Last Ditch Effort to Repeal the ACA Underway Next Week

A last-ditch effort is underway in the US Senate to repeal the Affordable Care Act and replace it with an alternative plan.  It’s called the Graham-Cassidy bill. Before October 1 the Bill could pass the Senate with only 51 votes.  After that, it would take 60 votes, meaning that changes to the ACA would need to be bipartisan.

The Congressional Budget Office (CBO) - which evaluates the impact of health bills in terms of cost and impact on private insurance coverage and Medicaid- will need several weeks for it to evaluate the Bill’s impact, so it’s unknown how many fewer people could be insured under it or what the impact on premiums may be.

Even though the bill won’t have a CBO evaluation & its impact on commercial and group insurance and Medicaid as well as the fiscal impact have no objective estimates, the US Senate is poised vote on the bill in the coming days. 

What would Graham – Cassidy do?  In a nutshell, it would:

·       End Medicaid expansion funding, turning the federal funding for Medicaid expansion into a block grant. States would be given a lump sum of money and decide what to do with it (e.g. help enrollees pay their premiums, set up a high-risk or reinsurance pools);

·       Send states a fixed amount of money per Medicaid enrollee (a per-capita cap) starting in 2020.  States could also opt to receive Medicaid funding as a block grant - a fixed amount of federal funding each year- regardless of how many participants are in the program (states couldn’t take a block grant for persons with disabilities);

·       Repeal the ACA individual and employer mandates;

·       Repeal ACA cost-sharing subsidies that lower marketplace premiums by 2020, and roll the funds into a block grant to states;

·       Loosen the ACA’s requirements that plans cover pre-existing conditions;

·       Allow everyone in the individual market to buy catastrophic plans;

·       Repeal ACA taxes on over-the-counter medicine, health savings accounts and medical devices;

·       End federal funding for Planned Parenthood for 1 year; and

·       Double maximum contributions to health savings accounts.

We’re encouraging our members to use APHA’s action alert to let Senator McCain know what you think of the bill itself (especially the profound changes to Medicaid) and the process that’s being used to debate and approve this Bill.  Here’s the text of the short letter that AzPHA sent to Senator McCain yesterday.

AzPHA Letter to Senator McCain regarding the Graham-Cassidy Bill

Dear Senator McCain:

The Arizona Public Health Association and our members urge you to trust your instincts regarding the process that is being used in the Senate regarding the Graham-Cassidy Bill.

We agree with your previous statements and commitments suggesting that Regular Order is the best policy for debating and passing key legislation, especially legislation that impacts Arizonans in a profound and personal way like access to health care.

As you know, legislation that goes through the time-tested processes of debate and input from all sides is more likely to build buy-in and consensus.  Legislation and public policy built together is much more likely to be successful in the long-run.

Now more than ever, we need solutions to our Nation’s problems that are built together, with input from all.

We thank you for your leadership and your statesmanship.

Sincerely, 

Will Humble, MPH

Executive Director, 

Arizona Public Health Association

 

AZ Supreme Court to Hear Challenge to Medicaid Restoration & Expansion

The Arizona Supreme Court announced this week that they'll hear the Biggs v. Betlach case.  The lawsuit was filed by a group of legislators challenging the method used by the legislature to authorize AHCCCS' hospital assessment.  It's a charge to hospitals that's used annually to draw down the federal match required to pay the state's share for covering "childless adults" under our state's Medicaid program (covering them was a pre-requisite to expanding Medicaid eligibility to 138% of poverty).

The Plaintiffs basically argue that the assessment is a tax rather than an assessment charged by the Agency.  Raising a tax requires a super majority while authorizing an agency director to, by rule, assess a fee only takes a simple majority.  The hospital assessment used the latter mechanism.

There's plenty of agency practice history in assessing fees based on authority that came from a simple majority vote...  and some good case law too.  For example, when I was the ADHS Director, we raised the fees (in 2009) for our licensed facilities in order to pay for all of our licensing programs' operations.  That authorization came via a simple majority vote budget bill.

We're probably going to be OK, but you never know.  No date has been set for the Hearing.

Final Push Underway in Senate to Repeal the ACA

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.

Big Decisions about Az Medicaid Eligibility Around the Corner

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.

Policy Tools to Fight Obesity

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.

Prescribing Practices Fueling Opioid Epidemic

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.

ADHS Releases Robust Opioid Action Plan

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.

Federal Healthcare Efficiency Agency on the Chopping Block

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.

Affordable Care Act Driving Use of Preventive Services

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.

Proposed AzPHA Resolutioin Calling for at least 50 Minutes of Recess in Grades K-5

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.

Proposed AzPHA Resolution to Restrict Texting while Driving

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.

Proposed AzPHA Resolution to Move Tobacco & Nicotine Purchase Age to 21

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.

Look for the Public Health Leverage

One of the things that’s most important to remember when you’re a public health practitioner is to look for your leverage.  By that I mean it’s important to set your priorities and use your resources in a way that creates the biggest long-term change with the resources that you have. 

Sometimes that means looking to statutory levers to improve health outcomes.  A good example of that is the Smoke Free Arizona Act, a voter initiative that banned tobacco smoking in workplaces, bars and restaurants.  By all accounts, it has had a profound impact on public health by limiting secondhand exposure and reducing smoking rates. High return on investment.

Sometimes a policy change does the trick.  For example, Maricopa County Department of Public Health worked hard with the community colleges to make their campuses smoke free.  Again, a smart move as it uses policy leverage to influence public health outcomes.

Sometimes it’s changing a rule or regulation.  A few years ago, the Arizona Department of Health Services overhauled their licensing regulations for health care institutions to make it easier to integrate acute care and behavioral health services in order to improve public health outcomes. 

Sometimes leverage means using your contracting authority as a payer of services to drive a public health intervention.  An example of that is the Executive Order issued last year directing AHCCCS to leverage contracts with their Medicaid managed care plans to limit the first fill of addictive prescription opioids to 7 days except for cancer, chronic disease and trauma.

Fortunately, the Substance Abuse and Mental Health Services Administration also recognizes that it has leverage in helping to reduce the opioid painkiller epidemic by releasing grant funds to states to implement interventions that reduce the number of people with Opioid Use Disorders and to reduce the number of opioid-related deaths. 

Earlier this year Arizona received a $24M Opioid State Targeted Response (STR) grant to implement a series of projects and interventions to stem the tide of opioid addiction and deaths.  AHCCCS is administering the grant, and is implementing prevention and treatment activities and working with other state agencies, Regional Behavioral Health Authorities, and contractors to increase access to Opioid Use Disorder treatment and coordinate and integrate care, recovery support services and prevention activities to reduce Opioid Use Disorders and opioid-related overdose deaths. 

The project plan includes developing and supporting state, regional, and local level collaborations and service enhancements to develop and implement best practices to comprehensively address the full continuum of care related to opioid misuse, abuse and dependency.

There are several core areas of work underway including:

  • Increasing use of data-driven decision-making;

  • Improving access, participation, and retention in comprehensive Medication Assisted Treatment services;

  • Increasing prevention activities to reduce Opioid Use Disorder and opioid-related deaths; and

  • Purchasing Rx drug drop boxes, toolkit trainings, technical assistance, and implementing Screening, Brief Intervention and Referral to Treatment (SBIRT) in targeted areas.

Of course, each of these elements are complex to implement and have all sorts of activities and collaborative projects underway.  If you’re interested on reading more you can explore their website materials including their Arizona Opioid STR Fact Sheet and the detailed 52-page Opioid STR Project Narrative Arizona.

Shana Malone from AHCCCS is the project lead for the STR grant and will be serving as the moderator in our “Payer” breakout sessions at our upcoming Fall Conference and Annual Meeting on September 28 entitledArizona’s Opioid Epidemic: Evidence – Interventions - Policy.  

In addition, our keynote speaker will be Jon Perez, Regional Administrator for SAMHSA who will share his perspective on where SAMHSA is headed regarding the epidemic.

We look forward to you joining us at this important and timely conference.  You can View our Agenda, register, and check our sponsorship opportunities on our www.azpha.org website.

Stopping the ACA Cost Sharing Subsidies is the Very Definition of a Bad Deal

Whether or not the federal government continues to pay the cost sharing subsidies for health insurance premiums under the ACA is causing consternation in the health insurance industry- big time.  That’s because the President has implied that he may direct the Executive Branch to stop paying the subsidies... and the subsidies are a big factor in setting premium rates.

Cost-sharing subsidies are paid directly to insurers by the fed's to help cover out-of-pocket costs like deductibles and copayments for people that earn between 100 and 250% of the federal poverty level who buy a marketplace “silver plan”.  A Congressional Budget Office analysis published this week found that if the federal government stops paying the subsidies, the price for “silver plans” on the Marketplace would go up by an average of 20% next year.  

Interestingly, stopping the payments would also increase the federal budget deficit.  How could that be?

People earning up to 400% of the poverty level qualify for advance premium tax credits, which are different from the cost sharing subsidies.  Because health insurance premiums would increase by an average of 20% without the cost sharing subsidies, the federal government would be responsible for paying out more in advance premium tax credits because the premiums will be higher than they would have been had they continued the subsidies.

The CBO report found that the net result would be a $194 billion increase in the federal budget deficit over the next decade.

Just sayin'

8/17/17 Update: A White House Spokesperson is reported to have said yesterday that HHS will make the CSR payments in August, but declined to state whether future months' CSR will be distributed.

U.S. House Committee Passes Bill w/ Big Cuts to Public Health

Before leaving for their August Recess, the House Appropriations Committee passed an appropriations bill that will substantially cut funding for the CDC (a $163 million cut) and HRSA (a $397.62 million cut).  The bill would entirely eliminate HRSA’s family planning programs and decrease funding for key CDC immunization and tobacco control efforts. If these cuts go through as planned there would undoubtedly be reductions to our state's grants from CDC and HRSA.

APHA issued a statement expressing its disappointment with the proposed cuts and urged the House to work in a bipartisan manner to restore the cuts.  The Senate Appropriations Committee won't be taking any action on the budget bill until after the August recess.

Anti Voter Initiative Laws Take Effect Today

107 years ago Arizona's founders protected ordinary voters with a state constitution that guaranteed AZ residents the power of referendum, recall and initiatives.  Many of the bold moves to improve public health policy have come via citizens initiatives. A few examples are:

  • The Smoke Free Arizona Act;
  • The TRUST Commission for tobacco education and prevention;
  • First Things First;
  • Proposition 204 (from 2000) which extended Medicaid eligibility to 100% of federal poverty

This legislative session, Arizona's legislative and executive branches passed and signed two bills (HB2244 and HB2404) that will impair our ability to use voter initiatives to improve public health in the future.  HB 2404 prevents signature gatherers from getting paid by the signature (for voter initiatives) and HB2244 changes the citizen's initiative compliance standard from "substantial compliance" to "strict compliance" with the requirements for putting initiatives on the ballot.

More than a dozen AzPHA members circulated petitions for a non-partisan political committee called The Voters of Arizona that soiught to challenging these new limits on voter initiatives. Their goal had been to collect 75,000 signatures by this week in an effort to keep these new laws on hold (called a referendum) until the Arizona voters have an opportunity to weigh in during the November 2018 election.

Sadly, they recently canceled their Referendum effort to focus on a lawsuit- and they will not be using the signatures that team AzPHA gathered.  A Superior Court judge yesterday ruled that the court will not take action to stop implementation, but perhaps the case will be appealed.

Thank you team AzPHA for your participation in the signature gathering effort.  Sorry that our effort was in vain. 

Interim Report: of the U.S. Commission on Combating the Opioid Crisis

Last week the federal Commission on Combating Drug Addiction and the Opioid Crisis released their Interim Report.  It’s just a 10 page report- so it’s not a huge commitment like most federal documents.  The main recommendation is to declare a national emergency under either the Public Health Service Act or the Stafford Act. 

Such a declaration would mobilize and provide the authority for federal agencies (e.g. HHS) to take additional policy steps to address the opioid epidemic and put pressure on Congress to focus on funding interventions.  The recommendations range from wonky kinds of things like the Institutes for Mental Diseases exclusion in Medicaid programs to broader issues like medically assisted treatment to state-type issues like state Naloxone distribution laws.  A final report is due later in the year. 

The President and HHS Secretary talked about the report at a media conference Tuesday morning.  The conference quickly turned to a discussion about North Korea.  Sadly, the President and Secretary announced that they don't intend to take the Commission's advice and declare a national emergency.

Emergency Rules for Opioid Reporting Finalized

Last week the Arizona Attorney General certified new emergency rules established by the state health department to address the ongoing opioid epidemic.  The regulations apply to the facilities that the agency regulates like skilled nursing facilities, outpatient treatment clinics, hospitals and the like. 

Basically, the new regulations require the health care facilities that they license to adopt and implement policies and procedures relating to the prescribing and administration of opioids.  There are a few webinars scheduled to help facilities understand & implement the new regulations. The ADHS also began expanded blood screening for suspected opioid overdose cases in order to better characterize the epidemic.

New Study Finds Spike in Opioid-caused Car Crashes

There seems to be no end to the damage that opioid painkillers are having in our society.  The latest sign that the epidemic is causing widespread public health damage is highlighted in this abstract published in the American Journal of Public Health where the researchers found a huge increase in the number of drivers killed while under the influence of prescription painkillers. 

The prevalence of prescription opioids detected in fatally injured drivers analyzed in the six study states increased from 1.0% in 1995 to 7.2% in 2015.  The researchers looked at drivers who died within 1 hour of a crash in California, Hawaii, Illinois, New Hampshire, Rhode Island and West Virginia. Those states routinely test for drugs in people who have died in car crashes.

It's no secret that Arizona and the U.S. are in the midst of an unprecedented opioid epidemic. Public health professionals, healthcare providers, managed care organizations and first responders have been implementing interventions to improve prescribing practices, better manage addiction, and quickly intervene during overdoses to mitigate the epidemic- yet the crisis has worsened. Policy makers in Arizona and across the nation, including the governor, have taken note and are prioritizing resources and policy directives to mitigate the crisis. 

Our Fall AzPHA Conference and Annual Meeting (September 28) will focus on this critical public health crisis.  The conference, titled Arizona's Opioid Epidemic: Evidence - Interventions - Policy, will present recent Arizona opioid epidemic data and will explore interventions and future policy initiatives within public health, healthcare and managed care systems, first responders, state government, and county health departments to mitigate the epidemic. 

Sign up today at www.azpha.org and take advantage of our early bird registration rates.