Will Humble Prevention, Tobacco, Wills Blog

How Much Compromise is Too Much?

That’s the basic question regarding a bill that is progressing that would move the buy age for tobacco products including e-cigarettes to 21 – but would also pre-empt existing and future local regulation of tobacco products (including e-cigs).

AzPHA has been a long-time supporter of legislative changes to move the tobacco buy age to 21 from the current 18. There is a ton of medical and population-based evidence suggesting that moving the buy age to 21 would be an effective tool for reducing the number of people addicted to nicotine and tobacco – saving many lives.  Tobacco smoking remains the number one preventable cause of premature death (although obesity is expected to overtake tobacco in the next few years).

Our preference has always been to implement a “tobacco 21” law that would cleanly move the buy age for tobacco and e-cigs to 21.  Clean in the sense that the bill would do just that- and not impair cities, towns, universities etc. ability to be more restrictive.

A great example of that is Senator Carter’s SB 1363 which would have cleanly moved the buy age for both e-cigs and tobacco to 21.  We wholeheartedly supported that bill.  Sadly, it never even got a hearing in the Senate because it was assigned to the Commerce Committee instead of Health Committee- and the Commerce Chair didn’t hear the bill.  So, a couple of months ago it looked like a tobacco 21 bill was dead again this session.

Then, last month, along comes a “strike all” amendment to SB 1147 by Senator Allen which also would raise the buy age to 21 but also includes a pre-emption clause preventing any other jurisdiction from implementing tobacco or e-cig control measures that aren’t included in the 1147 bill and that aren’t covered in the Smoke Free Arizona Act. 

The preemption pieces would effectively open up currently tobacco free campuses to anyone over the age of 21 and would allow for vending machines containing e-cigarettes and conventional tobacco in areas where kids could have access to them.  Here are examples of what the pre-emption clause of 1147 would:

Void Phoenix, Tempe and other cities’ zoning boundaries for tobacco retailers that prohibit the sale of tobacco products within 1,320 ft of a school, park, day care facility, among others public places.

Remove local prohibitions on tobacco marketing and advertisements on or near public property, such as near schools, bus stops, park benches.

Eliminate licensing requirements for retail tobacco establishments.

Allow tobacco vending machines in liquor stores where minors can enter without anyone verifying their age. Currently, some cities only allow vending machines in bars that ID customers to ensure they’re 21 and specialty clubs that require membership. 

On the penalty side- SB1147 would create new criminal penalties on those 18-21 rather than primarily placing the penalties on the establishments that sell to people under 21.

The challenge for organizations like ours when deciding whether to support or oppose SB 1147 is to weigh whether the benefit of the 21 buy age intervention is outweighed by the downside posed by the pre-emption.

To be honest- when I read SB1147 for the first time (after the amendments) I was on the fence about whether we should support the bill.  It sure was tempting to get T-21 finally into state law.  But in the end, we decided to stick with the rest of the public health community and oppose the bill for good reasons- because the pre-emption pieces and the fact that the bill doesn’t classify e-cigs with tobacco products really move the balance of the bill as a negative. 

Maybe in the next couple of years we can get a bill that won’t have pre-emptions, would have a more balanced set of penalties, and would include e-cigs in the definition of tobacco products.

So that’s the reason for the title of this piece.  How much compromise is too much compromise- and as a secondary thing- how patient should one be to hold out for a clean intervention.  

I have no doubt that we will eventually get a clean T-21 bill through the legislature.  The question is how many years it’ll take.  Hopefully not as many as it took to get the hands-free cell phone law that was just passed and signed.  That took too many years.  Way too many.

SB 1147 is being heard on Monday in the House’s Committee of the Whole and it could even go to a 3rd read the same day (the Committee of the Whole is the last chance to amend measures in either chamber before bills go to the floor for a 3rd read- which is the floor vote).  Even if it passes the House this week it’ll still need to go back to the Senate because it’s a strike all bill.

Will Humble Assurance & Licensure, Behavioral Health, Public Health, State Legislature, Wills Blog

Legislative Update: May 6, 2019

Legislative Update

We’re moving full force into the budget negotiations process now. By all accounts it looks to be a more deliberative process than in years past because of the tight party affiliation margins and the disconnect between the executive budget priorities and those of the legislature. It’s likely that we’ll have at least a few more weeks before a final budget is complete- and it might even go into June this year. 

Public Health Bills Signed by the Governor

SB 1165 now HB 2318 Hands Free Cell Requirement 

This bill was a long time coming- but were on the precipice of having this good public policy finally happen- all that’s left is for the Gov to sign it. It will prohibit 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.  It’ll change driving behaviors and save lives.

Violations are a civil money 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. Warnings for a year and a half – and then the penalties kick in.

 

SB 1247 Residential Care Institutions

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 the old law 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

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 1040 Maternal Mortality Report

This bill was signed by the Governor this week.  The new law will establish an Advisory Committee on Maternal Fatalities and Morbidity.

It requires ADHS and the Committee to hold a public hearing to receive public input regarding the recommended improvements to information collection concerning the incidence and causes of maternal fatalities and severe maternal morbidity and complete a report (including recommendations) by the end of this year.

SB 1089 Telemedicine

This week the Governor signed this bill will improve healthcare access and help lower costs. With this legislation, any healthcare service covered in-person by a commercial insurer will also be covered when provided through telemedicine. Currently, Arizona law limits telemedicine coverage to a handful of medical services.

HB 2488 Veteran Suicide Annual Report (Lawrence)

Requires ADHS (starting this year) to complete an annual report on veteran suicides in Arizona that includes the number and rate of veterans who died by suicide, trends, an analysis of the years of potential life lost, a comparison of Arizona’s resident veteran suicide rate to those of the nation, and the relative risk of suicide by race or ethnicity, age group, gender and region. 

The report is also supposed to analyze patterns of drugs, or combinations of drugs, that were used by Arizona’s resident veterans when drug poisoning was the mechanism of suicide. The idea is to create the surveillance and data linkages needed to inform suicide prevention strategies based upon medical risk factors that significantly correlate to suicide.

SB 1109 Short Term Limited Health Plans- extension – AzPHA Position: Opposed

This bill has passed both chambers and has been signed by the Governor.  It authorizes the sale of short- term limited health plans in Arizona for terms up to 3 years.  The previous limit was 1 year.  These plans don’t cover pre-existing conditions and have limited consumer protection because they aren’t required to cover the essential health services under the ACA and can drop enrollees.  We urged a not vote because of the poor consumer protections.

On the Governor’s Desk for Signature

 SB 1468 Suicide Prevention Training

This good bill is awaiting the Governor’s signature.  It will require school districts, charter schools, and Arizona teacher training programs to include suicide awareness and prevention training in their continuing education curricula.  It’ll require AHCCCS to make suicide awareness and prevention training available (fortunately some evidence- based tools curricula already exist).

Starting in the 2020 school year, school districts and charter schools would need to provide training in suicide awareness and prevention to school personnel in grades 6 to 12.  The bill also establishes requirements for suicide awareness and prevention training and specifically says that the training use evidenced-based training materials and instruct participants on how to identify the warning signs of suicidal behavior in adolescents and teens.

SB 1085 Association Health Plans (AzPHA Opposed)

This bill was passed by the House this week and is awaiting the Governor’s signature.  He’s sure to sign it. It basically provides a regulatory structure at the state level to regulate AHPs in AZ – serving to make them more available in Arizona. A primary concern for folks interested in public health and consumer protection is that AHPs don’t need to cover the essential health benefits, they can charge differently depending on gender and age. 

Additionally, we’re concerned that if an employer offers a “skinny” benefit plan that barely meets the definition of minimum value (and doesn’t include important essential health benefits) families could be prevented from benefitting from the subsidies that would otherwise be available to them on the Marketplace.

Back in August (at the direction of the President) the US Department of Labor issued a final rule that established criteria for determining when employers can join in an association and be treated as an employer sponsor of a group health plan.  The federal regulation loosens the rules for additional plans to come onto the market, allowing more small businesses including individuals who work for themselves to join these plans.  This bill will make these plans more available in AZ.

Will Humble Prevention, State Legislature, Wills Blog

New Study Shows Positive Economic Impact from SB1354

It’s been clear from the start that SB 1354 – the most important access to care bills this year- would do a great deal both in the short-term by boosting the primary care loan repayment program and really enhance graduate medical education residencies over the coming years (important because where a practitioner does her or his residency greatly influences where they ultimately practice).  Arizona’s primary care physician shortage is one of the worst in the nation (meeting only 42% of the state’s needs).

The public health merit of a bill is often not enough to carry the day – especially when a financial appropriation is involved- because the return on investment matters too.  Fortunately, the Arizona Hospital and Healthcare Association and the Arizona Rural Health Association commissioned a study to measure how SB 1364 would affect the economy and patient access to care.

The result of the independent economic impact study found that the SB 1354 investments would have a “significant positive economic impact” to the state and expanded patient access to care over the next ten years.

The report found that the bill would enable hospitals across the state to increase the number of post-graduate physician residents they train and found that increasing the number of physician residents at three rural hospitals alone would result in 845 new high- paying jobs and $911 million in economic output over ten years.  Additionally, the bill lessens the issue of physicians leaving Arizona after graduation because they are unable to secure the limited amount of in-state residency positions.

Almost 75% of medical students who finish post-graduate training in Arizona stay in Arizona. This means state funding for physician residencies will move the needle on the state’s physician shortage and be a game-changer for rural communities.

The bill sailed through the Senate but stalled in the House – as the Rules Committee never heard the Bill (and that committee is no longer meeting).  But- portions of the bill or even the whole bill could be included in the final budget as what’s called a Budget Reconciliation Bill or BRB.

Will Humble Affordable Care Act, Wills Blog

US Justice Department Files its Argument Against the ACA

A few months ago a federal judge in Texas (Judge Reed O’Connor) dealt a blow to the ACA when he ruled in Texas v. Azar that the ACA is unconstitutional in its entirety…  including the implementation of market reforms (e.g. protections for folks with pre-existing conditions), the health insurance marketplaces, and the expansion of Medicaid. He didn’t issue an injunction ordering the suspension of the law – so the ACA will remain the law of the land for now.

The DOJ made it clear that they have no intention of defending any of the provisions of the ACA (including covering pre-existing conditions) because they agree with the plaintiff States. That message came in a short statement by the Attorney General when he notified the court that they fully side with Judge O’Connor’s decision in Texas v. Azar & won’t defend the ACA.

This week the Department of Justice filed their argument against the ACA with the court. The government argues that since the “individual mandate” has now been effectively eliminated by the tax overhaul law last year the whole ACA unconstitutional.

Last week’s filing concedes that the administration had previously argued that parts of the ACA could remain in effect even if the individual mandate were struck down, but they are changing that position now and their position is that the court should strike down the law in its entirety.

Because of the makeup of the 5th Circuit Court of Appeals, the court will likely uphold O’Connor’s decision and the case will probably end up with the US Supreme Court…  which has a different cast of characters than it did when the ACA was originally upheld back in 2012 by a 5-4 vote.

Since then, Gorsuch replaced Scalia and Kavanaugh replaced Kennedy.  Both Scalia and Kennedy voted against the ACA- so not much on that score has changed.

Chief Justice Roberts voted with the majority that upheld the law.  His argument rested on the ACA’s link to the financial penalties for not having health insurance. But remember, the financial penalties for not having health insurance were removed from the IRS tax codes in last year’s federal tax overhaul, pulling out the structure that Roberts used in his argument.

In the 2012 Ruling, Justice Roberts wrote that: “… the Affordable Care Act’s requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax… because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.” 

Roberts rejected the Administration’s argument that the federal government’s authority to regulate interstate commerce provides the authority needed for the ACA to be constitutional (the Court struck down that argument 5-4).

The bottom line is that the ACA, including its protections for folks with pre-existing conditions, may very well be in jeopardy if Roberts views the ACA as fundamentally different now that the financial penalties are gone.

Will Humble Medicaid, Oral Health, State Legislature, Wills Blog

AzPHA Action Alert: Support Comprehensive Oral Health Coverage for Pregnant Medicaid Members

The State Legislature is transitioning to focusing on the State budget.  There are a few items we’ll need to ask you to press for in the next couple of weeks with the legislators in your district including: 1) preventative and comprehensive oral health services for pregnant Medicaid members; 2) increased investment in funding for the state loan repayment program and health profession residencies (especially for primary care); and 3) for funding Kids Care. This week we’ll focus on Oral Health.

Please take a few minutes and send an email (or make a call) to the Senator and Representatives for your Legislative District and to urge them to include funding for preventative oral health coverage for pregnant Medicaid members in the State budget.

To make it easy, we’ve built a template message for you to send to your Senator and Representatives below. 

You’ll need three messages in total because each Legislative District has one Senator and two Representatives.  To find your Senator and Representative go to:  https://www.azleg.gov/findmylegislator/

_________________________________

Here’s a draft message for you to send (it helps if you personalize it a bit):

Dear Senator _______ (or Dear Representative _______),

I’m urging you consider adding a dental benefit for pregnant mothers within Arizona’s AHCCCS program as you consider funding priorities for the State budget in the next few weeks. 

Adding this important benefit makes both solid public health and economic sense, and there’s good evidence.

A new systematic overview of published studies has found a clear relationship between periodontal disease and pre-term birth and low birth weight.

About 7.2% of AZ live births were low birthweight – or about 5,760 of the 80,000 births every year in AZ.  The newly published suggests that periodontal disease is contributing to 1,036 low birthweight weight babies each year in AZ including 520 pre-term babies per year in our state’s Medicaid program.

Nationally, the average health care cost for a low birth weight baby during the first year of life is $55,393 compared to $5,085 for a non-low birth weight baby…  meaning that periodontal disease costs the state in the neighborhood of $29M in the first year from low birth weight births that are attributable to periodontal disease compared with only $2.6M for a similar number of non pre-term births.

The small investment for this new benefit (only $178,000 in State funds and $458,000 from the Federal Medicaid authority) will result in healthier mothers and healthier babies while saving the state money.

Legislation supporting this benefit (SB1088) passed the Senate with a wide margin and both the House Health and the House Appropriations Committees have given SB1088 strong bi-partisan support.

This new benefit is strongly supported by the Arizona Public Health Association, the Oral Health Coalition and a large number of affiliated groups including the March of Dimes, the Arizona Dental and Arizona Dental Hygienists Associations, the Alliance of Community Health Centers, the College of Obstetrics and Gynecology, and the Arizona Health Plans Association.

We urge you to put funding for this new program on your list of priorities for the State budget this coming year.

Thank you for your consideration.

Sincerely,

Your name & Legislative District

Will Humble Behavioral Health, Wills Blog

The Teen Suicide Epidemic & Social Media

The number of kids in the U.S. who visited emergency rooms for suicidal thoughts and suicide attempts has doubled in the last 10 years.  A new article in JAMA Pediatrics found that the number of children between 5 and 18 who received a diagnosis of suicidal ideation or suicide attempts increased from 580,000 in 2007 to 1.12 million in 2015.  The average age of a child at the time of evaluation was only 13, and 43% of the visits were in children between 5 and 11. Pretty alarming.

The authors also state that no conclusions can be drawn regarding the cause for the observed increase, which is likely multifactorial.  Possible reasons for the big increase include stress passed down from parents and caregivers, the rise of social media, and increasing rates of cyberbullying.

Is Social Media a Factor?

A study published in the journal  Clinical Psychological Science entitled Increases in Depressive Symptoms, Suicide-Related Outcomes, and Suicide Rates Among U.S. Adolescents After 2010 and Links to Increased New Media Screen Time found a disturbing possible link between teen social media usage and suicide.

The authors found what appears to be a very clear link between social media usage and teen suicide rates. Adolescents who spent more time on new media (including social media and electronic devices such as smartphones) were more likely to report mental health issues, and adolescents who spent more time on non-screen activities (in-person social interaction, sports/exercise, homework, print media, and attending religious services) were less likely.

The study establishes an association between suicide and social media use- which is different from establishing cause and effect…  but it’s hard to overlook the link between social media and teen suicide. Several other studies have shown the direct link between expanded social media usage and teen depression.

Another study from 2017 in  Clinical Psychological Science found teens who use their digital devices more than 5 hours per day are 70% percent more likely to have thoughts of suicide and high school girls who use social media daily are 14% more likely to feel depressed than those who use it only sparingly.

Will Humble Behavioral Health, State Legislature, Wills Blog

School Suicide Prevention Training in Final Stretch at the Legislature

As the article above mentions- interventions to stem the tide of childhood suicides is multi-factoral and will require a variety of interventions. One such promising intervention that’s on the cusp of approval here is Arizona is SB 1468 which would require some suicide prevention training among some Arizona teachers and school staff.

The Bill (which passed the Senate 28-2 and awaits final approval in the House) would requires school districts, charter schools, and Arizona teacher training programs to include suicide awareness and prevention training in their continuing education curricula.  The bill would require AHCCCS to make suicide awareness and prevention training available (fortunately some evidence- based tools curricula already exist).

Starting in the 2020 school year, school districts and charter schools would need to provide training in suicide awareness and prevention to school personnel in grades 6 to 12.  The bill also establishes requirements for suicide awareness and prevention training and specifically says that the training has to use evidenced-based training materials and instruct participants on how to identify the warning signs of suicidal behavior in adolescents and teens.

Note: Another suicide prevention bill (HB 2488) which requires the ADHS to annually compile a veteran suicide surveillance and prevention report was signed this week (see below in our Legislative Update). 

Will Humble Uncategorized, Wills Blog

Legislative Update- April 23

Legislative Update

We’re to the part of the legislative session when bills that passed one chamber are approaching the finish line in the second.  There was some decent action on good bills this week- and a few of our priority bills cleared the House this week! Here’s this week’s Legislative Tracking Spreadsheet courtesy of our public health policy interns Tim Giblin & Annissa Biggane.

Below is a summary for the bills that passed last week -t hey still need to be signed but the Governor however:

Public Health Bills on the Governor’s Desk

SB 1165 now HB 2318 Texting and Driving (Brophy McGee- Campbell)

This bill was a long time coming- but were on the precipice of having this good public policy finally happen- all that’s left is for the Gov to sign it. It will prohibit 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.  It’ll change driving behaviors and save lives.

Violations are a civil money 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. Warnings for a year and a half – and then the penalties kick in.

SB 1247 Residential Care Institutions (Brophy McGee)

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. 

Note: still needs to go back to the Senate for a procedure before transmittal to Gov.

SB 1211 Intermediate Care Facilities (Carter)

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 1040 Maternal Mortality Report (Brophy-McGee)

This bill passed both chambers unanimously but in slightly different forms, so while it passed the House last week 60-0 it still needs to get re vetted in the Senate- which should be no problem.  The new law will establish an Advisory Committee on Maternal Fatalities and Morbidity.

It requires ADHS and the Committee to hold a public hearing to receive public input regarding the recommended improvements to information collection concerning the incidence and causes of maternal fatalities and severe maternal morbidity and complete a report (including recommendations) by 12/31/19.

Note: still needs to go back to the Senate for a procedure before transmittal to Gov.

SB 1089 Telemedicine

Last week in a vote of 60-0 the house passed this good telemedicine parity bill which will improve healthcare access and help lower costs. With this legislation, any healthcare service covered in-person by a commercial insurer will also be covered when provided through telemedicine. Currently, Arizona law limits telemedicine coverage to a handful of medical services. The bill will now go to the Governor to sign into law.

Public Health Bills Signed by the Governor

SB 1109 Short Term Limited Health Plans- extension – AzPHA Position: Opposed

This bill has passed both chambers and has been signed by the Governor.  It authorizes the sale of short- term limited health plans in Arizona for terms up to 3 years.  The previous limit was 1 year.  These plans don’t cover pre-existing conditions and have limited consumer protection because they aren’t required to cover the essential health services under the ACA and can drop enrollees.  We urged a not vote because of the poor consumer protections.

HB 2488 Veteran Suicide Annual Report (Lawrence)

Requires ADHS (starting this year) to complete an annual report on veteran suicides in Arizona that includes the number and rate of veterans who died by suicide, trends, an analysis of the years of potential life lost, a comparison of Arizona’s resident veteran suicide rate to those of the nation, and the relative risk of suicide by race or ethnicity, age group, gender and region.  The report is also supposed to analyze patterns of drugs, or combinations of drugs, that were used by Arizona’s resident veterans when drug poisoning was the mechanism of suicide.

The idea is to create the surveillance and data linkages needed to inform suicide prevention strategies based upon medical risk factors that significantly correlate to suicide.

State Budget

Not much action above the water on the state budget. The state is expected to have a $1B surplus this year and there’s differences of opinion about how much to put in the rainy day fund and of course what other priorities rise to the top of each legislator’s list. 

Our top budget priorities are getting the needed state match for Kids Care (more on that below), an appropriation to cover a new oral health benefit for pregnant Medicaid members (SB 1088), and an increase in the state loan repayment program and residency funds to improve access to care in rural and underserved areas (SB 1354).

Here’s this week’s Legislative Tracking Spreadsheet courtesy of our public health policy interns Tim Giblin & Annissa Biggane.

Will Humble Disease Control, Vaccination, Wills Blog

Measles Communication Resources Site

With the rising number of measles cases in the US and globally- and no end in sight for the erosion of immunization rates in Arizona and elsewhere- it’s more important than ever for our public health system to have resources at their fingertips for how to prepare for and to rapidly and effectively respond to vaccine preventable diseases- measles in particular.  Sadly, this is our new reality.

I found a good resource this week that was developed by the National Public Health Information Center- which is basically a Measles Resources website. The site has a Resource Library with fact sheets, infographics, social media tools, a sample op-ed for you to use once a case is identified.  There’s also an Outbreak Communication Guide for actions you can take before, during and after an outbreak, and the CDC’s measles microsite.

Will Humble Behavioral Health, Injury Prevention, Wills Blog

Preventing Suicide: A Toolkit for High Schools

SAMHSA has a toolkit that is aimed at being part of a nationwide effort to help the one out of every fifteen high school students who attempt suicide each year. The toolkit is called Preventing Suicide: A Toolkit for High Schools and it helps high schools and school districts to design and implement strategies to prevent suicide and promote behavioral health.

It provides guidelines for school administrators, principals, mental health professionals, health educators, guidance counselors, nurses, student services coordinators, teachers and others for identifying those teenagers who are at risk and it provides resources for taking appropriate actions to provide help.

It provides high schools with useful information on the many federal, state and community programs that are available to help strengthen their suicide prevention efforts, including the National Suicide Prevention Lifeline (link is external) 1-800-273-TALK (8255). This Lifeline is a 24-hour, toll-free, confidential suicide prevention hotline available to anyone in suicidal crisis or emotional distress.

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