Social Determinants

Leveraging Managed Care Contracts to Address Social Determinants

Medicaid programs across the country and our own Medicaid agency (AHCCCS) are increasingly considering how best to address the social factors, such as housing, healthy food, and economic security, that can affect health and medical expenditures (social determinants).

That’s because social determinants of health drive as much as 80% of population health outcomes.  It’s easy to see why there’s such an interest in addressing social determinants as Medicaid program administrators look for ways to contain costs.

Many Medicaid programs including ours have focused much attention on the social determinants that drive costs in expensive or high needs populations (e.g., people with disabilities or a mental illness or HIV/AIDs)… but as the knowledge about how profound social determinants are in terms of costs overall, many are now thinking about how they can address social determinants across the general Medicaid population.

An organization called State Health and Value Strategies has developed an Issue Brief that explores practices states are using to address social factors using Medicaid 1115 waivers and in their managed care contracts The issue Brief also includes steps states can take to implement these practices.

The issue brief includes a review of Medicaid managed care contracts in 17 states and Medicaid 1115 provisions in 6 states.  There are quite a few examples in the report- so I’ve just picked a couple to give examples:

Aligning financial incentives to support SDOH interventions.  States are deploying a range of tools to strengthen the financial incentive for plans to address SDOH. These include the use of withhold payments linked to SDOH-sensitive outcomes and allowing plans to count investments in high-impact social services toward the numerator of their medical loss ratio (MLR).

Creating opportunities for affordable housing. Medicaid does not directly pay for housing, but states are increasingly identifying new ways to connect people to housing resources; providing housing-related services that can be covered via Medicaid; and encouraging their Medicaid managed care plans to participate in broader, cross-sector initiatives to address the affordability and safety of housing.

Building a stronger network of community-based organizations and collaboration with providers. Recognizing that many community-based organizations operate on tight budgets and lack experience contracting with health care plans and providers, states are investing in community-based resources and fostering stronger working relationships between such organizations and health care plans/providers.

Coding the Social Determinants

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

AHCCCS is recommending that providers routinely screen for and document the presence of social determinants (as appropriate within their scope of practice) and to document them in claims data. They began monitoring claims for the presence of the codes about a year ago.  You can review the Social Determinant ICD-10 Codes on the AHCCCS website.

It’s Switchover Time at the Legislature

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

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

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

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

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

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

 

Bills that Passed through the House or Senate

Access to Care & Healthcare Workforce

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

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

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

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

SB 1174 Tribal Area Health Education Center

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

SB 1355 Native American Dental Care

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

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

 

Licensing & Vital Records

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

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

 

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

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

 

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

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

Tobacco & Nicotine

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

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

Surveillance & Social Determinants

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SB 1456 Vision Screening- AzPHA Position: Yes

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

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

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

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

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

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

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

Good Bills that are Effectively Dead

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

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

HB 2162  Vaccine Personal Exemptions (Hernandez)

HB 2352 School Nurse and Immunization Postings (Butler)

HB 2172  Rear Facing Car Seats (Bolding)

HB 2246  Motorcycle Helmets (Friese)

SB 1219  Domestic Violence Offenses & Firearm Transfer

HB 2247  Bump Stocks (Friese)

HB 2248  Firearm Sales (Friese)

HB 2161  Order of Protection (Hernandez)

SB 1119 Tanning Studios (Mendez)

HB 2347  Medicaid Buy-in (Butler)

HB 2351  Medical Services Study Committee (Butler)

The Intersection of Public Health and Housing

Affordable, safe, and stable housing directly impacts an individual’s health and well-being and improves people’s ability to manage chronic diseases and mental conditions, access education and employment, and build healthy relationships.  Persons that are homeless face illness at three to six times the rate of housed individuals and are three to four times more likely to prematurely die than the general population.

Ensuring that patients have stable housing can also reduce healthcare costs.  An analysis of Oregon Medicaid claims data found people placed in stable and affordable housing reduced their overall Medicaid expenditures by 12%. Housing placement also correlated with a 20% increase in primary care visits and an 18% decrease in emergency department visitations among Oregon Medicaid members. 

It’s no surprise then that hospitals and health systems are increasingly interested in supporting access to stable and quality housing as a strategy to reduce downstream healthcare spending, especially as they move toward value-based payment models.

CMS is catching on too.  A couple of years ago they released a bulletin emphasizing the importance of designing Medicaid benefits packages that incorporate the social determinants of health. They outlined allowable coverage of housing-related activities and services for individuals with disabilities and older adults requiring long-term services and supports, like conducting individual tenant housing assessments, assisting with the housing search and application process, or offering tenancy sustaining services.

Last month the HHS Secretary suggested that CMS will be introducing a payment model allowing hospitals to directly pay for housing and other social services using federal Medicaid dollars. The statement suggests that this shift stems from a broader interest in better alignment between health and human services and that such a model would be tested by the Center for Medicare and Medicaid Innovation (CMMI).

While direct spending on room and board still isn’t allowed under the Medicaid statute, several state Medicaid programs are pursuing demonstration waivers that allow for innovations or flexibilities in Medicaid-managed care programs to address housing needs or other social determinants of health.

North Carolina recently received approval of its Section 1115 waiver which will allow their Medicaid managed care contractors to cover evidence-based, non-medical interventions that have a direct impact on members health outcomes and costs. The pilots will be implemented regionally to address housing, food security, transportation, employment, and interpersonal safety. I think North Carolina is the first state to receive this type of waiver, but I'm not 100% sure about that.

CMMI is also exploring the impact of screening and referrals for health-related social needs (including housing) of Medicaid and Medicare dual beneficiaries. They’ll be measuring whether screenings and referrals to community-based organizations and social services generate improvements in health outcomes and reductions in healthcare spending. The model is being piloted through 31 organizations in 23 states including at AHCCCS.

‘Opportunity Zones’ & Public Health

When you think about the tax bill passed by congress last year you probably think about the permanent reduction in corporate tax rates and changes in the person income tax standard deductions and stuff like that.  But there was a sleeper provision in the law that could influence the built environment and therefore public health.  It’s a provision in the law called ‘Opportunity Zone’ investment tax deferment.

The ‘Opportunity Zones’ part of the new tax law provides incentives to investors to put their money into areas designated by states as low income or underdeveloped.  The law lets investors defer (or eliminate) their capital gains tax obligation when they invest the money in a designated ‘Opportunity Zone’. If they hold the investment for 7 years, 15% of their capital gains liability can be written off.  If they hold the investment for 10 years, then their entire capital gain tax liability can be written off.

The theory is that geographically targeted tax cut opportunities will encourage new clusters of economic activity to form which has the potential to improve conditions that influence the social determinants of health within the designated ‘Opportunity Zones’.

There are very few conditions that are put on the program in terms of what is a qualifying investment, except that the investment must be within a state designated Opportunity Zone.  Developers must make a substantial improvement on the property in the first 30 months.  Investors need to show that 70% of their capital is in the opportunity zone and 50% of their activities.

The governor of each state decides where the Opportunity Zones are (they can name 25% of the qualifying low-income Census tracts as Opportunity Zones).  Our Governor delegated that decision to the Arizona Commerce Authority.  Arizona’s Opportunity Zone nominations were submitted to the US Treasury Department a few months ago and have already been approved.  Here’s the map of the Opportunity Zones Arizona selected.

A couple of months ago the U.S. Department of the Treasury released their guidance on the Opportunity Zone tax law provisions.  The Internal Revenue Service issued proposed regulations in October. 

The AZ Commerce Authority has some material on their website with a more in-depth view of Opportunity Zones including a Guidance Update Webinar Presentation and an Opportunity Funds Guidance Update Webinar Video October 2018.

One thing is clear- the incentives built into the Opportunity Zone parts of the tax bill are huge- and there will be billions of dollars moving into these Opportunity Zones in the coming years.  What remains to be seen is what impact the program will have on the built environment and economic opportunities in these areas and what public health impacts will occur – both good and bad – as a result of the investments that are made in these communities. 

Very few guardrails exist for what kinds of developments qualify for the tax deferral- and no doubt there will be some good things (affordable housing) and bad things (investments that don’t improve conditions) in Opportunity Zone communities in the coming years.

US DHS Proposed Regulations Chill Programs that Address Social Determinants

Last Saturday the US Department of Homeland Security Secretary Kirstjen Nielsen proposed new rules that (when adopted) will consider a much wider range of public benefits when they evaluate applications for an immigration change of status or extension of stay request.  

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

Here are some take-aways from the draft: 

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

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

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

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

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

A few months ago, DHS issued a discussion draft of the rule change that would have also included programs like Women Infant and Children (WIC) program, school lunch programs, subsidized marketplace health insurance and even participation in the Vaccines for Children program.

Even though the new draft doesn’t include vaccinations (VFC), WIC and marketplace insurance- many families will believe that the regulations do include these benefits and will elect not to use these important safety net benefits- as doing so will risk their immigration status.  As a result, families will have a more difficult time improving the health status of their families.  

The proposed new rules are 447 pages long- but a key place to look are pages 94-100 (that’s where the outline the new list of benefits that they intend to include).  The official proposal will be published in the Federal Register in a few weeks.  Once it’s officially published, the public will be able to comment on the proposed rule for 60 days.  The official version in the Federal Register will contain information about how to submit comments. I’ll keep my eye out for that.

History of Considering Public Benefits

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

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

Congress is Back in Session: Important Bills in the Balance

Members of the U.S. House of Representatives return to Washington D.C. this week.  They’ll be discussing important public health bills including the Labor-HHS-Education appropriations bill for fiscal year 2019 and the reauthorization of the Farm Bill.

Last week the Senate passed H.R. 6157 which is the combined Defense and Labor, Health and Human Services, Education and Related Agencies appropriations bill for FY19.  This one is the eighth and ninth out of 12 spending bills to be passed by the Senate for FY19.  The legislation includes increased NIH funding and boosted resources for opioid treatment, prevention, and recovery programs.  Here’s a list of some of the adopted amendments:

  • Schumer-Collins amendment to increase funding for Lyme disease activities (3759).
  • Cortez-Masto-Ernst amendment to provide for conducting a study on the relationship between intimate partner violence and traumatic brain injury (3825).
  • Peters-Capito amendment to ensure youth are considered when the Substance Abuse and Mental Health Services Administration follows guidance on the medication-assisted treatment for prescription drug and opioid addiction program (3870).
  • Heitkamp amendment to provide funding for the SOAR (Stop, Observe, Ask, Respond) to Health and Wellness Program (3893).
  • Casey amendment to provide funding for the Secretary of Health and Human Services to establish the Advisory Council to Support Grandparents Raising Grandchildren (3875).
  • Schatz-Hirono amendment to assess the ongoing mental health impact to the children and families impacted by a volcanic eruption covered by a major disaster declared by the President in calendar year 2018 (3897).
  • Heller-Manchin amendment to provide additional funding for activities related to neonatal abstinence syndrome (3912).
  • Heitkamp-Murkowski amendment to improve obstetric care for women living in rural areas (3933).
  • Durbin-Grassley amendment to provide for the use of funds by the Secretary of Health and Human Services to issue regulations on direct-to-consumer advertising of prescription drugs and biological products (3964).

The House hasn’t adopted its FY19 Labor, Health and Human Services, and Education appropriations bill. It’s unclear how both chambers will resolve differences in funding levels between their bills. The House could work on its Labor, Health and Human Services, and Education bill or skip a floor vote and start negotiations with the Senate.  The Farm Bill, which funds WIC & SNAP also hangs in the balance. Here's a summary of the Farm Bill.   The current legislation is scheduled to expire Sept 30th.

Bottom line: with only a few legislative days before the end of FY18, it’s likely that a continuing resolution will keep the government funded into FY19.

The APHA has several tools that you can use to get the attention of your Representative or Senator.  They’ve developed APHA’s Speak for Health advocacy resources, including state-specific fact sheets to help you be a better advocate.  They also have tools to help you meet with your members of Congress or their staff or invite them to visit you and Email or call your members of Congress using the APHA action alert as a phone script or email message. It’s quick and easy.

Loneliness as a Public Health Threat

I was surprised to learn this week that loneliness raises the risk of premature death by up to 50 percent-that makes loneliness a public health hazard on the scale of smoking and alcohol. Yet many medical and public health professionals haven't heard about how many risks it poses.

Loneliness means that a person has a small support network and minimal interpersonal contact, and it becomes more common with age.  When a person’s children move or a spouse dies many people find it harder to engage in social activities. Seniors in rural areas are particularly susceptible. Geographic isolation and lack of public transportation combine to keep them alone.

Lack of human contact has serious physiological consequences. Studies show that without human contact our risk of functional decline increases as does our risk of mobility loss. The risk of clinical dementia goes up by 64%.   These health problems further isolate those suffering from social isolation, threatening a vicious cycle of physical, emotional, and psychological decline.

Better support access to existing services is a good start as an intervention.  For example, programs like Meals on Wheels can identify isolated seniors and connect them with resources to reduce loneliness. Other places like churches and city senior centers also serve as important community connectors and potential evaluation and intervention points for lonesome people.

Medicare could prioritize coverage for programs like SilverSneakers which keeps seniors active and creates opportunities for social connections through group exercise.  The Welcome to Medicare and annual Medicare exams could provide opportunities for screening and interventions.  

Medicare Advantage plans could cover benefits to address social isolation.  With an ROI analysis, interventions to reduce isolation could reducing health care costs (the triple aim) while improving outcomes. Developing a reliable tool to screen seniors for social isolation would help as well. 

AzPHA Public Health Policy Update: March 19, 2018

AHCCCS Update: Coding the Social Determinants of Health

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

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

 

FDA Proposes Rulemaking to Reduce Nicotine Levels in Tobacco Products

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

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

 

AzPHA Comments on ADHS School Vaccination Rulemaking

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

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Legislative Session Update 

Committee Highlights Last Week

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

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

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

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

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

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

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

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

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

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Committee Highlights this Week

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

HB 2064:  medical marijuana; packaging; labeling

 

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

SB 1245:  appropriation; SNAP; benefit match; produce

SB 1420:  medical marijuana; inspection; testing; appropriation

 

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

SB 1445:  AHCCCS; dental care; pregnant women

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

HB 2038 Drug overdose review teams; records                

HB 2071 Rear-facing car seats

HB 2084 Indoor tanning; minors; restricted use      

HB 2127 Children's health insurance program

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

HB 2228 Annual waiver, applicability (tribes)

HB 2323 Schools; inhalers; contracted nurses

HB 2324 Community health workers; voluntary certification

HB 2389 Syringe access programs; authorization

SB 1022 ADHS; homemade food products            

SB 1083 Schools; recess periods

SB 1445 AHCCCS Dental care, pregnant women

SB 1377 Dental therapy, licensure, regulation

SB 1394 Abortion reporting 

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

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House Bills

HB 2038 Drug overdose review teams; records                

Passed the House 57-0-2

Assigned to Senate Health and Human Services Committee

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

 

HB 2071 Rear-facing car seats         

Passed House 33-25-1

Assigned to Senate HHS & Commerce and Public Safety Committees 

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

 

HB 2084 Indoor tanning; minors; restricted use

Passed House 45 - 15

Assigned to Senate HHS and Commerce & Public Safety Committees

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

 

HB 2127 Children's health insurance program

Passed House 46-12-1

Assigned to HHS & Appropriations Committees

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

 

HB 2197 Health professions, workforce data

Passed House 60 – 0

Assigned to HHS and Commerce & Public Safety Committees

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

 

HB 2208 Prohibition, photo enforcement

Passed the House 31-27-1

Assigned to the Senate Transportation Committee

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

 

HB 2228 Annual waiver, applicability

Passed the House 58-0-1

Passed in the Senate HHS Committee

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

 

HB 2323  Schools; inhalers; contracted nurses

Passed House 58 – 0 - 1

Assigned to Senate Education Committee

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

 

HB 2324 Community health workers; voluntary certification

Passed House 56 – 1 - 3

Assigned to HHS and Commerce & Public Safety Committees

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

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

 

HB 2389  Syringe access programs; authorization

Passed House 56 – 0 - 4

Assigned to the Senate Government Committee

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

 

Senate Bills

SB 1022    DHS; homemade food products            

Passed Senate 30-0

Assigned to House Health Committee

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

 

SB 1083    Schools; recess periods

Passed Senate 26-3-1

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

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

 

SB 1245 Snap Benefit Match

Passed Senate 25 - 5

Assigned to House Health and Appropriation Committees

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

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

 

SB 1261 Texting while driving

Passed Transportation Committee- Ready for a Senate Floor Vote

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

 

SB 1377 Dental therapy, licensure, regulation

Passed Senate 22 – 8

Assigned to House Health Committee

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

 

SB 1394 Abortion reporting

Passed Senate 17 - 13

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

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

 

SB 1420 Medical marijuana; inspection; testing; appropriation

Passed Senate 27 – 3

Assigned to House Military, Veteran and Regulatory Affairs Committee

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

 

SB 1445 AHCCCS Dental care, pregnant women

Passed Senate 27 - 3

Assigned to House Health & Appropriations Committees

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

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

 

SB 1470  Sunrise process; health professions

Passed Senate 21 - 9

Assigned to House Government Committee

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

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

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

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

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Public Health Bills that Failed to Thrive

HB 2064 Medical marijuana; packaging; labeling              

Dead for now

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

HB 2109 Tobacco possession; sale; age; signage                

Sadly, dead for now

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

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AzPHA Member Kelli Donley Publishes Again

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

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

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

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

About the author: 

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

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AzPHA Public Health Policy Update- November 16, 2017

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

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

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

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

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

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

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

 

AzPHA’s Positions on the Sunrise Hearings

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

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

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

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

 

Arizona Community Health Workers Association

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

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

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

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

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

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

 

Arizona Naturopathic Medical Association

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

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

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

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

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

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

 

Restaurant Calorie Labeling Back on Track?

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

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

This kind of nutrition clarity is a real opportunity for public health change.  Not only will the new labels give the public key information to help them make better decisions about what they buy for themselves and their families- it’ll give pause to restaurants before they label their menus- giving them an opportunity to change ingredients to lower calorie counts.  It may even spur a trend away from “super-sizes” and toward more appropriate and reasonable serving sizes.  With 32% of the calories consumed in the US tied to eating outside the home- this is an important opportunity.  

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

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

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

 

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

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

 

Open Enrollment for Marketplace Health Insurance

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