Author: Will Humble

A final push to “repeal and replace” the Affordable Care Act is underway in the US Senate. Today Senators Bill Cassidy & Lindsey Graham along with Senators Heller and Johnson unveiled a revised version of their legislation to repeal and replace the Affordable Care Act (ACA). A window of opportunity until September 30 is available for the supporters of the Amendment (for this federal fiscal year). 

It’s called the Cassidy-Graham proposal and it’s essentially an Amendment to the Better Care Reconciliation Act that failed awhile back. Here’s a summary of the content of the Bill, it would:

• Eliminate the ACA’s marketplace subsidies and enhanced matching rate for the Medicaid expansion and replace them with a block grant. Block grant funding would be well below current law federal funding for coverage, would not adjust based on need, would disappear altogether after 2026, and could be spent on virtually any health care purpose, with no requirement to offer low- and moderate-income people coverage or financial assistance.

• Convert Medicaid’s current federal-state financial partnership to a per capita cap, which would cap and cut federal Medicaid per-beneficiary funding for seniors, people with disabilities, and families with children.

• Eliminate federal subsidies to purchase individual market coverage;

• Eliminate the ACA’s individual mandate to have insurance or pay a penalty; and

• When the Bill’s block grant period ends in 2026, it would repeal the ACA’s major coverage provisions with no replacement.

At the same time, the Senate Health, Education, Labor and Pensions Committee is trying to develop a bipartisan health bill that likely would focus on marketplace stability, including assuring that health insurers receive the cost sharing subsidies. Because insurers will soon be setting their 2018 insurance rates, there’s interest in trying to finalize legislation this month, but it is not clear whether an agreement will be reached in the Senate—and then with the House.

Depending on what happens in the next couple of weeks we may issue an Action Alert for our members.

During the 2015 Legislative Session, the Legislature passed and the Governor signed a bill requiring AHCCCS to annually submit an Amendment to their 1115 Demonstration Waiver asking permission to implement the following requirements for “able-bodied adult” Medicaid members:

• Limit lifetime AHCCCS coverage for all able-bodied adults to 5 years except for certain circumstances;
• Require all able-bodied adults to become employed or actively seeking employment or attend school or a job training program;
• Require most members to verify monthly any changes in family income; and
• Ban eligible persons from enrolling in AHCCCS for 1 year if a member knowingly fails to report a change in income.

The Obama Administration officials denied these waiver requests in 2016, but the landscape in that regard looks very different today.

AzPHA submitted our response letter on this year’s waiver application back in February.  Several hundred people and organizations turned also in comments regarding the waiver request.  More than 90% of the commenters expressed concerns about the various items in the waiver including the 5-year limitation on benefits, monthly income reporting and other proposed requirements.  Five percent of the commenters expressed support for the waiver request.

Here are links to the Individual Comments, Organization Comments, and Tribal Comments.

Arizona’s 2017 request to the federal government to tighten its Medicaid eligibility has been delayed by about 5 months, but all indications are that AHCCCS will submit the directed waiver to CMS in the near future.  Signals from CMS suggest that all or most of the request will be approved this time (see this letter this letter from Seema Verma of CMS & and Secretary Price to governors for details).

Stephanie Innes from the AZ Daily Star wrote a good article over the weekend diving into how Arizona is Moving Ahead With Proposal To Add AHCCCS Work Requirements.

Stay tuned- although there’s not much our members can do to influence the outcome at this point.

Obesity remains one of America’s most pervasive, expensive and deadly health problems.  Obesity increases the risk of developing high blood pressure, heart disease, type 2 diabetes, stroke, arthritis, liver disease, kidney disease, Alzheimer’s disease, gallbladder disease and mental health issues, as well as many types of cancer.  During pregnancy it increases the chances of complications, including diabetes, cesarean delivery and stillbirth.  Each year, obesity is associated with more than 100,000 premature deaths in the US (2,000 in Arizona).

These days more than one-third of U.S. adults are obese (29% in Arizona).  Back in 1990 only 10% of adults were obese.   Needless to say- a Big problem.

The causes of obesity are complicated but the bottom line is that most Americans don’t eat enough healthy food or get enough physical activity.  Communities designed for transportation by cars, jobs that require hours sitting behind a desk, and entertainment revolves around watching a screen all encourage a sedentary lifestyle. Processed food and sugar-sweetened beverages are heavily advertised, and often less expensive and more readily available than healthier alternatives.  In lots of places there aren’t grocery stores where people can buy affordable and nutritious food.

What can be done?

A new report from the Trust for America’s Health Trust for America’s Health does a really good job documenting the extent of the surveillance and public health problems posed by obesity- but more importantly- it provides a host of evidence based (and practical) state and local policies that are being implemented that are making a difference.  These tools provide states and communities with info so that they don’t need to reinvent the wheel.

State policies play a big role in improving access to healthy food and increasing physical activity.  THAH has developed a new feature that tracks the status of each state’s efforts on more than two dozen policies aimed at preventing obesity and supporting health.  

Here’s where you can view state policies to prevent obesity– excellent information that our members can use to advocate for the advancement of state laws and policies that can make a difference.

Over the past 15 years the number of prescription opioid painkillers has gone up by 400% yet the amount of pain or disability that Americans experience has remained unchanged.   From 2000 to 2014, more than 165,000 people in the US have died from overdoses related to prescription opioid use.

One critical component to turning the corner on this epidemic is to identify higher risk populations that rely heavily on opioids.  That info can give us important information which can be used to craft targeted interventions among high risk folks.  

There was a super interesting study published in the Journal of the American Board of Family Medicine last week that found more than half of all opioid prescriptions in the US are written for people with anxiety, depression, and other mood disorders.

People with mood disorders are at increased risk of abusing opioids, yet they received many more prescriptions than the general population, according to an analysis of data from 2011 and 2013.

The study, Prescription Opioid Use among Adults with Mental Health Disorders in the United States concluded that the 16% of Americans who have mental health disorders receive over half of all opioids prescribed in the United States.

The study found that 19% of the 38 million Americans with mood disorders use prescription opioids, compared to 5% percent of the general population — after controlling for physical health, level of pain, age, sex and race.

These findings are surely applicable to Arizona as well – and it provides really important information that we can surely use to augment the findings of the Arizona Department of Health Services’ report that was published this week outlining the results of their enhanced surveillance and recommended policy interventions.

This week the Arizona Department of Health Services released their ”Opioid Overdose Epidemic Response Report” in accordance with the public-health emergency declaration issued by the Governor in June.  The executive order required the agency to release a report with surveillance results and policy recommendations.

The Report is robust and has many practical and specific recommendations and planned policy and operational interventions that, if implemented, would clearly have a significant impact on the epidemic.  The full report is 92 pages long, but you can get a fairly-complete picture by reading the first 38 pages.

Intervention recommendations are included for various categories including: state opioid legislation; federal interventions; youth prevention; law enforcement; medical education curriculum; insurance parity; regulatory boards; correctional facilities; continuity of care; educating the public; and controlled substances prescription monitoring program (CSPMP) improvements.

There are literally dozens of recommendations, but I picked out a few of the more interesting ones below:

• Impose a 5-day limit on all first fills for opioid naïve patients for all payers;
• Require pharmacists to check the CSPMP prior to dispensing an opioid;
• Require different labeling and packaging for opioids (“red caps”);
• Require 3 hours of opioid-related CME for all professions that prescribe or dispense opioids;
• Establish an all payers claims database to establish better surveillance data;
• Eliminate dispensing of controlled substances by prescribers;
• Regulate pain management clinics to prohibit “pill mill” activities;
• Establish enforcement mechanisms for pill mills and illegal opioid dispensing;
• Enact a good Samaritan law to allow bystanders to call 911 for a potential opioid overdose;
• Allow Medicaid to pay for substance abuse treatment in correctional facilities;
• Remove the IMD exclusion to allow facilities to receive reimbursement for substance abuse treatment;
• Remove the pain satisfaction score completely from the CMS HCHAP (patient satisfaction) score; and
• Require federal health care facilities to maintain state licensure (e.g. VA, IHS). 

For the full picture including some results from the enhanced surveillance you should visit the Full Report which is quite impressive and a testament to the team effort that went into the development of the report.

Sheila Sjolander from ADHS will be kicking off our September 28 Fall Conference & Annual Meeting with the results of the Report.  About 150 folks are already registered, and if registration trends hold, this may be our most well-attended conference in quite some time- and a great networking opportunity to boot.  You can View our Agenda and Register on our AzPHA website.

Despite AHRQs groundbreaking work in analyzing data and making recommendations to clinicians and the health care system, guiding systems toward services and interventions that have a positive return on investment, and providing an evidence base for value-based reimbursement… the President’s budget envisions a large cut to AHRQ’s budget and mission.

The President’s budget proposes that AHRQ be merged with the National Institutes of Health and cutting that budget by 20%.  His proposed budget would cut $6 billion from the NIH the year of the proposed merger with AHRQ.

Back in July, the House Appropriations Committee released their fiscal year 2018 Labor, Health and Human Services, and Education funding bill, which includes a 10% reduction in AHRQ’s budget (to $300M) and also proposes merging most of AHRQ’s activities into NIH. The USPSTF uses the systematic evidence review to develop a recommendation and follows a rubric for assigning grades based on the magnitude of net benefit anticipated for the preventive service (that is, benefits minus harms) and the certainty of that estimate. When a decision to issue a recommendation for specific segments of the population is being made, the ability to clearly and easily identify the factors that define the specific population is important (for example, age, easily measured risk factors, or self-identified race/ethnicity). Although many features may distinguish a specific population under consideration, the final decision to issue a separate graded recommendation for that population is primarily based on whether a difference in magnitude of net benefit can be confidently identifiedThe USPSTF uses the systematic evidence review to develop a recommendation and follows a rubric for assigning grades based on the magnitude of net benefit anticipated for the preventive service (that is, benefits minus harms) and the certainty of that estimate. When a decision to issue a recommendation for specific segments of the population is being made, the ability to clearly and easily identify the factors that define the specific population is important (for example, age, easily measured risk factors, or self-identified race/ethnicity). Although many features may distinguish a specific population under consideration, the final decision to issue a separate graded recommendation for that population is primarily based on whether a difference in magnitude of net benefit can be confidently identified

Two weeks ago, the House Committee on Rules released a combined appropriations bill for Fiscal Year 2018.  That budget also has AHRQ on the chopping block, with a similar budget reduction as the Appropriations Committee & the President’s budget.

All in all, not good news for those of us that are interested in addressing patient safety, healthcare quality, and reducing costs.

A prevention model of health is weaving its way into the fabric of traditional models of care.  The Affordable Care Act is expanding the use of preventive services in the US health care delivery system.  Preventive health care services avert diseases and illnesses from happening in the first place rather than treating them after they happen.

The United States Preventive Services Task Force analyzes the evidence base and cost effectiveness of various preventive services.  They publish a running list of “Category A & B” preventive services that are evidence based best practices that have a positive return on investment.  Category A & B Preventive Health Services are covered at no cost to consumers in the Qualified Health Plans offered on the Marketplace. In addition, many employer-based and government-sponsored health plans include Category A & B Preventive Services in the health insurance plans they offer to their members.

The United States Preventive Services Task Force recommends more than 50 preventive health services for clinicians to use in their practice.  They include various screening tests, counseling, immunizations, and preventive medications for adults, adolescents, and kids.  Their most recent recommendation is to screen for obesity in kids 6 years and older and offer or refer them to comprehensive, behavioral interventions to promote improvements in weight status.

The Task Force operates within the Agency for Healthcare Research and Quality (AHRQ) and consists of a panel of experts representing public health, primary care, family medicine, and academia.  They update the list of recommended services by reviewing best practices research conducted across a wide range of disciplines.

The AHRQ & Team Force use a systematic evidence review to develop the recommendations and follow a rubric for assigning grades based on the magnitude of net benefit and costs anticipated for the preventive service (basically the return on investment).

The overarching mission of the AHRQ, including their administration of the Preventive Services Task Force, is to reduce healthcare costs by analyzing data and making recommendations to clinicians and the health care system and guiding systems toward services and interventions that have a positive return on investment.   In other words, they find ways of preventing bad health outcomes and examine the evidence to identify interventions and prevention services that have a positive ROI.

AHRQ’s research has become more important in recent years as value-based reimbursement arrangements tie payment to clinical quality.  Clearly, AHRQ is one of our country’s beacons of evidence based decision making.

AzPHA Members will be voting on the following Resolution at our September 28, 2017 Annual Meeting.

Background and Summary

The percentage of children with obesity in the United States has more than tripled since the 1970s. Today, about one in five school-aged children is obese.  Childhood obesity has immediate and long-term impacts on physical, social, and emotional health. For example:

• Children with obesity are at higher risk for having other chronic health conditions and diseases that impact physical health, such as asthma, sleep apnea, bone and joint problems, type 2 diabetes, and risk factors for heart disease.
• Children with obesity are bullied and teased more than their normal weight peers, and are more likely to suffer from social isolation, depression, and lower self-esteem.
• Childhood obesity also is associated with having obesity as an adult, which is linked to serious conditions and diseases such as heart disease, type 2 diabetes, metabolic syndrome, and several types of cancer.

Children and adolescents that participate in at least 1 hour of physical activity per day benefit from multiple health benefits, including lower risk for becoming obese.  Schools provide a unique venue for youth to meet the activity recommendations.  However, schools have been facing increasing challenges in allocating time for physical education and physical activity.

There is a growing body of research focused on the association between school-based physical activity, and academic performance among school-aged youth.  A recent report from the CDC’s entitled The Association Between School-based Physical Activity, Including Physical Education, and Academic Performance examined the association between school-based physical activity, including physical education, and academic performance, including indicators of cognitive skills and attitudes, academic behaviors.

The CDC found that “… across all 50 studies that they examined there were a total of 251 associations between physical activity and academic performance, representing measures of academic achievement, academic behavior, and cognitive skills and attitudes. Measures of cognitive skills and attitudes were used most frequently.”  

During the 2017 Arizona Legislative Session, House Bill 2082 was introduced which would have required all schools to have 50 minutes of recess per day from K through 5th grade.  The Bill was passed by the House of Representatives but stalled in the State Senate. 

Data from the CDC report provides evidence that such a bill, should it become law, would have a positive impact on academic achievement as well as physical activity.  The report found that time spent in recess appears to have a positive relationship with children’s attention, concentration, and/or on-task classroom behavior. All eight studies found one or more positive associations between recess and indicators of cognitive skills, attitudes, and academic behavior; none of the studies found negative associations between recess time and academic achievement.

AzPHA Resolution September 2017

Whereas, the Arizona Public Health Association recognizes that childhood obesity continues to pose an increasing public health threat; and

Whereas, children that are obese are at higher risk for having other chronic health conditions and diseases that impact physical health, such as asthma, sleep apnea, bone and joint problems, type 2 diabetes, and risk factors for heart disease; and

Whereas, children and adolescents that participate in at least 1 hour of physical activity per day benefit from multiple health benefits, including lower risk for becoming obese; and

Whereas, schools provide a unique venue for youth to meet the activity recommendations; and

Whereas, there is a growing body of research focused on the association between school-based physical activity, and academic performance among school-aged youth; and  

Whereas, recess has a positive relationship with children’s attention, concentration, and on-task classroom behavior;

Therefore, be it resolved that the Arizona Public Health Association supports a law in Arizona that would require all schools to have 50 minutes of recess per day from K through 5th grade and prohibit the withholding of recess for academic or behavioral reasons.

AzPHA Members will be voting on the following proposed Resolution at our September 28, 2017 Annual Meeting

Background and Summary

Texting has become a social norm in recent years because of the popularity of smart phones.  The scientific literature on the dangers of driving while sending a text message from a mobile phone, or driving while texting is growing. A study at the Accident Research Center1 provided strong evidence that retrieving and sending text messages has a detrimental effect on a number of safety-critical driving measures including detecting and responding correctly to road signs, detecting hazards, time spent with eyes off the road.

Several studies have linked texting while driving to be the cause of life-threatening accidents due to driver distraction.  A recent National Traffic Highway Safety Administration NHTSA report found that teens have the highest prevalence of cell phone use while driving and rank at the top of the list for being distracted at the time of a fatal crash. 

For many years, Arizona has been one of only 3 states that did not restrict the use of smart phones while driving.  During the 2017 Arizona Legislative Session SB 1080 was passed and signed which restricts texting and driving among new drivers for the first 6 months of their license (if they’re under 18).  Using the phone in an emergency is still allowed and citations can only be issued if the driver committed another violation.  Prior to this, the only other limitation in AZ to this kind of distraction applied to school bus drivers. 

A study of US crash data called Driver distraction and crashes: An assessment of crash databases and review of the literature found that driver distraction (among all ages) is a contributing factor in 8% to 13% of crashes including cell phone distractions of between 1.5 to 5%.

Arizona’s new law only restricts texting and driving among new drivers for the first 6 months of their license (if they’re under 18), yet evidence suggests that texting while driving creates unnecessary and dangerous driver distractions that cause motor vehicle accidents that result in injuries and deaths.

1.       Hosking, S.G., Young, K.L., & Regan, M.A. (2006). “The effects of text messaging on young novice driver performance” (PDF). Retrieved 16 August 2014.

AzPHA Resolution September 2017

Whereas, the Arizona Public Health Association recognizes that texting has become a social norm in recent years because of the popularity of smart phones and studies have linked texting while driving to be the cause of life-threatening accidents due to driver distraction; and

Whereas, a recent National Traffic Highway Safety Administration NHTSA report found that smart phone use while driving is linked with distracted at the time of a fatal crash; and

Whereas, a study of US crash data found that driver distraction is a contributing factor in 8% to 13% of crashes including cell phone distractions of between 1.5 to 5%;

Therefore, be it resolved that the Arizona Public Health Association supports a law in Arizona that would prohibit texting and other smart phone use among all drivers.

AzPHA Members will be voting on the following Resolution at our September 28, 2017 Annual Meeting

Background and Summary

Tobacco use poses serious public health problems.  Over the past 50 years, tobacco control in the United States has led to an estimated 8 million fewer premature deaths. However, tobacco use continues to significantly affect public health, and more than 40 million Americans still smoke.

Nearly all adults who have ever smoked daily first tried a cigarette before 21 years of age.  The parts of the brain most responsible for cognitive and psychosocial maturity continue to develop and change through young adulthood, and adolescent brains are uniquely vulnerable to the effects of nicotine, including nicotine from electronic nicotine delivery devices (electronic cigarettes).

In 2009, the Family Smoking Prevention and Tobacco Control Act granted the U.S. Food and Drug Administration broad authorities over tobacco products but prohibited the FDA from establishing a nationwide minimum age to buy tobacco above 18.  The law directed the FDA to convene a panel of experts to conduct a study on the public health implications of raising the minimum age to purchase tobacco products and electronic nicotine delivery devices. 

At FDA’s request, the Institute of Medicine published a report entitledPublic Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products.  The report literature on tobacco use initiation, developmental biology and psychology, and tobacco policy and predicted the likely public health outcomes of raising the minimum legal age for tobacco products.

The report concluded that: “… Increasing the minimum age of legal access to tobacco products will prevent or delay initiation of tobacco use by adolescents and young adults, particularly those ages 15 to 17, and improve the health of Americans across the lifespan”.  The report also quantifies the immediate and long term accompanying public health outcome improvements.  The report concludes that there would be a 12% decrease in the prevalence of smoking among the cohort if the minimum age of purchase were moved to 21 years old from the current 18.

The analysis concluded that raising the minimum age to 21 will “… likely immediately improve the health of adolescents and young adults by reducing the number of those with adverse physiological effects such as increased inflammation and impaired immune functioning caused by smoking, as these could potentially lead to negative health consequences, including increased hospitalizations and lessened capacity to heal wounds. Adverse maternal, fetal, and infant outcomes—including preterm births, low birth weight, and sudden infant death—will also probably decrease due to reduced tobacco exposure in mothers and infants. Raising the minimum legal age will also lessen the population’s exposure to secondhand smoke and its associated health effects, both now and in the future.”

Over time, the report concludes that raising the minimum legal age for buying tobacco will likely lead to substantial reductions in smoking-related mortality observed for 30 years.  If the minimum legal age to purchase tobacco were raised to 21 nationally, there would be approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost for those born between 2000 and 2019.

Several jurisdictions have already raised the minimum legal age to buy tobacco.  New York City raised the age to 21, in 2013.  Hawaii did it in 2015, becoming the first state to go to the 21 (the Hawaii Public Health Association was instrumental in that effort). California followed suit in 2016, and New Jersey and Oregon did so in 2017.  In Arizona, Douglas and Cottonwood have passed local ordinances restricting the sale of tobacco to people 21 and older.

Proposed AzPHA Resolution – September 2017

Whereas, the Arizona Public Health Association recognizes that tobacco use poses serious public health problems; and

Whereas, nearly all adults who have ever smoked daily first tried a cigarette before 21 years of age; and

Whereas, the parts of the brain most responsible for cognitive and psychosocial maturity continue to develop and change through young adulthood, and adolescent brains are uniquely vulnerable to the effects of nicotine, including nicotine from electronic nicotine delivery devices; and

Whereas, increasing the minimum age of legal access to tobacco products and electronic nicotine delivery devices will prevent or delay initiation of tobacco use by adolescents and young adults and improve the health of Americans across the lifespan; and

Whereas, if the minimum legal age were raised to 21 in Arizona, there would be approximately 4,460 fewer premature deaths, 1,000 fewer deaths from lung cancer, and 840,000 fewer years of life lost for those born between 2000 and 2019;

Therefore, be it resolved that the Arizona Public Health Association supports raising the minimum legal age to purchase tobacco and electronic nicotine delivery devices in Arizona to 21 years old.