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.

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). 

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.

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.

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.

More Bad about AZ's Immunization Rates

School Vaccination Rates Drop Again this School Year

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.

As a means to maintaining herd immunity, Arizona law (ARS-872 & ARS-873) requires that all children attending school or child care have certain vaccines unless they're exempted by a doctor for medical reasons or by a parent for personal reasons.  

Each year, schools (6th grade, kindergarten, and child care/preschool) are supposed to turn in data about the vaccine exemptions in their school to the ADHS.  

There's bad news again in this year's report- continuing a multi-year trend toward higher exemption rates (worse vaccination rates). For the current school year:

  • 6th grade exemption rates went from 5.4% last year to 6.1% this year

  • Kindergarten exemption rates went from 5.4% to 5.9% 

  • Child care exemption rates increased from 4.3% percent to 4.5%

This year's results can be found on the ADHS' Immunization Coverage Level page.  You can check out individual school exemption rates on the Arizona School Vaccine Exemption Spreadsheet.

There are some pretty discouraging results in this year's results. For example, only 27% of Yavapai County schools (12/44) have herd immunity among 6th graders. Coconino County is only at 33% on the same measure (6/18). As in previous years, charter schools tend to have higher exemption rates than public schools. Lots of data to dive into in the spreadsheet. 

Arizona School Vaccine Exemption Spreadsheet

Sadly, several bills that would have improved rates weren't even heard in committee this year like HB 2162 which would have removed the personal exemption and HB 2352 which would have required schools to post on their school's immunization rates.

However, several bills were heard that would have eroded immunization rates even further including SB 1115, HB 2471, HB  2472, SB 1116, and HB 2470.  Fortunately those bills appear to be dead for this year- but may very well return.

Enough with the California Bashing

California had also been struggling to maintain herd immunity vaccination rates (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.

Just saying.

Legislative Update 

House Rules Committee Moves off the Dime 

To be honest, it was another pretty slow week at the Capitol. But, there was some needed action in the House Rules Committee- and some good things happened there (the House Rules committee passed 55 Senate bills this week but 55 are still in backstock). 

The Bills that we're interested in that were heard in House Rules all passed this week (see last week's blog), so there will be some action on those this week in Caucus and Committee of the Whole and maybe some floor votes (3rd Read) too. 

Conference Committee Deadline Approaching

This week will be an important one - especially for bills in which there's a difference between the House and Senate versions.  That's because Friday (4/19) is the last day for conference committee assignments (bills that have been amended in the opposite house need to return to their house of origin for another vote...  if there isn't agreement on the amendments a conference committee needs to meet to hammer out a solution).

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.

Your Task Assignment This Week

KidsCare is an important access to care program that gives lower-income families an opportunity to pay an affordable premium and receive Medicaid-like health insurance for their kids.  Right now KidsCare is providing coverage for about 35,000 children in working families. 

To keep KidsCare open, the state legislature needs to include $1.6M appropriation in this year's budget to cover the state's portion of this important federal program. 

Simply Click Here to ask your senator and representatives and urge them to insist on a final budget that protects KidsCare. The address you use will automatically send the email to your elected. Please edit the template language a little and personalize it- that works better.

Since the freeze was lifted in 2016, KidsCare has provided 114 children with cancer treatments, almost 8,000 children with behavioral health services, over 5,000 children services for autism, and helped nearly 3,500 children with asthma. 

Oral Health Research News

HRSA-led Study Reveals Use of Sealants Remains Low Among Children

HRSA’s National Survey of Children’s Health revealed that among children ages 6-17 years, only 1 in 5 had received dental sealants within the past year. Together with steps taken at home, in the dental office, or on a community-wide basis (e.g., water fluoridation), use of sealants among children helps prevent dental cavities. 

In the study, 82% of children ages 2-17 years had a preventive dental visit in the past year, but lower rates of specific preventive services: 75% cleanings, 46% fluoride treatments, and 44% tooth brushing/oral health care instructions. 

Research from this study shows preventive oral health services are lagging among young children and children from lower socioeconomic backgrounds. Further studies are needed to identify interventions that encourage the use of preventive services.

Read the abstract.

Legislative Update

The only committees that met last week were Rules and Appropriations. The other standing committees (e.g. Health and Human Services) have finished their work. The House Appropriations was particularly dramatic with several strike-everything bills and tensions running high- but nothing really tied to the public health bills we’re interested in. 

We have a whole bunch of bills that need to make it through the Rules Committees (especially the House Rules Committee) before they can go to the floor (the Rules Committee's job is to basically make sure the bill is constitutional). 

Lots of the bills that we care about will be heard this week in the Rules Committee Monday at 1:30pm (here's the agenda). I put an asterisk by the bills below that will be heard Monday. If they all pass- they could move quickly to floor votes (3rd read) this week. Here's this week's spreadsheet summary of the bills.

Bills that have been amended in the opposite house will need to return to their house of origin for another vote.  If there isn't agreement on the amendments, there may need to be conference committees set up to hammer out a solution.

In other news, we were delighted to see that the Senate Health and Human Services Committee this week unanimously recommended that Jami Snyder’s confirmation by the full Senate to be the new AHCCCS Director.  Her nomination will now go to the Senate floor for confirmation.

Steve Pierce was appointed to fill Representative Stringer's seat in District 1 late in the week- which is why there was no floor action in the House this week. 

Bills that still need Floor Votes (3rd Read)

* Means bill will be heard in the Rules Committee Monday (1:30pm).

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

Passed the Senate 30-0. Bill Passed the House Health Committee 9-0. Rules Committee this week. 

* SB 1085 Association Health Plans- 

Passed the Senate 24-6.  Passed the House Health and Human Services Committee 6-2-1. Rules Committee this week. 

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

Passed the Senate 27-3.  Passed the House Health & Human Services Committee 8-1.  Passed House Appropriations 7-4. Rules Committee Next. Will still need to get into the final budget.

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

Passed Senate 30-0. Passed the House Health & Human Services Committee 9-0.  Rules Committee this week. 

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

Passed Senate 20-10. Passed the House Transportation Committee 5-1-1.  Rules Committee this week. 

SB 1174 Tribal Area Health Education Center – AzPHA Position: Yes

Passed Senate 30-0. Passed the Senate Education Committee 13-0. Rules Committee Next.

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

Passed the Senate 30-0. Passed the House Health & Human Services Committee 9-0. Rules Committee this week. 

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

Passed the Senate 30-0.  Bill passed the House Health Committee 9-0. Rules Committee this week. 

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

Passed the Senate 30-0.  Passed through all House Committees- ready for a Floor Vote.

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

Passed Senate 28-2.  Passed House Appropriations Committee 10-1, Withdrawn at the HHS Committee, but can still move forward if it can pass the Rules Committee. This is the most important access to care bills this year- it would do a great deal both in the short-term by boosting the primary care loan repayment program and really enhancing graduate medical education residencies over the coming years (important because where a practitioner does her or his residency greatly influences where they ultimately practice).

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

Passed House 46-13.  Passed the Senate Health and Human Services Committee 7-0-1. Rules Committee Next.

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

Passed House 60-0. Passed the Senate Health and Human Services Committee 7-0-1. Passed 29-0 in the Senate, sent back to House because it's different than the original bill.  

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

Passed the Senate 30-0. Assigned to the House Health and Human Services Committee but didn't get a hearing- not a good sign.

* SB 1355 Native American Dental Care – AzPHA Position: Yes

Passed Senate 25-5.  Passed the House Health & Human Services Committee 9-0. Rules Committee this week. 

SB 1456 Vision Screening- AzPHA Position: Yes

Passed Senate 29-0. Passed the House Health & Human Services Committee 9-0. Rules Committee Next.

* SB 1468 Suicide Prevention- Schools- AzPHA Position: Yes

Requires school districts, charter schools, and Arizona teacher training programs to include suicide awareness and prevention training and requires the Arizona Health Care Cost Containment System Administration (AHCCCS) to make suicide awareness and prevention training available. Rules Committee this week. 

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

Passed the Senate 28-0. Assigned to the House Health and Human Services Committee- but not heard.  Not a good sign. Probably dead.

 

Bills that Have Been Passed & 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.

Here are a few of the materials that APHA published to commemorate this year’s Public Health Week celebration.

Healthy Communities

Each day of NPHW zeros in on a different public health topic, and today’s is “Healthy Communities.” It’s the perfect opportunity to kick off conversations around this year’s NPHW theme of “Creating the Healthiest Nation: For science. For action. For health.”

By now, the research is crystal clear: People’s health, longevity and well-being are connected to their communities — the places we live, learn, work, worship and play. Whether it’s healthy housing, clean drinking water or safe places for kids to play, many opportunities to improve health happen far outside the doctor’s office. In fact, some of the greatest opportunities to create the healthiest nation start with smart policies that prioritize people’s health.

On this first day of NPHW, call on decisionmakers to consider health in all policies, and ask your members of Congress to prioritize public health funding. Help us raise awareness of the critical role of public health systems in keeping us safe from preventable disease and injury. And don’t forget: We all have a role in creating healthier communities. Use this week to think about ways you can partner with family, friends and co-workers to make a positive difference.

For more on today’s NPHW theme and ways to take action, read their Healthy Communities fact sheet and help spread the word on social media.

Rural Health

America’s rural communities often face tall barriers to good health. Fortunately, those barriers aren’t insurmountable.

Today — the third day of National Public Health Week — join us in raising awareness about the health challenges facing rural communities and ways to close those health gaps and reach people where they are.

Rural communities face a range of health disparities, from higher burdens of chronic disease to limited access to primary care and prevention services. For example, rural Americans face a greater risk of death from the five leading causes of death — heart disease, cancer, unintentional injury, chronic lower respiratory disease and stroke. The opioid addiction epidemic has also hit rural places especially hard, with high rates of fatal drug overdoses.

But there are promising solutions, such as using telemedicine and school-based health centers to connect rural residents with health care and social services. Smart policy can make a life-saving difference, too, such as expanding access to the overdose-reversal drug naloxone and defending Medicaid expansions that widen access to mental health and addiction treatment. 

 

Firearm Violence

Gun violence is an epidemic in America. On this second day of National Public Health Week — which has a daily theme of “Violence Prevention” — about 100 Americans will be killed with guns, and hundreds more will be injured.  That's just today!

Beyond gun violence, 1 in 4 U.S. women experience intimate partner violence, 1 in 6 has been the victim of rape or attempted rape, and hundreds of thousands of children experience abuse and neglect. Yet violence is preventable with the right research, resources and policies.

In support of today’s NPHW theme, urge policymakers to pass commonsense measures to reduce gun violence and provide research funding on par with the nation’s gun violence epidemic. Learn about ways to help make your community safer for all, such as using trauma-informed services to identify victims of violence and calling on law enforcement officials to treat all people with dignity, respect and fairness.

You’re Alive Because our Ancestors Trusted Evidence

By: Dr Bob England & Will Humble April 1, 2019

E pluribus unum.  Out of many, one.  Our de facto national motto calls upon all of us to work for the good of the whole.

Perhaps nowhere is this better demonstrated than in public health. And in many ways, we’ve been wildly successful. Yet in our current policy discussions, we seem to have forgotten the history of how we created that success.

Our health-related discussions have become dominated by how we pay for health care. Right or left, Democrat, Republican, or other, all we seem to talk about is health care finance reform of some sort. Health care has become more complex and expensive and in innumerable ways much better than in our distant past. But most of the significant improvements in our health and our lifespan have nothing to do with health care per se.

Since the mid-19th century, our average life expectancy at birth has boomed from around 38 years to 79, more than doubling our time on Earth. But the vast majority of that improvement is because of public health measures that reduced deaths early in life.

A person who made it to age 70 in the mid-19th century could expect to live another 11 years – to 81 years of age. Now, a person who makes it to age 70 can expect to live another 15 years – only four years longer than our ancestors more than 150 years ago.

This is despite our increasing use of health care in our later years. In other words, our enormous health care expenditure has only marginally added to life expectancy.

The obvious question is, how did we achieve the rest of it?  We used evidence to drive policy, systems, and environmental improvements.

Water and sewer sanitation dramatically decreased intestinal disease (little more than a century ago, one in ten of us died from a waterborne disease). Food safety greatly reduced dangerous intestinal illnesses. Improvements in housing and working conditions reduced overcrowding and led to plummeting rates of tuberculosis and other infectious diseases long before we had medical treatment for them. Universal vaccination programs (and the “herd immunity” that resulted) made once widespread diseases rare. Workplace and motor vehicle safety standards dramatically cut deaths from accidents.

All of the above were achieved through various policies, laws, and regulations. What they all have in common is that these public policies were informed by scientific evidence and implemented in ways that dramatically benefitted us all. Sure, those policy decisions were controversial in their day. Of course there were political debates. But eventually, the evidence, the truth, won out. And we all reap the benefits today.

We have a long way to go, of course. All manner of health indicators vary dramatically by race, ethnicity, and socioeconomic status. Residents of a zip code only two miles from our state Capitol die an average of 14 years earlier than those in another zip code a mere 20 miles away. Fourteen years! Sure, some of these differences are the result of our crazy-quilt health care system, but most of it can be laid at the feet of those same social determinants of health that we’ve been addressing over centuries – differences in our physical and social environment, such as crowding, sanitation, economic status, educational opportunity, and so forth.

It’s not that we don’t know how to address these problems. We have good evidence about what interventions work. Our economic impact evaluations often tell us with reasonable accuracy that the cost of an intervention is less than the cost of the illness we can prevent.

Yet we’ve stopped our progress. Life expectancies are beginning to slightly decline. And many of our disparities in health, with causes largely rooted in social inequities, are growing wider. We’ve ignored opportunities to further improve health, and we’ve cut our public health efforts even in some long-standing areas that have benefitted us all. We’ve lost sight of what got us here.

Sadly, it seems like we’re living in an era in which evidence is often considered “just another opinion.” Many of our decision-makers have lost the ability to know which recommendations to trust. And we seem to have fallen back into our preconceived worldview – reinforced by watching, reading, and listening only to opinions which we already hold, evidence to the contrary be damned.

It’s time to get back to using objective evidence to drive our public policy in ways that further the health of us all. Of us all.  E pluribus Unum.

—Bob England, MD, MPH was director of the Maricopa County Department of Public Health from 2006-2018. He can be reached at benglandaz@gmail.com.

—Will Humble, MPH is the executive director of the Arizona Public Health Association and former director for the Arizona Department of Health Services.  He can be reached at willhumble@azpha.org.

Today's National Public Health Week Topic: Violence Prevention

Gun violence is an epidemic in America. On this second day of National Public Health Week — which has a daily theme of “Violence Prevention” — about 100 Americans will be killed with guns, and hundreds more will be injured.  That's just today.

Beyond gun violence, 1 in 4 U.S. women experience intimate partner violence, 1 in 6 has been the victim of rape or attempted rape, and hundreds of thousands of children experience abuse and neglect. Yet violence is preventable with the right research, resources and policies.

In support of today’s NPHW theme, urge policymakers to pass commonsense measures to reduce gun violence and provide research funding on par with the nation’s gun violence epidemic. Learn about ways to help make your community safer for all, such as using trauma-informed services to identify victims of violence and calling on law enforcement officials to treat all people with dignity, respect and fairness.

Also remember (see below) that we have some free upcoming free Mental Health First Aid Certification Opportunites for AzPHA Members.

For more on Tuesday’s NPHW theme and ways to take action, read our Violence Prevention fact sheet and help spread the word on social media. And join APHA and the Coalition to Stop Gun Violence for a gun violence prevention Twitter chat at 4 p.m. ET today. Use the hashtag #PublicHealth4GVP to join in.

Also today, as part of APHA’s NPHW celebrations, the Association will host a webinar at 3 p.m. ET with the Aetna Foundation and U.S. News & World Report on the recently released Healthiest Communities ranking. RSVP for the event now.

Join APHS tomorrow for the 9th annual #NPHWchat hosted by @NPHW (RSVP here), and on Thursday for NPHW Student Day activities. Don’t forget to check our calendar of local NPHW events to see what’s happening in your community.

_______________________

Free Mental Health First Aid Certification Opportunities for AzPHA Members

AzPHA is delighted to announce that we’re partnering with Crisis Response Network to provide our members a free opportunity to become certified in Mental Health First Aid.  We’ll have 3 separate opportunities in the next few months to take the 8-hour (one day) Mental Health First Aid course in which you’ll learn risk factors and warning signs for mental health and addiction concerns, strategies for how to help someone in both crisis and non-crisis situations, and where to turn for help.

When you take a course, you’ll learn how to apply the Mental Health First Aid action plan in a variety of situations, including when someone is experiencing:

  • Panic attacks

  • Suicidal thoughts or behaviors

  • Nonsuicidal self-injury

  • Acute psychosis (e.g., hallucinations or delusions)

  • Overdose or withdrawal from alcohol or drug use

  • Reaction to a traumatic event

Upon completion of the one-day course you’ll receive a three-year certification.  It’s a terrific opportunity to build your public health skill set while enhancing your professional credentials.

We’re offering the free Mental Health First Aid course on:

If you have any questions or concerns please reach out to Shelby Graves at Shelby.Graves@CrisisNetwork.org.

Arizona Family Health Partnership Snags Title X Family Planning Grant

The Arizona Family Health Partnership is once again the sole Title X Family Planning grantee for Arizona. They received their Notice of Award last week for up to 3 years. The grant is for the $5.2M per year.

Title X is a super important public health program that provides folks with comprehensive family planning and related preventive health services. It's designed to prioritize the needs of low-income families or uninsured people. Its overall purpose is to promote positive birth outcomes and healthy families by allowing individuals to decide the number and spacing of children.

The services provided by Title X grantees include family planning and contraception, education and counseling, breast and pelvic exams, breast and cervical cancer screening, screenings and treatment for sexually transmitted infections and HIV.  It also focuses on counseling, referrals to other health care resources, pregnancy diagnosis, and pregnancy counseling. Title X funding does not pay for abortions.

The AFHP has been the awardee for these services in AZ for many years. When I was at the ADHS, we didn't apply for the Title X grant because our team believed that the AFHP did a really good job providing these services.  A couple of years ago one of the state budget bills required the ADHS to apply for the Title X grant.

Many people believe the line item was included in the budget in hopes that ADHS rather than AFHP would get the grant.  The motivation for that is that the ADHS is prohibited from contracting with Planned Parenthood for Title X services (which do not include abortion services), while AFHP (as an independent nonprofit) could continue to contract with Planned Parenthood.

Legislative Update

This week will be a tricky one - especially in the House.  That's because Representative Stringer (R-Prescott) resigned last week (I'm sure you've heard about the details regarding why- so I'll spare you that).  His replacement hasn't been named yet by the Yavapai County Board of Supervisors. Until someone is named it'll probably slow things down in the house- because the party margin is now 30-29... meaning that for partisan votes there aren't 31 Republicans anymore (temporarily).

There's not much new since last week's legislative update except a new strike all bill (SB 1147) which makes changes to how cigarettes and e-cigarettes are regulated.  Here's the House's summary of the Bill.  It received a pass recommendation from the House Health and Human Services Committee (5-4).

If you read the summary you'll see that the bill is pretty complicated and involves a number of different laws- plus- there were a number of confusing amendments that were discussed in committee.

We'll pay a lot of attention to this bill in the coming week and make sure that our position is consistent with our previous resolutions on this important public health subject.

Lots of bills still need to go to the Rules Committee before being released to a floor vote.  Here's our weekly spreadsheet with the bill updates. 

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Remember- there's only a month to go until our Spring Summit:  From Ideas to Action: Addressing Arizona Children's Oral Health Disparities 

Thanks to a generous grant from the Arizona Oral Health Coalition & the Denta Quest Foundation, we are able to offer a special registration discount for AzPHA members of only $65

Register as a Member of AzPHA  …………………………………...….…….     $65

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Judge Strikes Medicaid Work Requirement Waivers

A federal judge on Wednesday struck down Medicaid work requirements for “able-bodied” adults in Arkansas and Kentucky. The requirements are somewhat similar to community engagement requirements that CMS has approved in Arizona (and scheduled for implementation on January 1, 2020).

The rulings found that the KY and AR waivers pose numerous obstacles to getting health care that haven't been adequately addressed by CMS and the state officials in those states.

The ruling doesn't apply to the AZ community engagement/work requirement waiver (which has already been approved) and probably won't impact AHCCCS’ pending community engagement/work requirements scheduled for a 1/1/20 start date.

US Justice Department Won't Defend the ACA

A couple of 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 it's 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.

Last week the DOJ made it crystal 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 clear 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.

The December 2018 ruling isn’t the last word. The case has been appealed to the federal appellate court system.  It 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 taxbecause 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.

How Can AZ Prepare for a Post ACA America?

It's easy to see how the ACA could end up being struck down in a couple of years once this case gets to the highest court. Gone would be the health insurance market reforms like protection for folks with pre-existing conditions, community rating pricing and guarantee issue as well as Medicaid expansion and the health insurance marketplaces.

Prior to the ACA, the standards to protect people with pre-existing conditions were determined at the state level.  Most states including AZ had very limited protections. 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.

Fortunately, Arizona is partially in control of our own destiny if the ACA is struck down. We couldn't do much about Medicaid rolling back to pre-ACA levels or the loss of subsidies on the Marketplace, but we could have some control over the market reforms like pre-existing condition exclusions, community pricing, and guarantee issue.

Several states have enacted their own laws to be consistent with the ACA market reforms. Several states already have their own laws that incorporate some or all the ACA insurance market protections. Arizona could do the same. 

The good news is that we have time before the Texas v. Azar case makes it to the Supreme Court. A good 1st step would be for the Governor to ask our state agencies to generate (or commission) a report outlining the real-life impact in Arizona in the event that the Texas v. Azar suit is successful. The report would put forward options for state-based health insurance market reform laws to require things like prohibiting pre-existing condition exclusions.

Such a report would give the Arizona State Legislature an analysis to evaluate public policy options for state-based market reforms.

I know what you're thinking, it's impossible to pass these kind of market reforms in Arizona.  Maybe, but many thought that Arizona's expansion of our Medicaid system back in 2013 was impossible.  That case study shows that with the right kind of leadership on the 9th floor, anything is possible.