The Arizona State Legislature's 2017 Regular Legislative Session ended yesterday. We had some solid gains in terms of public policy that influences public health. We also had some missed opportunities and some losses (especially when it comes to future voter initiative possibilities), but on the whole, lots of good things happened.
A big thank you to Eddie Sissions and all of the members of the AzPHA Public Policy Committee for their work tracking and advocating for and against bills this session. Thank You!
Access to Care
Emergency Dental Care
The biggest public health win came inside the Budget. Arizona will shortly be providing all of the matching funds needed to ensure that all adult Medicaid members have access to emergency dental services (up to a cap of $1,000 per person per year). Adult Medicaid members that are members of AHCCCS' Arizona Long Term Care System had emergency dental services restored last year, so this year's action fills the last gap in dental emergency care for adults. Kids that have their insurance through AHCCCS have comprehensive dental coverage that includes preventative services.
Primary Care Loan Repayment
The state budget authorized an additional $350K per year to go into the state's loan repayment program, bringing the total funds to $1M per year... which will potentially qualify Arizona for up to an additional $1M in federal funds. These new resources are timed perfectly to take advantage of the revamping of the program over the last few years. In a nutshell, this program gives primary care and other front line health practitioners an opportunity to get significant relief for their student loan debt by practicing in rural and underserved AZ.
The state budget includes a measure allowing the Arizona Department of Health Services to increase their newborn screening fees by $6 per test so the AZ State Lab can afford to test babies for Severe Combined Immune Deficiency syndrome. Babies born with Severe Combined Immunodeficiency look normal at birth but they can’t fight infections. They often die before 1 year of age without medical treatment. But if SCID is caught at birth (before the onset of infection) a bone marrow transplant can successfully treat the disorder. It’s especially important to test for SCID in Arizona because the disorder is much more common in certain populations in Arizona: 1/2,000 among Navajo’s and Apache’s and about 1/20,000 among Latinos.
Clarifying Certified Registered Nurse Anesthetist Practice
Nurse anesthetists are a kind of registered nurse who is skilled in the administration of anesthesia and pain management. They are a key practitioner all across Arizona, especially in rural areas. Some disconnects with respect to the supervision of nurse anesthetists and prescribing and administration authority had been causing access to care problems especially in rural AZ.
In a nutshell, SB 1336 outlines medication orders and prescribing authority for nurse anesthetists and makes it clear that a physician isn't liable for anesthetic administration by a nurse anesthetist. It also modifies the definition of "presence" (relating to supervision) of these folks, and outlines medication orders and prescribing authority. This new law got through the process with some hard work and compromise by folks who kept their eye on the access to care ball in AZ.
Outpatient Occupational Therapy for Adult Medicaid Members
AHCCCS currently provides coverage for occupational therapy services in an inpatient hospital setting to all of their members (when medically necessary), for outpatient members under 21, and for adults that are enrolled in the Arizona Long Term Care System portion of AHCCCS. The state budget funds AHCCCS so that it can start providing coverage for occupational therapy as an outpatient health service for all their enrollees (when it's medically necessary).
Involuntary Commitment Procedures
Existing state law has procedures for civil commitment of a person for mental health treatment if a court finds enough evidence that the person (as a result of mental disorder), is a danger to self or others, or has a disability in need of treatment but won't or can't accept voluntary treatment. The court can then order the patient to undergo treatment.
Last year, the State Supreme Court amended the rules for enforcement of Tribal Court Involuntary Commitment Orders to allow the enforcement of tribal court orders upon the acceptance by the clerk of the filing of the tribal court order rather than upon the certification of the order. In other words- some tribal members had delays in getting treatment because of the new rules.
HB2084 will allow a mental treatment facility to admit a patient for involuntary treatment for a mental health disorder pending the filing of a tribal courts involuntary commitment order, providing a mechanism for a more smooth access to care- especially for tribal members.
Tools for Schools
Schools will be better able to help kids with asthma to manage their symptoms next school year thanks to the passage of HB 2208. It will let trained school staff to administer (or help administer) an inhaler for a student in respiratory distress. The new law also outlines the training required and provides immunity from civil liability (lawsuits).
The old statute allowed kids to have & use inhalers if it was prescribed by a doctor and the school had an annual written documentation from the parent or guardian authorizing the student to have and self-administer their inhaler. The new law will let trained school district and charter school staff to help the child to use their inhaler.
UA's Western Region Public Health Training Center has Stock Albuterol Inhaler Training for School Personnel available on their website already... and the e-learning course provides the training needed for schools to implement this new law.
Sunscreen Use at Schools & Camps
Schools, parents and kids will be better able to protect children from damaging UV rays as a result of the passage of HB 2134 which will make it clear that kids can take and use sunscreen at school and camps... and that school, preschool and camp staff can help them put it on.
Why was this needed, you ask? The FDA regulates sunscreen as an over-the-counter drug. School districts set their own policies concerning the administration of "medication" (including over the counter sunscreen) to kids. Some school districts and camps prohibit the administration of "over-the-counter drugs" (e.g. sunscreen) unless a parent provides written consent and an order from a physician. This new law will make it clear for schools, camps, and day cares that it's OK for kids to have and use sunscreen. It'll also give schools, camps and day cares protection from lawsuits.
Arizona will shortly join the 47 other states that have laws on the books restricting the use of smart phones while driving. SB 1080 will ban brand-new teen drivers from using their smart phone while driving for the first 6 months of their license (if they're under 18). Using the phone in an emergency will still be OK. Tickets can only be issued if the driver committed another violation. The new law allows sound only smart phone functions under specified conditions. Prior to this, the only other limitation in AZ to this kind of distraction was for school bus drivers.
Drug Overdose & Poisoning Prevention
HB 2493 sets up a drug overdose review team at the ADHS (much like the child fatality review team). It'll be a 21-member consisting of nine heads of various government entities (or their designees) and 12 members appointed by the ADHS Director to:
- Develop a data collection system regarding drug overdoses;
- Conduct an annual analysis relating to drug overdose fatalities;
- Develop standards and protocols;
- Provide training and technical assistance to local Teams;
- Develop investigation protocols for law enforcement and the medical community;
- Study state and local laws, training and services in order to recommend policies to decrease drug overdose fatalities; and
- Educate the public regarding drug overdose fatalities.
Looks like a good opportunity to get some better surveillance, standards, protocols, and explore new laws that could help with the ongoing opioid painkiller epidemic.
HB2091 was passed at the very end of the Session and will (assuming it's signed) remove the requirement that SNAP (food stamp) recipients file fingerprints prior to becoming eligible for benefits. This had been a barrier for seniors to participate in the program because of perceived stigma.
HB2372 was also passed in the waning minutes of the Session and (if signed) will extend the Temporary Assistance for Needy Families program to 2 years lifetime participation from the current 1 year.
New Laws Posing Public Health Challenges
Changes to the Voter Initiative Process
Many of the bold moves to improve public health policy have come via the citizens initiative process that's written into Arizona's constitution. A few examples are the Smoke Free Arizona Act; the Tobacco, Revenue, Use, Spending and Tracking Commission (Proposition 303 from 2002) for tobacco education and prevention; First Things First; and Proposition 204 from 2000 which extended Medicaid eligibility to 100% of federal poverty for childless adults and creating the AZ Area Health Education Centers. Future citizens initiatives geared to improve public health will be more difficult to get on the Arizona ballot as a result of the passage of 2 new laws: HB 2404 & HB 2244.
- HB 2404 prevents signature gatherers from getting paid by the signature (for voter initiatives), making it more difficult to provide the work incentive needed for gatherers to be efficient. This will make it more difficult to get the large number of signatures that are needed to get citizens initiatives on the ballot in the future.
- House Bill 2244 changes the citizens initiative compliance standard to "strict compliance" with all of the requirements regarding the entire process of getting on the ballot. The previous criteria meant that citizens initiatives needed to be in "substantial compliance" with the requirements. This new law does require the Secretary of State generate a rule handbook with the requirements.
A group of folks will be organizing to collect 75,000 signatures by August 12 in an effort to keep these new laws on hold (called a Referendum) until the voters of Arizona have an opportunity to weigh in during the November 2018 election. We'll stay in touch with the groups organizing this effort and we'll keep our AzPHA members informed regarding how they can participate in the signature gathering process.
One component of the state budget requires the Arizona Department of Health Services to apply to become the Title X family planning grantee in Arizona. Federal Title X funds provide about $5M in family planning resources statewide. When I was the ADHS Director we never applied to be the Title X grantee because the Arizona Family Health Partnership (an Arizona nonprofit) did such a good job administering the grant.
The challenge that this new law poses is that if ADHS is successful becoming the Title X grantee, they'dbe prohibited by state law (ARS 35-196.05) from contracting with Planned Parenthood of Arizona to provide the family planning services- and many many Arizonans rely on Planned Parenthood a their access point for family planning.
There were several missed opportunities to improve public health that were proposed but failed to get through the legislative process:
- Voluntary Certification for Community Health Workers
- Comprehensive oral health coverage for pregnant Medicaid members
- Requirements for recess time for physical activity in schools
- Requirement for hospitals to offer influenza vaccines to seniors in hospitals
- Regulation of tanning bed studios
- Changing the age at which folks can but tobacco products and e-cigarettes to 21 from 18
Note: according to state law, most of these changes won't come into effect until 90 days after the end of the legislative session- which is in mid August.
I'll be doing a webinar at 12 noon on May 25 summarizing this year's legislative session. Tiffany has sent out a couple of notices inviting people to register- and we'll send out a couple more.
Our Public Policy Committee will continue to meet over the phone on an ad-hoc basis the rest of the year to talk about policy at the federal level and issues that may relate to AHCCCS waiver requests. We will also be following efforts to collect signatures to suspend implementation of the voter initiative laws until voters have an opportunity to approve or deny the laws at the ballot box in November 2018. Our materials will continue to be posted on Basecamp. For information about participating in the committee activities contact email@example.com