AzPHA Public Health Policy Update- November 16, 2017

AZ’s New Minimum Wage Law Expected to Improve Infant Mortality

We’ve known for a long time in public health that a primary driver of health status is family income.  More family resources generally result in better health outcomes. New data suggest (not surprisingly) that increases in the minimum wage result in lower infant mortality.

Could the passage of Proposition 206 in November of 2016 be an evidence-based public health intervention that will lower infant mortality in Arizona?  The answer is yes!

In 2014, Arizona’s infant mortality rate was 6.2 deaths per 1,000 live births- well above other comparable countries including Japan (2.1), France (3.5), and the UK (3.9).  The national rate in the US is 5.8/1,000.  Here are Arizona’s Infant Mortality Rates: PDF | Excel

A team of researchers recently published a study in the American Journal of Public Health examining the effects of state minimum wage laws on infant mortality and low birthweight rates.  They found that a $1 increase in the minimum wage is associated with a 4% decrease in infant mortality and a 1% to 2% decrease in low birthweight births.  They concluded that…  “if all states in 2014 had increased their minimum wages by $1 dollar there would likely have been 2,790 fewer low birthweight births and 518 fewer post-neonatal deaths for the year.”

This research adds to a growing scientific literature on the beneficial effects of various income supports on improved birth outcomes and reinforces the fact that social determinants of health related to income have a significant impact on population and public health outcomes.

Of course, there are many factors at play when it comes to infant mortality and low birth weight- but it looks like Proposition 206, which raised the minimum wage in AZ to $10 this year and to $12 by 2020 will help us on our quest to improve Arizona’s infant mortality and low birth weight rates. 

 

AzPHA’s Positions on the Sunrise Hearings

Whenever health related professions ask to be regulated or want to expand their scope of practice a state law says that the regulation needs to be done only to protect the public interest.  Applicants that want to go through the process need to submit a report to the state legislature explaining the factors demonstrating that their request meets these standards.

A “Committee of Reference” studies the sunrise applications and delivers its recommendations to House and Senate leadership. This year there are 3 applications in the hopper and they’ll be heard on Tuesday, November 28 starting at 9 am in the House of Representatives.

In a nutshell, the Community Health Workers Sunrise Application asks for a pathway to set up a process for voluntary registration of CHWs; the Arizona Naturopathic Medical Association would like permission for them to sign medical waivers from the state’s school vaccination requirements; and the Dental Care for AZ Sunrise Application asks for authorization from the legislature to license a new class of dental professionals.

Here are AzPHA’s statements to the House and Senate Committee of Reference for the upcoming November 28 Sunrise Hearings.  We’re taking positions on the CHW and Naturopath Sunrise Applications (but not the Dental Therapist application).

 

Arizona Community Health Workers Association

We urge the Committee to recommend approval of the application submitted by the Arizona Community Health Workers Association for Certification/Registration for Community Health Workers.

Community Health Workers (CHWs) are an established group of health professionals that build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy. 

A variety of agencies use CHWs to serve communities in ways including access to primary care, prenatal care, chronic disease self-management, long-term care, utilization of services, and behavioral health.  CHW services are effective at improving health outcomes and reducing costs and providing a unique opportunity for provider groups as they increasingly adopt value-based purchasing practices.

There is currently no simple way for health care providers and members of the community to verify that a CHW is proficient in core competencies. Certification and registration will assure that CHWs meet minimum standards including education, continuing education, training, experience, and other qualifications. With certification and registration, payors reimbursing CHWs for services would have clarity about CHWs core competencies and their scope of practice allowing this workforce to become integrated with a medical team and/or in the community.

CHWs work with vulnerable populations. Registration of CHWs meeting minimum standards is essential for patient safety by assuring that CHWs have a background check, follow HIPAA regulations, and safeguard against inappropriate actions and/or behaviors.

In short, we are supportive of this application because CHW services are effective at improving health outcomes and reducing costs. In the absence of certification/registration, the community cannot be assured of CHWs’ core competencies, scope of practice, and that procedures are in place to safeguard patients.

 

Arizona Naturopathic Medical Association

We urge the Committee to recommend denial of the application submitted by the Arizona Naturopathic Medical Association to expand their scope to include medical exemptions from Arizona’s school vaccination requirements.

The Arizona Public Health Association is concerned about several aspects of this application, most importantly, that it could further erode Arizona’s vaccination rates resulting in the loss of herd immunity. 

We believe that medical exemptions are an important component of Arizona’s school vaccine requirement system. However, medical exemptions should be signed by physicians that are current with the latest scientific literature regarding vaccines. New vaccinations and combinations of vaccinations are approved on an ongoing basis by the Food and Drug Administration and are evaluated consistently by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP).

Guidance and recommendations from the CDC and ACIP are critical for physicians to understand the nuances of the various vaccines, their complex schedules, and data regarding evidence-based reasons for medical exemptions.  Medical exemptions are best signed by physicians that are current with these resources.

Our review of data regarding vaccines suggest that Naturopathic Physicians provide very few vaccinations in Arizona (less than 0.01% of all vaccinations in Arizona are provided by Naturopaths).  Because so few Naturopathic Physicians (NDs) provide vaccines, our concern is that they will not be well informed about when a medical exemption is appropriate, and that some NDs will err on the side of signing medical exemptions rather than study the detail provided by the FDA, CDC and ACIP. There is also a risk that a relatively small number of NDs could sign large numbers of medical exemptions and jeopardize herd immunity.

We urge the Committee to recommend denial of the application submitted by the Arizona Naturopathic Medical Association to expand their scope to include medical exemptions from Arizona’s school vaccination requirements.

 

Restaurant Calorie Labeling Back on Track?

One of the things that was tucked into the Affordable Care Act was a provision that requires restaurants with 20 or more locations to post calorie content information for standard menu items directly on the menu and menu boards- a potentially powerful public health intervention in our effort to reduce obesity.

The FDA issued proposed draft regulations way back in 2011... but various delays have kept the rules from being implemented (by both the Obama and Trump Administrations).  Some places have been voluntarily posting nutrition information- but it’s still not officially required.

This kind of nutrition clarity is a real opportunity for public health change.  Not only will the new labels give the public key information to help them make better decisions about what they buy for themselves and their families- it’ll give pause to restaurants before they label their menus- giving them an opportunity to change ingredients to lower calorie counts.  It may even spur a trend away from “super-sizes” and toward more appropriate and reasonable serving sizes.  With 32% of the calories consumed in the US tied to eating outside the home- this is an important opportunity.  

Last week the FDA released draft implementation guidance addressing menu labeling issues like caloric disclosure, compliance and enforcement, and marketing materials.  The new guidance suggests that the compliance start day will now be May of 2018.

The new draft guidance includes expanded and new interpretations of policy, and identifies places where FDA intends to be more flexible in its approach. It also includes many graphical depictions conveying the FDA’s thinking on various topics and provides examples of options for implementation.

The new guidance addresses calorie disclosure signage for self-service foods like buffets, various methods for providing calorie disclosure information (including pizza which has been a big hang-up because its’ so often delivered), and compliance and enforcement.

 

President Nominates New HHS Secretary
The President selected Alex Azar, a former pharmaceutical executive and a top health official during the George W. Bush administration, to lead HHS. Azar also served as president of Lilly USA (an affiliate of Eli Lilly and Co.) and as a health-care consultant. During the Bush administration he was chief counsel a deputy director.

He has been highly critical of the ACA and supports converting Medicaid from an entitlement program into block grants. However, Dr. Georges Benjamin (Executive Director of the American Public Health Association, said “Azar is far less partisan than his predecessor. He’s smart, practical, listens to all sides…  We’ve got somebody whose heart is in the right place.” Time will tell.

 

Open Enrollment for Marketplace Health Insurance

The Affordable Care Act remains the law, and insurance enrollment for Arizonans runs through 12/15.  The University of Arizona Center for Rural Health (AzCRH) has certified staff (Navigators) to answer questions and help you enroll in health insurance coverage. Navigator services are free http://crh.arizona.edu/programs/navigator