Federal Public Health Bud

New Funding Opportunity Available for Arizona to Explore Strategies to Reduce Maternal Mortality

A couple of months ago (before the government shutdown happened) landmark federal legislation was passed and signed that will provide millions of dollars to help states determine why women are dying from pregnancy and childbirth at troubling rates.  

The new funding is great news because studies have found that at least half of childbirth-related deaths could have been prevented if health care providers had followed best medical practices to ensure complications were diagnosed and treated quickly and effectively.

The bill provides $12M in annual funding to the CDC to pass through to states with maternal mortality review committees and create committees in the 12 states that lack them.  Arizona has a committee in statute because of a law signed in 2011 - here's a link to the most recent report.

In order to qualify for funding, states need to demonstrate  that their “methods and processes for data collection and review use best practices to reliably determine and include all pregnancy-associated deaths and pregnancy-related deaths, regardless of the outcome of the pregnancy.” All indications are that the ADHS meets these CDC data standards and therefore would qualify for funding.

We and the Arizona Chapter of the March of Dimes will keep an eye out for the grant announcement and offer any assistance that the ADHS needs with their application for this important funding opportunity that can be used to save the lives of Arizona moms.

Maternal Mortality: A Tragic Trend Continues in the US and AZ

The US has the highest maternal mortality rate of any developed country.  Sadly, it’s getting worse each year.  About 800 American women die and 65,000 almost die during pregnancy or childbirth.

The number of deaths in AZ jumped from around 10 in 2015 to about 30 in 2016 (the last year for which ADHS has data posted). The numbers are rounded for statistical reasons (called cell suppression in the public health statistics trade.)

Nationally, back women die from pregnancy-related causes at three to four times the rate of white women, even after controlling for social determinants. Women in rural areas also have higher maternal mortality rates than urban women.  Here’s a story that highlights some of the issues in an easy to read way.

Fortunately, there are public health policy leverage points that can make a difference within state health departments and Medicaid agencies.  Medicaid is a leverage point because it pays for over half of all births each year in 25 states including Arizona.  

All states provide Medicaid coverage for women with incomes up to 133% of poverty during pregnancy and for 60 days after delivery.  But the scope of services covered before and after delivery vary between states.  As a result, some women lose coverage or Medicaid eligibility in certain states after that 60-day period (mostly in states without Medicaid expansion).

In Medicaid expansion states (like AZ) women have more opportunities to achieve better preconception health because they’re more likely to be able to access contraception and plan their pregnancies, receive primary care services to manage chronic conditions prior to and between pregnancies and access prenatal and perinatal care once pregnant.

Evidence-based policy making is a key.  Twenty-nine states (including Arizona) have committees that review maternal deaths and make public policy recommendations.  Back in 2011, Arizona passed, and the Governor signed a bill that amended our child fatality review statutes by adding reviews of maternal deaths.

The statute charges our existing Child Fatality State Teams to review maternal deaths (called the Maternal Mortality Review Subcommittee) and make policy recommendations. The primary goal is to identify preventive factors and make recommendations for systems change. The existing statute doesn't require an annual report- and the last report was published in 2017. Note: we've heard that there may be a Bill this session that will require an annual report of the committee's work.

Here are some of the recommendations from the most recent ADHS report (published in 2017):

  • All pregnant women should have access to prenatal care;

  • Encourage maternal care professionals, organizations, and health facilities to update their standards of practice and care to include all recommended guidelines for the prevention of medical complications;

  • Promote public awareness of the importance of healthy behaviors and women’s overall health prior to pregnancy;

  • Women should always wear proper restraints when riding in cars;

  • Maternal health-care systems require strengthened, prepared, and educated communities to improve deliveries in health facilities, particularly in rural areas;

  • Increase and streamline access to behavioral health services statewide, including training and education for advanced practice nurses in behavioral health services;

  • Support and implement community suicide prevention and awareness programs, such as Mental Health First Aid;

  • Health care providers should screen frequently for perinatal depression and domestic violence;

  • Institute and follow recommended California Maternal Quality Care Collaborative guidelines (www.cmqcc.org) for the timely transfer and transport to a higher-level care facility for any complications using regional transport services; and 

  • Educate providers on the availability of maternal postpartum resources such as home visiting programs.

Some states have gone further. For example, South Carolina’s Medicaid agency formed the South Carolina Birth Outcomes Initiative to advance reductions in early elective deliveries; incentivize Screening Brief Intervention and Referral to Treatment; promote long-acting reversible contraception; and support vaginal births.  One outcome of the SC initiative was to reimburse for long-acting birth control (LARC) devices provided in a hospital setting. 

Fortunately, Arizona has also included LARC reimbursement in a hospital setting post-partum.  This is an important policy intervention because it provides women with a long-acting and reversible option, so they can better plan future pregnancies – improving opportunities for preconception health, which is a key to improving health outcomes.

‘Opportunity Zones’ & Public Health

When you think about the tax bill passed by congress last year you probably think about the permanent reduction in corporate tax rates and changes in the person income tax standard deductions and stuff like that.  But there was a sleeper provision in the law that could influence the built environment and therefore public health.  It’s a provision in the law called ‘Opportunity Zone’ investment tax deferment.

The ‘Opportunity Zones’ part of the new tax law provides incentives to investors to put their money into areas designated by states as low income or underdeveloped.  The law lets investors defer (or eliminate) their capital gains tax obligation when they invest the money in a designated ‘Opportunity Zone’. If they hold the investment for 7 years, 15% of their capital gains liability can be written off.  If they hold the investment for 10 years, then their entire capital gain tax liability can be written off.

The theory is that geographically targeted tax cut opportunities will encourage new clusters of economic activity to form which has the potential to improve conditions that influence the social determinants of health within the designated ‘Opportunity Zones’.

There are very few conditions that are put on the program in terms of what is a qualifying investment, except that the investment must be within a state designated Opportunity Zone.  Developers must make a substantial improvement on the property in the first 30 months.  Investors need to show that 70% of their capital is in the opportunity zone and 50% of their activities.

The governor of each state decides where the Opportunity Zones are (they can name 25% of the qualifying low-income Census tracts as Opportunity Zones).  Our Governor delegated that decision to the Arizona Commerce Authority.  Arizona’s Opportunity Zone nominations were submitted to the US Treasury Department a few months ago and have already been approved.  Here’s the map of the Opportunity Zones Arizona selected.

A couple of months ago the U.S. Department of the Treasury released their guidance on the Opportunity Zone tax law provisions.  The Internal Revenue Service issued proposed regulations in October. 

The AZ Commerce Authority has some material on their website with a more in-depth view of Opportunity Zones including a Guidance Update Webinar Presentation and an Opportunity Funds Guidance Update Webinar Video October 2018.

One thing is clear- the incentives built into the Opportunity Zone parts of the tax bill are huge- and there will be billions of dollars moving into these Opportunity Zones in the coming years.  What remains to be seen is what impact the program will have on the built environment and economic opportunities in these areas and what public health impacts will occur – both good and bad – as a result of the investments that are made in these communities. 

Very few guardrails exist for what kinds of developments qualify for the tax deferral- and no doubt there will be some good things (affordable housing) and bad things (investments that don’t improve conditions) in Opportunity Zone communities in the coming years.

Federal Government Shut-Down & Public Health

Federal funding for several federal agencies and programs expired on Saturday. The President wouldn't sign a Senate-approved short-term continuing resolution extending funding for some federal agencies through Feb. 8.  The House subsequently approved a short-term continuing resolution that included $5.7 billion for a wall at the US Mexico border. The Senate couldn't pass that House Resolution, and federal funding for several agencies and programs then expired, forcing a shut down of some programs.

The shut-down won't impact very many core public health programs (except for WIC and IHS- which I'll get to in a sec). That's because a couple of months ago Congress passed a bill that included funding for the HHS family of agencies: CDC, HRSA, SAMHSA, NIH, CMS, FDA, AHRQ.  

Other federal agencies and programs, such as WIC, EPA, and the Indian Health Services are affected because they weren't in the HHS funding bill. Public health programs outside of HHS are affected (WIC is within the US Department of Agriculture- not HHS).

Fortunately, Arizona has enough funding to keep WIC clinics open for a few weeks at least. Providing this information broadly is important so participating families don't think the shutdown means that WIC clinics will be closed due to the shutdown.

Public health programs working in Indian Country funded by HHS will not be impacted butn some other IHS services will be impacted. IHS will continue to provide direct clinical health care services, but some programs and activities that aren't directly related to the safety of human life may not be available during a shutdown.

Tribally-operated health programs will continue to operate under the direction of the Tribe- and each Tribe will determine how to address the impact from a government shutdown. 

For more information about initial estimates for activities under the appropriations lapse you can review the HHS Contingency Staffing Plan for Operations in the Absence of Enacted Annual Agriculture and Interior Appropriations.

Kids Care & ACA Advocacy

Election season is upon us and KidsCare and healthcare generally are key issues we want candidates for state office to weigh in on.  The Children’s Action Alliance has a helpful election’s page up and running now!  On it you can link to it to point the communities your organization serves to where they can contact candidates, see where candidates stand on issues, and register to vote. CAA is also launching a digital ads campaign around the key questions for candidates today.

Here’s is a fact sheet from Families USA explaining what’s at stake for people with pre-existing conditions in Arizona. The issue is a bit complicated to understand, but here goes for anyone that’s interested. Currently, there is a lawsuit, Texas v Azar, making its way through the courts that challenges the ACA as unconstitutional. 

Arizona Attorney General Mark Brnovich has signed Arizona on as a plaintiff state. If the lawsuit is successful, the protections for people with pre-existing conditions, along with other parts of the ACA, will be repealed.  

We don’t know the timetable on a final court decision, but we do know that, if the lawsuit is successful, Arizona’s law is set up so that these protections will essentially be repealed simultaneously in state statute.

Senate Passes Budget Including Health Agencies

Yesterday the US Senate passed the FY19 Defense and Labor, Health and Human Services and Education appropriations bill.  It would provide funding for health agencies for FFY19.  The bill contains a continuing resolution through December 7, 2018 in case the House doesn't take action on the bill in short order. Here's a summary:

CDC: $7.9B which is an increase of $126 million from FY18. The bill creates a $50M infectious disease rapid response fund (but the funds only become available for use in the event of a public health emergency). The bill includes $10M to continue efforts to track children and families affected by the Zika virus and $5M to address infectious diseases related to the opioid crisis. 

HRSA: $6.8B, a $107M increase from FY18. This funding includes a $26M increase for the Title V Maternal and Child Health block grant and a $12M increase for the Healthy Start program. 

SAMHSA: $5.7B, which is a $584M increase from FY18.  Sadly, the legislation maintains a prohibition on federal funds for the purchase of syringes or sterile needles but allows communities with rapid increases in cases of HIV and hepatitis to access federal funds for other stuff like substance use counseling and treatment referrals. The bill also includes $1.5B for the state opioid response grants.

The bill doesn't include the bad policy riders that were in previous versions that would have eliminated funding for important reproductive health services (Title X).

You can read the bill’s text here, the committee report here, and a summary here.

Call to Action: Labor HHS Education Bill Cuts to Family Planning

Call to Action: Labor-HHS-Education Appropriations Bill

For the first time in more than 20 years, Congress is on track to pass a Labor-HHS-Education spending bill before the end of the fiscal year. Last week, the House agreed to move to conference with the Senate to work out the differences between each chamber’s version of the  bill. The bills contains a number of bad funding cuts.

The House version eliminates funding for the Title X family planning program and the HHS Teen Pregnancy Prevention Program. I can't tell whether the Senate version does the same or not.  The House bill also cuts all funding for the CDC's Climate and Health program and once again fails to fund CDC research into firearm morbidity and mortality prevention. The bill also weakens the Affordable Care Act by blocking funds for implementing the law. 

Congress only has a few legislative days left to finalize the Labor-HHS-Education spending bill before the end of the fiscal year. If they don't pass something they'll probably pass a continuing resolution to keep key public health agencies operating (actually- not a bad outcome honestly). 

Now is the time to Speak for Public Health! You can use this link to Contact your members of Congress and ask them to support robust funding for key public health agencies and programs, and urge them to reject any controversial policy riders that would threaten public health.

Congress is Back in Session: Important Bills in the Balance

Members of the U.S. House of Representatives return to Washington D.C. this week.  They’ll be discussing important public health bills including the Labor-HHS-Education appropriations bill for fiscal year 2019 and the reauthorization of the Farm Bill.

Last week the Senate passed H.R. 6157 which is the combined Defense and Labor, Health and Human Services, Education and Related Agencies appropriations bill for FY19.  This one is the eighth and ninth out of 12 spending bills to be passed by the Senate for FY19.  The legislation includes increased NIH funding and boosted resources for opioid treatment, prevention, and recovery programs.  Here’s a list of some of the adopted amendments:

  • Schumer-Collins amendment to increase funding for Lyme disease activities (3759).
  • Cortez-Masto-Ernst amendment to provide for conducting a study on the relationship between intimate partner violence and traumatic brain injury (3825).
  • Peters-Capito amendment to ensure youth are considered when the Substance Abuse and Mental Health Services Administration follows guidance on the medication-assisted treatment for prescription drug and opioid addiction program (3870).
  • Heitkamp amendment to provide funding for the SOAR (Stop, Observe, Ask, Respond) to Health and Wellness Program (3893).
  • Casey amendment to provide funding for the Secretary of Health and Human Services to establish the Advisory Council to Support Grandparents Raising Grandchildren (3875).
  • Schatz-Hirono amendment to assess the ongoing mental health impact to the children and families impacted by a volcanic eruption covered by a major disaster declared by the President in calendar year 2018 (3897).
  • Heller-Manchin amendment to provide additional funding for activities related to neonatal abstinence syndrome (3912).
  • Heitkamp-Murkowski amendment to improve obstetric care for women living in rural areas (3933).
  • Durbin-Grassley amendment to provide for the use of funds by the Secretary of Health and Human Services to issue regulations on direct-to-consumer advertising of prescription drugs and biological products (3964).

The House hasn’t adopted its FY19 Labor, Health and Human Services, and Education appropriations bill. It’s unclear how both chambers will resolve differences in funding levels between their bills. The House could work on its Labor, Health and Human Services, and Education bill or skip a floor vote and start negotiations with the Senate.  The Farm Bill, which funds WIC & SNAP also hangs in the balance. Here's a summary of the Farm Bill.   The current legislation is scheduled to expire Sept 30th.

Bottom line: with only a few legislative days before the end of FY18, it’s likely that a continuing resolution will keep the government funded into FY19.

The APHA has several tools that you can use to get the attention of your Representative or Senator.  They’ve developed APHA’s Speak for Health advocacy resources, including state-specific fact sheets to help you be a better advocate.  They also have tools to help you meet with your members of Congress or their staff or invite them to visit you and Email or call your members of Congress using the APHA action alert as a phone script or email message. It’s quick and easy.

There's Hope for More Valley Fever Research Funds

Representatives Kyrsten Sinema and David Schweikert introduced a bill last week that, if it passes, will increase the funding that’s available for valley fever research.  The bill supports new research and incentivizes the development of innovative treatments to fight the disease. The bill would:

  • Provide incentives to researchers working to find new treatments for Valley Fever;
  • Streamline the approval and review process for new treatments of the disease;
  • Direct HHS to conduct research on Valley Fever and sets up a Valley Fever Advisory Committee to oversee the work; and
  • Establish a grant program to facilitate Valley Fever research by universities, hospitals, and non-profits.

Valley fever (Coccidiomycosis) treatment research funds are extremely limited, in part, because it’s a regional illness (unique to the desert southwest).  If the entire country were susceptible to the illness, there would probably be more private research funds invested because there would be a large commercial market for a treatment. 

Basically, that’s why we need an investment of federal funds and policy, because the return on the research investment for valley fever isn’t adequate to recoup costs of developing a treatment because not enough people are susceptible to the illness (because it’s limited to the desert southwest).

AzPHA Policy Update: Child Separation, Government Restructuring, House Health Budget Bill

APHA Policy Statement on Child Separation

More than 2,300 children have recently suffered the traumatic experience of being forcibly separated from their parents by the federal government.  Despite the fact that the president has issued an Executive Order to end the practice, thousands of kids are currently separated from their parents.  Some of them are in various facilities in Arizona.

The American Public Health Association (our parent organization) issued a statement last week regarding the policy of child separation recently implemented (and now suspended) by the federal government.  Rather than paraphrase- I thought I’d just block and paste it below:

"The Trump administration’s policy of separating parents and children at the U.S.-Mexico border will have a dire impact on their health, both now and into the future. 

"As public health professionals we know that children living without their parents face immediate and long-term health consequences. Risks include the acute mental trauma of separation, the loss of critical health information that only parents would know about their children’s health status, and in the case of breastfeeding children, the significant loss of maternal child bonding essential for normal development. Parents’ health would also be affected by this unjust separation.

"More alarming is the interruption of these children’s chance at achieving a stable childhood. Decades of public health research have shown that family structure, stability and environment are key social determinants of a child’s and a community’s health.

"Furthermore, this practice places children at heightened risk of experiencing adverse childhood events and trauma, which research has definitively linked to poorer long-term health. Negative outcomes associated with adverse childhood events include some of society’s most intractable health issues: alcoholism, substance misuse, depression, suicide, poor physical health and obesity.

"There is no law requiring the separation of parents and children at the border. This policy violates fundamental human rights. We urge the administration to immediately stop the practice of separating immigrant children and parents and ensure those who have been separated are rapidly reunited, to ensure the health and well-being of these children.”

 

AZ’s System for Regulating the Facilities Caring for Separated Children

Some of the children that have been separated from their parents by the federal government are being cared for in AZ at places run by an organization named Southwest Key. There are 13 such facilities in AZ.  They’re licensed by the Arizona Department of Health Services and classified as Child Behavioral Health Facilities.  Even though they’re licensed by the ADHS, the agency doesn’t conduct routine unannounced inspections at them because they’re accredited by the Council on Accreditation.

Arizona law says that when a facility like this is accredited by an appropriate independent body, the ADHS shall accept the accreditation in lieu of a routine agency inspection. Specifically, ARS 36-424 (B) states that: “The (ADHS) director shall accept proof that a health care institution is an accredited health care institution in lieu of all compliance inspections required by this chapter if the director receives a copy of the institution's accreditation report for the licensure period”.

However, the ADHS still has an obligation to investigate complaints at these facilities because ARS 36-424 (C) says that: “On a determination by the director that there is reasonable cause to believe a health care institution is not adhering to the licensing requirements of this chapter… (the ADHS) may enter on and into the premises…  for the purpose of determining the state of compliance with this chapter, the rules adopted pursuant to this chapter and local fire ordinances or rules.”

You can view the status of these facilities at www.azcarecheck.com and search for the words Southwest Key.  You’d be able to see the results of any complaint investigations or enforcement actions against these facilities- but not the backup accreditation documents from the Council on Accreditation.

 

Supporting Separated Children & Parents

A publication called “Child Trends” put out a blog last week entitled Supporting Children and Parents Affected by the Trauma of Separation that contains evidenced-based guidance for parents and officials.  Hopefully some of the persons within the federal government and care facilities are familiar with and are applying this important information (like Trauma Informed Care) in their policies and procedures like:

 

Federal Government Restructuring Proposed by President

Last week the President Trump unveiled a wide-ranging plan to reorganize many functions within the federal government.  The proposal is posted on the White House website.  It’s 132 pages long- but it’s formatted in a way that’s easy to follow – with an index and formatting that makes it easy to read.

It proposes reorganizing various federal government functions in a wide range of programs.  For example, it proposes creating a new Federal Food Safety Agency that would absorb the various USDA and FDA food safety programs- moving everything to a stand-alone food safety agency.

WIC and SNAP would move out of the USDA and into HHS. Environmental programs at the Department of Interior and the USDA would move over to the EPA.  It also proposes reducing the size of the US Public Health Service Commission Corps from 6,500 officers to 4,000 officers with a Reserve Corps for public health emergencies.  It also plans to merge the Education and Labor Departments to consolidate work force programs.

There are many, many other proposals, like privatizing the US Postal Service.

So far this is just a proposal from the President and his team.  Any such restructuring would need to be authorized by congress.  Here’s a link to the wide-ranging report.  Of course, we’ll continue to track the public health portions of this.  It seems super-unlikely to see any action before the November election.

 

Federal FY 19 Health-related Budget Bill

The House Labor, Health and Human Services, and Education Appropriations Subcommittee released the FY19 House Appropriations report. The bill includes $177B in discretionary funding, which is essentially the same as FY18.  Here’s a summary:

CDC

The bill proposes total funding level of $7.6 billion, or $663 million decrease from FY18, but most of the decrease is due to the transfer of the strategic national stockpile to another part of HHS.

HRSA

The bill proposes a total funding level of $6.5 billion, a $196 million decrease from FY18. Title X Family Planning funding would be eliminated completely.  Primary Health Care would get a 7% decrease.

SAMHSA

The bill proposes a total funding level of $5.6 billion for SAMHSA, a $448 million increase above FY18, mostly because the Substance Abuse Block Grant and the State Opioid Response Grants would be significantly increased.