Tobacco

HHS Agencies Begin to Engage on E-Cigarette Lung Injuries... and what’s the Root Policy Cause of the Vaping Epidemic?

Late last week the CDC issued an Advisory about their investigation of a multi-state outbreak of severe pulmonary disease associated with e-cigarette product (devices, liquids, refill pods, and/or cartridges) use. As of September 6, 2019, over 450 possible cases of lung illness associated with the use of e-cigarette products have been reported to CDC from 33 states. As of Friday, there had been 5 deaths have been confirmed in California, Illinois, Indiana, Minnesota, and Oregon.

CDC also developed a case definition to classify cases consistently.  State and county health departments will now be able to use the new case definition to determine if cases are confirmed or probable (after examining the medical records of suspected cases and consulting with the clinical care team to exclude other possible causes).

Unlike nationally reportable conditions like communicable diseases, these cases require clinicians and public health to interview patients to determine product use and individual behaviors- which means that there’s no active surveillance system to look for injuries like these.  With more health departments and emergency departments actively looking, it’s certain that more cases will be identified, and we should be able to learn more about what’s actually happening and why pretty soon.

There aren’t enough data yet to determine what specifically might be causing the cases but many of the samples tested by the states contained significant amounts of Vitamin E acetate. Vitamin E acetate is in topical consumer products or dietary supplements, but data are limited about its effects after inhalation.

While the FDA and CDC don’t have enough data presently to conclude that Vitamin E acetate is the cause of the lung injury, they urged consumers to not use vaping products that might contain Vitamin E acetate (but I couldn’t find out how consumers would be able to tell that). The statement also said that “… no youth should be using any vaping product, regardless of the substance”.

FDA “Intends to” Better Regulate Flavored Vaping Products

Today the US Department of Health and Human Services Secretary announced that: “… the FDA intends to finalize a compliance policy in the coming weeks that would prioritize the agency’s enforcement of the premarket authorization requirements for non-tobacco-flavored e-cigarettes, including mint and menthol, clearing the market of unauthorized, non-tobacco-flavored e-cigarette products. The FDA plans to share more on the specific details of the plan and its implementation soon.”  I guess we’ll learn more about that the Federal Register in the weeks to come.

Today’s announcement that FDA intends to do more came out after preliminary numbers from the National Youth Tobacco Survey showed a continued rise in the rates of youth e-cigarette use, especially among the non-tobacco flavors that appeal to kids.  In particular, the preliminary data showed that more than 25% of high school kids are current (past 30 day) e-cigarette users in 2019 and the overwhelming majority cited the use of popular fruit and menthol or mint flavors.

Sadly, nothing in the HHS or FDA materials from today suggested that they intend to use any of their authority to tightly regulate the advertising and marketing of e-cigarettes. That fact that they were silent on that makes me believe that that might not be in the cards.

Arizona Policy Interventions Last Legislative Session were Unsuccessful

One of the key public health policy interventions that could make a dent in the vaping epidemic here in Arizona was last year’s SB 1363 Tobacco Product Sales (Tobacco 21) sponsored by Senator Heather Carter.  The bill would have classified electronic cigarettes as a tobacco product (allowing it to be regulated like tobacco – including covering it in the Smoke Free Arizona Act) and moving the buying age for cigarettes and electronic cigarettes to 21 years old.  Sadly, that bill never got a hearing at the Legislature.

So, What’s the Root Policy Cause of the Vaping Epidemic?

In short, it’s judicial branch interpretations of the FDA’s authority to regulate e-cigarettes under the Family Smoking Prevention and Tobacco Control Act.

In June 2009, President Obama signed into law the Family Smoking Prevention and Tobacco Control Act, which gave the FDA the power to regulate the tobacco industry. Under the Act, nicotine and cigarettes can’t be banned but flavorings like fruit or mint can.  Additionally, the law required new tobacco products seeking to enter the market to meet FDA pre-market standards (including electronic cigarette regulation). The statutory language left open the possibility that electronic cigarettes may be able to be regulated as a nicotine delivery device- and as such could have required a prescription.

The FDA exercised that authority by directing the U.S. Customs and Border Protection to reject the entry of electronic cigarettes into the US on the basis they were unapproved drug delivery devices.

A series of lawsuits then followed FDA’s decision. In a December 2010 landmark decision in the Smoking Everywhere v. FDA case, the U.S. Court of Appeals in Washington ruled the FDA can only regulate e-cigarettes as a tobacco product (e.g. that e-cigs can’t be regulated as a nicotine delivery device- which could have included a prescription requirement). The court said that if therapeutic claims are made then the FDA might be able to regulate e-cigs as a nicotine delivery device.  That order is here and the 25-page decision is here.

In a subsequent ruling in December 2010, the appeals court also ruled against the FDA in a 3–0 unanimous decision, finding that the FDA can only regulate e-cigarettes as tobacco products. The judges ruled that such devices would only be subject to drug legislation if they are marketed for therapeutic use – E-cigarette manufacturers had successfully proven that their products were targeted at smokers and not at those seeking to quit.

Editorial Note: Here lies the root cause of why we are where we are right now.  Had the judges found that the FDA had the authority to regulate e-cigarettes as a nicotine delivery device- they could have required a prescription (for smoking cessation purposes) on e-cigs and the marketing wildfire that resulted in the addiction of a generation of young people to high levels of nicotine could have been averted. 

Following those court rulings, in April 2011 the FDA announced it will regulate e-cigarettes like traditional cigarettes and other tobacco products under the Food Drug and Cosmetics Act, however, they never exercised their authority to regulate the marketing and advertising of e-cigarettes, and here we are…  in the middle of a teen and young adult vaping epidemic.

Some State Legislatures Tackling E-cigs

E-cigarette use by kids is growing across the nation including in AZ.  A couple of weeks ago the FDA Commissioner called out the manufacturers of electronic cigarettes for their clear efforts to market to teenagers and put them on notice that additional regulations could be on the way. 

All of you reading this have seen them around these days.  They have various looks.  For example- some of the most popular ones mimic USB flash drives so that they’re easily disguised adults (teachers and parents).  They even actually plug into an USB port for charging!

Almost all of them contain nicotine which is of course highly addictive, harmful to adolescent brain development, and a health danger for pregnant women. E-cigarette aerosol can also contain cancer-causing chemicals, heavy metals like lead, and volatile organic compounds. Evidence shows that even those without nicotine are harmful to the lungs.

E-cigs are now the most commonly used tobacco products among youth and young adults, with e-cigarette use growing 900% among high school students from 2011 to 2015.  In 2016, more than two million U.S. middle and high school students had used e-cigarettes in the past 30 days.

Middle aged e-cig users are quite different from younger users. Most middle aged e-cigarette users (aged 45 years and older) are either current or former regular cigarette smokers.  Less than 2% had never been cigarette smokers!  In contrast, among 18-23 year olds, 40% have never been regular cigarette smokers. A big concern is that many of these younger e-cig users will transition to actual cigarettes.

Some states have implemented legislative approaches to combat e-cigarette use. Pricing is among the most frequent interventions.  Raising the price of e-cigarette reduces demand just like for other tobacco products, especially for younger users- that tends to dominate the approaches. Legislation to increase the price of e-cigarette products fall into three categories: 1) price increases based on the current sales price; 2) pricing e-cigarettes and vapor products at the same rates as regular cigarettes; and 3) imposing a per milliliter (ml) price increase on liquid nicotine or consumable material.

 

Percentage Price Increases

Two states have established percentage price increases for e-cigarettes. Pennsylvania increased the price of e-cigarette products (i.e., the electronic oral device with heating coil, battery, etc., as well as the liquid or substance used in the e-cigarette) by 40%.  Minnesota increased the price of tobacco products including e-cigarette products by 95%.

Washington state introduced a bill that would raise the prices of vapor products by 60%. In New Mexico, an amendment was introduced to raise the price of e-cigarettes by 76% of the product value. This would be an increase from the current 25% set out in statute.

Legislators in New York recently introduced two bills (A011338 and S01089) to treat e-liquid cartridges as “tobacco products” and increase the price of cartridges by 75% of the wholesale price. A governor’s budget proposal in Rhode Island called for raising the price of e-cigarettes by 80% of the wholesale cost. Similarly, Kentucky proposed an amendment to increase the price of e-cigarettes by 15%.

 

Pricing Equalized to Cigarettes

California is adopting regulations to increase e-cigarettes prices equal to their Cigarette Distribution Tax ($0.10 per cigarette).  District of Columbia increased the price of vapor products equal with the rate imposed on a pack of 20 cigarettes.

 

Price Increases Per Fluid Amount

Six states increased prices of vapor products, liquid nicotine, or consumable material per fluid ml. Delaware (vapor products), Kansas (consumable material), Louisiana (vapor products and e-cigarettes), and North Carolina (vapor products) added $0.05 per fluid ml. Louisiana’s law increased the price of consumable nicotine liquid solution or other material containing nicotine that is depleted as a vapor product.

New Jersey passed legislation raising the price of nicotine liquid by $0.10 per fluid ml. West Virginia increased the price of e-cigarette liquid by $0.075 per ml.  Puerto Rico legislature approved a bill to increase the price of e-cigarettes by $3, nicotine cartridges by $0.05 for every millimeter of nicotine solution or any other substance in each nicotine cartridge, and vaporizers by $6 for every unit.

Legislation increasing the price of e-cigarettes, other electronic smoking devices, and e-liquids can encourage users to quit, seek and sustain cessation, prevent youth initiation, and reduce consumption among those who continue to use them. Many states have taken proactive steps to stem the tide using the fact that young people are price sensitive. Perhaps we’ll see some proposals from the Arizona State Legislature.  However, how successful the effort will be depends on the makeup and view of the next legislature and governor.

FDA Steps Up Tobacco Control (A Bit)

Last week the FDA Commissioner called out the manufacturers of electronic cigarettes for their clear efforts to market to teenagers and put them on notice that additional regulations could be on the way.  You probably heard about this in the media this week.  When I went to the FDA website to get the details, I discovered that the media had overstated FDA’s intervention commitments.

Apparently, the FDA is at least considering removing certain flavored e-cigarettes from the market and shortening the time to market review for most cigarettes now being sold.  At a press conference last week, he acknowledged that his agency has failed to recognize the extent of the problem.  Here’s a direct quote from him.  

The quote did strike me as unusual from a member of this administration for its candor:  "We didn't predict what I now believe is an epidemic of e-cigarette use among teenagers, and today we can see that this epidemic of addiction was emerging when we first announced our plan last summer. Hindsight, and the data now available to us, reveal these trends. And the impact is clearly apparent to the FDA."

The FDA  issued more than 1,300 warning letters and civil money penalty complaints to retailers who illegally sold JUUL and other e-cigarette products to minors during a nationwide.  Last week’s action also included a request to 5 e-cigarette manufacturers to put forward plans to immediately and substantially reverse these trends toward marketing to teens or face a potential decision “to reconsider extending the compliance dates for submission of premarket applications”.

At least it's a start.

Medicaid Network Adequacy: A Key to Access to Care

AHCCCS is rolling out new integrated care contracts on October 1, and most members will be receiving services for both acute and behavioral care from these managed care organizations.  One of the keys to making sure that members have access to a health care provider when they need it is for AHCCCS to make sure each managed care organization has an adequate network of contracted providers.  After all, having health insurance isn’t much good if there’s no place for you to get care in your area or if the doctors are booked and you can’t get an appointment.  That’s where “network adequacy” comes in.

AHCCCS sets their network adequacy standards in what’s called their “AHCCCS Contractors Operations Manuals”, or ACOMs for short.  From now through May 28, 2018 AHCCCS is accepting public comment on their proposed ACOM manuals for network expectations for the integrated care contracts that start on October 1.

Geographic Standards

One of the keys is to make sure that there are providers reasonably nearby Medicaid members.  ACOM 436- Minimum Network Requirements will set the expectations for geographic access to care. It’s pretty long as you’ll see if you click on the link.  But here are a couple examples of the key proposed standards that are out for public comment. 

For kids, they propose requiring their contracted managed care organizations to ensure that 90% of members live within 10 miles or 15 minutes of a primary care provider in Maricopa and Pima counties.  For all other counties, they’re proposing that 90% of members lives within 30 miles or 40 minutes of a primary care provider.  For kids dental in Maricopa & Pima counties, they’re proposing requiring their contractors to make sure that 90% of members live within 15 minutes or 10 miles of a provider.  For the other counties, they’re proposing that 90% of members live within 40 minutes or 30 miles of a provider.

The Manual also proposing a process for managed care organizations ask for an exemption from the standards based on outlined reasons and the criteria by which they’ll consider approving the exemptions.  Those of you that are well versed in these aspects of access to care can comment on the proposed standards and the exemption criteria through May 28 at this web link.

Appointment Wait Time Standards

Another Manual that’s out for public comment is about how long it takes to make an appointment to see various kinds of providers.  That one is called ACOM 417, Appointment Availability, Monitoring and Reporting.

The 417 Manual proposes that routine primary care appointments be set within 21 calendar days of the member’s request.  For more urgent appointments, the proposal is for “… as expeditiously as the member’s health condition requires but no later than 2 business days of request”.  For Specialty provider referrals the proposal is “… as expeditiously as the member’s health condition requires but no later than 3 business days from the request”.  For routine specialty care appointments it’s within 45 calendar days of referral.  For dental provider appointments it’s “… as expeditiously as the member’s health condition requires but no later than 3 business days of request, and for routine care appointments within 45 calendar days of request

They’re also proposing a process for managed care organizations ask for an exemption from the standards based on outlined criteria.  They also outline the criteria by which they’ll consider approving the exemptions.

Those of you that are well versed in these aspects of access to care can comment on the proposed standards and the exemption criteria through May 28 at this web link.  We’ll talk this over with our Public Health Policy Committee and turn in comments sometime in May.  Let me know if you want to get onto our Policy Committee Basecamp and I’ll sign you up.

 

FDA Pursuing E-Cigarette Interventions

Last week the FDA announced several interventions to better regulate e-cigarette makers.  It’s no secret that e-cigarettes have become wildly popular with kids.  E-cig makers have become increasingly crafty in attracting kids to use their products- which often have high nicotine levels.  Some of the new products look like a USB flash drive- making it easier for them to sneak into what are supposed to be tobacco product free-areas.  Many fall under the JUUL Brand but also “myblu” and “KandyPens”.

The strategies that FDA announced last week include: 1) an “undercover” investigation into retailers that are selling these JUUL products to kids and issuing warning letters and other enforcement actions; 2) raising concerns with eBay regarding their listing of JUUL products on their website; 3) contacting manufacturers like JUUL Labs and requiring them to submit like documents like their product marketing strategy, research on the health, toxicological, and behavioral or physiologic effects of the products; and 4) enforcement actions focused on companies that are marketing products in ways that are misleading to kids.

Time will tell whether these strategies make a difference- but one thing is clear- we’ll continue to be in a long-term battle with companies that will continue to creatively find new ways to addict America’s youth to their nicotine products.

 

Legislative Session Update

There wasn’t much action on the public health bills we’re working on and tracking last week. Unless you’ve been out of town or on vacation you know that pretty much all last week was absorbed with the debate about weather and how to fund increases for K-12 schools.  There were huge peaceful marches on the Capitol on both Thursday and Friday.  The Legislature adjourned early last week.

The Governor has proposed increasing teacher salaries by 20% by the year 2020. The teachers are looking for a more robust commitment for all other school staff and a dedicated revenue stream to support the investment.  The Governor proposes paying for the increase in several ways- in part by increasing the assessment on hospitals to help pay for Medicaid, and in part by decreasing planned funding for things like provider increases for programs that serve people with disabilities (because of the increase in the minimum wage).  The plan assumes state revenue will increase by 4.8% per year over the next 3 years (over the last 3 years it’s increased by between 3 and 4% per year). 

Late last Friday afternoon the Governor issued a media release stating that an agreement had been reached with the legislature on a way to fund the 20% by 2020 idea, but the media release didn’t explain how it would be paid for.  Here’s the latest information that I have- but of course this could change when the actual proposal comes out later this week. Robert Robb from the Republic had the most digestible explanation of the plan that I’ve been able to find.

The phased-in cost of the teacher pay increase is $580M. The phased-in school-assistance portion is $370M (a total of $950M).  Maintaining all other state programs over that period is about $850M and that’s without any population increase or inflation.  At 4.8% revenue growth per year (the past 3-year average is between 3 and 4%) there’d be a $150M deficit in 2020 even if there were no increases in spending anywhere else in state government.  If revenue growth were less than 4.8%, there’d be a bigger deficit.  If revenue increases average more than 4.8% things might be OK.  If there’s a recession, we’d be in big trouble. 

You can see how important it is to get the revenue stream right.  If revenues and expenses are unbalanced, the increases for schools and teachers will absorb all other funds and there won’t be anything available to address public health or social determinant priorities and might even force reductions in other state services like health care and public health. 

 

Medicaid Changes Partially Support the Teacher Salary Proposal

There are a couple of “efficiency items” that the Governor identified within our Medicaid program that will partially pay for some of the teacher salary increase.  One relates to the assessment on hospitals that pays the state portion of the Medicaid expansion deal that was reached a few years ago.  The other is a proposed change to eliminate something called “prior quarter coverage”.

Hospital Assessment

One item listed as an “efficiency savings” to help pay for the teacher salary proposal increase the hospital assessment, which pays for Medicaid expansion, by $35 to $39M.  The Governor has proposed moving behavioral health services for childless adults to the same funding stream as acute care (tobacco taxes and the hospital assessment pay for acute care coverage for childless adults and those covered through Medicaid expansion).  The assessment on  hospitals would increase by 12% from $287 million to $326M.

Prior Quarter Coverage

Back on January 1, 2014 AHCCCS began covering people that qualify for Medicaid for the 3 months prior to their eligibility date.  So, if a person applying for AHCCCS qualifies during any portion of three months immediately preceding the month in which the member applied for AHCCCS coverage, they’ll reimburse providers for covered services.  They’ve submitted a waiver request to CMS to stop this practice.  In FY 2017 they spent a total of about $21M for prior quarter coverage- so stopping the practice would save about $11 - $12M in state funds. This waiver is in the hands of CMS right now.

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Here’s a snapshot of where the various bills we’re working on are in the system. 

HB 2038 Drug overdose review teams; records (Signed into Law)

HB 2071 Rear-facing car seats (Stalled in Senate)

HB 2084 Indoor tanning; minors; restricted use (Now called SB 1290 as Striker) 

HB 2127 Children's health insurance program (Now called SB 1087 as Striker)

HB 2197 Health professions, workforce data (Ready for Senate Floor Vote)

HB 2208 Prohibition, photo enforcement (Effectively dead)

HB 2228 Annual waiver, applicability (Signed by Governor)

HB 2323 Schools; inhalers; contracted nurses (Ready for Senate Floor Vote)

HB 2324 Community health workers; voluntary certification (needs Senate floor vote)

HB 2389 Syringe access programs; authorization (Basically dead)

HB 2484 local food tax; equality (Signed by Governor)

SB 1022 ADHS; homemade food products (Signed by Governor) 

SB 1083 Schools; recess periods (Signed by Governor)

SB 1245 Snap Benefit Match (Needs Rules Committee & Budget Line)

SB 1261 Texting while driving (Now HB 2159 traffic violations; traffic survival school)

SB 1420 Medical marijuana; inspection; testing; appropriation (Needs House Rules)

SB 1445 AHCCCS Dental care, pregnant women (Needs House Rules Committee)

SB 1377 Dental therapy, licensure, regulation (Failed in House now HB2235 in Senate)

SB 1389  HIV; needs assessment; prevention signed by the Governor last week.

SB 1394 Abortion reporting (Signed by Governor)

SCR 1005 Voter Initiative Sunset (striker in the House)

 

Public Health-related bills signed so far:

HB 2038 Drug overdose review teams; records was passed and signed.  Once it takes effect later this year, law enforcement agencies will now be required to provide unredacted reports to the chairperson of a local Drug Overdose Fatality Review Team on request. 

HB 2228 Annual waiver, applicability was signed by the Governor.  It’s good. It will direct AHCCCS to exempt tribes from their directed waiver request that asks for CMS 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 was signed by the Governor.  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 2484 local food tax; equality, which will ban Arizona cities and counties from taxing sugary drinks as a public health intervention.

SB 1022  DHS; homemade food products ADHS will 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.

SB 1083 Schools; recess periods was passed and signed!  Beginning next school year K-3 will need to have at least 2 recess periods. Grades 4 and 5 will need to have 2 recess periods the year after that.

SB 1389  HIV; needs assessment; prevention was signed by the Governor last week.  It requires the ADHS to establish and implement an HIV Action Program. 

SB 1394 Abortion reporting was passed by the House and signed by the Governor.  It will require the ADHS to collect and report additional data regarding abortions that are performed in AZ.

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AZ Public Health Policy Update: April 23, 2018

Feds Overhaul Essential Health Benefit Options

The Affordable Care Act required all health insurance policies sold on the Exchange and in the small group & individual markets to cover as set of “essential health benefits”.   Each Governor selects their state’s essential health benefits by choosing among options like their state employee plan, a small group market plan etc.  Each state has 10 options to pick from.  Governor Brewer selected the state employee plan as Arizona’s benchmark and Ducey did the same a couple of years ago.  Not a bad choice, because the benefits are generally robust- except that since the state employee plan doesn’t cover abortion services the state benchmark doesn’t either (although non-Medicaid plans can elect to cover those services).

Last week the Centers for Medicare & Medicaid Services issued an annual "Notice of Benefit Payment Parameters for 2019“. It outlined a big change.  Beginning in 2019 CMS will be giving Governors a lot more flexibility in selecting their state’s essential health benefit package.  Instead of 10 options, states will be able to choose among any of the essential health benefit benchmark plans used by any other state.  The new rules could have a profound impact on health insurance access and benefits.

It remains to be seen whether our Governor will choose a different benchmark plan moving forward.  Here’s a list of the various states’ insurance benefits benchmark mandates: [EHBs by State]

Legislative Session Update

The Governor vetoed 10 bills last Friday - apparently to send a message to the legislature that he wants the "20% by 2020" teacher funding bill on his desk forthwith. 

Luckily, the Community Health Worker voluntary certification bill needed to go back to the House for a Final Read- or it’s quite possible that it would have been veto number 11.  He did veto a good bill HB 2089 which would have required school districts to develop guidelines, information and forms on the dangers of heat-related illnesses, sudden cardiac death and prescription opioid use.

Last week was a busy one for the bills that we’re working on, so this update will be long again.  Once the session is over my updates will get shorter, I promise!

SB 1389   HIV; needs assessment; prevention was signed by the Governor last week.  It requires the ADHS to establish and implement an HIV Action Program to: 1) complete a statewide HIV Prevention and Care Needs Assessment (Assessment) of target populations (by November 1, 2020); 2) identify community-based agencies that serve the HIV population and that are outside of the known HIV service system; 3) conduct outreach to increase community involvement in HIV prevention, education and stigma reduction; 4) develop a social media initiative to engage at-risk populations to be tested for HIV infection; and 5) analyze data from the Assessment annually to develop and implement HIV training and education initiatives.

SB 1445 AHCCCS Dental care, pregnant women cleared the full Senate but still needs a House Rules hearing and a floor vote. It'll need an appropriation (to provide oral health coverage to pregnant Medicaid members)… so much of the discussion right now is about how much it would cost.

The direct cost to AHCCCS is estimated to be a little less than $268K/year.  However, the Joint Legislative Budget Committee (JLBC) believes that it could have secondary costs. Their thinking goes something like this: pregnant Medicaid enrollees that are not yet receiving prenatal care will discover that there's an oral health benefit and will make a dental appointment. The hygienist or dentist will discover the pregnancy and inform their health plan about the pregnancy. At that point, their eligibility category would switch to one with a higher state match rate (and presumably begin receiving prenatal care- which if it happened would be a good thing). 

The JLBC analysis assumes that 25% of the estimated 5,000 pregnant women currently enrolled in the expansion population but not receiving prenatal care will, because of the new benefit, go to the dentist- causing their eligibility to change (to a category called SOBRA), generating a $3.7M refinancing cost. 

Honestly, it seems unlikely to me that women who aren’t getting prenatal care will present to a dentist or hygienist for a cleaning.  I can see it if they have a toothache, but any secondary cos from a dental emergency would be associated with last year’s emergency dental benefit - not this new (proposed) preventative oral health benefit.  We’ll see what happens during the upcoming budget process.

A new problem is that the effort to raise teacher’s pay is probably going to jeopardize many programs that may have otherwise been funded, like this one.  It’s still possible that this might happen- but it’s a lot less likely now because of the effort to raise teacher’s salaries 20% by 2020.

HB 2159 traffic violations; traffic survival school has been languishing for the last few weeks.  Last week the bill passed the House and has been assigned a Conference Committee to resolve the differences with the Senate version.  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.

HB 2228 Annual waiver, applicability was signed by the Governor this week.  It’s good. It will direct AHCCCS to exempt tribes from their directed waiver request that asks for CMS 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 2235 dental therapy; regulation; licensure has had a long and somewhat bizarre trip through the legislature.  The original bill (SB 1377) 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.  They could also practice anywhere.  The original bill passed the Senate but died in the House Health committee.  It came back to life a couple of weeks ago as what’s called a Strike Everything Amendment but stalled out again.  Then, this week, an amendment to the amendment was offered that seems to please everybody- and it passed the Senate 30-0.  It still needs to go back to the House, but it has a real chance now.

The Senate version limits dental therapists to only practicing at a Federally Qualified Community Health Center (or look-alike), or a nonprofit dental practice or organization that provides dental care to low-income and underserved individuals, or a private dental practice that provides dental care for CHC patients of record.  The amended bill also prohibits a dental therapist from performing nonsurgical extractions of permanent teeth unless under the direct supervision of a dentist.

The “school safety” bill called SB 1519 protective orders; schools; appropriations was proposed late last week by Senator Smith. Here’s a link to the introduced version.  It contains many of the things outlined by the Governor a few weeks ago related to firearms, schools and protection orders. A centerpiece is something called a “Severe Threat Order of Protection” which outlines a process to restrict firearm access for people who are a danger to themselves or others. There are also measures that would require AHCCCS to develop and post suicide prevention training and a statewide school safety hotline would also be established. 

There’s no provision in the bill for comprehensive background checks or restrictions on things called “bump stocks” which makes guns fire quicker. There are some other troublesome parts of the bill. 

Our folks in the Public Health Policy Committee (including AzPHA member Jean Ajamie who is a school safety expert) has been doing some analysis of the bill (you can see that stuff on our Committee Basecamp- let me know if you’d like to join that group). We haven’t taken a position yet- most likely we’ll remain neutral.  The bill passed the Senate Commerce and Public Safety Committee this week. Next week will be the Senate Rules Committee.  There’s no mirror bill in the House at their point.  Stay tuned.

HB 2323  Schools; inhalers; contracted nurses was signed by the Governor this week.  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 was passed by the Senate this week (24-6)!  It passed the Senate in an amended form (including a provision to ensure that state procurements don’t favor contracting with certified vs non-certified CHWs).  There are two important steps left.  Because the Senate amended the House bill, it needs to go back to the House where Rep. Carter will likely formally concur with the Senate changes.  Then it needs a “Final Read” vote in the House to formally agree with the amendments the Senate added.  Assuming it passes the House again, then it’s on to the Governor for his approval (hopefully) The Senate amendments got the Goldwater Institute to be neutral- so I think we’re in good shape for a signature.

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Here’s a snapshot of where the various bills we’re working on are in the system. 

HB 2038 Drug overdose review teams; records (Signed into Law)

HB 2071 Rear-facing car seats (Stalled in Senate)

HB 2084 Indoor tanning; minors; restricted use (Now called SB 1290 as Striker) 

HB 2127 Children's health insurance program (Now called SB 1087 as Striker)

HB 2197 Health professions, workforce data (Ready for Senate Floor Vote)

HB 2208 Prohibition, photo enforcement (Effectively dead)

HB 2228 Annual waiver, applicability (Signed by Governor)

HB 2323 Schools; inhalers; contracted nurses (Ready for Senate Floor Vote)

HB 2324 Community health workers; voluntary certification (Senate floor vote this week)

HB 2389 Syringe access programs; authorization (Basically dead)

HB 2484 local food tax; equality (Signed by Governor)

SB 1022 ADHS; homemade food products (Signed by Governor) 

SB 1083 Schools; recess periods (Signed by Governor)

SB 1245 Snap Benefit Match (Needs Rules Committee & Budget Line)

SB 1261 Texting while driving (Now HB 2159 traffic violations; traffic survival school)

SB 1420 Medical marijuana; inspection; testing; appropriation (Needs House Rules)

SB 1445 AHCCCS Dental care, pregnant women (Needs House Rules Committee)

SB 1377 Dental therapy, licensure, regulation (Failed in House now HB2235 in Senate)

SB 1394 Abortion reporting (Signed by Governor)

SCR 1005 Voter Initiative Sunset (striker in the House)

 

Public Health-related bills that have been passed and signed:

HB 2038 Drug overdose review teams; records was passed and signed.  Once it takes effect later this year, law enforcement agencies will now be required to provide unredacted reports to the chairperson of a local Drug Overdose Fatality Review Team on request. 

HB 2228 Annual waiver, applicability was signed by the Governor.  It’s good. It will direct AHCCCS to exempt tribes from their directed waiver request that asks for CMS 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 was signed by the Governor.  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 2484 local food tax; equality, which will ban Arizona cities and counties from taxing sugary drinks as a public health intervention.

SB 1022  DHS; homemade food products ADHS will 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.

SB 1083 Schools; recess periods was passed and signed!  Beginning next school year K-3 will need to have at least 2 recess periods. Grades 4 and 5 will need to have 2 recess periods the year after that.

SB 1389  HIV; needs assessment; prevention was signed by the Governor last week.  It requires the ADHS to establish and implement an HIV Action Program. 

SB 1394 Abortion reporting was passed by the House and signed by the Governor.  It will require the ADHS to collect and report additional data regarding abortions that are performed in AZ.

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House Bills

HB 2038 Drug overdose review teams; records                

Passed and Signed

Law enforcement agencies will now 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.

HB 2071 Rear-facing car seats         

Stalled in Senate

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.  No action has yet been taken in the Senate so this bill is effectively dead.

HB 2084 Indoor tanning; minors; restricted use

Passed House but Stalled in Senate- now SB1290

This bill had been languishing in the Senate after passing the House by a 45-15 vote. Because of its lack of movement in the Senate it had appeared to be dead again this year.  However, this week it reappeared as a Strike All amendment in the House again as SB 1290.  It has now passed the House and has been sent back to the Senate.

HB 2127 Children's health insurance program

Stalled in Senate- now SB 1087 in House

After passing the House, this bill had been languishing in the Senate and appeared dead.  However, it was resurrected this week in the form of SB 1087 and was passed again by the House Health Committee last Thursday.  It still needs another House floor vote before it goes back to the Senate again.  It would remove 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

Ready for Senate Floor Vote

This bill is looking good and ready for a final Senate floor vote.  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

Died in Senate

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 but stalled in the Senate.  Honestly, it looks dead.

HB 2228 Annual waiver, applicability

Signed by Governor

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

Signed by Governor

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

Needs Final Read in House

This was passed by the Senate this week (24-6)!  It was in an amended form (including a provision to ensure that state procurements don’t favor contracting with certified vs non-certified CHWs).  There are two important steps left.  Because the Senate amended the House bill, it needs to go back to the House where Rep. Carter will likely formally concur with the Senate changes, and then it needs a “Final Read” vote in the House to formally agree with the amendments the Senate added.  Assuming it passes the House again, then it’s on to the Governor for his approval (hopefully) The Senate amendments got the Goldwater Institute to be neutral- so I think we’re in good shape for a signature.

HB 2389 Syringe access programs; authorization 

Dead

This basically looks dead for this year. The bill that passed the House was great- providing clear decriminalization of needle exchange programs (needle exchange programs are technically a class 6 felony right now).  The version that passed the Senate only decriminalizes syringe exchange programs when and where the ADHS declares a public health emergency because of the rapid spread of infectious diseases.

It went to a Conference Committee this consisting of Rivero, Navarrete, Udall, Borelli, Brophy McGee, and Mendez… but Wednesday, Brophy McGee was replaced with Petersen, basically killing the House version- and the bill was dropped from the Conference Committee agenda- basically killing it.  Honestly, the Senate version of the bill wouldn’t have helped public health much if it all. Maybe next year.

HB 2484 local food tax; equality

Signed by Governor

The Governor signed this bill, which bans Arizona cities and counties from taxing sugary drinks as a public health intervention. The bill doesn’t specifically mention taxes on sugary drinks, but states that any tax on food needs to be uniform.  products must be uniform. Right now, there aren’t any Arizona cities or counties that are taxing soda and other sugary drinks, and this new law will ensure that it stays that was. 

 

Senate Bills

SB 1022    DHS; homemade food products            

Signed by Governor

ADHS will 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.

SB 1083    Schools; recess periods

Signed by Governor

This was passed and signed!  Beginning next school year K-3 will need to have at least 2 recess periods.  Grades 4 and 5 will be added the following year. This makes AZ a national leader in state school recess policy. A big shout out to AzPHA member Scott Turner and Christine Davis from Arizonan’s for Recess for their heavy lifting to make this happen!

SB 1245 Snap Benefit Match

Needs House Rules Committee and Budget Line Item

This Bill needs House Rules review before a House floor vote (and of course needs to make it through the budget process). 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 1261 Texting while driving

Now HB 2159 and Moving Again in House

This has been languishing for the last few weeks because 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, passed the House and is headed back to the Senate and has been assigned a Conference Committee.

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.

SB 1377 Dental therapy, licensure, regulation

Moving Again in Amended Form

This has had a long and somewhat bizarre trip through the legislature.  The original bill (SB 1377) 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.  They could also practice anywhere.  The original bill passed the Senate but died in the House Health committee.  It came back to life a couple of weeks ago as what’s called a Strike Everything Amendment but stalled out again.  Then, this week, an amendment to the amendment was offered that seems to please everybody- and it passed the Senate 30-0.  It still needs to go back to the House, but it has a real chance now.

The Senate version limits dental therapists to only practicing at a Federally Qualified Community Health Center (or look-alike), or a nonprofit dental practice or organization that provides dental care to low-income and underserved individuals, or a private dental practice that provides dental care for CHC patients of record.  The amended bill also prohibits a dental therapist from performing nonsurgical extractions of permanent teeth unless under the direct supervision of a dentist.

SB 1394 Abortion reporting

Signed by Governor

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.).

SB 1420 Medical marijuana; inspection; testing; appropriation

Needs House Rules Approval

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

Needs House Rules and Floor Vote & a Budget Line Item

This unanimously cleared the House Appropriations committee last week.  We were hoping to get a Rules committee hearing next week, but it’s not on the agenda, sadly.  The big hurdle will be getting an appropriation to cover the state match into the budget.

SB 1470  Sunrise process; health professions

After a dramatic start, this bill looks like it will have a consensus ending.  The sunrise process bill stakeholders negotiated changes to the current scope of practice sunrise process that everybody seems to be able to live with.  It passed in House this week by a 59-0 vote. It’s now ready for the Senate to concur in the House’s amendment.