Prevention

Arizona’s New Oral Health Plan Published

The Arizona State Oral Health Action Plan 2019-2020 Workgroup released the Arizona 2019-2022 Oral Health Action Plan this week.  The report articulates goals, delivers recommendations, and identifies strategies to improve the oral health of all Arizonans. It incorporates strategies gathered over three years of collaboration with health care stakeholders, state and regional oral health coalitions, educational institutions, professional associations, and grassroots organizations. This plan offers solutions to address the tremendous burden of preventable oral diseases that affect individuals across the lifespan by collaboratively creating a new blueprint to improve oral health and overall health.

The goals and objectives address four cross-cutting systems of care: Policy, Care, Community, and Financing.  The goal and objectives for each category begin on page 18 of the Report.  Recommendations include:

Policy—using data and stories to educate, advocating for Medicaid dental coverage for pregnant women, increasing the number of Arizonans with optimally fluoridated water, and establishing a state oral health surveillance plan;

Care —ensuring an adequate, diverse, and culturally competent workforce, incorporating oral health as an essential component of overall health and well-being through integrated inter-professional systems, and encouraging, supporting, and tracking inter-professional educational models of care;

Community—maintaining a statewide network of champions and leaders for oral health advocacy and planning, supporting evidence-based prevention and early detection programs, and implementing and disseminating consistent and uniform messaging; and  

Financing—financing oral health as an important component of overall health, funding and expanding oral health prevention, and sustaining financial support to improve health outcomes.

As is the case with any plan- the real key is translating the plan goals and objectives into public policy via administrative advocacy (policy interventions by state agencies), legislative advocacy (policy interventions like SB 1088 which would provide preventative oral health care for pregnant Medicaid members), by working with systems of care to improve inter-professional collaboration and by influencing policies by payors to drive better outcomes (e.g. teledentistry).

Measles & Mumps Cases in AZ

Arizona Has Lost Community Immunity in Many Places

In the last 2 weeks AZ public health officials have identified and confirmed cases of measles and mumps.  The mumps cases (2) were found in the SE valley and are under investigation by Maricopa County Public Health folks. Another mumps case has been confirmed in Cochise County.  The measles case was found in Tucson in a 12 month old- and appears to have been acquired after travelling to Asia. That case is being investigated by Pima County public health epidemiologists.

The basic detective work will include looking for susceptible contacts and conducting interventions to control the spread. Kids don't get the MMR vaccine until their first birthday, so infants are at high risk of getting the disease if they're exposed... so that group along with unvaccinated contacts (whether for medical or choice reasons) will be among the high priority contacts to identify.  You can see the investigation and control measures for both illnesses in Arizona's communicable disease rules (Pages 34-39).

Measles is more contagious than mumps- but both are easily spread (direct contact isn't needed to spread the virus).  Both are vaccine preventable diseases.  For measles (the most contagious disease), 95% of children need to be vaccinated to prevent spread.  

Whether these cases transition to an outbreak or epidemic will depend on where the index cases were prior to diagnosis, who was potentially exposed and the vaccination status of the contacts.  If the index cases were isolated or if they were in communities (or medical facilities) with vaccination rates above 95% it's unlikely that measles will spread beyond the first case. If they were among communities with lower vaccination levels, there's a good chance there will be more cases. Another wildcard will be whether there were potential infant contacts in doctors offices or clinics if potential exposures happened there.

Many parts of Arizona have vaccination levels lower than "herd immunity" levels, meaning that in many parts of the state we've lost community immunity.  Fortunately, Pima County has among the highest vaccination rates in the state, meaning there's a better chance of containing the disease.  Had the index case been from one of the many communities in AZ with much lower vaccination rates the risk would be higher. Of course- there are pockets of under vaccinated areas in every county- so many communities are at risk these days.  

Arizona is one of eighteen states that allows parents to opt out of vaccinating their child with a non-medical exemption Click this link to view the full report.  In fact, Maricopa County leads the nation in the highest number of non-medical exemptions.  

There are 30 Legislative Districts in AZ. You can click here to find out what District you live in so you can communicate with your elected officials about the importance of community immunity and ensuring they understand you support public policies that encourage immunizations.

BTW: there are science-based resources available to help parents make informative decisions about vaccines such as the CDC, Children’s Hospital of Philadelphia and TAPI.

More States Moving to Eliminate Non-Medical Exemptions (not in AZ)

There have been 127 cases of measles were confirmed in 10 states this year with outbreaks in Texas, Washington, and multiple jurisdictions in New York. The reported cases are centered primarily within communities where rates of children who are vaccinated against measles are below herd immunity (due to its high level of communicability, measles require a high rate of vaccination, between 95% to reach herd immunity).  

There are many communities in Arizona and across the country where the rates are much lower than 95%. For example, in Clark County, Washington (where a recent measles outbreak originated) the percentage of kindergarteners who received a vaccine for measles fell from 96% in 2004 to 85% in 2017.

Every state has vaccination requirements for kids starting school, and all states also have medical exemptions.  All but three states—California, Mississippi, and West Virginia—also allow non-medical exemptions (i.e., exemptions based on religious, philosophical, or personal beliefs).

Arizona currently has medical and religious exemptions for pre-school & medical and personal exemptions for public school attendance. HB 2070, which passed the House Health and Human Services Committee Thursday (5-4) would add a new religious exemption for public school.

Over the past 10 years, the number of non-medical exemptions has increased, especially in states that allow both religious and philosophical exemptions. Additionally, researchers have identified several areas in the US where large numbers of non-medical exemptions are granted, including in the Portland metro area, where Clark County, Washington, is located.

Some states are now beginning to do away with non-medical exemptions for school vaccination requirements.

In 2015, following an outbreak of measles at Disneyland, CA eliminated its non-medical exemptions (and immunization coverage recovered dramatically).  In California, vaccination rates rebounded substantially after the personal exemption was eliminated.  Vermont also eliminated its philosophical belief exemption in 2015 (but kept their religious exemption).

This year, a bill to remove the personal belief exemption for the MMR vaccine has passed the State of Washington's House of Representatives (HB 1638).  Many other states have also proposed eliminating non-medical exemptions, including Arizona (HB 2162 - which has not received a hearing), Iowa (HF 206), Maine (LD 798), Minnesota (SF 1520), and New York (S 2994 and A 2371).

Sadly, the bills that have received hearings in Arizona all work against improving our immunization rates, including HB 2470 Vaccination Religious Exemptions, HB 2471 Informed Consent, and HB  2472 Vaccinations- Antibody Titer.  All 3 Bills received Pass Recommendations in the Senate Health and Human Services Committee this week (by a 5-4 margin). They will likely be up for floor votes this week in the AZ House.

Legislative Update

All the legislative committees have big long agendas this week – as the deadline for bills to be head in their house of origin committees is rapidly approaching.  So, this will be a busy week. 

Our policy interns Tim Giblin and Annissa Biggane have been doing a great job tracking all the bills that we’re signed up for and against and monitoring amendments and the like. Here’s their detailed summary of all the various public health related bills and where they are in the system right now.

We have an Action Alert this week regarding some bills that will have a detrimental effect on vaccination rates- so please follow through on that this week- you can see more about that below.

Bills to Be Heard in Committee This Week

Monday

HB 2597  School Safety Plan Task Force (Hernandez) AzPHA Position: Yes

This well-researched bill came out of a workgroup established by students at Mountain View High School. It takes a proactive approach to prevent school violence.  The Bill asks schools to develop plans to outline how teachers and staff will respond to crisis situations, how they respond to warning signs of emotional or behavioral distress among students, partnerships with agencies to refer students to support services, and what services they’ll provide after a violent incident. This important bill will be heard in the House Education Committee on Monday, February 18 at 2pm.  We’re signed up in favor of the bill.

 

Tuesday

SB1399  School Health Pilot Program (Pace) AzPHA Position: Yes

This bill charges the AZ Department of Education with conducting a 3-year physical and health education professional development pilot program to improve the ability of physical and health educators in this state to provide high quality physical and health education to students in this state, improving student health and reducing Arizona health care cost containment 10 system and other health-related costs.  Appropriates $9.5M for planning, implementing, and evaluating the pilot.  This important bill will be heard in the Senate Education Committee on Tuesday, February 18 at 2pm. We’re signed up in favor of the bill and I’ll be speaking in Committee.

 

Wednesday

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

This bill prohibits using a hand-held cell phone while driving.  There are some common-sense exemptions for example if the person is using it hands free etc.  Penalties are a civil penalty (no driving points) with the first offense being between $75- $150 and the 2nd offense between $150 and $250.  We are signed up in support of this bill.  Will be heard in Senate Transportation Wednesday at 9 am.  We’re signed up in favor of the bill and I’ll be speaking in Committee.

 

Thursday

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

This bill would add a requirement that physicians provide to parents and guardians the full vaccine package insert and excipient summary for each vaccine that will be administered.  Physicians already provide a Vaccine Information Summary to parents and guardians for each vaccine administered, which is noted in the medical record.

This new requirement would mandate provision of the 12-15 page insert, which is not presented in a format that incorporates health literacy principles. Hearing will be Thursday, February 21 at 9 am in the House of Representatives Health and Human Services Committee.  We’re signed up opposed to the the bill and I’ll be speaking in Committee.

 

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

These bills would mandate that doctors inform parents and guardians that antibody titer tests (which involve a venous draw) are an option in lieu of receiving a vaccination and that there are exemptions available for the state requirements for attending school.   Hearing will be Thursday, February 21 at 9 am in the House of Representatives Health and Human Services Committee.  Hearing will be Thursday, February 21 at 9 am in the House of Representatives Health and Human Services Committee.  We’re signed up opposed to the bill and I’ll be speaking in Committee.

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

This bill would add an additional exemption to the school vaccine requirements into state law.  Currently there are medical and personal exemptions.  The bill doesn't include any verification of the religious exemption from a religious leader, just a declaration from the parent that they are opposed to vaccines on religious grounds.  Hearing will be Thursday, February 21 at 9 am in the House of Representatives Health and Human Services Committee.  We’re signed up opposed to the bill and I’ll be speaking in Committee.

ACTION ALERT: Please contact the following Representatives and let them know that you oppose HB 2470, HB 2471 & 2472 as they will decrease immunization coverage and jeopardize herd immunity.

Please focus your attention on the lawmakers in bold- especially those of you that know them!

 

John Allen

jallen@azleg.gov

Nancy Barto

nbarto@azleg.gov

Kelli Butler

kbutler@azleg.gov

Gail Griffin

ggriffin@azleg.gov

Alma Hernandez

ahernandez@azleg.gov

Jay Lawrence

jlawrence@azleg.gov  

Becky A. Nutt

bnutt@azleg.gov

Pamela Powers Hannley

ppowershannley@azleg.gov

Amish Shah

ashah@azleg.gov


Bills Heard in Committee Last Week

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

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

This intervention will provide more oversight to ensure background checks are done and that the facilities are compliant with state regulations.  This bill passed through the Senate Health & Human Services this week and will be moving to the floor.

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

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

Under current law these facilities (Hacienda de los Angeles and similar facilities run by the ADES are exempt from state licensing requirements This Bill passed the Senate Health & Human Services this week and will be moving to the floor.

 

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

This bill would expand AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding. Passed the Senate Health & Human Services Committee on 1/23.  This Bill passed through the Senate Appropriation Committee this week and will be headed to the floor next.

 

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

This bill would basically set up a quasi-regulatory program at the ADHS to license electronic cigarette manufacturers in Arizona and specify that only licensed electronic cigarette manufacturers can sell products in Arizona.  It gives no regulatory authority to the ADHS to enforce that vape shops get licensed and they only must do it every 5 years. There are no penalties for noncompliance and penalties are against the purchaser instead of the retailer.  This bill passed the House Health Committee by a 5-4 vote this week.

 

Bills that Have Passed a Chamber

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

Expands the definition of tobacco products to include e-cigarettes. Among other things, it'll make it clear that it's illegal to sell e-cigarettes to minors. The penalty for selling to minors remains at $5K. Unanimously passed in the full Senate and was transmitted to the House this week.

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

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

Measles Outbreaks, Personal Exemptions, Parent Education & School Exclusions:

Interventions to Protect Kids & Stop the Spread of Disease

The Social Contract & Herd Immunity

At the core – vaccines are really about community protection.  Our public health system depends on a solid network of providers that are available to vaccinate kids for all the nasty infectious diseases that have plagued humanity for millenia.  Vaccinating yourself and your kids is more about community protection than personal protection. It’s a social contract that we have with each other to keep all of us healthy.

We need just about everybody to participate in our shared social contract to vaccinate in order to get the herd immunity.  When communities have herd immunity, those who can’t be vaccinated and folks with weakened immune systems will still be protected because the viruses can’t circulate.  Measles needs a 95% community vaccination rate to achieve herd immunity.

 

School Enrollment Requirements & Exemptions

To achieve herd immunity and prevent the spread of measles and other communicable diseases, every state including Arizona requires kids in public school to be vaccinated against a series of diseases, including measles.

All states allow an exemption from the required vaccines when it’s medically necessary.  Seventeen states (including Arizona) allow parents to exempt their kids from the requirements because of personal or philosophical beliefs (called personal belief exemptions).  BTW: HB 2162 would change that by removing Arizona’s personal belief exemption (it hasn’t been scheduled for a hearing).  States with a personal exemption option usually have lower vaccination rates than states without that option.

States also have authority to exclude kids that are unvaccinated from school during a vaccine preventable disease outbreak. In Arizona, ARS § 15-873(C) states that students “… who lack documentary proof of immunization shall not attend school during outbreak periods of communicable immunization-preventable diseases”.  The decision to exclude kids during an outbreak rests with the directors of the county health departments and school administrators and is prescribed in Arizona’s Communicable Disease Rules.

 

Immunization Rates Among AZ Schools

Arizona has many pockets in which our vaccination rates are below 95%, mostly in high income areas and among certain charter schools. One of our best sources of vaccine coverage data comes from schools and childcare centers- which are required to report their vaccination coverage and exemption rates for 19-35 month old’s, kindergartners, and 6th graders.

Public health agencies aren’t the only group of folks interested in school exemption rates. Many parents are interested in finding out whether their child’s school is has a high vaccination rate.  For the last several years, the ADHS has been posting the vaccination rates of schools across the state.

Last year exemption rates increased across all age categories. Exemptions rose from 3.9% to 4.3% for child care, from 4.9% to 5.4% for kindergarten and from 5.1% to 5.4% for 6th grade.  As is always the case, exemption rates were much higher in charter schools. Data for exemption rates and vaccine coverage rates by county and school are available on the ADHS website.  Note: updated exemption rates will be available in a couple of months.

 

Educating Parents

Arizona’s public health system has been doing some creative work to improve our immunization rates. One is an innovative on-line immunization education course that’s designed to serve as part of a potential new personal exemption process.  

Last year a pilot project was conducted recently at a dozen or so schools in Maricopa County to learn how to best implement an immunization education module, get feedback from school staff, and identify whether parents learned new information about vaccines using a pre-and post-knowledge assessment survey.

A new more robust pilot is planned for the 2019-2020 school year. The county health departments and the ADHS are partnering in the project.  At participating schools (hopefully as many as 125 schools), parents who want to exempt their kids from the school enrollment vaccination requirements will be asked to complete the Immunization Education Course first.  Upon completion, they’ll be able to download their school’s exemption form.

The online course is designed only for the use of Personal Beliefs Exemptions in grades K-12 at pilot program schools. It doesn’t change the process to request and obtain a Medical Exemption form or the Religious Beliefs Exemption form.

Hopefully the project will demonstrate positive results and will include an academic partner so the eventual results can be published and other states can learn from this important work.

We don’t have much time, though.  Vaccination rates are already below herd immunity levels for measles in many parts of the state, and all it'll take right now is a sentinel measles case in the right place at the right time and we’ll have a measles outbreak- maybe one as bad as the one happening right now in Washington state and across much of Western Europe.

CA Eliminated Personal Exemptions & Vaccination Rates Improved A Lot

California had also been struggling to maintain herd immunity vaccination rates- especially in higher income areas (just like us).  After trying a variety of interventions- and following a measles outbreak associated with Disneyland- the California Assembly passed & Governor Brown signed Senate Bill 277 (in 2015) which abolished personal exemptions in California.

The intervention worked.  In the following years, CA had sharp increases in vaccination rates among kindergarteners entering school. During the 2014–2015 school year the statewide kindergarten full-vaccination rate was only 90.4%. After implementing the new law, the kindergarten full-vaccination rate rose to >95% and has stayed there. 

By the way- a few months ago the Second District Court of Appeal in Los Angeles found that the CA law didn’t violate freedom of religion or the right to an education.

The court said that… “Compulsory immunization has long been recognized as the gold standard for preventing the spread of contagious diseases”.  The court said the new law was not discriminatory and was a valid measure to protect public health.  Just saying.

Legislative Update

State Legislature Bill Update

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

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

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

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

 

Bills that Will Be Heard in Committee This Week

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

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

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


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

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

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

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

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

 

Bills that Were Heard in Committee Last Week

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

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

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

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

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

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

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

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

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

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

SB 1341 Tanning Studios (Carter) – AzPHA Position YES

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

State Legislature Bill Update

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

Tobacco Bills:

SB 1009 Electronic Cigarettes, Tobacco Sales (Carter)

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

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

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

HB 2073 Vapor Products; Regulation (Shope)

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


Maternal & Child Health:

SB 1088 Dental Care During Pregnancy (Carter)

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

SB 1040 Maternal Mortality Report (Brophy-McGee)

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

 

HB 2125 Child Care Subsidies (Udall)

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

HB 2337 Family Planning (Salman)

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

Injury Prevention:

HB 2069 Texting and Driving (Kavanaugh)

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

HB 2165  Distracted Driving (Townsend)

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

HB 2172  Rear Facing Car Seats (Bolding)

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

HB 2246  Motorcycle Helmets (Friese)

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

HB 2075  Electronic Prescribing (Cobb)

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

Firearm Safety

HB 2247 Bump Stocks (Friese)

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

HB 2248 Firearm Sales (Friese)

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

HB 2161 Order of Protection (Hernandez)

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

HB 2249  Mental Health and Firearm Possession (Friese)

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

Harm Reduction:

HB 2148 Syringe Access Programs (Rivero)

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

SB 1119 Tanning Studios (Mendez)

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

Vaccines

HB 2162 Vaccine Personal Exemptions (Hernandez)

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

HB 2352 School Nurse and Immunization Postings (Butler)

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

Agency Administration

HB 2004 Nuclear Management Fund (Kavanaugh)

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

 

HB 2280  Interfacility Ambulance Transports (Weninger)

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

SB 1011 Information and Referral Service (Carter)

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


AHCCCS Coverage & Services

HB 2347 Medicaid Buy-in (Butler)

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

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

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

HB 2351 Medical Services Study Committee (Butler)

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

HB 2120  Chiropractic Coverage (Barto)

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

SB 1088 Dental Care During Pregnancy (Carter)

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


Food Safety & Insecurity

HB 2178  Milk Manufacturing License Exemption

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

HB 2186  School Meals (Udall)

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


Access to Care

HB 2218 State Loan Repayment (Blanc)

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

HB 2376  Associated Health Plans (Barto)

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

Medical Marijuana

HB 2149  Cannabis Definition (Rivero)

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

HB 2412  Medical Marijuana Cards (Powers Hannley)

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

New Funding Opportunity Available for Arizona to Explore Strategies to Reduce Maternal Mortality

A couple of months ago (before the government shutdown happened) landmark federal legislation was passed and signed that will provide millions of dollars to help states determine why women are dying from pregnancy and childbirth at troubling rates.  

The new funding is great news because studies have found that at least half of childbirth-related deaths could have been prevented if health care providers had followed best medical practices to ensure complications were diagnosed and treated quickly and effectively.

The bill provides $12M in annual funding to the CDC to pass through to states with maternal mortality review committees and create committees in the 12 states that lack them.  Arizona has a committee in statute because of a law signed in 2011 - here's a link to the most recent report.

In order to qualify for funding, states need to demonstrate  that their “methods and processes for data collection and review use best practices to reliably determine and include all pregnancy-associated deaths and pregnancy-related deaths, regardless of the outcome of the pregnancy.” All indications are that the ADHS meets these CDC data standards and therefore would qualify for funding.

We and the Arizona Chapter of the March of Dimes will keep an eye out for the grant announcement and offer any assistance that the ADHS needs with their application for this important funding opportunity that can be used to save the lives of Arizona moms.

Recently Passed Federal Public Health Legislation

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

Improving Access to Maternity Care HR 315

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

Preventing Maternal Deaths Act of 2018 HR 1318

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

PREEMIE Reauthorization Act of 2018  S 3029

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

Agriculture Improvement Act of 2018 – The Farm Bill HR 2

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

State Offices of Rural Health Reauthorization Act: S 2278

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

The Action for Dental Health Act of 2018

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

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

PEPFAR Extension Act of 2018  HR 6651

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

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

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

Infrastructure for Alzheimer's Act S 2076

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

US Supreme Court Declines to Hear Appeal Regarding Reproductive Health

This week the US Supreme Court declined to hear a case that would have given them an opportunity to overturn a lower court ruling that found that Medicaid agencies can’t exclude providers offering preventive reproductive health services like annual health screens, contraceptive coverage and cancer screening because they also offer abortion services.  Lower federal courts had ruled that while states have broad authority to ensure that Medicaid health care providers are qualified, that power has limits. 

The case isn’t about elective abortion services per se (the Hyde Amendment from 1977 makes it clear that federal funds can’t be used to pay for abortions except in cases of rape, incest, or life endangerment). The question is whether providers can be excluded from Medicaid contracts for preventive services like annual health screens, contraceptive coverage and cancer screening because they also separately offer abortion services outside of their public dollar contracts. 

The Supreme Court’s decision to decline the case will have implications here in Arizona. In 2016, Governor Ducey signed a bill giving the director of the AHCCCS the power (at his or her discretion) to disqualify any provider that doesn’t fully segregate the public dollars they get and ensure that none of those funds went toward providing elective abortions- including overhead expenses like rent, lights and A/C.

While that law is still on the books (as ARS 36-2930.05), it hasn’t been implemented. After a lawsuit was filed back in '16, attorneys for AHCCCS agreed not to implement the law and stipulated that AHCCCS won’t try to cut family planning dollars from Planned Parenthood or any other organization because it hasn’t fully segregated out the costs of abortion services to the satisfaction of the director.  The implementation hold agreed to in the stipulation was until Rules (Administrative Code) could be adopted- which they estimated would take about 2 years.

In exchange, the attorneys for the providers agreed to drop their lawsuit challenging the legality of the measure until there are actual rules in place.  I checked on the AHCCCS and Secretary of State’s website and can’t find any Rules fleshing out the criteria- but I might have missed them.

In any event- the fact that the US Supreme Court this week declined to hear a case similar to Arizona’s suggests that- at least for now- the status quo remains...  and Arizona’s Managed Care Organizations that contract with AHCCCS are free to contract with Planned Parenthood or other providers even though they may not be segregating expenses as required in ARS 36-2930.05.Of course- that could change at any time if the Supreme Court changes their mind and agrees to hear a similar case in the future.

Support School Attendance Vaccination Requirements

Please express your support for immunization requirements for public school attendance and informed use of appropriate vaccine exemptions by signing on to this letter of support to the Governor.

By simply clicking here you can add your name to the growing list of Arizonans that believe that it’s important to protect Arizona children against vaccine preventable diseases and protect community immunity that protects the most vulnerable among us. Here’s the letter:

Dear Governor Ducey,

We, the undersigned, want to express our full support for this resolution adopted by the Arizona Medical Association (ArMA):

“ArMA supports adopting requirements that parents (or guardians) who do not wish to have their children vaccinated receive public health-approved counseling that provides scientifically accurate information about the childhood diseases, the available vaccines, the potential adverse outcomes from catching diseases, the risks unvaccinated children pose to children who cannot be vaccinated for medical reasons, the risks of vaccine side effects, and the procedures that are implemented to exclude unvaccinated children if an outbreak of disease occurs in the area administered by the local or state public health agency.

ArMA also supports adopting requirements that parents annually sign an affirmative statement that acknowledges the risks they are accepting for their own children and the children of others by claiming a personal exemption from mandatory vaccination requirements.”

As residents of Arizona, we actively support and encourage you to work with the Arizona Department of Health Services (ADHS), all County Health Departments, and longstanding partners of The Arizona Partnership for Immunization (TAPI) to maintain high levels of immunization coverage rates in our schools and our communities…to keep your constituents safer and healthier.

 

Merger of CVS & Aetna Finalized

Last week CVS Health completed their acquisition of Aetna. You know CVS through their pharmacy stores- and Aetna through their health insurance businesses (in AZ that includes Mercy Care and Mercy Maricopa Integrated Care). 

Aetna will be a stand-alone unit within CVS and led by members of its current management team.  It’s essentially a vertical integration- as it combines Aetna (primarily a health care insurer) with CVS (primarily a retailer).

The US Justice Department required Aetna to divest its Medicare prescription drug business to WellCare Health Plans before approving the merger.

One of the goals of the merger is to integrate Aetna's medical information and analytics into CVS Health's pharmacy data- creating a new model of care delivery.

The new company says they’ll be introducing new programs to target more efficient management of chronic disease with services focusing on self-management for patients with chronic conditions, expansion of chronic care management services at MinuteClinic, nutritional and behavioral counseling and benefit navigation support.  The plan includes expanded preventive health screenings to better manage high cholesterol, high blood pressure and diabetes.

A major focus will be on better managing five chronic conditions: diabetes, cardiovascular disease, high blood pressure, asthma and behavioral health.

There are some academics and other analysts that suggest the merger is anticompetitive and won’t result in better care or outcomes- but it looks to me like it has a pretty good chance of improving outcomes- especially if they focus on better management of chronic medical conditions combined with more convenient and numerous service sites.

CVS has been moving their mission from its traditional pharmacy business model for some time- bringing it more in line with providing health care and other services.  Several years ago- as this new model was emerging, CVS decided to stop selling cigarettes etc. as they rightly saw those sales as inconsistent with that of a business focusing on improving health outcomes.

New Physical Activity Guidelines

It’s no secret that obesity is a core public health challenge of our time- largely as a result of the lack of physical activity and poor nutrition.  In fact, 80% of US adults and adolescents aren’t getting enough physical activity.  Physical activity fosters normal growth and development and can make people feel, function, and sleep better and reduce risk of many chronic diseases.

A couple of weeks ago JAMA’s 2018 Physical Activity Guidelines Advisory Committee published a systematic review of the science supporting physical activity and health in HHS’ 2018 Physical Activity Guidelines Advisory Committee Scientific Report.  The HHS Physical Activity Guidelines for Americans Report (2nd edition) recommended the following:

  • Preschool-aged children (3 through 5 years) should be physically active throughout the day to enhance growth and development.

  • Children and adolescents aged 6 through 17 should do 60 minutes or more of moderate-to-vigorous physical activity daily.

  • Adults should do at least 150 minutes to 300 minutes a week of moderate-intensity, or 75 minutes to 150 minutes a week of vigorous-intensity aerobic physical activity. They should also do muscle-strengthening activities 2 days a week.

  • Pregnant and postpartum women should do at least 150 minutes of moderate-intensity aerobic activity a week.

The 2018 recommendations emphasize that moving more and sitting less will benefit nearly everyone. Individuals performing the least physical activity benefit most by even modest increases in moderate-to-vigorous physical activity. Additional benefits occur with more physical activity. Both aerobic and muscle-strengthening physical activity are beneficial.

The JAMA Committee concluded that the  Physical Activity Guidelines for Americans Report (2nd edition)   provides information and guidance on the types and amounts of physical activity that provide substantial health benefits. Health professionals and policy makers should facilitate awareness of the guidelines and promote the health benefits of physical activity and support efforts to implement programs, practices, and policies to facilitate increased physical activity and to improve the health of the US population. 

You can dive into the systematic review on the JAMA site. Their review largely validates the 2018 guidelines.

Research Published about Vaccine Exemption Policies

It’s no secret that many states including Arizona are struggling to maintain enough vaccination coverage to achieve “herd immunity”.  Herd immunity simply means that you have enough vaccination coverage to protect the entire community - including people that for medical reasons can’t be vaccinated and folks who’ve been vaccinated but still may be susceptible (because vaccines aren’t 100% effective).

Requiring kids in public school to be vaccinated is one of the most important public policy tools to ensure herd immunity.  Arizona does that through statutes labeled ARS-872 & ARS-873 - which require kids to be vaccinated if they attend public school (unless they have an exemption). In Arizona, there are medical, religious, and “personal” exemptions. The problem over the last few years is that more and more parents are exercising the personal exemption option.

Arizona’s immunizations rates continue to decline: 1) immunization rates have decreased across all age groups from 2012 to 2017; 2) personal exemption rates continue to be highest in charter schools, followed by private and public schools in 2017; and 3) overall personal exemption rates increased in the last year- going from 3.9% to 4.3% for pre-school; 4.9% to 5.4% for Kindergarten and 5.1% to 5.4% among 6th graders.

Of course- when looking toward interventions to stem the tide it’s important to look to the scientific literature to see what’s going on in other states.  A very informative article about personal vaccine exemptions was published recently entitled The state of the antivaccine movement in the US: A focused examination of nonmedical exemptions in states and counties.

The researchers conducted a detailed analysis of personal exemptions within each of the 18 states that allow nonmedical exemptions to their school vaccine requirements. Here’s a map of which states allow non-medical school exemptions.

The researchers found that several counties, especially those with large metropolitan areas, are at high risk for vaccine-preventable pediatric infection epidemics.  Since 2009, personal exemptions have risen in 12 of the 18 states that currently allow philosophical-belief exemptions.  On average, states that allow non-medical exemptions have 2.5 times higher exemption rates.

The also dove into the data and found that there is a direct correlation between higher personal exemption rates and lower vaccination rates.  That might be intuitive- but it’s important because it shows that personal exemption rates for school requirements is a good measure of real immunization rates.

The discussion portion of the article discusses the efficacy of interventions in various states, and basically found that more aggressive approaches – like eliminating personal exemptions entirely- are more effective at long term improvements in vaccination rates than softer approaches.

Definitely worth a read.

AZ Develops Pain & Addiction Curriculum for Clinicians

It's no secret that getting a public health handle on the opioid crisis will take a multi-pronged effort for an extended period.  Part of the solution was the policy development, passage and implementation of the Arizona Opioid Epidemic Act.  Other elements include developing and implementing new Opioid Prescribing Guidelines and developing new regulations for pain management clinics.

Another huge element is changing the culture of pain and addiction care.  ADHS has completed a Arizona Pain and Addiction Curriculum that approaches pain and addiction in a new way - as complex, interrelated, public-health issues. 

The curriculum was jointly developed by Deans and Curriculum Representatives from every MD, DO, NP, PA, ND, DMD and DPM program in Arizona.  The program stresses not only the new evidence base of pain and addiction care.

Resources for programs consist of both a Pain and Addiction Curriculum and a Pain and Addiction Faculty Guide.  Because it was created and facilitated by public health, it’s accessible online at any time, to the appreciation of other teaching programs across the country.

Kudos to ADHS and the dozens of stakeholders for this novel work and especially AzPHA member Lisa Villarroel MD.  Work on this scale hasn’t been done before in the US - so kudos to our Arizona teaching programs for being so open and collaborative. This is another example of the stakeholder driven innovative work being done right here in Arizona that's likely to be adopted as a best practice in other states.

Tucson Voters Lead the Way

Last week Tucson voters approved Proposition 407 approving $225M in Bonds for improving the outdoor built environment.  The funds will be used over the coming years for playgrounds, sports fields, pools, splash pads, recreation centers, pedestrian pathways, bike pathways, and pedestrian & bike safety infrastructure. 

The plan includes 25 new splash pads, 22 new playgrounds and 17 shade structures installed at city parks in the next several years.  Tucson will be reopening 2 city pools that have been closed and will make renovations the 22 other public pools.  Improvements are also planned for sports fields, 28 new walking paths in parks, 26 new ramadas, 19 new restrooms and an amphitheater.

Safety and mobility projects will connect people to parks, schools, shopping and transportation. New sidewalks, enhanced major street crossings, off-street biking and walking paths and residential street traffic calming are also slated in the plan which will provide more than 210 km of enhancements across Tucson.

The improvements won’t happen overnight though.  The $225M in improvements is spread over 9 years.  You can learn more about the proposed Parks and Connections projects using Tucson’s Interactive Story Map.

Congrats to the voters of Tucson for investing in their built environment and creating more opportunities for folks to enjoy the outdoors and get some exercise!

New Federal Opioid Intervention Becomes Law

A couple weeks ago congress passed and the president signed the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act. Much like Arizona’s Arizona Opioid Epidemic Act – approval of the bill was bipartisan, with a House vote of 393-8 and 98-1 in the Senate.

The final bill creates, expands and reauthorizes programs and policies across several federal agencies, and focuses on prevention, treatment and recovery. The text of the Act is extremely long, but you can view a high level summary on this landing page.

Some of the provisions are in line with recommendations in the 2017 ADHS Opioid Response Report like calling for changing an old federal regulation that prohibited Medicaid from covering patients with substance abuse disorders who were getting treatment in a mental health facility with more than 16 beds. The effect of the former law limited the number of beds available for low-income patients suffering from addiction- so hopefully the network of treatment facilities will expand as a result of this change in the law. The new federal law allows for 30 days of residential treatment coverage.

The new law allows nurse practitioners and physician assistants to prescribe buprenorphine, which is an anti-addiction medication that requires a special license and extra training.  For the next 5 years, it will also allow nurse anesthetists, nurse midwives and clinical nurse specialists to prescribe buprenorphine.  Right now, only about 5% of doctors are licensed to prescribe it.  It’ll take time for the inventory of prescribers to increase because of the training that’s required- but over time this provision will help network capacity especially in rural areas.

The Act also creates a grant program for comprehensive recovery centers that include housing and job training, as well as mental and physical health care. It will also increase access to medication-assisted treatment.

Some aspects of that law that relate to Medicaid include:

  • Temporarily requires coverage of medication-assisted treatment under Medicaid;

  • Prohibiting the termination of Medicaid eligibility for juveniles who are inmates of public institutions;

  • Requiring CMS to establish a demonstration project to increase provider treatment capacity for substance-use disorders;

  • Requiring state Medicaid programs to establish drug management programs and drug-review and utilization requirements for at-risk members; and

  • Extending enhanced federal matching rate for expenditures regarding substance-use disorder health-home services under Medicaid.

Interestingly, the bill includes a provision to help stop the flow of black-market opioids into the country by mail, especially synthetic fentanyl and its analogs.  The US Postal Service will need to provide the name and address of the sender and the contents of at least 70% percent of all international packages, and 100% of packages from China.

All international shipments will need to have the name and address of the sender by the end of 2020.  The Postal Service was also given the authority to block or destroy shipments for which the information isn’t provided.

The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act is long and comprehensive so I can’t cover everything….  But the bottom line is that public health policy – both here in AZ and now nationally is beginning to address the epidemic.

More States Implementing School-based Nutrition & Physical Activity Policies

Obesity remains a complex health issue in the United States. Several factors—including behavioral, environmental, and genetic—interact and contribute to increasing obesity rates. Approximately 19% of children and adolescents aged 2-19 years old are obese and face a greater risk of developing chronic and other conditions like diabetes, heart disease, cancer, high blood pressure, asthma, and sleep apnea. By 2012, the estimated annual cost of obesity in the United States was $147 billion, in addition to other social and emotional costs.

The causes of childhood obesity include unavailability of healthy food options, easy access to unhealthy foods, lack of physical activity, as well as policy and environmental factors that do not support healthy lifestyles. Schools play a significant role in diet and activity through the foods and drinks offered and the opportunities for physical activity provided.

Recognizing the unique position of schools, states have enacted and proposed legislation to prevent and reduce childhood obesity by: (1) ensuring that nutritious food and beverages are available at schools, and (2) establishing physical activity and education standards at schools. Below is an overview of current laws and recent state and territorial legislative activities to increase the availability of healthy foods and opportunities for physical activity in schools.

School Nutrition Legislation

Children and adolescents consume much of the food they need each day while at school. Children may receive meals from federal programs like the National School Lunch Program and the School Breakfast Program, or they may purchase competitive food and drinks (i.e., food that’s purchased from school-based vending machines, snack bars, or concessions outside of the school’s food service program). Many states have adopted policies to make competitive foods healthier, set limits on food for rewards, and impose restrictions on food and beverage marketing in schools.

A Colorado statute prohibits public schools from making available any food or beverage that contains any amount of industrially produced trans-fat on school grounds. In Kentucky, each school must limit access to retail fast foods in cafeterias to no more than one day each week. Laws in New Jersey prohibit the sale of foods of minimal nutritional value, all food and beverage items listing sugar as the first ingredient, and all forms of candy on school property during the school day.

In 2017, California’s governor approved a bill limiting the advertisement of food and beverages during the school day in schools, school districts, or charter schools participating in federal lunch and breakfast programs. California also prohibited participation in corporate incentive programs that reward children with food and beverages that do not comply with nutrition standards. New Hampshire proposed similar legislation prohibiting the advertisement of any food or beverage that does not meet the minimum nutrition standards as set forth by the school district, as well as participation in a corporate incentive program that rewards children with food and beverages.

Recognizing that many schools lack the necessary equipment to support the storage, preparation, and service of minimally processed and whole foods, the Washington State legislature introduced a bill that would establish a competitive equipment assistance grant program for public schools to improve the quality of food service meals that meet federal dietary guidelines and increase the consumption of whole foods. In 2017, Puerto Rico proposed a bill requiring that vending machines located in public schools only contain products of high nutritional value according to the standards imposed by the federal government.

Physical Activity Legislation

According to CDC, children and adolescents should have one hour or more of physical activity every day. State policymakers often target physical activity and education curriculums in K-12 schools to combat the childhood obesity epidemic. Promising trends include: improving physical education curricula, integrating physical activity into the school day and maximizing recess opportunities, as well as enhancing physical activity opportunities in school-based after-school programs.

Many states have statutes in place or have proposed legislation imposing physical activity and education requirements in schools. Last legislative session, Arizona approved a new law mandating that public schools include recess in their curriculum. Other states have gone further. 

Iowa, Louisiana, North Carolina, and Texas require 30 minutes of physical activity each school day. Arkansas requires 90 minutes of physical activity each week for grades K-6. South Carolina sets a minimum standard of 150 minutes per week for grades K-5. Colorado requires 600 minutes of physical activity each month for full-time elementary students.  Tennessee amended its statute to require a minimum of 130 minutes of physical activity per full school week for elementary school students and a minimum of 90 minutes for middle and high school students.

Educating Parents to Improve Vaccination Rates

It’s no secret that many states including Arizona are struggling to maintain enough vaccination coverage to achieve “herd immunity”.  Herd immunity simply means that you have enough vaccination coverage to protect the entire community - including people that for medical reasons can’t be vaccinated and folks who’ve been vaccinated but still may be susceptible (because vaccines aren’t 100% effective). Generally, herd immunity happens when a community has a vaccination rate above 95%.

A couple of months ago the ADHS released their latest school reporting data on vaccine exemption rates (medical, personal and religious).  Here’s a 2-page summary of some of the results.  This year’s report covers the 2017-2018 school year. The data show that:

  • Immunization rates have decreased across all age groups from 2012 to 2017;

  • Personal exemption rates continue to be highest in charter schools, followed by private and public schools in 2017; and 

  • Overall personal exemption rates increased in the last year- going from 3.9% to 4.3% for pre-school; 4.9% to 5.4% for Kindergarten and 5.1% to 5.4% among 6th graders.

Requiring kids in public school to be vaccinated is one of the most important public policy tools to ensure herd immunity.  Arizona does that through statutes labeled ARS-872 & ARS-873 - which require kids to be vaccinated if they attend public school (unless they have an exemption). In Arizona, there are medical, religious, and “personal” exemptions. The problem over the last few years is that more and more parents are exercising the personal exemption option.

According to our current statute, parents can get a personal exemption if they “… sign a statement to the school administrator stating that (they) have received information about immunizations provided by the ADHS and understand the risks…” (as defined in R9-6-701-708). Despite numerous interventions to improve immunization rates among AZ school children- we continue to lose ground. In several parts of the state and among certain demographic groups (high income zip codes and some charter schools for example) we’ve lost herd immunity- which means we’re at real risk for outbreaks.

Arizona’s public health system has been doing some creative work to improve our immunization rates. One of my favorites is an innovative on-line immunization education course that’s designed to serve as part of a potential new personal exemption process. The Maricopa County Department of Public Health worked with a University of Arizona medical student and the ADHS Immunizations Program to design and conduct the test pilot program. The new education course was piloted at 16 schools in Maricopa County (8 elementary, 5 middle or junior high and 3 high schools) last school year.  The pilot objectives were to:

  • Learn how to best implement the immunization education module developed by ADHS in Maricopa County schools;

  • Get feedback from school staff regarding the use of the module to ensure a smooth rollout in the future; and

  • Identify whether parents learned new information about vaccine preventable diseases and vaccines using a brief anonymous pre-and post-knowledge assessment survey.

The pilot was small & wasn't designed as a formal study and therefore wasn't able to draw any conclusions about the effectiveness of the modules- but it’s a promising intervention that has a good chance of helping improve immunization rates.

There’s a lot of interest among a host of public health stakeholders in continuing to pursue this educational (informed consent) process as part of the personal exemption process.  I’m optimistic that executive branch decision-makers will recognize the value that a more robust parent education policy can have in improving rates and that AZ will continue to develop and implement this innovative intervention.

Part of what makes me optimistic are comments that the Governor recently made during an interview with the Arizona Republic in which (about 25 minutes into the interview) he states that "This is a public-health issue, I’m a big believer in freedom and choice on a lot of issues, but… if your kid’s going to be in the public-school system in Arizona, they’re going to be vaccinated."

The bottom line is that despite our work to date, vaccination rates continue to decline and are below the herd immunity threshold in some parts of the state and among some demographic groups.  Additional interventions are clearly needed.  Perhaps the education modules will help.  But it may be that the only real solution is to look to other states that have eliminated the personal exemption.  California provides a promising case study.