Social Determinants

Weigh in on the US Department of Homeland Security's new "Public Charge" Rules

The US Department of Homeland Security is proposing new changes to what is commonly referred to as their public charge’ rule.  If they’re adopted as-is, the new regulations would make it harder for families who are following all the rules of legal immigration to enter the U.S. or obtain a green card to become a legal, permanent resident. This means people trying to become new Americans legally would risk their status simply by turning to available services of Medicaid (and possibly CHIP/KidsCare), SNAP (aka food stamps), Medicare Part D, and housing assistance. You can learn more about what “public charge” is here

DHS is accepting public comments on their rule package through December 10.  We’d like your help to put together comments from the Arizona public health community.  Here’s some background:

DHS already uses information about whether applicants for legal permanent residency receive Temporary Assistance for Needy Families and Supplemental Security Income (SSI) when they evaluate applications.  After these proposed new rules are adopted, they’ll also consider whether applicants receive Medicaid (AHCCCS), Medicare Part D Low Income Subsidy, the Supplemental Nutrition Assistance Program (food stamps), and Section 8 Housing program.  Once adopted, applicants that receive any of these benefits will be far less likely to be approved for a status change or stay extension.  I didn’t see any exemptions for children- so presumably benefits used by any noncitizen family member including kids would count.  Here are some take-aways from the proposal:  

  • This is an issue of legal immigration- unauthorized migrants are largely ineligible for public assistance;

  • The use of public benefits by citizen children would not be considered a public charge;

  • This does not directly impact green card holders (the public charge test is not applied to green card holders applying for citizenship);

  • While CHIP (KidsCare) hasn’t been included in the proposed list of benefits that will count against individuals, the proposal draft seeks comments about whether CHIP should be included;

  • The proposed rule is not retroactive – meaning the public benefits received before the rule is final will not be counted as a public charge; and 

  • The proposed rules would not apply to refugees because existing statute prevents DHS from using the criteria for refugees.

  • Even though the new draft doesn’t include vaccinations (VFC), WIC and marketplace insurance- many families will believe that the regulations do include these benefits and will elect not to use these important safety net benefits- as doing so will risk their immigration status.  As a result, families will have a more difficult time improving the health status of their families.  An estimated 200,000 Arizonans will be impacted directly and many more may avoid using services they need due to fear and misinformation. The good news is that your voice matters! 

Turning in public comments matters because: 1) Federal law requires the government read and consider every unique comment before issuing a final rule and significant or copious comments could slow down the process and give policymakers more time to reconsider the final rule change; 2) Comments can later provide an opportunity to challenge the regulations in court; and 3) Comments give our communities a chance for their voice to be heard.

DHS will group all identical comments and count them as one comment. To make the most impact, it’s important to add your own words and ideas to your comments so it can be counted as a unique comment. Take a moment to highlight how your professional career or personal experiences has informed your view of what the Feds are proposing.  Below are example comments for you to consider using or modifying, along with your own words, and step by step instructions on how to submit your own comments.  

I oppose the Department of Homeland Security’s proposed rule change to "public charge.”  The policy will undermine access to essential health, nutrition, and shelter for immigrants and their family. One in four children in Arizona, and nearly 20 million children nationwide, live with at least one immigrant parent. By forcing choices no family should have to make, it puts our whole country at risk. This will policy is short-sighted and will only create costs shifts to states as well as create, bigger more expensive problems down the road. DHS should immediately withdraw its proposal. 

A community’s overall health depends on the health of all of its members. The proposed rule change will lead to higher rates of uninsured adults and children. Without insurance, families may delay care or forego it altogether. This means there will be more children in school, and adults in the workplace, without needed preventive services and untreated illnesses. Treatment for life-threatening conditions such as asthma keeps children in school. More people delaying care until the last possible moment will strain emergency resources. Hospitals’ and clinics’ uncompensated care burdens will increase. Children with Medicaid and CHIP have better health as adults, with fewer hospitalizations and emergency room visits; they also earn more and pay more in taxes. 

CHIP (KidsCare in Arizona) is designed especially for working families and should not be considered a public charge. Including CHIP would be a double hit to families who work hard and play by all the rules of our immigration system only to have the American dream become that much more unattainable. 

The loss of access to SNAP would further exacerbate food insecurity. SNAP is a critical source of support for struggling households; research shows how SNAP lifts people out of poverty, reduces hunger and obesity, and improves school attendance, behavior, and achievement. The consequences of food insecurity are especially detrimental to the health, development, and well-being of children.

We’ll be turning in public comments on the rule change before the December 10 deadline…  but please consider turning in your own unique comments!

History of Considering Public Benefits

The term “public charge” as it relates to admitting immigrants has a long history in immigration law, appearing at least as far back as the Immigration Act of 1882.  In the 1800s and early 1900s “public charge: was the most common ground for refusing admission at U.S. 

In 1999, the INS (DHS didn’t exist yet) issued Rules to "address the public’s concerns about immigrant fears of accepting public benefits for which they remained eligible, specifically medical care, children's immunizations, basic nutrition and treatment of medical conditions that may jeopardize public health.” Here's that final Rule from 1999, which didn't include Medicaid our housing benefits in the public charge definition.

AzPHA Public Health Policy Update: March 19, 2018

AHCCCS Update: Coding the Social Determinants of Health

ICD-10 diagnosis codes that relate to the Social Determinants of Health can be a valuable source of information to improve health outcomes.  Social Determinants of Health codes can identify the conditions in which people are born, grow, live, work, and age like education, employment, physical environment, socioeconomic status and social support networks- data that can provide managed care organizations information with which to improve outcomes and reduce costs.

AHCCCS is recommending that providers routinely screen for and document the presence of social determinants (as appropriate within their scope of practice) and to document them in claims data. AHCCCS will begin to monitor claims for the presence of these codes after April 1, 2018. You can review the Social Determinant ICD-10 Codes on the AHCCCS website.

 

FDA Proposes Rulemaking to Reduce Nicotine Levels in Tobacco Products

The FDA issued an “advance notice of proposed rulemaking” last week to get input for them to develop new standards for the maximum nicotine level in cigarettes. They say they’re interested in reducing the level of nicotine in cigarettes to make them “minimally addictive or nonaddictive”.  

Those of you that are familiar with the evidence base in this area should take this opportunity to provide input to the FDA. It has the potential to be a big intervention in our decades long battle public health battle with tobacco.  Electronic comments can be submitted through June 14 at https://www.regulations.gov

 

AzPHA Comments on ADHS School Vaccination Rulemaking

The ADHS has an administrative rulemaking open to adjust their school and child care vaccine requirements. Our public health policy committee turned in a response last week (it had a short comment period- just a week).  You can see our comments on the proposed rules on our AzPHA Blog). 

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Legislative Session Update 

Committee Highlights Last Week

HB 2324 Community health workers; voluntary certification had another terrific week. The bill got a Do Pass recommendation from the Senate Commerce and Public Safety Committee last week (7-0-1).  As you’ll recall, the week before the Senate Health and Human Services Committee gave it a Do Pass recommendation. We’re getting a lot closer to the finish line. Our next hurdle will be the Senate Rules Committee followed by a floor vote in the Senate.  Because there are some changes in the language since it passed the House, it’ll need to go back to accommodate those differences after that. But it is looking good!  

This Bill is a top priority for us. It asks the ADHS with developing a voluntary certification program for community health workers. The rulemaking would include certification standards including qualifications, core competencies, and continuing education requirements.

HB 2197 Health professions, workforce data also had a good week, getting a pass recommendation from the Senate Commerce and Public Safety Committee last week.  It would require AZ health licensing boards to collect certain data from applicants (beginning January 2020) to get better data about health professions workforce distribution and needs.  The data would be confidential.  Over the long-term this bill would be helpful in providing better data with which to improve the distribution and capacity of the public health workforce in Arizona.

HB 2228 Annual waiver, applicability received a pass recommendation from the Senate HHS Committee last week.  This bill would direct AHCCCS to exempt tribes from their directed waiver requests to CMS (asking permission to implement work requirements for some Medicaid members).  The recently submitted Waiver request includes an exemption for American Indians, but this would place the exemption into statute.

HB 2389  Syringe access programs; authorization was substantially amended in the Senate Government Committee last week (not in a good way).  The amended bill passed the committee, but its amended form will be much less helpful as a public health intervention. The original bill essentially would have decriminalized needle exchange programs. The amendment makes it such that needle exchange would only be decriminalized when and where the ADHS declares a public health emergency because of the rapid spread of an infectious disease. Hopefully we can get the amendment removed.  If we can’t and it passes and is signed as amended it’ll have little public health utility.

SB 1245 Snap Benefit Match earned a pass recommendation from the House Health Committee last week.  Its next stop is the House Appropriation Committees.  This good Bill would appropriate $400K to ADES to develop a produce incentive program within the Supplemental Nutrition Assistance Program for members to buy Arizona-grown fruits and vegetables.  It would also provide matching funds to SNAP-authorized vendors as an incentive to participate in the fruits and vegetable program.  

SB 1377 Dental therapy, licensure, regulation failed to get a pass recommendation from the House Health Committee last week (5-4).  It would have set up a new licensed class of dental professionals called a Dental Therapist. Their scope of practice would be somewhat less than a DDS, but they could do some procedures like filling cavities. This has been a somewhat controversial bill as there are stakeholders of both sides that are quite passionate about their position on this Bill. 

SB 1420 medical marijuana; inspection; testing; appropriation received a pass recommendation by the House Military, Veterans & Regulatory Affairs Committee last week. This bill would require the ADHS to set up testing standards for medical marijuana and begin enforcing the standards beginning in 2019.

SB 1261 Texting while driving has been languishing for the last few weeks, as it hasn’t been called up for a floor vote in the Senate.  Last week, the language from SB 1261 was added as an amendment onto HB 2159 traffic violations; traffic survival school.  This bill, with the addition of the texting language, is now in the House awaiting a final vote.  If anybody has influence with Speaker Mesnard now would be a great time to contact him and ask him to bring it to the floor.

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Committee Highlights this Week

Monday, March 19th, Senate Commerce & Public Safety 2 pm, SHR 1

HB 2064:  medical marijuana; packaging; labeling

 

Wednesday, March 21st, House Appropriations 9 am, HHR1

SB 1245:  appropriation; SNAP; benefit match; produce

SB 1420:  medical marijuana; inspection; testing; appropriation

 

Thursday, March 22nd, House Health 9am, HHR 4

SB 1445:  AHCCCS; dental care; pregnant women

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The following public health related bills passed their committee of origin and have gone over to the other chamber. Some have been assigned to committees in the new chamber, but some haven't yet.  Where available, I've listed the committee assignments in the detail section below.  We’re keeping track of the hearing dates and times. 

HB 2038 Drug overdose review teams; records                

HB 2071 Rear-facing car seats

HB 2084 Indoor tanning; minors; restricted use      

HB 2127 Children's health insurance program

HB 2208 Prohibition, photo enforcement (we’re against this one)

HB 2228 Annual waiver, applicability (tribes)

HB 2323 Schools; inhalers; contracted nurses

HB 2324 Community health workers; voluntary certification

HB 2389 Syringe access programs; authorization

SB 1022 ADHS; homemade food products            

SB 1083 Schools; recess periods

SB 1445 AHCCCS Dental care, pregnant women

SB 1377 Dental therapy, licensure, regulation

SB 1394 Abortion reporting 

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Remember to stay engaged and voice your opinion via the www.azleg.gov commenting system.  Click the following links for: Request to Speak account registration form; a Step-by-step use of the Request to Speak platform; and to Locate your Elected Officials

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House Bills

HB 2038 Drug overdose review teams; records                

Passed the House 57-0-2

Assigned to Senate Health and Human Services Committee

Under this proposed Bill, law enforcement agencies would be required to provide unredacted reports to the chairperson of a local Drug Overdose Fatality Review Team on request.  All information and records acquired by a Team are confidential and not subject to subpoena, discovery or introduction into evidence in a civil or criminal proceeding or disciplinary action.  We’re signed up in support of this one of course.

 

HB 2071 Rear-facing car seats         

Passed House 33-25-1

Assigned to Senate HHS & Commerce and Public Safety Committees 

This Bill would require kids under 2 years old to be in a rear-facing restraint system unless the child weights at least 40 pounds or is at least 40 inches tall.  We’ve signed up in support of this bill.  Dual assigned in the Senate, and not yet scheduled in either of the Senate committees.

 

HB 2084 Indoor tanning; minors; restricted use

Passed House 45 - 15

Assigned to Senate HHS and Commerce & Public Safety Committees

Tanning facility operators would be prohibited from allowing a person under 18 years of age to use a "tanning device". Tanning facilities couldn’t advertise or distribute materials that claim that using a tanning device is free from risk or will result in medical or health benefits. We’ve signed on in support of this of course. Bummer that it's dual assigned in the Senate.

 

HB 2127 Children's health insurance program

Passed House 46-12-1

Assigned to HHS & Appropriations Committees

This removes the trigger that automatically freezes the KidsCare program if FMAP (the federal contribution) drops below 100%.  It allows the state to freeze it if costs are more than the state or federal allotment. The bill does not require the state to appropriate any money for a state share.  We’ve signed up in support of this bill because it provides a pathway to keep KidsCare if the federal government drops its contribution level. 

 

HB 2197 Health professions, workforce data

Passed House 60 – 0

Assigned to HHS and Commerce & Public Safety Committees

This bill had a good week, getting a Do Pass recommendation from the Senate Commerce and Public Safety Committee last week.  It would require AZ health licensing boards to collect certain data from applicants (beginning January 2020) to get better data about health professions workforce distribution and needs.  The data would be confidential.  Over the long-term this bill would be helpful in providing better data with which to improve the distribution and capacity of the public health workforce in Arizona.

 

HB 2208 Prohibition, photo enforcement

Passed the House 31-27-1

Assigned to the Senate Transportation Committee

This one would prohibit cities and other jurisdictions from having photo enforcement of red light and speeding violations.  While nobody likes getting a ticket in the mail, the data suggest that photo enforcement saves lives and prevents injuries (especially red-light photo enforcement).  We’ve signed up in opposition to the bill.  This bill passed the House 31-27 last week and is moving on to the Senate Transportation Committee- not on their agenda yet.

 

HB 2228 Annual waiver, applicability

Passed the House 58-0-1

Passed in the Senate HHS Committee

This would direct AHCCCS to exempt tribes from their directed waiver requests to CMS asking permission to implement work requirements for some Medicaid members.  The recently submitted Waiver request includes an exemption for American Indians, however, this would place the exemption into statute.

 

HB 2323  Schools; inhalers; contracted nurses

Passed House 58 – 0 - 1

Assigned to Senate Education Committee

This bill adds contracted nurses to the list of people who are authorized to provide emergency inhaler medication in case of respiratory emergencies. Some charter and independent schools don’t employ nurses directly but engage them through contracts.

 

HB 2324 Community health workers; voluntary certification

Passed House 56 – 1 - 3

Assigned to HHS and Commerce & Public Safety Committees

This Bill had another terrific week. The Bill got a Do Pass recommendation from the Senate Commerce and Public Safety Committee last week (7-0-1).  As you’ll recall, the week before the Senate Health and Human Services Committee gave it a Do Pass recommendation. We’re getting a lot closer to the finish line. Our next hurdle will be the Senate Rules Committee followed by a floor vote in the Senate.  Because there are some changes in the language since it passed the House, it’ll need to go back to accommodate those differences after that.  But it is looking good!  

This Bill is a top priority for us. It asks the ADHS with developing a voluntary certification program for community health workers. The rulemaking would include certification standards including qualifications, core competencies, and continuing education requirements.

 

HB 2389  Syringe access programs; authorization

Passed House 56 – 0 - 4

Assigned to the Senate Government Committee

This Bill was substantially amended in the Senate Government Committee last week.  The bill (as amended) passed the committee, but in its amended form will be much less helpful as a public health intervention.  The original bill essentially would have decriminalized needle exchange programs.  The amendment makes it such that needle exchange would only be decriminalized when and where the ADHS declares a public health emergency because of the rapid spread of infectious diseases. Hopefully we can get the amendment removed.  If we can’t and it passes and is signed as amended it’ll have very little public health utility.

 

Senate Bills

SB 1022    DHS; homemade food products            

Passed Senate 30-0

Assigned to House Health Committee

ADHS would be required to establish an online registry of food preparers that are authorized to prepare "cottage food products" for commercial purposes. Registered food preparers would be required to renew the registration every three years. This is a sensible addition to the current cottage industry food law and we’ve signed up in support. Being heard in the House Health Committee this week (Thursday).  Should have no problems at all.

 

SB 1083    Schools; recess periods

Passed Senate 26-3-1

Assigned to and Passed House Education Committee 9-0 on Monday

District and charter schools would be required to provide at least 2 recess periods during the school day for pupils in grades K-5 if this passes. We’ve signed in support of this bill because there is good evidence that opportunities for physical activity at school are associated with improved health, behavior, and academic achievement of students.  Here is a good evidence review from the CDC entitled The Association Between School-based Physical Activity and Academic Performance. Great couple of weeks for this bill. Hopefully there’s a floor vote on this shortly.

 

SB 1245 Snap Benefit Match

Passed Senate 25 - 5

Assigned to House Health and Appropriation Committees

This Bill earned a Do Pass recommendation from the House Health Committee last week.  Its next stop is the House Appropriation Committees.  This good Bill would appropriate $400K to ADES to develop a produce incentive program within the Supplemental Nutrition Assistance Program for members to buy Arizona-grown fruits and vegetables.  It would also provide matching funds to SNAP-authorized vendors as an incentive to participate in the fruits and vegetable program.  

This Bill would appropriate $400K to ADES to develop the infrastructure for a produce incentive program within the Supplemental Nutrition Assistance Program (SNAP) for members to buy Arizona-grown fruits and vegetables.  It would also provide matching funds to SNAP-authorized vendors as an incentive to participate in the fruits and vegetable program.  It has passed the full Senate and will be heard this Thursday at 9 am in House Health.  

 

SB 1261 Texting while driving

Passed Transportation Committee- Ready for a Senate Floor Vote

This would prohibit drivers from “using a portable wireless communication device to read, write, or send an electronic message while driving” (unless the car is stopped).  The first violation would be a petty offense with a fine between $25 and $99.  It has passed its committees and is ready for a floor vote, which hasn’t happened yet.  Not a good sign.

 

SB 1377 Dental therapy, licensure, regulation

Passed Senate 22 – 8

Assigned to House Health Committee

This bill failed to get a Pass recommendation from the House Health Committee last week (5-4).  It would have set up a new licensed class of dental professionals called a Dental Therapist. Their scope of practice would be somewhat less than a DDS, but they could do some procedures like filling cavities. This has been a somewhat controversial bill as there are stakeholders of both sides that are quite passionate about their position on this Bill.   Being heard this week (Thursday at 9 am) in the House Health Committee.

 

SB 1394 Abortion reporting

Passed Senate 17 - 13

Assigned to the Judiciary and Federalism, Property Rights & Public Policy Committees

This one would require the ADHS to collect and report additional data regarding abortions that are performed in AZ. The data would be collected and reported by providers and would include the reason for the abortion (economic, emotional health, physical health, whether the pregnancy was the result of rape or incest, or relationship issues etc.).  The bill was given a Do Pass recommendation last week by the House Judiciary & Public Safety Committee- although it was amended slightly by removing the requirement that physicians ask and report specifically why the woman is asking for the procedure.

 

SB 1420 Medical marijuana; inspection; testing; appropriation

Passed Senate 27 – 3

Assigned to House Military, Veteran and Regulatory Affairs Committee

This would require the ADHS to set up testing standards for medical marijuana and begin enforcing the standards beginning in 2019.  We’re supporting this legislation.  It passed the full Senate last week and was given a Pass recommendation by the House Military, Veterans & Regulatory Affairs Committee this week.

 

SB 1445 AHCCCS Dental care, pregnant women

Passed Senate 27 - 3

Assigned to House Health & Appropriations Committees

Last week SB 1445 AHCCCS Dental care, pregnant women was passed by the Senate (27 – 3).  This Bill would provide oral health coverage for pregnant Medicaid members. It has moved on to the House and is assigned to the House Health Committee (which gave as similar bill a pass recommendation last year).  Because it involves money its also assigned to the House Appropriations Committee.  The benefit would be limited to $1000/year.  Lots of good public health reasons to support this one. 

This is a priority Bill for AzPHA.  It would provide oral health coverage for pregnant Medicaid members.  The benefit would be limited to $1000 and could be used for other than emergency dental procedures (beginning October 1, 2017 all adult Medicaid members became eligible for up to $1000 in emergency dental services per year).  Lots of good public health reasons to support this one. 

 

SB 1470  Sunrise process; health professions

Passed Senate 21 - 9

Assigned to House Government Committee

To be honest- this bill has been flying under the radar at least with me.  If it passes and is signed it’d make huge changes to the health professions scope of practice system we use today. The current sunrise process is a collaborative, inclusive process that allows time for consideration and review of the complicated health care delivery proposals.  The current process requires a Committee of Reference hearing, which allows a consideration of a proposed scope change and its potential patient safety and care implications. 

SB 1470 would change the scope of practice system so that all a profession needs to do is prepare a written sunrise report right before the regular legislative session. It would allow the legislative standing committees (rather than Committees of Reference) to consider a sunrise proposal. During legislative session, long agendas and the fast pace limits the time to consider serious issues impacted by changes in scope of practice, including prescribing, complex health care procedures, complicated review, and reflection on curriculum, training and education.

We had a Public Health Policy Committee call last week and recommended to our Board that we take a position opposing the bill- which we did last week.  I testified that, rather than eliminating the pre-session hearings for scope of practice changes that they consider modifying the bill so that requests for new Scope changes go to the ADHS Director for a recommendation back to the Legislature.  

The Bill passed the House Government Committee last week.  There was reportedly a stakeholder meeting on the bill last week.  We’ll stay tuned.

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Public Health Bills that Failed to Thrive

HB 2064 Medical marijuana; packaging; labeling              

Dead for now

This Bill proposes that medical marijuana dispensaries be prohibited from selling a marijuana product that’s packaged or labeled in a manner that’s "attractive to minors". Due to voter protection, this legislation requires the affirmative vote of at least 3/4 of the members of each house of the Legislature for passage.  Dead for now.

HB 2109 Tobacco possession; sale; age; signage                

Sadly, dead for now

This Bill would prohibit furnishing a tobacco product to a person who is under 21 years of age. The definition of "tobacco product" is expanded to include "electronic smoking devices". We’ve signed up in support. It received a Do Pass recommendation from the House Health Committee three weeks ago but the Commerce chair hasn’t put it on the agenda, so it’s effectively dead for now. Kudos to Rep. Boyer for sponsoring this.

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AzPHA Member Kelli Donley Publishes Again

COUNTING COUP is the latest novel by AzPHA member Kelli Donley, who works in public health in Phoenix. The book is about the Phoenix Indian School, and like Donley's other novels, has a strong public health theme. Here’s a short description of her book, which you can order from Amazon:

Happily consumed with her academic career, Professor Avery Wainwright never planned on becoming sole guardian of her octogenarian Aunt Birdie. Forced to move Birdie—and her failing memory—into her tiny apartment, Avery’s precariously balanced life loses its footing. 

Unearthed in the chaos is a stack of sixty-year-old letters. Written in 1951, the letters tell of a year Avery’s grandmother, Alma Jean, spent teaching in the Indian school system, in the high desert town of Winslow, Arizona. The letters are addressed to Birdie, who was teaching at the Phoenix Indian School. The ghostly yet familiar voices in the letters tell of a dark time in her grandmother’s life, a time no one has ever spoken of. 

Torn between caring for the old woman who cannot remember, and her very different memories of a grandmother no longer alive to explain, Avery searches for answers. But the scandal and loss she finds, the revelations about abuses, atrocities, and cover-ups at the Indian schools, threaten far more than she’s bargained for. 

About the author: 

Kelli Donley is a native Arizonan. She is the author of three novels, Under the Same Moon, Basket Baby and Counting Coup. Inspiration for this novel was found hearing colleagues’ stories about childhoods spent at the Phoenix Indian School. Kelli lives with her husband Jason, children and small ark of animals in Mesa, Arizona. She works in public health, and blogs at: www.africankelli.com.

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AzPHA Public Health Policy Update- November 16, 2017

AZ’s New Minimum Wage Law Expected to Improve Infant Mortality

We’ve known for a long time in public health that a primary driver of health status is family income.  More family resources generally result in better health outcomes. New data suggest (not surprisingly) that increases in the minimum wage result in lower infant mortality.

Could the passage of Proposition 206 in November of 2016 be an evidence-based public health intervention that will lower infant mortality in Arizona?  The answer is yes!

In 2014, Arizona’s infant mortality rate was 6.2 deaths per 1,000 live births- well above other comparable countries including Japan (2.1), France (3.5), and the UK (3.9).  The national rate in the US is 5.8/1,000.  Here are Arizona’s Infant Mortality Rates: PDF | Excel

A team of researchers recently published a study in the American Journal of Public Health examining the effects of state minimum wage laws on infant mortality and low birthweight rates.  They found that a $1 increase in the minimum wage is associated with a 4% decrease in infant mortality and a 1% to 2% decrease in low birthweight births.  They concluded that…  “if all states in 2014 had increased their minimum wages by $1 dollar there would likely have been 2,790 fewer low birthweight births and 518 fewer post-neonatal deaths for the year.”

This research adds to a growing scientific literature on the beneficial effects of various income supports on improved birth outcomes and reinforces the fact that social determinants of health related to income have a significant impact on population and public health outcomes.

Of course, there are many factors at play when it comes to infant mortality and low birth weight- but it looks like Proposition 206, which raised the minimum wage in AZ to $10 this year and to $12 by 2020 will help us on our quest to improve Arizona’s infant mortality and low birth weight rates. 

 

AzPHA’s Positions on the Sunrise Hearings

Whenever health related professions ask to be regulated or want to expand their scope of practice a state law says that the regulation needs to be done only to protect the public interest.  Applicants that want to go through the process need to submit a report to the state legislature explaining the factors demonstrating that their request meets these standards.

A “Committee of Reference” studies the sunrise applications and delivers its recommendations to House and Senate leadership. This year there are 3 applications in the hopper and they’ll be heard on Tuesday, November 28 starting at 9 am in the House of Representatives.

In a nutshell, the Community Health Workers Sunrise Application asks for a pathway to set up a process for voluntary registration of CHWs; the Arizona Naturopathic Medical Association would like permission for them to sign medical waivers from the state’s school vaccination requirements; and the Dental Care for AZ Sunrise Application asks for authorization from the legislature to license a new class of dental professionals.

Here are AzPHA’s statements to the House and Senate Committee of Reference for the upcoming November 28 Sunrise Hearings.  We’re taking positions on the CHW and Naturopath Sunrise Applications (but not the Dental Therapist application).

 

Arizona Community Health Workers Association

We urge the Committee to recommend approval of the application submitted by the Arizona Community Health Workers Association for Certification/Registration for Community Health Workers.

Community Health Workers (CHWs) are an established group of health professionals that build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy. 

A variety of agencies use CHWs to serve communities in ways including access to primary care, prenatal care, chronic disease self-management, long-term care, utilization of services, and behavioral health.  CHW services are effective at improving health outcomes and reducing costs and providing a unique opportunity for provider groups as they increasingly adopt value-based purchasing practices.

There is currently no simple way for health care providers and members of the community to verify that a CHW is proficient in core competencies. Certification and registration will assure that CHWs meet minimum standards including education, continuing education, training, experience, and other qualifications. With certification and registration, payors reimbursing CHWs for services would have clarity about CHWs core competencies and their scope of practice allowing this workforce to become integrated with a medical team and/or in the community.

CHWs work with vulnerable populations. Registration of CHWs meeting minimum standards is essential for patient safety by assuring that CHWs have a background check, follow HIPAA regulations, and safeguard against inappropriate actions and/or behaviors.

In short, we are supportive of this application because CHW services are effective at improving health outcomes and reducing costs. In the absence of certification/registration, the community cannot be assured of CHWs’ core competencies, scope of practice, and that procedures are in place to safeguard patients.

 

Arizona Naturopathic Medical Association

We urge the Committee to recommend denial of the application submitted by the Arizona Naturopathic Medical Association to expand their scope to include medical exemptions from Arizona’s school vaccination requirements.

The Arizona Public Health Association is concerned about several aspects of this application, most importantly, that it could further erode Arizona’s vaccination rates resulting in the loss of herd immunity. 

We believe that medical exemptions are an important component of Arizona’s school vaccine requirement system. However, medical exemptions should be signed by physicians that are current with the latest scientific literature regarding vaccines. New vaccinations and combinations of vaccinations are approved on an ongoing basis by the Food and Drug Administration and are evaluated consistently by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP).

Guidance and recommendations from the CDC and ACIP are critical for physicians to understand the nuances of the various vaccines, their complex schedules, and data regarding evidence-based reasons for medical exemptions.  Medical exemptions are best signed by physicians that are current with these resources.

Our review of data regarding vaccines suggest that Naturopathic Physicians provide very few vaccinations in Arizona (less than 0.01% of all vaccinations in Arizona are provided by Naturopaths).  Because so few Naturopathic Physicians (NDs) provide vaccines, our concern is that they will not be well informed about when a medical exemption is appropriate, and that some NDs will err on the side of signing medical exemptions rather than study the detail provided by the FDA, CDC and ACIP. There is also a risk that a relatively small number of NDs could sign large numbers of medical exemptions and jeopardize herd immunity.

We urge the Committee to recommend denial of the application submitted by the Arizona Naturopathic Medical Association to expand their scope to include medical exemptions from Arizona’s school vaccination requirements.

 

Restaurant Calorie Labeling Back on Track?

One of the things that was tucked into the Affordable Care Act was a provision that requires restaurants with 20 or more locations to post calorie content information for standard menu items directly on the menu and menu boards- a potentially powerful public health intervention in our effort to reduce obesity.

The FDA issued proposed draft regulations way back in 2011... but various delays have kept the rules from being implemented (by both the Obama and Trump Administrations).  Some places have been voluntarily posting nutrition information- but it’s still not officially required.

This kind of 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.  

Last week the FDA released draft implementation guidance addressing menu labeling issues like caloric disclosure, compliance and enforcement, and marketing materials.  The new guidance suggests that the compliance start day will now be May of 2018.

The new draft guidance includes expanded and new interpretations of policy, and identifies places where FDA intends to be more flexible in its approach. It also includes many graphical depictions conveying the FDA’s thinking on various topics and provides examples of options for implementation.

The new guidance addresses calorie disclosure signage for self-service foods like buffets, various methods for providing calorie disclosure information (including pizza which has been a big hang-up because its’ so often delivered), and compliance and enforcement.

 

President Nominates New HHS Secretary
The President selected Alex Azar, a former pharmaceutical executive and a top health official during the George W. Bush administration, to lead HHS. Azar also served as president of Lilly USA (an affiliate of Eli Lilly and Co.) and as a health-care consultant. During the Bush administration he was chief counsel a deputy director.

He has been highly critical of the ACA and supports converting Medicaid from an entitlement program into block grants. However, Dr. Georges Benjamin (Executive Director of the American Public Health Association, said “Azar is far less partisan than his predecessor. He’s smart, practical, listens to all sides…  We’ve got somebody whose heart is in the right place.” Time will tell.

 

Open Enrollment for Marketplace Health Insurance

The Affordable Care Act remains the law, and insurance enrollment for Arizonans runs through 12/15.  The University of Arizona Center for Rural Health (AzCRH) has certified staff (Navigators) to answer questions and help you enroll in health insurance coverage. Navigator services are free http://crh.arizona.edu/programs/navigator