consent (Barto) – AzPHA Position: Opposed

This bill would add a requirement that physicians provide to parents and guardians the full vaccine package insert and excipient summary for each vaccine that will be administered.  Physicians already provide a Vaccine Information Summary to parents and guardians for each vaccine administered, which is noted in the medical record.  This new requirement would mandate provision of the 12-15 page insert, which is not presented in a format that incorporates health literacy principles.  Bill is likely dead but we’re remaining vigilant and will work with Stakeholders like TAPI to hold it back in the House.

HB  2472 Vaccinations- Antibody Titer (Barto) – AzPHA Position: Opposed

These bills would mandate that doctors inform parents and guardians that antibody titer tests (which involve a venous draw) are an option in lieu of receiving a vaccination and that there are exemptions available for the state requirements for attending school.   Bill is likely dead but we’re remaining vigilant and will work with Stakeholders like TAPI to hold it back in the House.

HB 2470 Vaccination Religious Exemptions (Barto) – AzPHA Position: Opposed

This bill would add an additional exemption to the school vaccine requirements into state law.  Currently there are medical and personal exemptions.  The bill doesn’t include any verification of the religious exemption from a religious leader, just a declaration from the parent that they are opposed to vaccines on religious grounds.  Bill is likely dead but we’re remaining vigilant and will work with Stakeholders like TAPI to hold it back in the House.

Good Bills that are Effectively Dead

Unless a miracle happens- this is the last time you’ll see me mention the bills below in my policy updates

SB 1363  Tobacco Product Sales (Tobacco 21) (Carter)

HB 2162  Vaccine Personal Exemptions (Hernandez)

HB 2352 School Nurse and Immunization Postings (Butler)

HB 2172  Rear Facing Car Seats (Bolding)

HB 2246  Motorcycle Helmets (Friese)

SB 1219  Domestic Violence Offenses & Firearm Transfer

HB 2247  Bump Stocks (Friese)

HB 2248  Firearm Sales (Friese)

HB 2161  Order of Protection (Hernandez)

SB 1119 Tanning Studios (Mendez)

HB 2347  Medicaid Buy-in (Butler)

HB 2351  Medical Services Study Committee (Butler)

Will Humble Public Health Law, State Legislature, Wills Blog

Legislative Update- Week of February 25

We’re roughly at the 1/3 to the halfway point in the legislative session now.  This coming week the only committees meeting are the Appropriations committees.  Lots of floor activity this upcoming week and then onto the delight of seeing how the Senate deals with House bills and how the House deals with Senate bills. 

The action this week will be in the Republican and Democratic Caucus meetings, the Committee of the Whole (in which the whole membership of a legislative house sits as a committee and operating under informal rules) and Third Read- which is the final tallied vote. You can follow the Third Read votes this week at www.azleg.gov.

The Appropriations committees will meet this week- but the public health bills with dollars attached have already been heard in the Approps Committees except for SB1399 (the School Health Pilot Program) which is being held at the Stakeholder and Sponsor request until procurement issues get resolved.

Leila Barraza, Senator Carter and I did a webinar this week on the UA Telemedicine system summarizing the legislative session so far.  You can click here to view webinar or view the Presentation Slides.

Here’s this week’s bill summary in spreadsheet format.

Bills Heard in Committee Last Week

SB 1060 (Strike-all Amendment) Electronic Cigarettes. Smoke Free Arizona Act (Carter) – AzPHA Position: YES

Includes e-cigarettes in the definition of tobacco products and smoking for the purposes of the Smoke Free Arizona Act.  Allows smoking in retail stores that sell electronic smoking devices exclusively and have an independent ventilation system.  Because the Act was voter approved- this modification to the law will require a 3/4 majority of both houses. The Striker was Approved by the Senate Health and Human Services Committee last Wednesday.

SB 1165 Texting and Driving Prohibition (Brophy McGee) – AzPHA Position: YES

This bill prohibits using a hand-held cell phone while driving.  There are some common-sense exemptions for example if the person is using it hands free etc.  Penalties are a civil penalty (no driving points) with the first offense being between $75- $150 and the 2nd offense between $150 and $250.  We are signed up in support of this bill.  Approved by the Senate Transportation Committee this week.  Floor vote next.

SB1399 School Health Pilot Program (Pace) AzPHA Position: Yes

This bill charges the AZ Department of Education with conducting a 3-year physical and health education professional development pilot program to improve the ability of physical and health educators in this state to provide high quality physical and health education to students in this state, improving student health and reducing Arizona health care cost containment 10 system and other health-related costs.  Appropriates $9.5M for planning, implementing, and evaluating the pilot.  Approved by the Senate Education Committee this week.  Appropriations Committee next.

HB 2470 Vaccination Religious Exemptions (Barto) – AzPHA Position: Opposed

This bill would add an additional exemption to the school vaccine requirements into state law.  Currently there are medical and personal exemptions.  The bill doesn’t include any verification of the religious exemption from a religious leader, just a declaration from the parent that they are opposed to vaccines on religious grounds.  Approved 5-4 by the House Health & Human Services Committee this week.  Floor vote next.

HB 2471 Informed Consent (Barto) – AzPHA Position: Opposed

These bills would add a requirement that physicians provide to parents and guardians the full vaccine package insert and excipient summary for each vaccine that will be administered.  Physicians already provide a Vaccine Information Summary to parents and guardians for each vaccine administered, which is noted in the medical record.  This new requirement would mandate provision of the 12-15 page insert, which is not presented in a format that incorporates health literacy principles.  Approved 5-4 by the House Health & Human Services Committee this week.  Floor vote next.

HB  2472 Vaccinations- Antibody Titer (Barto) – AzPHA Position: Opposed

These bills would mandate that doctors inform parents and guardians that antibody titer tests (which involve a venous draw) are an option in lieu of receiving a vaccination and that there are exemptions available for the state requirements for attending school.   Approved 5-4 by the House Health & Human Services Committee this week.  Floor vote next.

HB 2597School Safety Plan Task Force (Hernandez) AzPHA Position: Yes

This well-researched bill came out of a workgroup established by students at Mountain View High School. It takes a proactive approach to prevent school violence.  The Bill asks schools to develop plans to outline how teachers and staff will respond to crisis situations, how they respond to warning signs of emotional or behavioral distress among students, partnerships with agencies to refer students to support services, and what services they’ll provide after a violent incident.  Approved by both the House Education and Public Safety Committees this week.  Floor vote next.

HB 2718 Syringe Services Programs (Rivero) AzPHA Position: Yes

Decriminalizes syringe access programs, currently a class 6 felony. To qualify, programs need to list their services including disposal of used needles and hypodermic syringes, injection supplies at no cost, and access to kits that contain an opioid antagonist or referrals to programs that provide access to an opioid antagonist.  Approved by the International Affairs Study Committee this week.  Floor vote next.

 

Bills that Have Passed a Chamber

SB 1009 Electronic Cigarettes, Tobacco Sales (Carter) – AzPHA Position: YES

Expands the definition of tobacco products to include e-cigarettes. Among other things, it’ll make it clear that it’s illegal to sell e-cigarettes to minors. The penalty for selling to minors remains at $5K. Unanimously passed in the full Senate and was transmitted to the House this week.

SB 1040 Maternal Mortality Report (Brophy-McGee) – AzPHA Position: YES

This bill would require the Child Fatality Review Team subcommittee on maternal mortality to compile an annual statistical report on the incidence and causes of “severe maternal morbidity” with recommendations for action.  The current law requires a review of the data but no report. Unanimously passed in the full Senate and was transmitted to the House this week.

SB 1174 Tribal Area Health Education Center

The Health Education System consists of five area health education centers each representing a geographic area with specified populations that currently lack services by the health care professions.  The current regional centers include: 1) Eastern Arizona AHEC; 2) Greater Valley AHEC; 3) Northern Arizona AHEC; 4) Southeast Arizona AHEC; and 5) Western Arizona AHEC/Regional Center for Border Health.  This bill adds an area health education center focusing on the Indian health care delivery system. Approved by the Senate. Passed out of the Senate by a vote of 30-0.

Will Humble Public Health Law, Vaccination, Wills Blog

Are School Attendance Vaccination Requirements Constitutional?

There was a lot of contentious debate in both the Arizona Senate and House this week regarding bills that have proposed that would add a religious exemption for school attendance vaccination requirements.

Much of the testimony from parents centered around their belief that public school vaccination requirements are unconstitutional, so I thought I’d take a deeper dive into that subject this week before I get to this week’s bill summary.

There are a couple flagship US Supreme Court cases that address school vaccine requirements.  The first case (from 1905) is called Jacobson v. Massachusetts, in which a guy named Henning Jacobson challenged Massachusetts law that required everybody to be vaccinated against Smallpox or face fine or imprisonment. 

Justice Marshall Harlan delivered the decision for a 7-2 majority, holding that the freedom of the individual must sometimes be subordinated to the common welfare.  The majority opinion rejected Jacobson’s claim that the 14th Amendment gave him the right to refuse vaccination.  However, the court held that there needs to be exceptions for people with medical contra-indications. 

A later Supreme Court case (in 1922) called Zucht v. King directly addressed the constitutionality of school attendance vaccination requirements.  In that case, the Court held that a school system could refuse admission to a student who failed to receive a required vaccination.

In that case, San Antonio the family of Rosalyn Zucht challenged San Antonio’s ordinance requiring that students present a certificate of vaccination for smallpox before attending school (public or private).  Rosalyn’s parents were unwilling to vaccinate her, so she was excluded from both public and private schools in San Antonio.

The family argued that since smallpox wasn’t present in town at the time, there was no emergency requiring vaccination, and that she was deprived of liberty without due process of law by effectively making vaccination compulsory. The Texas state courts denied her claims, and the family appealed to the United States Supreme Court.

The Court found no reason to question the fairness with which the city ordinance was applied and found that the ordinance reflected the broad discretion needed by authorities to protect the public health.

Will Humble Disease Control, Prevention, Wills Blog

More States Moving to Eliminate Non-Medical Exemptions (not in AZ)

There have been 127 cases of measles were confirmed in 10 states this year with outbreaks in Texas, Washington, and multiple jurisdictions in New York. The reported cases are centered primarily within communities where rates of children who are vaccinated against measles are below herd immunity (due to its high level of communicability, measles require a high rate of vaccination, between 95% to reach herd immunity).  

There are many communities in Arizona and across the country where the rates are much lower than 95%. For example, in Clark County, Washington (where a recent measles outbreak originated) the percentage of kindergarteners who received a vaccine for measles fell from 96% in 2004 to 85% in 2017.

Every state has vaccination requirements for kids starting school, and all states also have medical exemptions.  All but three states—California, Mississippi, and West Virginia—also allow non-medical exemptions (i.e., exemptions based on religious, philosophical, or personal beliefs).

Arizona currently has medical and religious exemptions for pre-school & medical and personal exemptions for public school attendance. HB 2070, which passed the House Health and Human Services Committee Thursday (5-4) would add a new religious exemption for public school.

Over the past 10 years, the number of non-medical exemptions has increased, especially in states that allow both religious and philosophical exemptions. Additionally, researchers have identified several areas in the US where large numbers of non-medical exemptions are granted, including in the Portland metro area, where Clark County, Washington, is located.

Some states are now beginning to do away with non-medical exemptions for school vaccination requirements.

In 2015, following an outbreak of measles at Disneyland, CA eliminated its non-medical exemptions (and immunization coverage recovered dramatically).  In California, vaccination rates rebounded substantially after the personal exemption was eliminated.  Vermont also eliminated its philosophical belief exemption in 2015 (but kept their religious exemption).

This year, a bill to remove the personal belief exemption for the MMR vaccine has passed the State of Washington’s House of Representatives (HB 1638).  Many other states have also proposed eliminating non-medical exemptions, including Arizona (HB 2162 – which has not received a hearing), Iowa (HF 206), Maine (LD 798), Minnesota (SF 1520), and New York (S 2994 and A 2371).

Sadly, the bills that have received hearings in Arizona all work against improving our immunization rates, including HB 2470 Vaccination Religious Exemptions, HB 2471 Informed Consent, and HB  2472 Vaccinations- Antibody Titer.  All 3 Bills received Pass Recommendations in the Senate Health and Human Services Committee this week (by a 5-4 margin). They will likely be up for floor votes this week in the AZ House.

Will Humble State Legislature, 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 2 pm.

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 Disease Control, Medicaid, Nutrition, Oral Health, Physical Activity, Prevention, Public Health, Public Health Law, State Legislature, Wills Blog

Legislative Update

All the legislative committees have big long agendas this week – as the deadline for bills to be head in their house of origin committees is rapidly approaching.  So, this will be a busy week. 

Our policy interns Tim Giblin and Annissa Biggane have been doing a great job tracking all the bills that we’re signed up for and against and monitoring amendments and the like. Here’s their detailed summary of all the various public health related bills and where they are in the system right now.

We have an Action Alert this week regarding some bills that will have a detrimental effect on vaccination rates- so please follow through on that this week- you can see more about that below.

Bills to Be Heard in Committee This Week

Monday

HB 2597  School Safety Plan Task Force (Hernandez) AzPHA Position: Yes

This well-researched bill came out of a workgroup established by students at Mountain View High School. It takes a proactive approach to prevent school violence.  The Bill asks schools to develop plans to outline how teachers and staff will respond to crisis situations, how they respond to warning signs of emotional or behavioral distress among students, partnerships with agencies to refer students to support services, and what services they’ll provide after a violent incident. This important bill will be heard in the House Education Committee on Monday, February 18 at 2pm.  We’re signed up in favor of the bill.

 

Tuesday

SB1399  School Health Pilot Program (Pace) AzPHA Position: Yes

This bill charges the AZ Department of Education with conducting a 3-year physical and health education professional development pilot program to improve the ability of physical and health educators in this state to provide high quality physical and health education to students in this state, improving student health and reducing Arizona health care cost containment 10 system and other health-related costs.  Appropriates $9.5M for planning, implementing, and evaluating the pilot.  This important bill will be heard in the Senate Education Committee on Tuesday, February 18 at 2pm. We’re signed up in favor of the bill and I’ll be speaking in Committee.

 

Wednesday

SB 1165 Texting and Driving Prohibition (Brophy McGee) – AzPHA Position: YES

This bill prohibits using a hand-held cell phone while driving.  There are some common-sense exemptions for example if the person is using it hands free etc.  Penalties are a civil penalty (no driving points) with the first offense being between $75- $150 and the 2nd offense between $150 and $250.  We are signed up in support of this bill.  Will be heard in Senate Transportation Wednesday at 9 am.  We’re signed up in favor of the bill and I’ll be speaking in Committee.

 

Thursday

HB 2471 Informed Consent (Barto) – AzPHA Position: Opposed

This bill would add a requirement that physicians provide to parents and guardians the full vaccine package insert and excipient summary for each vaccine that will be administered.  Physicians already provide a Vaccine Information Summary to parents and guardians for each vaccine administered, which is noted in the medical record.

This new requirement would mandate provision of the 12-15 page insert, which is not presented in a format that incorporates health literacy principles. Hearing will be Thursday, February 21 at 9 am in the House of Representatives Health and Human Services Committee.  We’re signed up opposed to the the bill and I’ll be speaking in Committee.

 

HB  2472 Vaccinations- Antibody Titer (Barto) – AzPHA Position: Opposed

These bills would mandate that doctors inform parents and guardians that antibody titer tests (which involve a venous draw) are an option in lieu of receiving a vaccination and that there are exemptions available for the state requirements for attending school.   Hearing will be Thursday, February 21 at 9 am in the House of Representatives Health and Human Services Committee.  Hearing will be Thursday, February 21 at 9 am in the House of Representatives Health and Human Services Committee.  We’re signed up opposed to the bill and I’ll be speaking in Committee.

HB 2470 Vaccination Religious Exemptions (Barto) – AzPHA Position: Opposed

This bill would add an additional exemption to the school vaccine requirements into state law.  Currently there are medical and personal exemptions.  The bill doesn’t include any verification of the religious exemption from a religious leader, just a declaration from the parent that they are opposed to vaccines on religious grounds.  Hearing will be Thursday, February 21 at 9 am in the House of Representatives Health and Human Services Committee.  We’re signed up opposed to the bill and I’ll be speaking in Committee.

ACTION ALERT: Please contact the following Representatives and let them know that you oppose HB 2470, HB 2471 & 2472 as they will decrease immunization coverage and jeopardize herd immunity.

Please focus your attention on the lawmakers in bold- especially those of you that know them!

 

John Allen

[email protected]

Nancy Barto

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Kelli Butler

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Gail Griffin

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Alma Hernandez

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Jay Lawrence

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Becky A. Nutt

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Pamela Powers Hannley

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Amish Shah

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Bills Heard in Committee Last Week

SB 1247 Residential Care Institutions (Brophy McGee) AzPHA Position: Yes

This good bill will require more robust staffing background checks for facilities that provide services for children and will remove the “deemed status” designation for child residential behavioral health facilities.  Under current law, facilities in this category (e.g. Southwest Key) can be accredited by a third party (e.g. Council on Accreditation) and avoid annual surprise inspections by the ADHS.

This intervention will provide more oversight to ensure background checks are done and that the facilities are compliant with state regulations.  This bill passed through the Senate Health & Human Services this week and will be moving to the floor.

SB 1211 Intermediate Care Facilities (Carter) AzPHA Position: Yes

Like SB 1247, this bill closes a licensing loophole.  This good bill will require more robust staffing background checks for facilities that provide services to people with disabilities at intermediate care facilities.  These facilities would also require a license to operate from the Arizona Department of Health Services beginning on January 1, 2020. 

Under current law these facilities (Hacienda de los Angeles and similar facilities run by the ADES are exempt from state licensing requirements.  This Bill passed the Senate Health & Human Services this week and will be moving to the floor.

 

SB 1088 Dental Care During Pregnancy (Carter) AzPHA Position: Yes

This bill would expand AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding. Passed the Senate Health & Human Services Committee on 1/23.  This Bill passed through the Senate Appropriation Committee this week and will be headed to the floor next.

 

HB 2073 Vapor Products; Regulation (Shope) – AzPHA Position: Opposed

This bill would basically set up a quasi-regulatory program at the ADHS to license electronic cigarette manufacturers in Arizona and specify that only licensed electronic cigarette manufacturers can sell products in Arizona.  It gives no regulatory authority to the ADHS to enforce that vape shops get licensed and they only must do it every 5 years. There are no penalties for noncompliance and penalties are against the purchaser instead of the retailer.  This bill passed the House Health Committee by a 5-4 vote this week.

 

Bills that Have Passed a Chamber

SB 1009 Electronic Cigarettes, Tobacco Sales (Carter) – AzPHA Position: YES

Expands the definition of tobacco products to include e-cigarettes. Among other things, it’ll make it clear that it’s illegal to sell e-cigarettes to minors. The penalty for selling to minors remains at $5K. Unanimously passed in the full Senate and was transmitted to the House this week.

SB 1040 Maternal Mortality Report (Brophy-McGee) – AzPHA Position: YES

This bill would require the Child Fatality Review Team subcommittee on maternal mortality to compile an annual statistical report on the incidence and causes of “severe maternal morbidity” with recommendations for action.  The current law requires a review of the data but no report.

Will Humble Medicaid, Wills Blog

“AHCCCS Works” Reporting System RFP

A few weeks ago CMS approved Arizona’s request to include work requirements and/or community engagement and reporting requirements as a condition of Medicaid enrollment beginning on January 1, 2020.  CMS’ Letter to Director Snyder is 18 pages long and contains conditions and details- so refer to that letter for the nuts and bolts of what they said.

The work requirement/community engagement Waiver request was mandated by Senate Bill 1092 (from 2015) which requires AHCCCS to ask CMS’ permission to implement new eligibility requirements for “able-bodied adults”. 

The work/community engagement requirements (which begin 1/1/20) will require some “able-bodied” members between the ages of 19 to 49 years-old to participate in community engagement activities for at least 80 hours per month and report their activities monthly.  Activities can include employment, including self-employment; less than full-time education; job or life skills training; job search activities; and community service.

A member who fails to comply in any given month will be suspended from AHCCCS coverage for 2-months but automatically reinstated after that. Members won’t be terminated for failing to comply.

There are several categories of folks that will be exempted from the requirements – you can see that full list in a previous blog post.

A few weeks ago, AHCCCS released a Request for Proposal (SOLICITATION # YH19-0028) to find a vendor to develop the system that AHCCCS members would use to report community engagement activities, work activities, report exclusions, and/or to notify AHCCCS why they haven’t met the work/community engagement requirements. The solicitation reminds bidders that the system has to communicate via file transfer or web interfaces with their eligibility and enrollment system and connect to the “AZTECS” system so it can identify members that are participating in SNAP or Cash assistance eligibility.   Bids are due February 19, 2019.

Hopefully AHCCCS will find a solid vendor that will deliver a system that is easy to use for AHCCCS members with an intuitive interface, easy to use functions, and very accurate connectivity with other databases so that members will have an easy time reporting their compliance with the new requirements.

Will Humble Prevention, Vaccination, Wills Blog

Measles Outbreaks, Personal Exemptions, Parent Education & School Exclusions:

Interventions to Protect Kids & Stop the Spread of Disease

The Social Contract & Herd Immunity

At the core – vaccines are really about community protection.  Our public health system depends on a solid network of providers that are available to vaccinate kids for all the nasty infectious diseases that have plagued humanity for millenia.  Vaccinating yourself and your kids is more about community protection than personal protection. It’s a social contract that we have with each other to keep all of us healthy.

We need just about everybody to participate in our shared social contract to vaccinate in order to get the herd immunity.  When communities have herd immunity, those who can’t be vaccinated and folks with weakened immune systems will still be protected because the viruses can’t circulate.  Measles needs a 95% community vaccination rate to achieve herd immunity.

 

School Enrollment Requirements & Exemptions

To achieve herd immunity and prevent the spread of measles and other communicable diseases, every state including Arizona requires kids in public school to be vaccinated against a series of diseases, including measles.

All states allow an exemption from the required vaccines when it’s medically necessary.  Seventeen states (including Arizona) allow parents to exempt their kids from the requirements because of personal or philosophical beliefs (called personal belief exemptions).  BTW: HB 2162 would change that by removing Arizona’s personal belief exemption (it hasn’t been scheduled for a hearing).  States with a personal exemption option usually have lower vaccination rates than states without that option.

States also have authority to exclude kids that are unvaccinated from school during a vaccine preventable disease outbreak. In Arizona, ARS § 15-873(C) states that students “… who lack documentary proof of immunization shall not attend school during outbreak periods of communicable immunization-preventable diseases”.  The decision to exclude kids during an outbreak rests with the directors of the county health departments and school administrators and is prescribed in Arizona’s Communicable Disease Rules.

 

Immunization Rates Among AZ Schools

Arizona has many pockets in which our vaccination rates are below 95%, mostly in high income areas and among certain charter schools. One of our best sources of vaccine coverage data comes from schools and childcare centers- which are required to report their vaccination coverage and exemption rates for 19-35 month old’s, kindergartners, and 6th graders.

Public health agencies aren’t the only group of folks interested in school exemption rates. Many parents are interested in finding out whether their child’s school is has a high vaccination rate.  For the last several years, the ADHS has been posting the vaccination rates of schools across the state.

Last year exemption rates increased across all age categories. Exemptions rose from 3.9% to 4.3% for child care, from 4.9% to 5.4% for kindergarten and from 5.1% to 5.4% for 6th grade.  As is always the case, exemption rates were much higher in charter schools. Data for exemption rates and vaccine coverage rates by county and school are available on the ADHS website.  Note: updated exemption rates will be available in a couple of months.

 

Educating Parents

Arizona’s public health system has been doing some creative work to improve our immunization rates. One is an innovative on-line immunization education course that’s designed to serve as part of a potential new personal exemption process.  

Last year a pilot project was conducted recently at a dozen or so schools in Maricopa County to learn how to best implement an immunization education module, get feedback from school staff, and identify whether parents learned new information about vaccines using a pre-and post-knowledge assessment survey.

A new more robust pilot is planned for the 2019-2020 school year. The county health departments and the ADHS are partnering in the project.  At participating schools (hopefully as many as 125 schools), parents who want to exempt their kids from the school enrollment vaccination requirements will be asked to complete the Immunization Education Course first.  Upon completion, they’ll be able to download their school’s exemption form.

The online course is designed only for the use of Personal Beliefs Exemptions in grades K-12 at pilot program schools. It doesn’t change the process to request and obtain a Medical Exemption form or the Religious Beliefs Exemption form.

Hopefully the project will demonstrate positive results and will include an academic partner so the eventual results can be published and other states can learn from this important work.

We don’t have much time, though.  Vaccination rates are already below herd immunity levels for measles in many parts of the state, and all it’ll take right now is a sentinel measles case in the right place at the right time and we’ll have a measles outbreak- maybe one as bad as the one happening right now in Washington state and across much of Western Europe.

Will Humble Prevention, Vaccination, Wills Blog

CA Eliminated Personal Exemptions & Vaccination Rates Improved A Lot

California had also been struggling to maintain herd immunity vaccination rates- especially in higher income areas (just like us).  After trying a variety of interventions- and following a measles outbreak associated with Disneyland- the California Assembly passed & Governor Brown signed Senate Bill 277 (in 2015) which abolished personal exemptions in California.

The intervention worked.  In the following years, CA had sharp increases in vaccination rates among kindergarteners entering school. During the 2014–2015 school year the statewide kindergarten full-vaccination rate was only 90.4%. After implementing the new law, the kindergarten full-vaccination rate rose to >95% and has stayed there. 

By the way- a few months ago the Second District Court of Appeal in Los Angeles found that the CA law didn’t violate freedom of religion or the right to an education.

The court said that… “Compulsory immunization has long been recognized as the gold standard for preventing the spread of contagious diseases”.  The court said the new law was not discriminatory and was a valid measure to protect public health.  Just saying.

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