Call to Action: Labor HHS Education Bill Cuts to Family Planning

Call to Action: Labor-HHS-Education Appropriations Bill

For the first time in more than 20 years, Congress is on track to pass a Labor-HHS-Education spending bill before the end of the fiscal year. Last week, the House agreed to move to conference with the Senate to work out the differences between each chamber’s version of the  bill. The bills contains a number of bad funding cuts.

The House version eliminates funding for the Title X family planning program and the HHS Teen Pregnancy Prevention Program. I can’t tell whether the Senate version does the same or not.  The House bill also cuts all funding for the CDC’s Climate and Health program and once again fails to fund CDC research into firearm morbidity and mortality prevention. The bill also weakens the Affordable Care Act by blocking funds for implementing the law. 

Congress only has a few legislative days left to finalize the Labor-HHS-Education spending bill before the end of the fiscal year. If they don’t pass something they’ll probably pass a continuing resolution to keep key public health agencies operating (actually- not a bad outcome honestly). 

Now is the time to Speak for Public Health! You can use this link to Contact your members of Congress and ask them to support robust funding for key public health agencies and programs, and urge them to reject any controversial policy riders that would threaten public health.

EPA Proposing Fuel Efficiency Standard Rollback

The EPA & National Highway Traffic Safety Administration are proposing a roll back of the existing vehicle fleet fuel efficiency standards, which require automakers to gradually increase the average fuel efficiency of their new fleets.  

Under the existing regulations, new cars, trucks, and SUVs fleets will need to average about 50 miles per gallon by 2025. The new EPA & NTHSA proposed rule will stop the progression of standards in 2021.  Rather that requiring a fleet average of 50 mpg by 2025, the new standard will stop at 38 mpg.  Last year, the average fleet fuel efficiency was about 25 mpg.  The current average fuel efficiency of all vehicles on the road is about 21 mpg.

Fuel efficiency standards are an important driver that pushes vehicle manufacturers to discover new ways of improving fuel efficiency and are an important strategy toward reducing greenhouse gas emissions.  The transportation sector is the largest contributor to atmospheric CO2 emissions.

You can submit comments directly to the EPA and NTHSA at this web portal (it’s Docket EPA-HQ-OAR-2018-0283).  The deadline to comment is October 23, 2018. There are only 138 comments in the system so far.  I have this on my to-do list.  Hopefully some of our members will weigh in as well

EPA Proposing Looser Methane Leak Regulations

The USEPA has proposed a new rule that will relax the regulation of methane emissions at oil and gas facilities.  Methane is a very powerful greenhouse gas.  A mole of CH4 emitted today lasts about 10 years  in the atmosphere on average, which is much less time than CO2.  But, because CH4 absorbs much more energy than CO2 (CH4 is 30 times more potent as a greenhouse gas than CO2) it has an outsize impact on climate change (but for a shorter time period).  

The plan announced today by EPA will roll back key provisions of the current methane regulations.  The new proposal reduces the frequency of emissions monitoring at oil and natural gas wells from twice a year to once a year or even every other year.  Facilities that compress gas for transport through pipelines will have their monitoring frequencies cut in half from 4 times a year to just twice.  It will also extend the time that companies will have to repair leaks of this potent greenhouse gas from 30 days to 60 days.  Here’s the proposal summary: https://www.epa.gov/sites/production/files/2018-09/documents/frnoilgasreconsideration2060-at54nprm20180910.pdf

At least it won’t let companies completely off the hook, but then that’s looking through rose-colored glasses I guess.

This new rollback hasn’t been published in the UA Administrative Register yet, and comments are not yet open.  The 60-day comment period will begin once it’s published in the Register.  The Docket ID number will be EPA-HQ-OAR-2017-0483 with comments at www.regulations.gov.

Health Insurance for People w Pre-existing Conditions in Jeopardy Again

A main driver for passing and implementing the Affordable Care Act was to ensure that people with pre-existing health conditions could buy health insurance.  Prior to the ACA- people with pre-existing medical conditions like diabetes faced real challenges getting health insurance.

Indeed, one of the most consistently popular parts of the ACA are the provisions that help people get  coverage regardless of health status.  The ACA prevents health insurance companies from denying someone a policy because they have a preexisting condition (called the “guaranteed issue” requirement), refusing to cover services that people need to treat a pre-existing condition (called “preexisting condition exclusions”), or charging a higher premium based on a person’s health status (called the “community rating” provision).   

You can think of pre-existing conditions exclusions, guarantee issue, and community rating as the three legs of the ACA stool.  Despite these largely popular provisions, there are people that want to knock over the stool.  Back in February, 20 states (including Arizona) filed a lawsuit in Texas federal court seeking to invalidate the 3 legs of the stool: preexisting condition exclusions, community rating, and guaranteed issue.

This most recent legal attack argues that the removal of the individual mandate penalty by the most recent federal tax cut legislation makes the ACA unconstitutional (the US Supreme Court upheld the ACA several years ago, in part, because the tax penalty provision provided a statutory hook for the ACA to rest on).  The lawsuit argues that because the mandate is an essential feature of the ACA, the rest of the law must be struck down too.  If the lawsuit eventually succeeds these central provisions of the ACA would go away and an estimated 17 million people could become uninsured again.

During the Obama Administration, the federal government defended the ACA from lawsuits like these.  Those days are over.  A couple of months ago, the U.S. Department of Justice announced that they agree with the plaintiff States that the ACA’s individual mandate is unconstitutional. The administration urged the court to strike down the law’s guaranteed issue, preexisting condition exclusion, and community rating provisions.

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

If the Federal courts (ultimately the US Supreme Court probably) rule in favor of the plaintiffs, States could still play as a regulator of insurance, as they could enact and enforce their own laws to protect residents from discrimination due to preexisting conditions.  In fact, several states already have their own laws to incorporate some or all of the ACA’s protections (Arizona does not). 

Oral arguments have been scheduled for next week in the Texas lawsuit. Arguments are scheduled to take place next Monday before Judge Reed O’Connor.  Whatever the Federal TX Court rules, the result will likely be appealed to the UA Appellate Court and eventually probably the US Supreme Court.

Center for Public Health Law & Policy

 

The Center for Public Health Law and Policy  is the cornerstone of the Sandra Day O’Connor College of Law’s nationally-ranked health law program. The Center brings together students, leading scholars, practitioners, and policymakers to address critical issues in law, ethics, policy, and the public’s health. The Center explores a wide range of issues, including national health care reform, communicable disease control, human subject research protection, emergency legal preparedness, obesity and injury prevention, health information privacy, and vaccination law and policy.

The Center for Public Health Law and Policy is also the home to the Western Region Office of the national Network for Public Health Law, funded in part by the Robert Wood Johnson Foundation. Led by Professor James G. Hodge, Jr., the Western Region Office provides technical assistance and other vital resources to public health practitioners, officials, attorneys, and advocates across 11 Western states and nationally. Since its inception in September of 2010, the Western Region Office has fulfilled nearly 3000 requests nationally, over 1000 of which directly aided requesters in the office’s home state of Arizona.

This fall the Network for Public Health Law is organizing the 2018 Public Health Law Conference, to be held October 4-6, in Phoenix, AZ. For more information, please visit: https://www.networkforphl.org/2018_conference/phlc18.

State Action to Stem Rising Prescription Drug Costs

By Association for State and Territorial Health Officials Staff

The high cost of prescription drugs is a persistent problem in the United States, with about 10 percent of overall health spending attributed to prescription drugs. In recent years, there has been increased interest among states to address the rising cost of prescription drugs. Just this year, 24 states passed 37 bills to stem rising drug costs. In total, state legislatures have introduced 160 bills targeting prescription drug costs in 2018.

States have pursued a wide range of strategies to tackle the high cost of prescription drugs, including policies that address drug price transparency, rate setting requirements to prevent price gouging, drug importation programs, generic drugs companies, and pharmacy benefit manager transparency.

 

Drug Price Transparency

Controlling healthcare costs is one of the three elements of the Triple Aim, along with improving population health and patient care experience. As a first step toward controlling costs, states are seeking more price transparency requirements from drug manufacturers. In 2018, six states passed legislation addressing drug price transparency. Many of these laws adopt more stringent transparency policies requiring drug manufacturers to justify price increases over certain thresholds. For example, Connecticut requires drug manufacturers to justify price increases for specific drugs if the price increases by 20 percent or more in a year or 50 percent over three years.

 

Price-Gouging and Rate Setting Requirements

Anti-price gouging and rate setting requirements use information collected from transparency laws to allow states to impose penalties for excessive drug price increases. Currently, Maryland is the only state with an anti-price gouging law. The policy allows the state Medicaid agency to notify the state’s office of the attorney general when an essential off-patent brand name drug or generic medication has an excessive price increase.

Maryland’s attorney general can then request justification from manufacturers for the price increase. If the rationale of the price increase is deemed unjustified by “the cost of producing the drug, or the cost of appropriate expansion of access to the drug to promote public health,” the state can impose civil penalties or use other mechanisms to penalize the manufacturer. However, a lawsuit has since been filed in federal court by drug manufacturers asserting violations of Constitutional law as it relates to interstate commerce. To date, twelve other anti-price gouging bills have been introduced in states, although none have been enacted.

 

Drug Importation

Earlier this year, Vermont became the first state to pass a drug importation bill, allowing the state to import wholesale prescription drugs from Canada for use by all state residents. The law requires the designation of a state agency to become a licensed drug wholesaler, or to contract with a licensed drug wholesaler. Several steps remain before Vermont’s program can go into effect, including the state health department receiving federal approval from HHS by July 2019. In addition, although the Utah legislature failed to pass a bill that would have created a program for importing drugs from Canada, the legislature requested that the Utah Department of Health conduct a feasibility study associated with drug importation.

 

Generic Drugs

Recently, Maine passed a law requiring brand name manufacturers to make samples of drugs available to generic drug manufacturers, with the intention of promoting competition by increasing access of information for companies developing lower-cost generic drugs. The law states that, “In order for there to be competition in the prescription drug market, developers of generic drugs and biosimilar biological products must be able to obtain quantities of the reference listed drug or biological product with which the generic drug or biosimilar biological product is intended to compete.”

 

Pharmacy Benefit Managers

Several states have passed bills regarding pharmacy benefit managers (PBMs), which require increased transparency and disclosure of information on drug rebates and concessions. For example, Nevada passed a law in 2017 requiring PBMs to disclose the amount of rebates received from drugs used to treat diabetes. Connecticut’s drug price transparency law also requires PBMs to provide information on rebates and other price concessions received from drug companies. Mississippi passed a law preventing PBM gag clauses, which stop pharmacists from sharing information with patients on lower-cost drug options.

 

Other State Policies

In Montana, the legislature passed a bill establishing an interagency committee to study state drug pricing and spending trends, which will make recommendations to the state legislature on drug pricing policies in late 2018. In addition, New York implemented an annual cap on drug spending in its Medicaid program. Under the law, if spending projections extend beyond the cap, the state health department must identify the costliest drugs and attempt to negotiate additional rebates with manufacturers. This law also gives the state the authority to develop an independent panel that can penalize manufacturers through various mechanisms.

 

Future Opportunities

Emerging state legislation to address the rising cost of drug prices in demonstrates potential paths forward to address drug prices at the state level. The National Academy of State Health Policy (NASHP) has developed model legislation to address drug price transparency, drug importation, rate setting, and pharmacy benefit managers. The NASHP resource includes model legislation for states, bill text from states that have already passed legislation, and relevant briefing documents.

Unique Career Opportunities in Mohave County

For those of you interested in developing and implementing public health policy at the local level- there’s nothing like running a county health department.  Especially in a rural county.  Rural counties offer a unique career experience that allows you to see all facets of public health.  Folks working in rural counties learn about all the various public health programs- providing a unique opportunity to build a career in public health.  Running a smaller rural county health department also positions you well for larger organizations later in your career.

Right now there are a couple of great career building opportunities in Mohave County including the Public Health Director and Director of Environmental Health.  Both are based in Kingman.  These kinds of jobs don’t come open very often, so take a ponder over the Labor Day weekend and think about it.  I’m not spinning this- these really are good career opportunities for ambitious public health professionals that are looking to expand their reach in developing and implementing local public health policy.

AzPHA Members Voting on New Resolutions

 

Three new Resolutions have been developed by our Resolutions Committee and have been forwarded by our Board for a vote of our Members. AzPHA Resolutions are important because our advocacy priorities are driven by Resolutions. AzPHA has dozens of Resolutions in place dating back to the 1930s. Our historic Resolutions are available on our Members Only site.  

Early resolutions focused on the importance of food safety regulations, tuberculosis prevention and treatment, tobacco control, family planning, and other contemporary public health issues. More recent Resolutions have focused on addressing the Opioid epidemic, certifying Community Health Workers, and regulating electronic cigarettes. 

Our AzPHA Members that are up to date on their dues and such are now electronically voting on the proposed Resolutions between August 28 and September 12, 2018.  Links to the proposed Resolutions are located below: 

Note: This voting is just open to AzPHA Members who are up to date with their dues.  Only members in good standing were sent the message with the voting link. Let me know if you believe that you’re an active member but didn’t get the email.  It went out on the morning of August 28 and was entitled “2018 AzPHA Election Announcement”

Congress is Back in Session: Important Bills in the Balance

Members of the U.S. House of Representatives return to Washington D.C. this week.  They’ll be discussing important public health bills including the Labor-HHS-Education appropriations bill for fiscal year 2019 and the reauthorization of the Farm Bill.

Last week the Senate passed H.R. 6157 which is the combined Defense and Labor, Health and Human Services, Education and Related Agencies appropriations bill for FY19.  This one is the eighth and ninth out of 12 spending bills to be passed by the Senate for FY19.  The legislation includes increased NIH funding and boosted resources for opioid treatment, prevention, and recovery programs.  Here’s a list of some of the adopted amendments:

  • Schumer-Collins amendment to increase funding for Lyme disease activities (3759).
  • Cortez-Masto-Ernst amendment to provide for conducting a study on the relationship between intimate partner violence and traumatic brain injury (3825).
  • Peters-Capito amendment to ensure youth are considered when the Substance Abuse and Mental Health Services Administration follows guidance on the medication-assisted treatment for prescription drug and opioid addiction program (3870).
  • Heitkamp amendment to provide funding for the SOAR (Stop, Observe, Ask, Respond) to Health and Wellness Program (3893).
  • Casey amendment to provide funding for the Secretary of Health and Human Services to establish the Advisory Council to Support Grandparents Raising Grandchildren (3875).
  • Schatz-Hirono amendment to assess the ongoing mental health impact to the children and families impacted by a volcanic eruption covered by a major disaster declared by the President in calendar year 2018 (3897).
  • Heller-Manchin amendment to provide additional funding for activities related to neonatal abstinence syndrome (3912).
  • Heitkamp-Murkowski amendment to improve obstetric care for women living in rural areas (3933).
  • Durbin-Grassley amendment to provide for the use of funds by the Secretary of Health and Human Services to issue regulations on direct-to-consumer advertising of prescription drugs and biological products (3964).

The House hasn’t adopted its FY19 Labor, Health and Human Services, and Education appropriations bill. It’s unclear how both chambers will resolve differences in funding levels between their bills. The House could work on its Labor, Health and Human Services, and Education bill or skip a floor vote and start negotiations with the Senate.  The Farm Bill, which funds WIC & SNAP also hangs in the balance. Here’s a summary of the Farm Bill.   The current legislation is scheduled to expire Sept 30th.

Bottom line: with only a few legislative days before the end of FY18, it’s likely that a continuing resolution will keep the government funded into FY19.

The APHA has several tools that you can use to get the attention of your Representative or Senator.  They’ve developed APHA’s Speak for Health advocacy resources, including state-specific fact sheets to help you be a better advocate.  They also have tools to help you meet with your members of Congress or their staff or invite them to visit you and Email or call your members of Congress using the APHA action alert as a phone script or email message. It’s quick and easy.

More States Following AZ’s Lead Establishing Overdose Review Teams

More States following AZ’s Lead to Establish Overdose Fatality Review Teams

Overdose fatality reviews allow states to better understand the circumstances surrounding fatal drug overdoses so they can design better interventions.  Review teams can uncover the individual and population factors and characteristics of potential overdose victims. Knowing the who, what, when, where, and how of fatal overdoses provides a better sense of the strategies and coordination needed to prevent future overdoses and results in the better allocation of overdose prevention resources and services.  

Nine states including AZ have set up teams so far. The Network for Public Health Law provides a good overview of the states that have review teams. Here are some of the laws [OK (HB 2798), RI (S 2577 and H 7697), and VA (SB 399)], DE (HB 211) and our own (HB 2038). The laws establishing fatal overdose reviews often include the entity authorized to create and manage the review team or committee, the membership requirements for teams or committees, the scope of work of the teams or committees, confidentiality and liability protections, and data access authorizations.