Federal Budget

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.)

‘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.

Recently Passed Federal Public Health Legislation

Congress has passed several bills in the last few weeks related to public health.  Here’s a quick summary and links to the laws.

Improving Access to Maternity Care HR 315

This bill requires HRSA to identify maternity care health professional target areas and publish data comparing the availability of and need for maternity care health services in health professional shortage areas and areas within those areas.

Preventing Maternal Deaths Act of 2018 HR 1318

This bill authorizes HHS grants to states to review maternal deaths, publish reports with the results.

PREEMIE Reauthorization Act of 2018  S 3029

This bill increases federal research on preterm labor and delivery, improve the care, treatment, and outcomes of preterm birth and low birthweight infants. 

Agriculture Improvement Act of 2018 – The Farm Bill HR 2

The Farm Bill reauthorizes food security programs through FY23 including Supplemental Assistance Program (SNAP) and SNAP nutrituon education.  It also removes hemp from the Controlled Substances Act, which would legalize hemp production and therefore changes how CBD is regulated.

State Offices of Rural Health Reauthorization Act: S 2278

This bill reauthorizes $12.5M annually through FY22 for the Federal Office of Rural Health Policy to make grants to each state office of rural health to improve health care in rural areas. This bill was approved by both the House and Senate but is not yet signed.

The Action for Dental Health Act of 2018

This bill provides an opportunity to improve oral health across the country.  The bill will provide additional resources to the CDC to increase funding for groups and organizations to qualify for federal grants that develop programs and expand access to oral health education and care in states and tribal areas

CDC will still need to flesh out the grant guidance in the coming months before they put out their announcement with the application and expectations. 

PEPFAR Extension Act of 2018  HR 6651

This bill extends certain provisions of the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003.

Sickle Cell Disease Research, Surveillance, Prevention, and Treatment Act of 2018  S 2465

This bill reauthorizes a sickle cell disease prevention and treatment program and to authorizes funding for grants for research, surveillance, prevention, and treatment of heritable blood disorders.

Infrastructure for Alzheimer's Act S 2076

This bill would create an Alzheimer's public health infrastructure across the country to implement effective Alzheimer's interventions focused on public health issues such as increasing early detection and diagnosis, reducing risk and preventing avoidable hospitalizations.

Action Alert to Save Nutrition Education Programs

The Farm Bill is currently in its final negotiations, and important funding for SNAP-Ed programs in Arizona and across the country is at stake. We need your help to urge Congress to maintain the Senate version of the Farm Bill to save this critical support for these programs.

The SNAP-Ed program provides nutrition education and resources to thousands of Arizonans. If the Senate version of the funding is not maintained in the final Bill (expected to be approved before this congress exits), Arizona won’t be able to offer effective food and nutrition programs to low-income communities who need it, especially in Congressional Districts 1 and 3.  

The new House of Representatives funding formula would significantly shift SNAP-Ed grants away from more than 15 other states, thus ending programs for people in hundreds of low-income communities throughout the country. 

Click here to urge Congressman Tom O'Halleran and Congressman Raúl Grijalva to maintain the Senate version of the Farm Bill to save this critical support for these programs!

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.

State Action to Stem Rising Prescription Drug Costs

By Association for State and Territorial Health Officials Staff

The high cost of prescription drugs is a persistent problem in the United States, with about 10 percent of overall health spending attributed to prescription drugs. In recent years, there has been increased interest among states to address the rising cost of prescription drugs. Just this year, 24 states passed 37 bills to stem rising drug costs. In total, state legislatures have introduced 160 bills targeting prescription drug costs in 2018.

States have pursued a wide range of strategies to tackle the high cost of prescription drugs, including policies that address drug price transparency, rate setting requirements to prevent price gouging, drug importation programs, generic drugs companies, and pharmacy benefit manager transparency.

 

Drug Price Transparency

Controlling healthcare costs is one of the three elements of the Triple Aim, along with improving population health and patient care experience. As a first step toward controlling costs, states are seeking more price transparency requirements from drug manufacturers. In 2018, six states passed legislation addressing drug price transparency. Many of these laws adopt more stringent transparency policies requiring drug manufacturers to justify price increases over certain thresholds. For example, Connecticut requires drug manufacturers to justify price increases for specific drugs if the price increases by 20 percent or more in a year or 50 percent over three years.

 

Price-Gouging and Rate Setting Requirements

Anti-price gouging and rate setting requirements use information collected from transparency laws to allow states to impose penalties for excessive drug price increases. Currently, Maryland is the only state with an anti-price gouging law. The policy allows the state Medicaid agency to notify the state’s office of the attorney general when an essential off-patent brand name drug or generic medication has an excessive price increase.

Maryland’s attorney general can then request justification from manufacturers for the price increase. If the rationale of the price increase is deemed unjustified by “the cost of producing the drug, or the cost of appropriate expansion of access to the drug to promote public health,” the state can impose civil penalties or use other mechanisms to penalize the manufacturer. However, a lawsuit has since been filed in federal court by drug manufacturers asserting violations of Constitutional law as it relates to interstate commerce. To date, twelve other anti-price gouging bills have been introduced in states, although none have been enacted.

 

Drug Importation

Earlier this year, Vermont became the first state to pass a drug importation bill, allowing the state to import wholesale prescription drugs from Canada for use by all state residents. The law requires the designation of a state agency to become a licensed drug wholesaler, or to contract with a licensed drug wholesaler. Several steps remain before Vermont’s program can go into effect, including the state health department receiving federal approval from HHS by July 2019. In addition, although the Utah legislature failed to pass a bill that would have created a program for importing drugs from Canada, the legislature requested that the Utah Department of Health conduct a feasibility study associated with drug importation.

 

Generic Drugs

Recently, Maine passed a law requiring brand name manufacturers to make samples of drugs available to generic drug manufacturers, with the intention of promoting competition by increasing access of information for companies developing lower-cost generic drugs. The law states that, “In order for there to be competition in the prescription drug market, developers of generic drugs and biosimilar biological products must be able to obtain quantities of the reference listed drug or biological product with which the generic drug or biosimilar biological product is intended to compete.”

 

Pharmacy Benefit Managers

Several states have passed bills regarding pharmacy benefit managers (PBMs), which require increased transparency and disclosure of information on drug rebates and concessions. For example, Nevada passed a law in 2017 requiring PBMs to disclose the amount of rebates received from drugs used to treat diabetes. Connecticut’s drug price transparency law also requires PBMs to provide information on rebates and other price concessions received from drug companies. Mississippi passed a law preventing PBM gag clauses, which stop pharmacists from sharing information with patients on lower-cost drug options.

 

Other State Policies

In Montana, the legislature passed a bill establishing an interagency committee to study state drug pricing and spending trends, which will make recommendations to the state legislature on drug pricing policies in late 2018. In addition, New York implemented an annual cap on drug spending in its Medicaid program. Under the law, if spending projections extend beyond the cap, the state health department must identify the costliest drugs and attempt to negotiate additional rebates with manufacturers. This law also gives the state the authority to develop an independent panel that can penalize manufacturers through various mechanisms.

 

Future Opportunities

Emerging state legislation to address the rising cost of drug prices in demonstrates potential paths forward to address drug prices at the state level. The National Academy of State Health Policy (NASHP) has developed model legislation to address drug price transparency, drug importation, rate setting, and pharmacy benefit managers. The NASHP resource includes model legislation for states, bill text from states that have already passed legislation, and relevant briefing documents.

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).

Arizona's 2018 Legislative Session in the Books

Well, Arizona’s legislative session ended last week, so you’re spared my impossibly long policy updates.  You can visit this PowerPoint to dive into the good things, bad things, and the missed opportunities this year.  It’s still a draft summary of the Session because the Governor hasn’t taken action on several bills (voluntary certification of community health workers, public health measures in schools, dental therapy, food truck licensing, and fresh produce in SNAP). BTW- Let me know if you see anything I've left out of the draft powerpoint so I can update it before my Webinar next week

I’ll be doing a Webinar about the legislative session on Thursday May 17 at noon in conjunction with the UA Center for Rural Health & the UA Telemedicine Program.  Visit the AZ Telemedicine Program’s Website to register.

 

FDA Finally Implementing ACA’s Menu Labeling Requirement

You might have noticed that more and more restaurants and fast food places are starting to put calorie and other nutrition information on their menus.  That’s not a coincidence or accident- they’re implementing the menu nutrition labeling requirements in the Affordable Care Act.  Section 4205 of the ACA requires restaurants with 20 or more locations to post calorie content information for standard menu items directly on the menu and menu boards.  Vending machine operators with 20 or more machines are also required to disclose calorie content for certain items. 

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. 

Anyway, the FDA announced this week that they’re finally implementing the requirements that were established by the ACA.  Another evidence-based policy intervention brought to you by the Affordable Care Act.

 

CMS Denies Kansas’ Request for 3-year Lifetime Medicaid Eligibility

This week the Centers for Medicare and Medicaid Services Administrator denied Kansas’ request to impose a 3-year lifetime limits on Medicaid eligibility. 

Her decision bodes well for us in Arizona- at least when it comes to lifetime coverage limits (although CMS is poised to almost certainly approve AZ’s work/work training request).  Arizona law requires AHCCCS to annually ask CMS for permission to require work (or work training) and income reporting for “able bodied adults” and a 5-year lifetime limit on AHCCCS eligibility (with some exceptions).

A few months ago AHCCCS turned in their official waiver request asking permission to implement those requirements.  The AHCCCS Director recently postponed the negotiation process of the lifetime limit request to expedite approval of the work requirements.  See his letter here.  Word on the street is that AHCCCS expects approval of the work requirements in June.

 

Mid-year Federal Budget Cut Request

This week the White House submitted a special message to Congress requesting they rescind $15B bill in budget authority from the current fiscal year. The proposal includes unobligated balances from prior-year appropriations and reductions to budget authority for mandatory programs.

Below are selected programs proposed for rescission by the Administration that may impact public health programs. For more information, view the entire rescission proposal here.

  • Children’s Health Insurance Fund: The proposal would rescind $5B in amounts made available by the Medicare Access and CHIP Reauthorization Act of 2015 to supplement the 2017 national allotments to states, including $3B in unobligated balances available on October 1, 2017. 

  • Child Enrollment Contingency Fund: The proposal would rescind $2B in amounts available for the CHIP Contingency Fund, of which there were $2.4B available. The Contingency Fund provides payments to states that experience funding shortfalls due to higher than expected enrollment. 

  • Centers for Medicare and Medicaid Innovation (Innovation Center): The proposal would rescind $800M in amounts made available for FY11-19 for the Innovation Center, of which there were $3.5B available on October 2017. The Innovation Center was created to test innovative payment and service delivery models to reduce program expenditures under Medicare, Medicaid, and CHIP while preserving or enhancing quality care.

 

Speak for Health: Fund Public Health in 2019

As Congress begins its work on the FY 2019 appropriations process, Speak for Health and tell our members of Congress  to reject the proposed cuts to important public health programs in the president's budget proposal and instead to prioritize public health by building upon the important increased investments in public health provided by Congress in FY 2018.

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Most of you know Dr. Bob England, who's been on the AZ public health scene for the last 30 years including 12 years as the Director of the Maricopa County Public Health Department.  You know that he's a terrific cartoonist.  But did you know he's an engaging travel writer?

Bob's been living for the last couple of months just outside of London.  He's been writing some terrifically entertaining travelogues- with a splash of public health of course. Take a few minutes when you're on a comfortable couch and enjoy Travelogue 1 & 2: Getting Settled.  Here’s Travelogue 3: Nutrition. Enjoy.

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If you haven’t yet become a member of AzPHA please consider joining our team!

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