Federal Budget

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.

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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