Maricopa County Hepatitis A Outbreak Slowing Because of Quick & Effective  Interventions

Maricopa County has 320 hepatitis A cases with 4 deaths predominantly affecting those experiencing homelessness, substance use and/or recent incarceration. A few months ago, Maricopa County Public Health activated its incident command system and have had all hands on deck with not only members of the County Epi team but also contracted staff and many, many volunteers.

Selecting and Executing an Intervention

After reviewing the data and learning from other jurisdictions around the country, the team determined that the most impactful and cost-effective intervention for quelling the outbreak was to focus on a vaccination campaign among high risk folks.

Of course- that means that they would need some funding to support the intervention. Team MCDPH built a proposal and went to the County Board of Supervisors and were able get a $600K appropriation last fiscal year for the intervention. They were also able to get an additional $1.7M for the current fiscal year. 

The intervention has been focusing on 3 main strategies to vaccinate those at highest risk to prevent further spread including 1) Vaccinating everyone who enters the Maricopa County jail system by hiring temporary staff; 2) Providing vaccine to partners who work with those at risk; and 3) Deploying field teams in partnership with cities to vaccinate people where they are.

AHCCCS stepped in to help as well- facilitating reimbursement to Maricopa County for the vaccinations given to Medicaid members.

By working with healthcare, community, faith-based and local government partners, the public health system has vaccinated over 14,000 residents at risk for hepatitis A. The results have been impressive. They have achieved a 66% reduction in the number of new cases since the peak of the outbreak. Vaccination efforts will continue until they can confirm that the outbreak is over.

Return on Investment

Each prevented hospitalization because of Hepatitis A saves about $25K. Emergency Department visits from Hepatitis A cost less but are still expensive- a few thousand dollars.

Persons experiencing homelessness are at much higher risk for hospitalization when they become infected with the Hepatitis A virus. For example, more than 71% of the 1,521 persons involved in a 2017 Hepatitis A outbreak were hospitalized (1,073) and 41 died.

Kentucky had a similar outbreak but they didn’t jump on it nearly as quick as Maricopa County Department of Public Health (MCDPH) and KY ended up with 4,000 cases. MCDPHs quick response likely prevented hundreds, if not thousands of cases- and untold hospitalization costs to say nothing of the lives saved.  BTW- the Hepatitis A Vaccine is $36 per dose.

Partnerships are Key

There are several keys to the success of this response including doing research to determine the most effective evidence-based interventions to use, working community, government and private partners on solutions, and making a compelling case to the Board of Supervisors to invest county funds on the proposed interventions.

Well done! This is a good example of an effective and targeted response to an important public health problem that has been causing bad health outcomes among a very high-risk population- and causing expensive downstream costs for Arizona’s healthcare system.

FY 20/21 State Agency Budget Requests

Each Fall state agencies turn in their official budget requests to the Governor's Office. In my experience while I served in the executive branch, there are usually conversations between the agency directors and governor's office staff before the official requests are turned in- and there was usually governor's office support for the requests 

The AZ state agencies turned in their requests a couple of weeks ago. Below is what they asked for:

Department of Health Services:

  • Asks for an increase of $1.4 M (GF) from their Emergency Medical Services Fund for:

  • Support Operatins within the Bureau of Emergency Medical Services & Trauma System;

  • Enhance funding to the 4 regional Emergency Management Services Councils;

  • Sustain contracted transportation services for high-risk expectant mothers and for physicians that provide follow-up services for uninsured newborns in intensive care centers;

  • Requests one-time funding of $200,000 from the state general fund (not the Newborn Screening Fund) to address aging equipment and ongoing increase of $56,000 for increased costs of reagents.

  • Seeks additional funding for Nursing Care Institution Resident Protection Revolving Fund to allow the agency to relocate residents to other facilities, maintenance of operation of a facility pending corrections of deficiencies or closure and reimbursement of residents for monies lost. The funds would go toward:

  • $100,000 to address pressure ulcers in nursing homes and training for nursing home staff;

  • $70,000 to provide evacuation tracking and staff tracing system to the 148 skilled nursing facilities in AZ; and

  • $25,000 for an annual conference on best practices on infection prevention in a skilled nursing facility.

Department of Economic Security:

  • Asks for an increase of $15M from the General Fund and $35M (Title XIX) to fund a DDD HCBS provider rate increase that emphasizes quality of direct care worker and service delivery;

  • Asks for $30.5 M (CCDF fund) to increase child care assistance rates to serve low income families in quality settings & continue suspense of the child care waiting list;

  • Seeks a $48.9 M (GF) and $116.1 (Title 19) funds to cover growth for 42,800 members of the DD ALTCS program for targeted case management, state-only case management & AzEIP populations this is based on a projected growth of 5% for ALTCS cases, 2% for targeted case management; 5% growth in state-only case management; 3% growth in AzEIP caseload, a 2% growth in ALTCS capitation & a 5% growth in state funded long term care room & board costs; and

  • Requests additional expenditure authority in the DD line items to use federal Title XIX funds for the DD populations.

AHCCCS: 

Requests an overall increase of $15.15B (Total Funds) of which $1.9B is state general fund (GF), $324.6 M in other appropriated funds, $1.8B in other non-appropriated funds & $11 in federal funds.

Changes driven by Caseload Growth in the population:

  • Increases in the ALTCS-EPD population by 4.8% in FY 2020 & FY 2021 by 3.72%

  • Forecasts for the Traditional T-19 growth to be flat;

  • Estimates growth in Prop 204 Population to increase by 4.14% in FY 2020 and decline in FY 2021 by 3.40%;

  • Changes in the Newly Eligible Adults to grow by 3.84% in FY 2021

  • Declines in the CMDP program are slightly for FY 2020 of -0/09% and increase by 0.43% in FY 2021; and

  • Adds KidsCare growth in FY 2021 of 14.83%.

  • Growth in the baseline Capitation Rate for all programs 3.0% due to a rebasing, changes in utilization, savings from pharmacy, provider increases, adjustments to assure actuarial soundness, and other factors;

  • Adjustment in the FMAP (federal match rate) going to 70% and making adjustments for KidsCare & the childless adults FMAP (match);

  • Seeks authorization or $10.5 M (Federal Funds) for the Medicaid School-Based Administrative Claiming Guide;

  • Reduces the hospital assessment fund to $78.8 M which is being used for the restoration of Prop 204 (childless adults, expansion population) populations in FY 2014;

  • Increases $43.1 (Federal Funds) for non-appropriated federal for regular and supplemental Prescription Rebates;

  • Continues expansion of the Graduate Medical Education program by moving forward the allocation from the FY 2020 appropriations act; and,

  • Seeks $11.9 M (GF) to cover federally mandated IT projects of Asset Verification System, Electronic Visit Verification & Provider Management System.

Department of Child Safety:

  • Increases funding for Adoption Services by $16.4 M (GF) due to increases in the caseload by a growth of 7%; reduce the Adoption Incentive funding due to a structural shortfall due to changes in federal computations; and provide incentive pays of a daily rate of $75 for families who adopt a child with a developmental disability or serious mental health issue;

  • Retains the current appropriation for CMDP in the AHCCCS budget but allocate 4 Single Line Items to manage expenditures and provide transparency with these SLIs: Health Service Request, Higher Level of Care, Care Management & Quality, & Administration and adds 104 FTE which is a 33 FTE increase over current CMDP allocation;

  • Enhances by $5.0 M (GF) to continue and Support the Field Structures within DCS;

  • Reauthorizes $5.0 M (Automation Projects Fund) to continue development & implementation of the Guardian (child welfare information system);

  • Requests $2.6 M (GF) for Legal Costs associated with defending DCS in the class action child welfare case;

  • Makes technical adjustments that provide for Extended Foster Care line item for costs of youth aged 18-21; &, consolidate special line item of Records Retention, Overtime, and General Counsel; and,

  • Asks for $5.4 M (Child Care Development Funds) to increase the Child Care Assistance Rates for low income and foster families to assure children are in quality settings and suspends the child care waiting list.

Federal Judge Issues Preliminary Injunction on the new DHS Public Charge Rules

A federal judge in New York on Friday temporarily blocked the Trump administration’s “public charge” rule linking immigrants’ legal status to their use of public benefits.

Judge George Daniels of the U.S. District Court for the Southern District of New York issued a nationwide Preliminary Injunction which temporarily stops the implementation of the recently filed “public charge” rules promulgated by the US Department of Homeland Security. The new framework would have become effective on Tuesday Oct. 15.

Remember, this is just a Preliminary Injunction, it’s not a final ruling on the merits of the case (PI’s are just that, preliminary).  Because the application of the law cannot be a state by state thing, it is a nationwide PI. 

The bottom line is that the new Rules would (if implemented) change the criteria the federal government uses to make decisions about legal permanent resident applications. The final rules will block legal immigrants from extending their temporary visas or gaining permanent residency if the government decides the applicant is likely to rely on public benefits in the future.

Under the new rule, any immigrant who receives at least one designated public benefit— including Medicaid, food stamps (SNAP), or public housing vouchers for more than 12 months within any three-year period will be considered a “public charge” and will be more likely to be denied a green card (legal permanent resident) by immigration officials.

The Feds already consider whether applicants for legal permanent residency receive Temporary Assistance for Needy Families or Supplemental Security Income (SSI) when they evaluate applications for permanent resident status.

Importantly, the final Rule won’t consider whether benefits were used by an applicant’s children. Likewise, if lawfully present kids receive benefits (e.g. Medicaid) that fact won’t be considered against them if the child later applies for legal permanent residency (a “green card”).

Public health note:  We know from both national reports and from assistors and community organizations working in Arizona, that families are afraid and withdrawing from or reluctant to participate in benefits for which they or their children are legally eligible. Nationally, nearly one in four children have an immigrant parent, and almost 90% of them are US citizens.  Missing out on safety net programs for which folks are entitled can result in bad health outcomes because of social determinants that won't be addressed and missed doctor's appointments which could result in missed developmental screenings and interventions.

States Increasingly Implementing Innovative Policy Approaches to Quell the E-Cigarette Use Epidemic Among Kids

Will Arizona Join In?

Electronic cigarette use among kids is a growing concern among some state and federal elected officials, appointees and other policymakers.  E-cigs are the most commonly used tobacco products among kids and young adults.  Nationally, e-cigarette use has grown 900% among middle and high school students from 2011 to 2015.

It’s happening in Arizona too.  Last year’s Arizona Youth Survey found that e-cig use was up dramatically across all three age groups:

  • 8th -graders: 21% reported using e-cigarettes in 2016- that’s up to 28% now

  • 10th-graders: 29.4% 2016, now it’s 39%

  • 12th-graders: 35% 2016, now it’s nearly half- at 46%.

Flavored e-cigs are far and away the most popular kind of e-cig for kids- and the data are clear that flavored e-cigs are attracting (and addicting) kids.  The data are striking.  

According to FDA, 96% percent of kids who started using e-cigs between 2016 and 2017 started with a flavored e-cig. The 2018 National Youth Tobacco Survey data found that 68% of current high school e-cig users used a flavored e-cig.

Those data are compelling- and it’s easy to see why some elected officials and appointed public health officials see regulating the sale of flavored e-cigarettes as  an important strategy to reduce youth e-cigarette use.

Regulating Flavored E-Cigarettes

As I mentioned in my policy update a few weeks ago, the HHS issued a press release announcing that they “intend” to remove all flavored e-cigarette products from the market until manufacturers of those products file premarket tobacco product applications with FDA.

Some Governors and state health officials have also taken executive and regulatory action to regulate flavored e-cigarettes. Last month Michigan became the first state to announce a ban on the sale of all flavored e-cigarettes. She based her decision on leadership from their state health department with their issuance of an emergency finding, and Governor Whitmer directed the agency to issue emergency rules banning the sale of vaping products.

New York's Governor Cuomo has instructed their state health department to convene an emergency session of their Public Health and Health Planning Council to consider banning flavored e-cigarettes. The Council adopted rules banning sales of most flavored e-cigarettes.

In Massachusetts, Governor Baker declared a public health emergency, and their state health department commissioner issued an order prohibiting the sale or display of all vaping products.

Some state legislatures are taking action on flavored e-gigs as well.

North Dakota’s governor signed HB 1477 prohibiting the sale of any flavored e-cigs.  Maine’s governor signed LD 1190 which penalizes the sale of flavored tobacco products, including e-cigarettes and flavoring, to anyone under 21.

The California legislature is considering matching bills (AB 739 and SB 38) that would prohibit tobacco retailers from selling flavored tobacco products including e-cigs.  

A similar Illinois bill (HB 3883) would create the Flavored Tobacco Ban Act which would prohibit the sale of any flavored tobacco product.

Massachusetts introduced companion bills (H 1902 and S 1279) that would prevent the sale of flavored cigarettes (and e-cigs).

Public Health advocates like ourselves can play an important role in building the evidence base and conducting the advocacy necessary to move elected and appointed officials to take action. 

Our administrative advocacy can take several forms- from collaborating with elected officials to develop legislation to take action- to working within state and county health departments to urge appointed officials to take action.  State health departments play a key role in catalyzing a response as well, if they take action.

So far, our Governor doesn’t appear to be supportive of banning the sale of flavored e-cigs in AZ.  He’s quoted in this article in the Arizona Capitol Times as saying “What I don’t want to do is take someone who is addicted (to nicotine), restrict them from finding a product and push them to the black market, so we’re going to have a measured approach.”

Perhaps if he knew that 96% percent of kids who started using e-cigs start with a flavored e-cig and that 68% of current high school e-cig users used a flavored e-cig  it would change his mind?

Please Promote Participation in the Title V Needs Assessment Survey

The 2020-2025 Maternal and Child Health Title V Needs Assessment Survey is underway, and they need your help to make sure they good data from the Assessment! 

This needs assessment is done every 5 years and is super important because the needs assessment results drive decision making and resource allocation for the next 5 years.  Getting good data from the needs assessment can make the difference between getting great public health results and getting just mediocre or even no result.

The Federal Title V MCH Block Grant is a key source of support (including funding) for promoting and improving the health and well-being of mothers, children, adolescents, including children/youth with special needs, and their families.  

In order to accurately identify the needs of Arizona’s women and children, a needs assessment is conducted every five years. The results of the survey help to develop the priorities for the next five years. 

The survey is available in English & Spanish and should take about 20 minutes to complete. The survey data collection period will end on December 31, 2019. All Arizona residents including service providers and families are welcomed to take the survey. 

Please participate in the survey and promote it with your partners and families. They have created two flyers, in English and Spanish that can be shared and distributed. In addition, they can mail printed copies of the flyer to your organization for waiting rooms. Printed flyers can be ordered through here.

Anyone with questions about the survey can contact the ADHS Office of Assessment and Evaluation at 602-542-2233 or at bwch.oae@azdhs.gov.

Member Vote: Proposed New AzPHA Board Member Slate

The AzPHA Board of Directors is pleased to propose a slate of incoming Board Members to replace the folks that will be transitioning off the Board at our Annual Meeting on October 29, 2019.  The Board has interviewed the candidates and is recommending that you (our members) approve their recommended slate of candidates. Please take a few minutes to vote on the recommended slate by October 14, 2019

AzPHA Board Recommendations

Vice President: Kim Van Pelt

Chief Regional Officer, First Things First CV

Dir. of Professional Development: Eric Tomlon, FACHE, MBA/MSHA

VP/Chief Operating Officer for Dignity Health Medical Group CV

Student Representative: Carolyn (Carly) Camplaign, JD

Sr. Program Coordinator, Center for Health Equity Research, NAU CV

Director of Public Policy: Zaida Dedolph

Director of Public Policy, Children's Action Alliance. CV

A Big Thank You to our outgoing Board members- they have served AzPHA for many years and have done a lot of hard work for our organization- than we thank you!

Please take the time to thank our outgoing Board members!  We appreciate your service to AzPHA and to the people of Arizona!

  • Marcus Johnson: Immediate Past President

  • Eddie Sissons: Director of Public Policy

  • Lauren Savaglio: Director of Professional Development

  • Adrienne Lent: Student Representative

EPA & NHTSA Preempt State Fuel Efficiency Standards

This week the EPA filed a Final Rule that stops states from setting their own fuel efficiency fleet standards. California and 13 other states have more slightly aggressive fuel efficiency standards than the current EPA standards (AZ does not).  If today’ final rule withstands certain challenges it'll prevent those states from having enhanced standards.

That's important because the EPA is about to roll back the current federal fleet emission standards.  More on that in a bit. 

Under the existing national regulations, new cars, trucks, and SUVs fleets need to average about 50 miles per gallon by 2025. But back in 2018 the EPA & NHTSA proposed a roll back of the existing national vehicle fleet fuel efficiency standards (the current CA standard is basically the same as the current federal standard).

If the CA standard and the current national standard are the same, then what's the big deal?

It's a big deal because the Administration has proposed (but not yet finalized) a Rule that will roll back the current standards by stopping the progression of standards in 2021.  Rather than requiring a fleet average of 50 mpg by 2025, the proposed new federal standard would stop at 38 mpg (last year, the average fleet fuel efficiency was about 25 mpg),

So basically, the EPA this week set the stage for preventing CA and 13 other states from keeping the current standard of 50 mpg by 2025 when the EPA officially rolls back the standard (probably in the coming weeks).

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

You Can Be a Part of Increasing the Transparency of Arizona Elections

Elections have profound impacts on public health – good and bad.  Persons that get elected to public office at the federal state and local level routinely make decisions that influence public health.  Elected officials at the federal, state and local level make funding decisions about important agencies that impact public health and pass or fail to pass important national public health policy laws. 

Elected officials also make important appointments at state and federal agencies (like CDC, HHS, HRSA, CMS & EPA at the federal level and ADHS, AHCCCS, ADEQ etc. at the state level).  The persons in those positions set agency priorities, have wide latitude to make important decisions and who to hire.  They also have broad Rulemaking authority and establish or don’t establish public health policy that can has a profound impact on public health.

In short, elections have a big impact on public health. That’s why it’s super important to have an informed electorate, so people can make informed decisions about what they decide in the ballot box- whether it’s a person running for elected office at the state, federal, or local level- or whether it’s about a voter initiative.

Sadly, voters aren’t as informed as they could be about the decisions they make at the ballot box because it’s legal in the US and in Arizona to spend money to influence elections and not disclose whose money it is or why they’re spending it.  Sometimes you might hear this being called “Dirty Money” or “Dark Money” – referring to political spending when the original source remains secret.  All sorts of organizations, corporations, and wealthy individuals spend large sums of money to advertise and otherwise influence elections while the source of those funds remains hidden from the voters.

Since 2010, more political advertising has been secretly funded in Arizona as a percentage of total campaign spending than in any other state.  In part that’s because Arizona law has essentially no requirement that folks disclose political spending.

That’s where the Outlaw Dirty Money voter initiative comes in.  It’s a voter initiative that has been filed with the Secretary of State to change the state constitution that, if passed by the voters, will mean that at least Arizona voters will have a right to know who is spending money to influence elections.  You can read the text here.  Here are the elements of the Initiative:

  • Organizations spending more than $20,000 in state races or $10,000 in local races would be required to report the original source of their funding;

  • Organizations would be required to disclose all original contributors who gave $5,000 or more in an election cycle, removing the existing practice of creating a maze of organizations to hide the original source;

  • The Citizens Clean Election Commission would write and enforce the regulations to implement the Outlaw Dirty Money Constitutional Amendment;

  • Voters can file a complaint directly with the Clean Elections Commission to report violations; and

  • Local governments can pass more stringent requirements than those set forth in this Amendment.

You Can Play a Part

It will take the signatures of 357,000 Arizona voters to put the Outlaw Dirty Money Initiative on the November 2020 ballot.  That’s a lot of signatures.  This is a grassroots effort, so the signature gathering is being done by volunteers- meaning that many people need to be involved in the signature gathering effort.

Terry Goddard, the Chairperson for the Initiative, recently paid a visit to an AzPHA Board Meeting and described the Initiative and provided me with several initiative petitions.  I am already busy gathering signatures for the Initiative, and I’m hoping that you will gather some signatures as well.

Simply contact me at willhumble@azpha.org and I will get you some petitions and describe what you need to do.

AzPHA Annual Report

At the end of each Fiscal Year (July 1 to June 30) the AzPHA publishes an Annual Report summarizing the activities of the previous year including a discussion of our activities, membership update and a summary of our financial position.  We just completed this year’s Annual Report and posted it in the Members Only portion of our website.  You can get to the Report and a host of other financial information here. Here's a quick summary:

The Arizona Public Health Association continued to make progress in all facets of our mission, including advocacy, professional development and networking.  We’ve increased our membership 27% in the last two year (632 at the end of FY-2019 compared with 496 members in FY-2017) and grown the number of sustaining Organizational Members.

In FY-19 we provided our members with timely policy updates (50 Public Health Policy Updates in FY 2019), targeted Action Alerts, and multiple comments on state public health matters (e.g. agency actions and legislative debates), and federal rulemakings (e.g. Title X, methane rule, public charge). We took public positions and testified in committee on many bills during the last legislative session.

We also continued to improve our website including our calendar of statewide public health events and blog content.  These improvements are also increasing our visibility on search engines.

AzPHA continued to diversify our revenue sources and improve our financial position (operating reserves), built new relationships with key partners, and enhanced our professional development and networking options. 

Feel free to view the full Annual Report when you get a chance.  We are a member organization In short, AzPHA is poised for another successful year.  Our progress toward improving our administrative and operational infrastructure positions us well for the coming year. 

Our enhanced individual and organizational membership, more aggressive and engaged advocacy work and our and fiscal diversification leave us in a strong position financially as we look toward the future of AzPHA and our Vision of Healthy Communities for Arizona.

Dispensary Owners File Retail Marijuana Voter Initiative 2.0

A group of Medical Marijuana Dispensary operators refiled a new proposed retail marijuana voter initiative this week. The revised language is largely the same as the language they submitted the first time around- but there are a few changes.

The first version said that the ADHS (who would regulate the program if it passes) sets standards for edible potency by=ut that they can't set standards lower than 10mg of THC.  The revised version makes it clear that they can't set standards above 10mg (a much better decision).  The new version also allows for an additional 26 retail marijuana store licenses (the former language would have basically limited licenses to the existing medical dispensaries. The new version also increases the criminal record expungement limit to possession of 2.5 ounces (in the first version it was 1 ounce.

Here's an old blog post with my initial thoughts about the Initiative.

We'll continue to review the language and evaluate whether basic public health principles related to our Retail Marijuana Resolution before taking any position.

_____________________________________________


AzPHA Member Vote on Updated Firearm Violence Prevention Resolution

Please Vote by October 4, 2019

In 2018, AzPHA members approved 3 new Resolutions including one entitled Resolution to Prevent Firearm Violence in Schools

This year we are proposing an update of last year’s firearm violence resolution. The updated version is entitled Resolution to Preventing Firearm Violence in the Community and Schools.

Our AzPHA Public Health Policy Committee developed the updated Resolution. The Board of Directors reviewed the Resolution at their September 20 meeting and have asked me facilitate an electronic vote of our members.

Accordingly, please review the updated Resolution and cast your vote at this link by close of business on Friday, October 4, 2019. We will announce the results in an October Public Health Policy Update and at the 2019 Annual Meeting on October 29, 2019.

Arizona Sexually Transmitted Infection Action Plan in the Works

The Arizona Department of Health Services is developing a Sexually Transmitted Infections Action Plan as part of something state government calls a "Goal Council Action".  I'm not 100% sure what a Goal Council exactly is, but an initial "STD Action Plan" was presented to and approved by the "Goal Council" last week.

The Plan includes numerous actionable interventions (below) - although there's no recommendation to decriminalize syringe service programs- which is a key evidence-based best practice to reducing the spread of some sexually transmitted infections. Below are the action items in the elements in the Plan. 

  • Promote policies that allow providers to prescribe treatment for partners.

  • Improve access to screening and treatment in rural Arizona by implementing standing orders for chlamydia, gonorrhea, and syphilis.

  • Identify ways to encourage expectant mothers to access prenatal care and receive syphilis screening and promote healthy pregnancies.

  • Utilize perinatal caseworkers to better understand the barriers to accessing care and link women to prenatal care and other social services to prevent reinfection and promote healthy pregnancies.

  • Expand partnerships with correctional facilities, home visiting programs, and groups that work with current and recovering drug users to address root causes of STD transmission.

  • On-board additional laboratories to electronic laboratory reporting via HL7 messaging or spreadsheet reporting. Initiate the enhancement of ADHS IT infrastructure to accept electronic case reports (eCR) from providers.

  • Expand multi-site resistance screening in Maricopa County.

  • Develop a plan to respond to emerging STDs like LGV and Chancroid.

The agency will be scheduling follow-up meetings with stakeholder subcommittees to discuss the action plan in more detail and establish next steps for implementation.

The Network for Public Health Law Launches Harm Reduction Legal Project

Individuals and communities across the United States are struggling with an epidemic of drug-related harm. Many states, including Arizona are hindered by laws and policies that reflect an outdated, punitive-focused approach to drugs and individuals who use them Like the fact that syringe service programs in Arizona are still technically committing felonies.

the Network for Public Health Law has launched the Harm Reduction Legal Project to address the legal and policy barriers that impair the implementation of evidence-based harm reduction measures. 

The Harm Reduction Legal Project provides direct guidance  to address legal and policy barriers to the creation, operation, and scale-up of harm reduction policies and programs.

Entities and individuals requesting assistance in navigating the often extremely confusing maze of existing laws and regulations that hamper harm reduction initiatives will have access to subject matter experts who can provide research, legal analysis, and strategic guidance as well as referrals to other knowledgeable experts and leading institutions. 

The Harm Reduction Legal Project provides real-time support to help organizations to successfully operate within existing law and policy while providing information to advocates who seek to modify existing legal restrictions on harm reduction initiatives.

To learn more or inquire about assistance from the Harm Reduction Legal Project, contact harmreduction@networkforphl.org or visit networkforphl.org/harmreduction

Some States Implementing Interventions to make Insulin more Affordable

Folks living with Type 1 diabetes and some people with Type 2 diabetes require daily insulin injections as part of their treatment. The cost of insulin per patient has nearly doubled in the last couple of years with an astonishing average annual cost of $5,700 per patient.

In fact, one in four individuals with diabetes (both those with and without health insurance) have said they have rationed or skipped taking insulin due to cost...  which can cause medical complications and be life-threatening.

The federal government hasn't done much to make it more affordable.  They (FDA) did announced a new policies to increase competition in the insulin market, but that hasn't done much. 

Some state legislatures have moved forward to make it more affordable.  For example, Colorado recently enacted H.B. 19-1216, which will cap the co-pay for a 30-day supply of insulin at $100 effective Jan. 1, 2020.

Oregon enacted SB 9 which will allow pharmacists to prescribe and dispense emergency refills of insulin to people with a previous prescription.

A New York bill, introduced this week would allow pharmacists to dispense emergency insulin and related supplies in a similar manner.

The Florida, Illinois, Michigan, New York, Pennsylvania, Rhode Island, and Wisconsin legislatures have introduced similar bills each of which would cap the out-of-pocket cost for a 30-day supply of insulin at $100 (none have yet been enacted as far as I can tell though).

Will Arizona be the next state to implement interventions to make insulin more affordable?

Federal Public Health Budget Progress (FY20)

Last week the Senate released the FY20 Labor, Health and Human Services, and Education appropriation bill.  The draft bill includes $178.3 billion discretionary funding, which is an approximate 1% increase over FY19.

Click here for the bill text, report language, and full summary.  document.  It's unclear how Congress will proceed with funding the federal government when the fiscal year ends on Sept. 30. Given current tension among various members of Congress and the differences between the House and Senate Labor, Health and Human Services, and Education bills, a short-term continuing resolution through November or early December seems likely.

Below is a high-level summary of the Senate bill. The bill is just a proposal, and the differences between the House and Senate bills will need to be resolved in conference.

At first glance, it appears that most public health programs are level funded when compared to the previous year’s funding levels. Notable public health provisions include:

CDC

The total proposed funding level for CDC is $7.5 billion, an approximate $180.5 million increase from FY19. The funding includes:

  • $140 million in new funding to support first year activities associated with ending the HIV epidemic.

  • $10 million, or a $5 million increase, to address infectious disease and the opioid epidemic.

  • $5 million to better inform how Adverse Childhood Experiences increase the risk of future substance use disorders, suicide, mental health conditions, and other chronic illnesses.

  • $10 million for a suicide prevention initiative to utilize data and evaluation to inform efforts to prevent suicide, especially among vulnerable populations.

  • A $100 million increase in funding to continue global health security efforts to accelerate capacity to prevent, detect, and respond to infectious disease outbreaks.

  • Level funding for ASTHO priority programs, including the Public Health Emergency Preparedness cooperative agreement at $675 million and the Preventive Health and Health Services Block Grant at $160 million.

SAMHSA

  • $1.5 billion for the state opioid response grant, which is level with FY19 funding.

HRSA

  • $50 million base funding for community health centers to increase outreach, testing, care coordination, and HIV prevention services, including the use of PrEP in high-need counties and states.

  • $677 million for the Title V Maternal and Child Health Services Block Grant, which is level with FY19 funding.

  • $25 million for the HIV/AIDS Bureau Special Projects of National Significance Program. This program supports the development, evaluation, and dissemination of innovative models of HIV care to improve the retention and health outcomes of Ryan White HIV/AIDS Program clients.

Office of the Assistant Secretary for Preparedness and Response

  • $11 million for the National Ebola Training and Education Center.

  • $275.5 million for the Hospital Preparedness Program. (Note: It is unclear from the report language text if this is an increase or level funding with FY19.)

AzPHA Members Voting on Updated Firearm Violence Prevention Resolution 

In 2018, AzPHA members approved 3 new Resolutions including one entitled Resolution to Prevent Firearm Violence in Schools

This year we are proposing an update of last year’s firearm violence resolution. The updated version is entitled Resolution to Preventing Firearm Violence in the Community and Schools.

Our AzPHA Public Health Policy Committee developed the updated Resolution. The Board of Directors reviewed the Resolution at their September 20 meeting and have asked me facilitate an electronic vote of our members.

Accordingly, please review the updated Resolution and cast your vote at this link by close of business on Friday, October 4, 2019. We will announce the results in an October Public Health Policy Update and at the 2019 Annual Meeting on October 29, 2019.

Background about AzPHA Resolutions

Many of AzPHA's  public health priorities are driven by Resolutions that are approved by our members.  AzPHA has dozens of Resolutions in place dating back to the 1930s.  They are all available on our Members Only site

Early resolutions focused on the importance of food safety regulations, tuberculosis control, family planning, and other contemporary public health issues.

More recent Resolutions have focused on support for addressing the Opioid epidemic, certifying community health workers, and addressing electronic cigarettes.  Our Resolutions are important to us because they set our public health advocacy priorities.

AzPHA Resolutions stay in place until and unless the Members vote to remove or update a Resolution. There is a process for developing new Resolutions.  Resolutions are developed by AzPHA Members and are forwarded to the Board for review. 

The Board reviews the Resolution and votes whether to forward the Resolution to the Members for approval.  Proposed Resolutions can be voted on electronically before the Annual Meeting or they can be voted on in-person at the Annual Meeting.  After approval of the resolutions, final copies are posted on the members only portion of our website

Arizona’s Efforts to Reduce Maternal Mortality and Severe Maternal Morbidity

By Mary Ellen Cunningham, AzPHA Board President

The United States ranks lower than Poland, Belarus and UAE among other nations in maternal mortality according to the CIA’s World Factbook.  A report from ACOG on maternal mortality tells us that the US Maternal Mortality rate is the only one raising among industrialized nations.  But deaths are the tip of the iceberg; it is estimated that 50-100 women experience severe maternal morbidity for every death. The CDC defines severe maternal morbidity as the unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman's health.  So, what is killing or injuring Arizona mothers?  A report published by ADHS based on available data shows us the leading causes of death or severe injury are cardiac and hypertensive disorders, hemorrhage and suicide/homicide and accidents.

In the past few years, there have been efforts nationally and within Arizona to change that trajectory.  Arizona has had a Maternal Mortality Review process, which was actually just a few lines added to the statute for Child Fatality Review, since 2011 which created a subcommittee to look into Arizona maternal deaths.  While many volunteers reviewed the cases monthly, there were no reporting requirements and never any funding attached. Additionally, the state agencies are often handicapped by the inability to hire new folks.

But all that is changing…very much for the better.  For over a year now, the Bureau of Women’s and Children’s Health, in partnership with the March of Dimes and the Arizona Perinatal Trust has been leading Arizona’s efforts to reduce maternal fatalities and severe morbidities through a collaborative process. A Severe Maternal Morbidity/Maternal Mortality Prevention Taskforce was formed on October 30, 2018 and engaged over 36 stakeholders representing the state agencies, tribes, maternal health experts, and healthcare systems.

The Task Force met a few times during the past year, reviewed data and participated in facilitated discussions.  ADHS developed a Maternal Mortality Action Plan based on the suggested strategies:

  • Sustained partnership with the Alliance for Innovation on Maternal Health (AIM)

  • Engage providers and patients

  • Secure funding

  • Expand the scope of data analysis with respect to racial disparities

  • Continuous communication with stakeholders

The Task Force is ongoing.  Information about it can be found here.

The March of Dimes, at the same time, led the effort to expand on the work of the existing Maternal Mortality Review process.  As a result of the hard work of many, and led by Senator Kate Brophy McGee, SB1040 was passed and signed by the governor at the end of the 2019 Legislative session.  SB1040 requires ADHS to gather together an advisory committee to look at the maternal mortality and morbidity review process and to report on that review to the chairs of the House and Senate Health committees by December 31, 2019 and to have a report to the governor on the incidence and cause of maternal fatalities and morbidity by December 31, 2020.

In the meanwhile, there was no grass growing under ADHS. They had applied for and were awarded a competitive grant from the CDC to support the maternal mortality efforts by standardizing the current maternal mortality review process; supporting the MMRC in developing actionable recommendations;  disseminating the findings of the MMRC to different audiences and leading and supporting the adoption of maternity safety bundles at birthing facilities.  This $450,000 a year for five years will also support needed staff. 

They also applied to become a part of the Alliance for Innovation on Maternal Health (AIM), a national effort of reducing maternal mortality and severe maternal morbidity and have started working with AIM and at the same time are awaiting to hear about an additional grant application to HRSA about maternal health.

The members of the legislatively required Advisory Committee on Maternal Mortality and Morbidity were selected from an open application process and has met once and will meet again this Monday, September 16 to continue its work. There is a very short window to accomplish much.  I was selected to represent ‘a public health organization.’ It is an Open Meeting, so anyone is welcome to attend. Here is a link to the details.

Finally, maternal mortality has become a focus of the governor’s Goal Council.  ADHS is finishing up a plan that incorporates the work and the recommendations of the multipartnered Task Force.  This Plan should be out soon.  It will not only address the acute side of maternal mortality like hemorrhage or hypertensive crisis but will address many of the social determinants of health like access to care.  As public health folk know, its what happens upstream that changes societies.

On a personal note, I have never felt so hopeful for mothers and babies in this state.  ADHS, the March of Dimes, the Arizona Perinatal Trust and countless medical personnel and health care systems both public and private have all worked tirelessly for generations to improve the outcomes for mothers and babies, but this coordinated effort is beyond anything any one group could accomplish. There is a golden opportunity right now with a mix of state and national efforts, political will and ample funding.  The battle is ours to win.