Maternal Health

Federal Court Decision Allows Implementation of the New Title X Family Planning Rules

The new regulations eliminate Title X’s long-standing requirement for non-directive pregnancy options counseling and requires a “bright line” of physical and financial separation between the provision of family planning and abortion services

Title X is a super important public health program that provides folks with comprehensive family planning and related preventive health services. It's designed to prioritize the needs of low-income families or uninsured people. Its overall purpose is to promote positive birth outcomes and healthy families by allowing individuals to decide the number and spacing of children.

The services provided by Title X grantees (the funding comes from the federal government) include family planning and contraception, education and counseling, breast and pelvic exams, breast and cervical cancer screening, screenings and treatment for sexually transmitted infections and HIV.  It also focuses on counseling, referrals to other health care resources, pregnancy diagnosis, and pregnancy counseling. Title X funding does not pay for abortions.

Back in March of this year, the US Department of Health & Human Services published in the Federal Register a final rule making changes to the federal regulations governing the Title X national family planning program. The final rules dramatically change the existing Title X family planning program nationally and in AZ.  The changes include:

  • Eliminating Title X’s long-standing legal and ethical requirement for non-directive pregnancy options counseling; and

  • Requiring a “bright line” of physical and financial separation between the provision of family planning and abortion services.

Numerous provider groups, state attorneys general and non-profit organizations sued and sought an injunction after the new Rules were announced in March (seeking an injunction to stop the rule from taking effect while the courts decide the legality of the rule). 

Legal History of the Case

Multiple federal district court judges blocked the new restrictive rules from going into effect. On June 20, 2019, a three-judge panel of the Ninth Circuit Court of Appeals granted the Trump Administration’s request to lift the preliminary injunctions, allowing the new Title X rules to be enforced. In early July, the 9th Circuit court ordered the cases be reheard en banc (meaning by all the judges on the 9th circuit versus a three-judge panel).

On July 11, the en banc court refused to block the new Title X rules from taking effect, rejecting 20 states, the District of Columbia, and reproductive right advocates request to impose an emergency stay (indefinitely or temporarily suspend or stop proceedings).

So, what’s the bottom line then?  For now- the new April Title X Rules that eliminate Title X’s long-standing legal and ethical requirement for non-directive pregnancy options counseling, and requiring a “bright line” of physical and financial separation between the provision of family planning and abortion services stand.  There have been mixed signals from HHS whether Title X grantees will be contractually required to immediately comply with the new rules or not. 

Earlier last week, published accounts suggested that HHS would be requiring immediate compliance with the new rules by their Title X contractors (including the Arizona Family Health Partnership).  Later in the week, journalists quoted anonymous HHS sources suggesting that Title X grantees wouldn’t be immediately required to adjust their business processes. Late Saturday night grantees got a letter saying the HHS “does not intend to bring enforcement actions against clinics (grantees) that are making good faith efforts to comply” with the new rules. Perhaps grantees (including the Arizona Family Health Partnership) will hear something more specific this week.

Most likely there will be an appeal and rehearing of the challenge to the April Rules in the coming weeks.

A big thanks to AzPHA members Hannah Fleming, Leila Barraza and James Hodge for helping to straighten out this complicated legal case!

Many States Using State Earned Income Tax Credits as a Prevention Strategy for ACEs

Is it Arizona’s Turn?

It’s no secret that exposure during childhood to negative events called adverse childhood experiences increase a person’s likelihood of having long-term chronic or behavioral health issues like heart disease, violence, suicide, and substance use.  ACEs like child abuse, neglect, parent incarceration, substance use, or separation are often clustered.

Policymakers in many states are looking for ways to prevent ACEs… which includes strategies to strengthen protective factors like social connectedness, access to healthcare and community resources, enhancing parental skills to promote healthy child development, and providing quality care and early education, and reduce risk factors before they occur. Arizona took a step forward this year by passing a budget bill that will draw down more than $60M in additional funds to support affordable childcare in Arizona.

Leading evidence-based policies to prevent ACEs before they occur are usually linked in some way to strengthening economic supports to help working families out of poverty and reduce parental stress. One well known economic support is the federal Earned Income Tax Credit

Many states are recognizing that they can also play a role through their state-based tax codes – and implementing Earned Income Tax Credits at the state level. Arizona hasn't done so yet.

Here’s how they work. The Earned Income Tax Credit is a refundable income tax credit that can be used to reduce the tax burden for low- to moderate-income working people.  The federal government along with 29 states have established them at the local level. Arizona doesn’t.

Economic support from Earned Income Tax Credits is associated with improved infant and maternal health, better school performance for children, and increased college enrollment. Research suggests they reduce risk factors for child abuse and neglect ACEs by offsetting the costs of raising a child among working families.

This webpage from the National Conference of State Legislatures has a host of information about which states have state based Earned Income Tax Credits and how they work. They’re usually based on a reference to the federal EITC.

State Earned Income Tax Credits are a promising economic support for working families that help to raise more than six million people—half of them children—above the poverty line each year.

Arizona lawmakers have long had a zeal for reducing taxes.  Perhaps next year they should look at taxes from a new angle- using tax policy to support an evidence-based policy a state based earned income tax credit- that will that prevent negative childhood events and bad public health outcomes.

Report Suggests Paternal Parental Work Flexibility Improves Maternal Outcomes

A new report published this week from the National Bureau of Economic Research found increasing a father's work flexibility after a baby is born reduces the risk of the mother having physical postpartum health complications and also improves her mental health.

Workplace flexibility has long been key factor in improving postpartum outcomes but less has been known about how a father's work hours flexibility influences outcomes.  The paper this week examined father's work flexibility and the affect that it has on intra-household responsibilities and the effect that that flexibility has on maternal outcomes. 

The paper examined the effect that work flexibility has in the months immediately following childbirth. The authors found that a dad's access to workplace flexibility improves maternal health. They modeled household demand for paternal presence at home in the context of a Swedish reform that granted new fathers more flexibility to take intermittent parental leave during the postpartum period.  

Increasing the father's work hours flexibility reduces the risk of the mother experiencing physical postpartum health complications and improved her mental health. The abstract concludes that "Our results suggest that mothers bear the burden from a lack of workplace flexibility–not only directly through greater career costs of family formation, as previously documented–but also indirectly, as fathers' inability to respond to domestic shocks exacerbates the maternal health costs of childbearing."

Interesting research in the context of what kinds of public health policy interventions are effective at improving maternal postpartum health, don't you think?

Legislative Session Wrap Up

Another legislative session is in the books.  All in all - a solid legislative session with some pretty significant public health policy gains.  The main areas where progress was made were in access to care, maternal and child health, assurance and licensure and injury prevention. 

There were several bills that didn't progress which would have been a public health benefit and several really good ideas which never even got a hearing- so there were missed opportunities- but overall a solid B+ session I'd say.

We had lots of help with our advocacy efforts this year. Annissa Biggane and Timothy Giblin worked hard each and every week tracking bills, doing triage, ferreting out schedules, and writing risk/benefit analyses.

Eddie Sissions carried a lot of water as usual. She has great insight and a keen ability to figure out the nuances of session and figuring out "how the water flows". Also a big help were our cadre of folks that called in to our bi weekly calls and strategy sessions.

The real key to our advocacy success is you - our membership.  The relationships you make with our elected officials and your focused advocacy efforts are super important to our success at influencing public policy.   Thank you all and well done this year!

I put together a Powerpoint summary of the 2019 legislative session to help y'all digest what happened this year.  I've got links on the pages that'll drive you to the actual bills. Take a look.  BTW- if you open the link with an Apple product like an iPad- the PowerPoint will look weird and unprofessional- so open it on a laptop and in PowerPoint.

Legislative Update

The only committees that met last week were Rules and Appropriations. The other standing committees (e.g. Health and Human Services) have finished their work. The House Appropriations was particularly dramatic with several strike-everything bills and tensions running high- but nothing really tied to the public health bills we’re interested in. 

We have a whole bunch of bills that need to make it through the Rules Committees (especially the House Rules Committee) before they can go to the floor (the Rules Committee's job is to basically make sure the bill is constitutional). 

Lots of the bills that we care about will be heard this week in the Rules Committee Monday at 1:30pm (here's the agenda). I put an asterisk by the bills below that will be heard Monday. If they all pass- they could move quickly to floor votes (3rd read) this week. Here's this week's spreadsheet summary of the bills.

Bills that have been amended in the opposite house will need to return to their house of origin for another vote.  If there isn't agreement on the amendments, there may need to be conference committees set up to hammer out a solution.

In other news, we were delighted to see that the Senate Health and Human Services Committee this week unanimously recommended that Jami Snyder’s confirmation by the full Senate to be the new AHCCCS Director.  Her nomination will now go to the Senate floor for confirmation.

Steve Pierce was appointed to fill Representative Stringer's seat in District 1 late in the week- which is why there was no floor action in the House this week. 

Bills that still need Floor Votes (3rd Read)

* Means bill will be heard in the Rules Committee Monday (1:30pm).

* SB 1040 Maternal Mortality Report (Brophy-McGee) – AzPHA Position: YES

Passed the Senate 30-0. Bill Passed the House Health Committee 9-0. Rules Committee this week. 

* SB 1085 Association Health Plans- 

Passed the Senate 24-6.  Passed the House Health and Human Services Committee 6-2-1. Rules Committee this week. 

SB 1088 Dental Care During Pregnancy (Carter) – AzPHA Position: YES

Passed the Senate 27-3.  Passed the House Health & Human Services Committee 8-1.  Passed House Appropriations 7-4. Rules Committee Next. Will still need to get into the final budget.

* SB 1089 Telemedicine Insurance Coverage (Carter) – AzPHA Position: Yes

Passed Senate 30-0. Passed the House Health & Human Services Committee 9-0.  Rules Committee this week. 

* SB 1165 Texting and Driving Prohibition (Brophy McGee) – AzPHA Position: YES

Passed Senate 20-10. Passed the House Transportation Committee 5-1-1.  Rules Committee this week. 

SB 1174 Tribal Area Health Education Center – AzPHA Position: Yes

Passed Senate 30-0. Passed the Senate Education Committee 13-0. Rules Committee Next.

* SB 1211 Intermediate Care Facilities (Carter) AzPHA Position: Yes

Passed the Senate 30-0. Passed the House Health & Human Services Committee 9-0. Rules Committee this week. 

* SB 1247 Residential Care Institutions (Brophy McGee) AzPHA Position: Yes

Passed the Senate 30-0.  Bill passed the House Health Committee 9-0. Rules Committee this week. 

SB 1245 Vital Records- Death Certificates (Brophy McGee) AzPHA Position: Yes

Passed the Senate 30-0.  Passed through all House Committees- ready for a Floor Vote.

SB 1354 Graduate Medical Information & Student Loan Repayment (Carter) AzPHA Position: Yes

Passed Senate 28-2.  Passed House Appropriations Committee 10-1, Withdrawn at the HHS Committee, but can still move forward if it can pass the Rules Committee. This is the most important access to care bills this year- it would do a great deal both in the short-term by boosting the primary care loan repayment program and really enhancing graduate medical education residencies over the coming years (important because where a practitioner does her or his residency greatly influences where they ultimately practice).

HB 2125 Child Care Subsidies (Udall) – AzPHA Position: YES

Passed House 46-13.  Passed the Senate Health and Human Services Committee 7-0-1. Rules Committee Next.

* HB 2488 Veteran Suicide Annual Report (Lawrence) AzPHA Position: Yes

Passed House 60-0. Passed the Senate Health and Human Services Committee 7-0-1. Passed 29-0 in the Senate, sent back to House because it's different than the original bill.  

SB 1009 Electronic Cigarettes, Tobacco Sales (Carter) – AzPHA Position: YES

Passed the Senate 30-0. Assigned to the House Health and Human Services Committee but didn't get a hearing- not a good sign.

* SB 1355 Native American Dental Care – AzPHA Position: Yes

Passed Senate 25-5.  Passed the House Health & Human Services Committee 9-0. Rules Committee this week. 

SB 1456 Vision Screening- AzPHA Position: Yes

Passed Senate 29-0. Passed the House Health & Human Services Committee 9-0. Rules Committee Next.

* SB 1468 Suicide Prevention- Schools- AzPHA Position: Yes

Requires school districts, charter schools, and Arizona teacher training programs to include suicide awareness and prevention training and requires the Arizona Health Care Cost Containment System Administration (AHCCCS) to make suicide awareness and prevention training available. Rules Committee this week. 

SB 1060 (Strike-all Amendment) Electronic Cigarettes. Smoke Free Arizona Act (Carter) – AzPHA Position: YES

Passed the Senate 28-0. Assigned to the House Health and Human Services Committee- but not heard.  Not a good sign. Probably dead.

 

Bills that Have Been Passed & Signed by the Governor

SB 1109 Short Term Limited Health Plans- extension – AzPHA Position: Opposed

This bill has passed both chambers and has been signed by the Governor.  It authorizes the sale of short- term limited health plans in Arizona for terms up to 3 years.  The previous limit was 1 year.  These plans don’t cover pre-existing conditions and have limited consumer protection because they aren’t required to cover the essential health services under the ACA and can drop enrollees.  We urged a not vote because of the poor consumer protections.

Arizona Family Health Partnership Snags Title X Family Planning Grant

The Arizona Family Health Partnership is once again the sole Title X Family Planning grantee for Arizona. They received their Notice of Award last week for up to 3 years. The grant is for the $5.2M per year.

Title X is a super important public health program that provides folks with comprehensive family planning and related preventive health services. It's designed to prioritize the needs of low-income families or uninsured people. Its overall purpose is to promote positive birth outcomes and healthy families by allowing individuals to decide the number and spacing of children.

The services provided by Title X grantees include family planning and contraception, education and counseling, breast and pelvic exams, breast and cervical cancer screening, screenings and treatment for sexually transmitted infections and HIV.  It also focuses on counseling, referrals to other health care resources, pregnancy diagnosis, and pregnancy counseling. Title X funding does not pay for abortions.

The AFHP has been the awardee for these services in AZ for many years. When I was at the ADHS, we didn't apply for the Title X grant because our team believed that the AFHP did a really good job providing these services.  A couple of years ago one of the state budget bills required the ADHS to apply for the Title X grant.

Many people believe the line item was included in the budget in hopes that ADHS rather than AFHP would get the grant.  The motivation for that is that the ADHS is prohibited from contracting with Planned Parenthood for Title X services (which do not include abortion services), while AFHP (as an independent nonprofit) could continue to contract with Planned Parenthood.

Extending Preventative Oral Health Coverage to Pregnant Medicaid Members will Save Money & Improve Birth Outcomes

Good oral health is more than just a nice smile. Having good oral health improves a person’s ability to speak, smile, smell, taste, touch, chew and eat. Untreated tooth decay leads to needless pain and suffering; difficulty in speaking, chewing, and swallowing; and missed school days. Evidence also suggests that poor oral hygiene and health increases the risk of other health problems like diabetes, stroke, heart disease and bad pregnancy outcomes. 

Physical and nutritional changes that occur during pregnancy often lead to an increased risk of dental and gum problems from increased inflammatory response, loosened ligaments and increased acidity in the mouth. In addition, several studies have found a link between gum infection and poor birth outcomes, such as pre-term deliveries, lower birth weight and high blood pressure, which can lead to serious complications for both mom and the baby.

Many studies have found a relationship between periodontal disease and worse birth outcomes- but until now there hasn’t been a systematic overview of systematic reviews.  Now there is.  This new systematic overview found a clear relationship between periodontal disease and pre-term birth, low birth weight and preeclampsia (potentially dangerous high blood pressure during delivery).  The researchers reviewed 23 systematic reviews (including between 3 and 45 studies) and found an association between periodontal disease and preterm birth (relative risk, 1.6), low birth weight (LBW; relative risk, 1.7), preeclampsia (odds ratio, 2.2), and preterm low birth weight (relative risk 3.4).

The implications of the study are profound.  The estimated population-attributable fractions for periodontal disease has a mid-point of 16%, 18% for low birth weight, and 22% for preeclampsia.  Let’s look at what that means here in AZ.

In 2015, 7.2% of AZ live births were low birthweight (less than 2.5 kg).  With about 80,000 births (5,760 low birthweight births a year), that means periodontal disease is potentially contributing to 1,036 low birthweight weight babies each year in AZ. 

About half of AZ births are paid for by our Medicaid program- meaning periodontal disease may be contributing to 520 low birth weight babies among Medicaid members every year.  Let’s look at what that might be costing.

An analysis by Truven Health Analytics a few years ago found that the average health care cost for a low birth weight baby during the first year of life is $55,393 compared with $5,085 for a non-low birth weight baby. 

Putting the two estimates together suggests that the 520 pre-term babies potentially attributable to periodontal disease (and paid for by Medicaid) would cost about $29M for the first year of life compared with only $2.6M for a similar number of non pre-term births, a savings to the state that is much greater than the estimated cost of the benefit (less than $200K in the first year).

Let’s do whatever we can to get comprehensive oral health coverage for pregnant Medicaid members   SB 1088 over the line this year and improve birth outcomes while reducing health care costs!  It’s being heard in the House Appropriations Committee Wednesday, March 20 starting at 2 pm.  We’re signed up in support of the initiative and I’ll be speaking briefly at the hearing.

You can help by contact the House Appropriations Committee members with the contact info at the end of this email and letting them know that investing in better oral health for pregnant Medicaid members will improve birth outcomes and reduce healthcare costs. The piece below is also posted on our website at: http://www.azpha.org/wills-blog

Member & email address

Regina E. Cobb rcobb@azleg.gov  

Diego Espinoza despinoza@azleg.gov

Charlene R. Fernandez cfernandez@azleg.gov

John Fillmore jfillmore@azleg.gov

Randall Friese rfriese@azleg.gov

John Kavanagh jkavanaugh@azleg.gov

Anthony T. Kern akern@azleg.gov

Aaron Lieberman alieberman@azleg.gov

Bret Roberts broberts@azleg.gov

Ben Toma btoma@azleg.gov

Michelle Udall mudall@azleg.gov

 

 

Legislative Committee Hearings This Week

Senate Health & Human Services Committee

Wednesday, March 13, 9 am (SHR 1)

 

HB 2125 Child Care Subsidies (Udall) – AzPHA Position: YES

Passed House 46-13.  Assigned to House Health and Human Services Committee.

 

HB 2488 Veteran Suicide Annual Report (Lawrence) AzPHA Position: Yes

Passed House 60-0. Assigned to Senate Health and Human Services Committee.

House Transportation Committee

Wednesday, March 13, 2 pm (HHR 2)

 

SB 1165 Texting and Driving Prohibition (Brophy McGee) – AzPHA Position: YES

Passed Senate 20-10. Assigned to House Transportation Committee. 

House Health & Human Services Committee

Thursday, March 14, 9 am (HHR 4)

SB 1088 Dental Care During Pregnancy (Carter) – AzPHA Position: YES

Passed the Senate 27-3.  Assigned to House Health & Human Services Committee.

 

SB 1211 Intermediate Care Facilities (Carter) AzPHA Position: Yes

Passed the Senate 30-0. Assigned to House Health & Human Services Committee.

Fed’s Making Big Changes to Title X Family Planning Funding

The US Department of Health & Human Services published in the Federal Register a final rule making changes to the federal regulations governing the Title X national family planning program. The final rules will dramatically change the existing Title X family planning program nationally and in AZ.  The changes will include:

Diminishing Title X’s ability to offer confidential, affordable, high-quality family planning care to people struggling financially or who are otherwise vulnerable and in need of care;

Eliminating Title X’s long-standing legal and ethical requirement for non-directive pregnancy options counseling; and

Requires a “bright line” of physical and financial separation between the provision of family planning and abortion services.

Numerous provider groups, state attorneys general and non-profit organizations are suing HHS seeking an injunction to stop the rule from taking effect while the courts decide the legality of the rule.

The American Medical Association along with Planned Parenthood Federation of America filed a lawsuit in Oregon.  Essential Access Health (the California Title X grantee) filed a lawsuit and the California AG filed a separate lawsuit to challenge the rule yesterday. 

There are now 23 State Attorney Generals that have announced plans to fight the final Title X rule, along with several nonprofits (AZ is not on the list). Others opposing the rule include health care providers of all stripes, public health associations including APHA, legal and ethical experts, reproductive justice advocates, policymakers and many others. A great reference to this activity is the story from the Washington Post, published before the last two states joined.

The Judicial branch of government will likely be the place that determines whether the new proposed final rules making these changes to Title X will actually go into effect.

It’s Switchover Time at the Legislature

The week before last was the deadline for bills to be heard in their chamber of origin- and much of last week’s action was on floor votes (called Third Read).  When a bill clears the House or Senate (having a 3rd reading with a recorded vote of the body) it’s transmitted to the other body of the legislature (the switchover). At that point, it gets 1st and 2nd read and assigned to a committee (s). Then it’s up to the chair to schedule the bill.

If heard, then it gets voted on and gets thru that body. If there are no changes, it’s sent back to its original body who then transmits it to the Governor. If there are changes the bill, goes back to the originating body to decide if they accept the changes. If they do, they’ll be a final read and recorded vote before transmitting to the Governor. If they don’t agree then it goes to conference committee. It can be a “simple” conference where the choice is the House or the Senate version. Most are free conference committees in which there are 3 members per body who serve.

Conference committees usually don’t take testimony.  The meetings are open but there’s usually only announcements from the floor to know when the group meets.  If there’s finally agreement, it goes back for acceptance of the conference report and a final vote by each side before it goes to the Governor.

_______

Lots of action last week with lots of 3rd read floor votes in the Senate. The House isn’t as far along in finishing 3rd reads.  This week we'll mostly be watching the 3rd Read votes.  We'd really like to get the hand free cell use bill, the syringe services bill, the GME bill and the e-cigarette smoke free AZ act bill through their chambers this week. Here's our document with all the particulars on bills this week.

Public health can breathe a little sigh of relief now that the Governor made it clear that he doesn’t   intend to sign any bill that would lower vaccination rates. We're already gambling with the lives of infants, people with disabilities, and immune optimized folks because of the erosion in our immunization rates and any of the 3 anti-vaccine bills this year (HB 2470, HB 2471, or HB  2472 would have done just that. 

We need public health policy decisions that improve vaccination rates, not decisions that put vulnerable people at even more risk.  With the Governor’s statements this we can now focus more of our efforts on the other (mostly good) public health policy bills out there.

 

Bills that Passed through the House or Senate

Access to Care & Healthcare Workforce

SB 1088 Dental Care During Pregnancy (Carter) – AzPHA Position: YES

Passed the Senate 27-3.  This bill would expand AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding. Good oral health is well established to improve birth outcomes including reducing pre-term birth while also preventing the transmission of caries from mom to infant after birth.  This priority bill was passed by the Senate this week and has been transferred to the House. Note that since this bull would have a needed appropriation it will need to be included in the final state budget.

SB 1089Telemedicine Insurance Coverage (Carter) – AzPHA Position: Yes

This Bill would put into law specific standards requiring non-Medicaid insurance companies to cover telemedicine.  There are criteria and standards in the law regarding contracting standards. Requires that coverage for telemedicine healthcare services if the service is covered when delivered in-person.   This bill would be good for access to care especially in rural Arizona which is why we’re supporting it. Passed 30-0.

SB 1174 Tribal Area Health Education Center

Health Education System consists of five area health education centers each representing a geographic area with specified populations that currently lack services by the health care professions.  The current regional centers include: 1) Eastern Arizona AHEC; 2) Greater Valley AHEC; 3) Northern Arizona AHEC; 4) Southeast Arizona AHEC; and 5) Western Arizona AHEC/Regional Center for Border Health.  This bill adds an area health education center that would focus on tribal areas and the Indian health care delivery system. Passed 30-0.  

SB 1355 Native American Dental Care

Passed Senate 25-5.  Requires AHCCCS to seek federal authorization to reimburse the Indian health services and tribal facilities to cover the cost of adult dental services.

** Kids Care: The Kids Care Reauthorization bills have all languished in their chamber of origin, however, we have good reason to believe that reauthorizing Kids Care including the appropriation needed to pay the state match (10%) will be negotiation in the state budget bills.

 

Licensing & Vital Records

SB 1247 Residential Care Institutions (Brophy McGee) AzPHA Position: Yes

Passed the Senate 30-0. This good bill will require more robust staffing background checks for facilities that provide services for children and will remove the “deemed status” designation for child residential behavioral health facilities.  Under current law, facilities in this category (e.g. Southwest Key) can be accredited by a third party (e.g. Council on Accreditation) and avoid annual surprise inspections by the ADHS.  This intervention will provide more oversight to ensure background checks are done and that the facilities are compliant with state regulations. 

 

SB 1211 Intermediate Care Facilities (Carter) AzPHA Position: Yes

Passed the Senate 30-0. Like SB 1247, this bill closes a licensing loophole.  This good bill will require more robust staffing background checks for facilities that provide services to people with disabilities at intermediate care facilities.  These facilities would also require a license to operate from the Arizona Department of Health Services beginning on January 1, 2020.  Under current law these facilities (Hacienda de los Angeles and similar facilities run by the ADES are exempt from state licensing requirements)

 

SB 1245 Vital Records- Death Certificates (Brophy McGee) AzPHA Position: Yes

This bill will make it clear that both state and county Registrars can provide certified copies of death certificates to licensed funeral home directors upon request.  There’s been some confusion about this authority and this bill would clear it up.   Passed the Senate 30-0.

Tobacco & Nicotine

SB 1009 Electronic Cigarettes, Tobacco Sales (Carter) – AzPHA Position: YES

Expands the definition of tobacco products to include e-cigarettes. Among other things, it'll make it clear that it's illegal to sell e-cigarettes to minors. The penalty for selling to minors remains at $5K. Passed the Senate 30-0.

Surveillance & Social Determinants

HB 2125 Child Care Subsidies (Udall) – AzPHA Position: YES

Passed House 46-13.  Makes a supplemental appropriation of $56 million from the Federal Child Care and Development Fund block grant in FY2018-19 to the Department of Economic Security for child care assistance. Another bill, HB 2124 would allocate the money as follows: $26.7 million for provider rate increases, $14 million to serve children on the waiting list, and $13.1 million to increase tiered reimbursement for infants, toddlers and children in the care of DCS. HB 2436 is a similar bill. Passed 46-13 and has moved over to the Senate.

HB 2488 Veteran Suicide Annual Report (Lawrence) AzPHA Position: Yes

Requires ADHS to annually compile a report on veteran suicides beginning January 1, 2020. The data in the report would be shared across the public health system and with the VA and will hopefully include surveillance results that are actionable to prevent veteran suicides.

SB 1040 Maternal Mortality Report (Brophy-McGee) – AzPHA Position: YES

This bill would require the Child Fatality Review Team subcommittee on maternal mortality to make recommendations on improving information collection. Passed the Senate 30-0.

Bills that Still Need to Have a Final (3rd Read) First Chamber Vote

SB 1165 Texting and Driving Prohibition (Brophy McGee) – AzPHA Position: YES

This bill prohibits using a hand-held cell phone while driving.  There are some common-sense exemptions for example if the person is using it hands free etc.  Violations are a civil $ penalty (no driving points) with the first offense being between $75- $150 and the 2nd offense between $150 and $250.  The bill would provide a state overlay so the cell phone use laws would no longer be different from jurisdiction to jurisdiction. We’re signed up in support of this bill.  This bill still needs to go to Committee of the Whole and get a Senate 3rd read.

HB 2718 Syringe Services Programs (Rivero) AzPHA Position: Yes

Decriminalizes syringe access programs, currently a class 6 felony. To qualify, programs need to list their services including disposal of used needles and hypodermic syringes, injection supplies at no cost, and access to kits that contain an opioid antagonist or referrals to programs that provide access to an opioid antagonist.  Approved by the International Affairs Study Committee this week.  Did not receive a hearing in Rules yet, we’ll work with stakeholders to get it heard in Rules.

SB 1354 Graduate Medical Information & Student Loan Repayment (Carter) AzPHA Position: Yes

This bill appropriates $50M from the General Fund to AHCCCS, UA Health Science Center, ADHS and the to address the state-wide shortage of physicians and nurses.  The bill has several elements with a rural focus. Elements include $20M for Graduate Medical Education in critical-access hospitals and community health centers in rural areas and $4M for the ADHS’ health practitioners loan repayment system. Many elements will be very good for access to care in rural AZ.  Bill still needs a final vote in the Senate and of course – since it’s a money bill it’ll need to go through the budget process.

SB 1060 (Strike-all Amendment) Electronic Cigarettes. Smoke Free Arizona Act (Carter) – AzPHA Position: YES

Includes e-cigarettes in the definition of tobacco products and smoking for the purposes of the Smoke Free Arizona Act.  Allows smoking in retail stores that sell electronic smoking devices exclusively and have an independent ventilation system.  Because the Act was voter approved- this modification to the law will require a 3/4 majority of both houses.  This bill still needs to go to Committee of the Whole and get a Senate 3rd read.

SB 1456 Vision Screening- AzPHA Position: Yes

This bill would require schools to provide vision screening services to students in grades prescribed by future ADHS rules, kids being considered for special education services, and students who are not reading at grade level by the third grade. Appropriates $100,000 from the state General Fund to the ADHS for the tracking and follow up.  This bill still needs to go to Committee of the Whole and get a Senate 3rd read.

HB 2471 Informed Consent (Barto) - AzPHA Position: Opposed

This bill would add a requirement that physicians provide to parents and guardians the full vaccine package insert and excipient summary for each vaccine that will be administered.  Physicians already provide a Vaccine Information Summary to parents and guardians for each vaccine administered, which is noted in the medical record.  This new requirement would mandate provision of the 12-15 page insert, which is not presented in a format that incorporates health literacy principles.  Bill is likely dead but we’re remaining vigilant and will work with Stakeholders like TAPI to hold it back in the House.

HB  2472 Vaccinations- Antibody Titer (Barto) - AzPHA Position: Opposed

These bills would mandate that doctors inform parents and guardians that antibody titer tests (which involve a venous draw) are an option in lieu of receiving a vaccination and that there are exemptions available for the state requirements for attending school.   Bill is likely dead but we’re remaining vigilant and will work with Stakeholders like TAPI to hold it back in the House.

HB 2470 Vaccination Religious Exemptions (Barto) - AzPHA Position: Opposed

This bill would add an additional exemption to the school vaccine requirements into state law.  Currently there are medical and personal exemptions.  The bill doesn't include any verification of the religious exemption from a religious leader, just a declaration from the parent that they are opposed to vaccines on religious grounds.  Bill is likely dead but we’re remaining vigilant and will work with Stakeholders like TAPI to hold it back in the House.

Good Bills that are Effectively Dead

Unless a miracle happens- this is the last time you’ll see me mention the bills below in my policy updates

SB 1363  Tobacco Product Sales (Tobacco 21) (Carter)

HB 2162  Vaccine Personal Exemptions (Hernandez)

HB 2352 School Nurse and Immunization Postings (Butler)

HB 2172  Rear Facing Car Seats (Bolding)

HB 2246  Motorcycle Helmets (Friese)

SB 1219  Domestic Violence Offenses & Firearm Transfer

HB 2247  Bump Stocks (Friese)

HB 2248  Firearm Sales (Friese)

HB 2161  Order of Protection (Hernandez)

SB 1119 Tanning Studios (Mendez)

HB 2347  Medicaid Buy-in (Butler)

HB 2351  Medical Services Study Committee (Butler)

Legislative Update

State Legislature Bill Update

All the legislative committees are off to the races now- busy considering the various bills assigned to them by the Speaker of the House or the President of the Senate.  In order to survive, Bills will need to be heard in all their house of origin committees in the next few weeks and then get a floor vote, pass that, and then move over to the other chamber.

Our Public Health Policy Committee met over the phone last week and we took positions on many bills- and we input them into the www.azleg.gov system to demonstrate our support.

This week I’ll start with a summary of bills scheduled for a hearing next week, followed by the bills that were heard last week. 

This week I'm not listing all the bills that haven’t seen action yet- but you’ll be able to find those on my blog at http://www.azpha.org/wills-blog

 

Bills that Will Be Heard in Committee This Week

SB 1247 Residential Care Institutions (Brophy McGee) – AzPHA Position: Yes

This good bill will require more robust staffing background checks for facilities that provide services for children and will remove the “deemed status” designation for child residential behavioral health facilities.  Under current law, facilities in this category (e.g. Southwest Key) can be accredited by a third party (e.g. Council on Accreditation) and avoid annual surprise inspections by the ADHS.

This intervention will provide more oversight to ensure background checks are done and that the facilities are compliant with state regulations.  Bill will be heard in Senate Health & Human Services on Wednesday at 8:30am in SHR1.  I’ll be speaking in favor at the hearing.


SB 1211 Intermediate Care Facilities (Carter) – AzPHA Position: Yes

Like SB 1247, this bill closes a licensing loophole.  This good bill will require more robust staffing background checks for facilities that provide services to people with disabilities at intermediate care facilities.  These facilities would also require a license to operate from the Arizona Department of Health Services beginning on January 1, 2020. 

Under current law these facilities (Hacienda de los Angeles and similar facilities run by the ADES are exempt from state licensing requirements.  Bill will be heard in Senate Health & Human Services on Wednesday at 8:30am in SHR1.  I’ll be speaking in favor at the hearing.

SB 1088 Dental Care During Pregnancy (Carter) – AzPHA Position: YES

This bill would expand AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding. Passed the Senate Health & Human Services Committee on 1/23.  Will be heard in the Senate Appropriation Committee Tuesday, Feb 12 at 2 pm.  I’ll be speaking in favor at the hearing.

 

Bills that Were Heard in Committee Last Week

SB 1009 Electronic Cigarettes, Tobacco Sales (Carter) – AzPHA Position: YES

Expands the definition of tobacco products to include e-cigarettes. Among other things, it'll make it clear that it's illegal to sell e-cigarettes to minors. The penalty for selling to minors remains at $5K. Passed the Senate Health & Human Services Committee 1/23.  Rules Committee is next.

SB 1040 Maternal Mortality Report (Brophy-McGee) – AzPHA Position: YES

This bill would require the Child Fatality Review Team subcommittee on maternal mortality to compile an annual statistical report on the incidence and causes of "severe maternal morbidity" with recommendations for action.  The current law requires a review of the data but no report. Passed the Senate Health & Human Services Committee on 1/23. Passed Rules & COW.  Floor vote soon.

HB 2125 Child Care Subsidies (Udall) – AzPHA Position: YES

Makes a supplemental appropriation of $56 million from the Federal Child Care and Development Fund block grant in FY2018-19 to the Department of Economic Security for child care assistance. Another bill, HB 2124 would allocate the money as follows: $26.7 million for provider rate increases, $14 million to serve children on the waiting list, and $13.1 million to increase tiered reimbursement for infants, toddlers and children in the care of DCS. HB 2436 is a similar bill. Passed the House Health Committee this week.  On to Rules.

SB 1011 Information and Referral Service (Carter) – AzPHA Position: YES

Appropriates $1.5 million from the general fund in FY2019-20 to the ADES for a statewide information and referral service for health care services, community services, human services and governmental services.  Passed the Senate Health & Human Services Committee this week.  On to Approps & Rules.

HB 2350 HB2513 SB1134 Kids Care (Butler, Brophy-McGee, Cobb) – AzPHA Position: YES

SB 1134 passed Senate Health and Human Services this week, on to Approps and Rules. These bills Would appropriate funding so that Kids Care could continue after the federal match rate goes below 100% on October 1, 2019.

SB 1341 Tanning Studios (Carter) – AzPHA Position YES

Would require people under 18 that want to use a commercial tanning bed service to have permission from their parent or guardian. This passed the Senate Commerce Committee Thursday.  On to Rules Committee then the Senate Floor.

Check Out AzPHA's Position on Multiple Bills

State Legislature Bill Update

More than 700 bills have so far been proposed by members of the Arizona State Legislature so far.  Our Public Health Policy Committee is busy sifting through them and looking for those that will have a public health impact.  We’ve taken public positions on the www.azleg.gov website on more than 20 bills with links to public health.  Below is a quick summary of those bills and the positions that AzPHA has taken.

Tobacco Bills

SB 1009 Electronic Cigarettes, Tobacco Sales (Carter) – AzPHA Position: YES

Expands the definition of tobacco products to include e-cigarettes. Among other things, it'll make it clear that it's illegal to sell e-cigarettes to minors. The penalty for selling to minors remains at $5K. Passed the Senate Health & Human Services Committee last Wednesday.

HB 2024 Electronic Cigarettes. Smoke Free Arizona Act (Kavanaugh) – AzPHA Position: YES

Includes e-cigarettes in the definition of tobacco products and smoking for the purposes of the Smoke Free Arizona Act.  Because the Act was voter approved- this modification to the law will require a 3/4 majority of both houses.

HB 2073 Vapor Products; Regulation (Shope) – AzPHA Position: Opposed

This bill would basically set up a regulatory program at the ADHS to inspect and license electronic cigarette manufacturers in Arizona and specify that only licensed electronic cigarette manufacturers can sell products in Arizona.  It gives no regulatory authority to the ADHS to enforce that vape shops get licensed and they only must do it every 5 years. There are no penalties for noncompliance and penalties are against the purchaser instead of the retailer.

SB 1363 Tobacco Product Sales (Tobacco 21) (Carter) - AzPHA Position: YES

Tis bill would move the tobacco product (and e-cigarette) buy age to 21.  Bill includes definitions and criteria as well as penalties for vendors that sell to people under 21.

 

Maternal & Child Health

SB 1088 Dental Care During Pregnancy (Carter) – AzPHA Position: YES

This bill would expand AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding. This bill passed the Senate Health Committee 8-0 this week!

SB 1040 Maternal Mortality Report (Brophy-McGee) – AzPHA Position: YES

This bill would require the Child Fatality Review Team subcommittee on maternal mortality to compile an annual statistical report on the incidence and causes of "severe maternal morbidity" with recommendations for action.  The current law requires a review of the data but no report. This bill passed the Senate Health Committee 8-0 this week!

HB 2125 Child Care Subsidies (Udall) – AzPHA Position: YES

Makes a supplemental appropriation of $56 million from the Federal Child Care and Development Fund block grant in FY2018-19 to the Department of Economic Security for child care assistance. Another bill, HB 2124 would allocate the money as follows: $26.7 million for provider rate increases, $14 million to serve children on the waiting list, and $13.1 million to increase tiered reimbursement for infants, toddlers and children in the care of DCS. HB 2436 is a similar bill.

 

Vaccines

HB 2162 Vaccine Personal Exemptions (Hernandez) -  AzPHA Position: Yes

This bill would remove the personal exemption option for parents to enroll in school when the child hasn’t had all the required school attendance immunizations.

HB 2352 School Nurse and Immunization Postings (Butler) – AzPHA Position: Yes

School districts and charter schools would be required to post on their websites whether a registered nurse is assigned to each school as well as required reports on immunization rates.

SB 1115 and HB 2471 Informed Consent (Boyer, Barto) - AzPHA Position: Opposed

These bills would add a requirement that physicians provide to parents and guardians the full vaccine package insert and excipient summary for each vaccine that will be administered.  Physicians already provide a Vaccine Information Summary to parents and guardians for each vaccine administered, which is noted in the medical record.  This new requirement would mandate provision of the 12-15 page insert, which is not presented in a format that incorporates health literacy principles.

HB  2472 and SB 1116 Vaccinations- Antibody Titer (Boyer, Barto) - AzPHA Position: Opposed

These bills would mandate that doctors inform parents and guardians that antibody titer tests (which involve a venous draw) are an option in lieu of receiving a vaccination and that there are exemptions available for the state requirements for attending school. 

 

Injury Prevention

SB 1165 Texting and Driving Prohibition (Brophy McGee) – AzPHA Position: YES

This bill prohibits using a hand-held cell phone while driving.  There are some common-sense exemptions for example if the person is using it hands free etc.  Penalties are a civil penalty (no driving points) with the first offense being between $75- $150 and the 2nd offense between $150 and $250.  We are signed up in support of this bill.

HB 2069 Texting and Driving (Kavanaugh) - AzPHA Position: Supporting SB 1165

Makes texting while driving on a highway a nonmoving civil traffic violation.  The penalty for the 1qst violation would be $100 and the second offense would be $300.  If a crash is involved the penalty would be $500 but if someone died it would be $10K.   subject to a civil penalty of $500, except that if the accident results in the death of another person, the civil penalty is $10,000.

HB 2165  Distracted Driving (Townsend) - AzPHA Position: Supporting SB 1165

A person who drives a vehicle while participating in an activity that willfully distracts the person from safely operating the vehicle is guilty of reckless driving, a class 2 (mid-level) misdemeanor.  I’m not sure if texting and driving would qualify or not- it probably does.

HB 2172  Rear Facing Car Seats (Bolding) - AzPHA Position: YES

Kids under two years of age need to be in a rear-facing restraint system unless the child weights at least 40 pounds or is at least 40 inches tall.

HB 2246  Motorcycle Helmets (Friese) – AzPHA Position YES

Motorcycle riders over 18 would be required to wear a helmet unless they pay a fee that would be set by ADOT. Violations would be a $500 civil penalty, but no points or other sanctions. 

HB 2075  Electronic Prescribing (Cobb) – AzPHA Position: Yes

Pushes the electronic prescribing requirement in last year’s Opioid Epidemic Act back to January 2, 2020 in all counties.  Being heard in House Health & Human Services Committee Thursday Feb 24 at 9 am.

Firearm Safety

SB 1219 Domestic Violence Offenses & Firearm Transfer AzPHA Position: Yes

Persons that have been adjudicated and the court rules that they may not possess a firearm must surrender their firearms to a law enforcement agency.  The law enforcement agency may then dispose of the firearm(s) in accordance with law.  People that have an Order of Protection against them must also surrender their firearms, although the law enforcement agency must return the firearm when the Order expires (after a background check).

HB 2247 Bump Stocks (Friese) – AzPHA Position: Yes

This bill would outlaw the sale of bump stocks on firearms.

HB 2248 Firearm Sales (Friese) – AzPHA Position: Yes

This bill would require a background check for all sales at gun shows.

HB 2161 Order of Protection (Hernandez) AzPHA Position: Undetermined

A person who is at least 18 years of age and who is either a law enforcement officer, a “family or household member” (defined), a school administrator or teacher or a licensed behavioral health professional who has personal knowledge that the respondent is a danger to self or others is permitted to file a verified petition in the superior court for a one-year Severe Threat Order of Protection (STOP order), which prohibits the respondent from owning, purchasing, possessing or receiving or having in the respondent’s custody or control a firearm or ammunition for up to one year.

HB 2249  Mental Health and Firearm Possession (Friese) AzPHA Position: Undetermined

An immediate family member or a peace officer is authorized to file a verified petition with a magistrate, justice of the peace or superior court judge for an injunction that prohibits a person from possessing, controlling, owning or receiving a firearm. Any court may issue or enforce a mental health injunction against firearm possession, regardless of the location of the person. Information that must be included in the petition is specified. If the court finds that there is clear and convincing evidence to issue a mental health injunction against firearm possession, the court must issue the injunction. Information that must be included in the injunction is specified.

 

Harm Reduction

HB 2148 Syringe Services Programs (Rivero) AzPHA Position: Yes

Decriminalizes syringe access programs, currently a class 6 felony. To qualify, programs need to list their services including disposal of used needles and hypodermic syringes, injection supplies at no cost, and access to kits that contain an opioid antagonist or referrals to programs that provide access to an opioid antagonist.

SB 1119 Tanning Studios (Mendez) – AzPHA Position YES

Would require people under 18 that want to use a commercial tanning bed service to have permission from their parent or guardian.

Agency Administration

SB 1247 Residential Care Institutions (Brophy McGee) – AzPHA Position: Yes

This good bill will require more robust staffing background checks for facilities that provide services for children and will remove the “deemed status” designation for child residential behavioral health facilities.  Under current law, facilities in this category (e.g. Southwest Key) can be accredited by a third party (e.g. Council on Accreditation) and avoid annual surprise inspections by the ADHS. This intervention will provide more oversight to ensure background checks are done and that the facilities are compliant with state regulations.

HB 2004 Nuclear Management Fund (Kavanaugh) – AzPHA Position: Undetermined

Assesses the Palo Verde nuclear plant $2.55M and gives it to ADEM, ADHS and other jurisdictions to compensate them for off-site nuclear emergency response plan response activities.  Being heard in House Appropriations Committee Wednesday Feb 23 at 2 pm.

HB 2280  Interfacility Ambulance Transports (Weninger) - AzPHA Position: Undetermined

A person may operate an "interfacility transfer ambulance service" by applying to the Department of Health Services for a certificate of operation with defined requirements.   The requirement to transport a patient under medical direction to the nearest, most appropriate facility as defined by federal Medicare guidelines does not apply to an interfacility transfer ambulance service with a certificate of operation.

SB 1011 Information and Referral Service (Carter) – AzPHA Position: YES

Appropriates $1.5 million from the general fund in FY2019-20 to the ADES for a statewide information and referral service for health care services, community services, human services and governmental services.  

 

AHCCCS Coverage & Private Insurance Coverage

HB 2347 Medicaid Buy-in (Butler) AzPHA Position: Undetermined

Would require AHCCCS to set up a program in which eligible people could pay a premium and receive Medicaid health insurance.

HB 2350 HB2513 SB1134 Kids Care (Butler, Brophy-McGee, Cobb) – AzPHA Position: YES

These bills Would appropriate funding so that Kids Care could continue after the federal match rate goes below 100% on October 1, 2019.

HB 2351 Medical Services Study Committee (Butler) – AzPHA Position: Yes

Establishes a 14-member Medical Services Purchase Program Study Committee to research and make recommendations for establishing and implementing a medical services purchase program. The Committee is required to submit a report of its findings and recommendations to the Governor

HB 2120  Chiropractic Coverage (Barto) - AzPHA Position: Undetermined

Would add chiropractic services to the list of reimbursable services under AHCCCS.  Being heard in House Health & Human Services Committee Thursday Feb 24 at 9 am.

SB 1088 Dental Care During Pregnancy (Carter) - AzPHA Position: Yes

This bill would expand AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding.

SB 1089 Telemedicine Insurance Coverage (Carter) – AzPHA Position: Yes

This Bill would put into law specific standards requiring non-Medicaid insurance companies to cover telemedicine.  There are criteria and standards in the law regarding contracting standards. Note: this is all Title 20 language and does not apply to Medicaid (AHCCCS).

Food Safety & Insecurity

HB 2178  Milk Manufacturing License Exemption - AzPHA Position: Undetermined

A restaurant wouldn’t be required to get a license to manufacture or distribute frozen desserts or frozen milk products if the product is manufactured or distributed and sold at the same facility for on-site consumption.

HB 2186  School Meals (Udall) AzPHA Position: Yes

Schools are required to provide a school meal to a student who requests it regardless of whether the student pays for a school meal or owes money for previous meals. Local education agencies are prohibited from taking a list of specified actions relating to unpaid school meal fees, including announcing or publicizing the names of students with unpaid school meal fees, requiring a student who cannot pay for a meal or who owes unpaid meal fees to work for a meal, and attempting to collect unpaid school meal fees from a student. Local education agencies are prohibited from using a debt collector to attempt to collect unpaid school meal fees.

 

Access to Care

HB 2218 State Loan Repayment (Blanc) – AzPHA Position: YES

Makes a supplemental appropriation of $500,000 from the general fund in FY2019-20 to the Department of Health Services to pay off portions of education loans taken out by physicians, dentists, pharmacists, advance practice providers and behavioral health providers participating in the primary care provider loan repayment program.  An additional $500K would be appropriated to pay off education loans taken out by physicians, dentists, pharmacists, advance practice providers and behavioral health providers participating in the rural private primary care provider loan repayment program.

HB 2376  Associated Health Plans (Barto) AzPHA Position: Undetermined

An association health plan is authorized to operate in Arizona if the plan is following federal laws and regulations, and if the plan's governing documents require the plan to be actuarially sound and the plan is actuarially sound.

Medical Marijuana

HB 2149  Cannabis Definition (Rivero) AzPHA Position: YES

Synchronizes the definitions of marijuana and cannabis in the state criminal code and the Arizona Medical Marijuana Act.  There has been some confusion in certain counties- as medical marijuana patients have been prosecuted for possessing extracts and preparations of marijuana that they bought at dispensaries. The appeal of this prosecutions will be heard by the state supreme court. This would make it clearer in state law that extracts and preparations are included in the Act.

State Legislature Bill Update

More than 700 bills have so far been proposed by members of the Arizona State Legislature so far.  Our Public Health Policy Committee is busy sifting through them and looking for those that will have a public health impact.  We’re not done looking through them yet- but below is a summary of what we know so far.

Tobacco Bills:

SB 1009 Electronic Cigarettes, Tobacco Sales (Carter)

Expands the definition of tobacco products to include e-cigarettes. Among other things, it'll make it clear that it's illegal to sell e-cigarettes to minors. The penalty for selling to minors remains at $5K. Being heard in Senate Health & Human Services Committee Wednesday Feb 23 at 9 am.

HB 2024 Electronic Cigarettes. Smoke Free Arizona Act (Kavanaugh)

Includes e-cigarettes in the definition of tobacco products and smoking for the purposes of the Smoke Free Arizona Act.  Because the Act was voter approved- this modification to the law will require a 3/4 majority of both houses.

HB 2073 Vapor Products; Regulation (Shope)

This bill would basically set up a regulatory program at the ADHS to inspect and license electronic cigarette manufacturers in Arizona and specify that only licensed electronic cigarette manufacturers can sell products in Arizona.  It’s unclear what the objective of this bill is and we have not yet taken a position on it yet.


Maternal & Child Health:

SB 1088 Dental Care During Pregnancy (Carter)

This bill would expand AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding.

SB 1040 Maternal Mortality Report (Brophy-McGee)

This bill would require the Child Fatality Review Team subcommittee on maternal mortality to compile an annual statistical report on the incidence and causes of "severe maternal morbidity" with recommendations for action.  The current law requires a review of the data but no report.

 

HB 2125 Child Care Subsidies (Udall)

Makes a supplemental appropriation of $56 million from the Federal Child Care and Development Fund block grant in FY2018-19 to the Department of Economic Security for child care assistance. Another bill, HB 2124 would allocate the money as follows: $26.7 million for provider rate increases, $14 million to serve children on the waiting list, and $13.1 million to increase tiered reimbursement for infants, toddlers and children in the care of DCS. HB 2436 is a similar bill.

HB 2337 Family Planning (Salman)

Would repeal the statute requiring the Department of Health Services to apply for the federal Title X family planning grant.

Injury Prevention:

HB 2069 Texting and Driving (Kavanaugh)

Makes texting while driving on a highway a nonmoving civil traffic violation.  The penalty for the 1qst violation would be $100 and the second offense would be $300.  If a crash is involved the penalty would be $500 but if someone died it would be $10K.   subject to a civil penalty of $500, except that if the accident results in the death of another person, the civil penalty is $10,000.

HB 2165  Distracted Driving (Townsend)

A person who drives a vehicle while participating in an activity that willfully distracts the person from safely operating the vehicle is guilty of reckless driving, a class 2 (mid-level) misdemeanor.  I’m not sure if texting and driving would qualify or not- it probably does.

HB 2172  Rear Facing Car Seats (Bolding)

Kids under two years of age need to be in a rear-facing restraint system unless the child weights at least 40 pounds or is at least 40 inches tall.

HB 2246  Motorcycle Helmets (Friese)

Motorcycle riders over 18 would be required to wear a helmet unless they pay a fee that would be set by ADOT. Violations would be a $500 civil penalty, but no points or other sanctions. 

HB 2075  Electronic Prescribing (Cobb)

Pushes the electronic prescribing requirement in last year’s Opioid Epidemic Act back to January 2, 2020 in all counties.  Being heard in House Health & Human Services Committee Thursday Feb 24 at 9 am.

Firearm Safety

HB 2247 Bump Stocks (Friese)

This bill would outlaw the sale of bump stocks on firearms.

HB 2248 Firearm Sales (Friese)

This bill would require a background check for all sales at gun shows.

HB 2161 Order of Protection (Hernandez)

A person who is at least 18 years of age and who is either a law enforcement officer, a “family or household member” (defined), a school administrator or teacher or a licensed behavioral health professional who has personal knowledge that the respondent is a danger to self or others is permitted to file a verified petition in the superior court for a one-year Severe Threat Order of Protection (STOP order), which prohibits the respondent from owning, purchasing, possessing or receiving or having in the respondent’s custody or control a firearm or ammunition for up to one year.

HB 2249  Mental Health and Firearm Possession (Friese)

An immediate family member or a peace officer is authorized to file a verified petition with a magistrate, justice of the peace or superior court judge for an injunction that prohibits a person from possessing, controlling, owning or receiving a firearm. Any court may issue or enforce a mental health injunction against firearm possession, regardless of the location of the person. Information that must be included in the petition is specified. If the court finds that there is clear and convincing evidence to issue a mental health injunction against firearm possession, the court must issue the injunction. Information that must be included in the injunction is specified.

Harm Reduction:

HB 2148 Syringe Access Programs (Rivero)

Decriminalizes syringe access programs, currently a class 6 felony. To qualify, programs need to list their services including disposal of used needles and hypodermic syringes, injection supplies at no cost, and access to kits that contain an opioid antagonist or referrals to programs that provide access to an opioid antagonist.

SB 1119 Tanning Studios (Mendez)

Would require people under 18 that want to use a commercial tanning bed service to have permission from their parent or guardian.

Vaccines

HB 2162 Vaccine Personal Exemptions (Hernandez)

This bill would remove the personal exemption option for parents to enroll in school even though they haven’t had all the required immunizations.

HB 2352 School Nurse and Immunization Postings (Butler)

School districts and charter schools would be required to post on their websites whether a registered nurse is assigned to each school as well as required reports on immunization rates.

Agency Administration

HB 2004 Nuclear Management Fund (Kavanaugh)

Assesses the Palo Verde nuclear plant $2.55M and gives it to ADEM, ADHS and other jurisdictions to compensate them for off-site nuclear emergency response plan response activities.  Being heard in House Appropriations Committee Wednesday Feb 23 at 2 pm.

 

HB 2280  Interfacility Ambulance Transports (Weninger)

A person may operate an "interfacility transfer ambulance service" by applying to the Department of Health Services for a certificate of operation with defined requirements.   The requirement to transport a patient under medical direction to the nearest, most appropriate facility as defined by federal medicare guidelines does not apply to an interfacility transfer ambulance service with a certificate of operation.

SB 1011 Information and Referral Service (Carter)

Appropriates $1.5 million from the general fund in FY2019-20 to the ADES for a statewide information and referral service for health care services, community services, human services and governmental services.  


AHCCCS Coverage & Services

HB 2347 Medicaid Buy-in (Butler)

Would require AHCCCS to set up a program in which eligible people could pay a premium and receive Medicaid health insurance.

HB 2350 HB2513 SB1134 Kids Care (Butler, Brophy-McGee, Cobb)

These bills Would appropriate funding so that Kids Care could continue after the federal match rate goes below 100% on October 1, 2019.

HB 2351 Medical Services Study Committee (Butler)

Establishes a 14-member Medical Services Purchase Program Study Committee to research and make recommendations for establishing and implementing a medical services purchase program. The Committee is required to submit a report of its findings and recommendations to the Governor

HB 2120  Chiropractic Coverage (Barto)

Would add chiropractic services to the list of reimbursable services under AHCCCS.  Being heard in House Health & Human Services Committee Thursday Feb 24 at 9 am.

SB 1088 Dental Care During Pregnancy (Carter)

This bill would expand AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding.


Food Safety & Insecurity

HB 2178  Milk Manufacturing License Exemption

A restaurant wouldn’t be required to get a license to manufacture or distribute frozen desserts or frozen milk products if the product is manufactured or distributed and sold at the same facility for on-site consumption

HB 2186  School Meals (Udall)

Schools are required to provide a school meal to a student who requests it regardless of whether the student pays for a school meal or owes money for previous meals. Local education agencies are prohibited from taking a list of specified actions relating to unpaid school meal fees, including announcing or publicizing the names of students with unpaid school meal fees, requiring a student who cannot pay for a meal or who owes unpaid meal fees to work for a meal, and attempting to collect unpaid school meal fees from a student. Local education agencies are prohibited from using a debt collector to attempt to collect unpaid school meal fees.


Access to Care

HB 2218 State Loan Repayment (Blanc)

Makes a supplemental appropriation of $250,000 from the general fund in FY2019-20 to the Department of Health Services to pay off portions of education loans taken out by physicians, dentists, pharmacists, advance practice providers and behavioral health providers participating in the primary care provider loan repayment program. 

HB 2376  Associated Health Plans (Barto)

An association health plan is authorized to operate in Arizona if the plan is in compliance with federal laws and regulations, and if the plan's governing documents require the plan to be actuarially sound and the plan is actuarially sound.

Medical Marijuana

HB 2149  Cannabis Definition (Rivero)

Syncronizes the definitions of marijuana and cannabis in the state criminal code and the Arizona Medical Marijuana Act.  There has been some confusion in certain counties- as medical marijuana patients have been prosecuted for possessing extracts and preparations of marijuana that they bought at dispensaries. The appeal of this prosecutions will be heard by the state supreme court. This would make it more clear in state law that extracts and preparations are included in the Act.

HB 2412  Medical Marijuana Cards (Powers Hannley)

This bill would make medical marijuana cards valid for 2 years instead of the current 1 year.

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.

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.

Leveraging State Policy to Reduce Maternal Mortality

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.

Black 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 super-interesting 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: state health departments and Medicaid agencies.

Medicaid finances 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 and coverage after delivery vary between states.  As a result, some women lose coverage or Medicaid eligibility after that 60-day period (mostly in states without Medicaid expansion).

In states (like AZ, which expanded Medicaid), 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 the key.  29 states including Arizona, have committees that review maternal deaths and make public policy recommendations.  Back in 2011, Arizona passed, and Governor Brewer signed a bill that amended our child fatality review statutes by adding reviews of maternal deaths. This change charged our existing Child Fatality State Teams to review maternal deaths (called the Maternal Mortality Review Subcommittee) and make policy recommendations. The primary goal for the Team is to identify preventive factors and make recommendations for systems change.  

One of the best parts of these review boards is that it is not just public health, but it's other agencies and community docs and corrections and academics all coming together to review these deaths.  Here are some of the recommendations from the most recent report:

  • All pregnant women must have access to prenatal care;

  • 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;

  • 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;

  • 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, the 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 LARC 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.