Will Humble Marijuana, Wills Blog

Retail Marijuana Voter Initiative: My First Impressions

A group of Medical Marijuana Dispensary operators have completed statutory language for a retail marijuana and marijuana law criminal justice reform voter initiative. I’ve been able to go through the Initiative language a couple of times now. The statutory language is 16 pages long- and there are a lot of provisions…  but below are some of my initial impressions from a public health perspective:

Good Things

  • Employers would still be able to have drug-free workplace policies and can restrict marijuana use by staff.

  • Driving while impaired (to the slightest degree) by marijuana would still be illegal.

  • The governance structure is decent. It’s with an executive branch agency- ADHS (the 2016 Initiative created would have created a self-serving commission).

  • I mostly like the criminal justice reform parts for possession of less than an ounce. Possession up to 2.5 oz is a reduced penalty. Possession of more than 2.5 oz (with some exceptions for home cultivation) appear to be left where they are as a Class 6 felony. Currently, possession of very small amounts of marijuana (w/o a MM Card) are a class felony 6. Convictions impair people’s ability to earn a living – placing stress on families because of low wages and limiting the ability of folks to support kids and families and pay child support etc. – basically impairing self-sufficiency. AZ is one of a very very few states with possession of small amounts being a felony, this Initiative would fix that.

  • I like the conviction expungement provisions for the same reasons as above- and the expungement process is reasonable and not a free-for-all.

  • The labeling and packaging requirements are reasonable.

  • The testing requirements make sense too.

  • The restrictions on advertising are pretty good.

The Bad Things

  • There are no penalties for persons over 21 that give or buy marijuana for people under 21. This is a major shortcoming. There’s no disincentive for older people to buy for people under 21. There are small penalties and low-grade misdemeanors for people under 21 that misrepresent their age to people over 21 for the purpose of buying marijuana – but no penalty for the older person whatsoever.

  • The buy age in the Initiative is 21 years old. Data suggests that the buy age should be 25 years old. Brains continue to develop up to age 24 (25 in males). Data suggest that marijuana is more harmful and is more likely to cause longer term behavioral health problems when people start using before 25 y.o. Here’s a new Surgeon General Advisory from this week on the subject.

  • The Initiative would allow the ADHS to regulate potency but prohibits the agency from limiting doses to less than 10mg. 10mg is a good “ceiling” regulation but a bad “floor” regulation. Having said that- dispensaries would still be able to produce edibles that are less than 10mg and sell them – it’s just that the ADHS can’t regulate below 10mg.

  • The excise tax is a good idea – but the funds don’t go toward public health or youth marijuana prevention programs. There’s a one-time distribution ($10M) to the ADHS from the existing medical marijuana fund for public health stuff, but nothing after that. There should be some excise tax funds going to prevention campaigns- in particular youth prevention. A lot more of the excise tax should go toward preventing the downside of the policy decision- e.g. preventing kids from using marijuana.

  • Some excise funds should go to the AZ Biomedical Research Commission to study the effects of this policy intervention.

  • The law would let people cultivate up to 6 plants or 12 per household. While there are some requirements for locking the plants away from kids in houses- enforcing that will be next to impossible and diversion to kids would happen for sure with basically no checks in the system.

  • The existing medical-marijuana dispensaries would have a corner on the market in perpetuity. This is anti-competitive and permanent. Current medical marijuana dispensaries will be allowed to apply to the ADHS for a license to run a retail marijuana store in early 2021. It’s possible that there could be a few more stores that open eventually, but not many, because the total number is limited to about 130 total (10% of the number of pharmacies in AZ). Existing medical marijuana dispensaries, with a handful of exceptions, would essentially be the only stores that exist. ADHS would regulate the program.

  • The Initiative appears to tie the hands of local authorities in setting zoning restrictions (although the League of Cities and Towns would be a better expert).

Will Humble Climate Change, Wills Blog

EPA Proposes Eliminating Methane Capture Regulations

This week the EPA proposed new rules that would reverse regulations adopted by the Obama administration requiring the natural gas industry to prevent fugitive methane gas releases. The existing rules were adopted during the previous administration as a measure to slow the emission of greenhouse gases causing climate change.

Under the proposal released this week the EPA would no longer specifically regulate the transmission and storage of the potent greenhouse gas… but treat it like a routine volatile organic compound. 

The rules proposed this week would eliminate the current requirements that require the industry to prevent methane releases at transmission and storage of methane at compressor stations, pneumatic controllers, and underground storage vessels (basically- the transmission and storage segment of the industry).  The proposed regulations would also eliminate methane emission limits from the transmission and storage segment of the industry. 

Methane (CH4) is a very powerful greenhouse gas. It absorbs much more energy than carbon dioxide (CO2) and is 30 times more potent as a greenhouse gas.  Methane has a half-life in the atmosphere of about 10 years (much less than CO2) but has a powerful impact during that time.

The U.S. oil and gas industry emits 13 million metric tons of methane from its operations each year (emissions of methane are about 2.3% of the production).  Most of these “fugitive” emissions came from leaks and equipment malfunctions in the transmission and storage of the gas- the very sector that the proposed rules deregulate. 

The climate impact of these leaks is roughly the same as the climate impact of carbon dioxide emissions from all U.S. coal-fired power plants.  [R.A. Alvarez el al., “Assessment of methane from US oil and gas supply chain”, Science (2018).]

In their comments this week – EPA officials stated that the industry has a powerful incentive to stop fugitive emissions of methane without regulation because they lose product via leaks. That argument only holds when the cost of fixing the leak is less expensive than the short-term cost of lost product.

Here’s a link to EPA’s proposed rules.  Public comment isn’t open because it’s not published in the Federal Register yet.  Once it’s published, there will be a 60-day comment period.  I’ll keep following this and put the link to the comment site in a future public health policy update.  The comments page – when available – will be at www.regulations.gov.

Editorial Note: In addition to the public health impacts from climate change caused by the obvious things like worse storms, water shortages, decreased agricultural output, impacts to assets from sea level rise (oceans are already 20cm higher then they were in WWII), and the geopolitical implications that these disruptions will cause from increased  conflicts, refugee crises and widespread social dislocation would almost certainly increase – climate change also causes a diversion of resources toward adaptation, diverting public and private resources from more efficient uses of capital.

This results in long-term decreased GDP growth and investment and capital losses. For example, the expected value of a future with 6°C of warming represents present value losses worth US$43trn—30% of the entire stock of manageable assets (the current market capitalization of all the world’s stock markets is around US$70trn).

The reason I mention this – is that as public health officials – we often focus on those direct public health impacts that are resulting and will continue to result from climate change. Convincing decision makers that aren’t partucularly interested in public health that the the climate crisis is serious and requires immediate aggressive interventions requires a variety of arguments. Here is an interesting, if dense, analyis recently published by The Economist.

Will Humble Medical Marijuana, Prevention, Wills Blog

U.S. Surgeon General’s Advisory:

Marijuana Use and the Developing Brain

The US Surgeon General (Jerome Adams MD) Issued  a concise advisory this week  that emphasizes the health risks of marijuana use in adolescence and during pregnancy. He released the Advisory in response to recent increases in access to marijuana and in its potency, along with misperceptions of safety of marijuana endanger our most precious resource, our nation’s youth.

Will Humble Vaccination, Wills Blog

AzDHS Immunization Action Plan:

Recommendations for Increasing Immunization Coverage Rates in Arizona

Immunization coverage rates in Arizona continue to fall. The ability for parents to opt their child out of vaccination is simple and is being done more frequently in Arizona. This has resulted in families and communities being at increased risk for vaccine preventable diseases. 

The ADHS recently led a stakeholder group that explored interventions and activities that could help to stop and reverse this negative trend and increase vaccine coverage rates across all Arizona communities. The group developed a report that included the following goals:

  1. Improve vaccine education to professionals who will interact with parents

  2. Implement public information campaigns to promote vaccination

  3. Evaluate the effectiveness of current vaccine education pilot in reducing exemptions

  4. Ensure private providers continue to provide childhood vaccination services

  5. Determine best practices for improving vaccination coverage

  6. Partner with the Department of Education to increase school vaccination rates and compliance

The team put together a 15-page report that includes recommendations to address each goal.  I couldn’t find a copy of the report on their website, but somebody sent me a copy. The recommendations are mostly educational or administrative- no major policy recommendations (like eliminating the personal exemption).  Take a look.  Sounds like we will be seeing more details about these goals and recommendations in the coming months.

Will Humble Affordable Care Act, Wills Blog

Group Gathering Signatures for the “Healthcare Quality Improvement Act”

A group called Healthcare Rising Arizona filed the paperwork with the AZ Secretary of State with language for a voter initiative called “Arizonans Fed Up with Failing Healthcare” that would make some changes to healthcare law and provide a backstop for consumers in case the Affordable Care Act is overturned by the US Supreme Court now that the tax penalty for not having health insurance has been removed from the ACA by the 2017 major tax law overhaul.

Here’s a link to the voter initiative language.  The folks running the campaign still need almost 238,000 valid signatures by July 2, 2020 to get on the ballot- no easy feat given the new requirements passed by the Legislature and signed by the Governor which make getting things on the ballot harder. There are 4 basic components to the measure:

Consumer Protections for Health Insurance

Some consumer protections for Arizonans in case the Supreme Court overturns the ACA now that the tax penalties for not having insurance are gone.  This initiative would prevent commercial health insurance companies in Arizona from doing the following things (if the ACA is overturned):

1) denying someone health insurance because they have a preexisting condition -called the “guaranteed issue” requirement;

2) refusing to cover individual services that people need to treat a pre-existing condition- called “pre-existing condition exclusions”; and

3) charging a higher premium based on a person’s health status – called the “community rating” provision.

Hospital Associated Infections

Requires private hospitals to meet national safety standards regarding hospital-acquired infections and gives the Arizona Department of Health Services the authority to impose civil penalties if hospitals fail to meet those standards.

Surprise Billing

Protects Arizona consumers against surprise medical bills from out-of-network providers and requires refunds if patients are overcharged.

Raises for Direct Care Workers

Gives direct care hospital workers a 5% wage increase each year for four years. Direct hospital care workers include nurses, aides, technicians, janitorial and housekeeping staff, social workers and non managerial administrative staff. Physicians are excluded.

The fly in the ointment on this one is that last bullet. My guess is that there wouldn’t be a whole lot of organized opposition to the measure without that last piece- requiring raises for hospital direct care workers. 

Honestly, I think the provisions that require raises for direct care workers is what will make the Initiative fail, and along with it the opportunity to provide consumer protections in the health insurance market in case the US Supreme Court overturns the ACA now that the tax penalties for not having health insurance have been eliminated.

We’ll continue to review the language and evaluate whether to take a position on this and other voter initiatives that are I the works like the retail marijuana initiative and the Voter’s Right to Know Amendment.

Will Humble Early Childhood, Maternal Health, Medicaid, Prevention, Wills Blog

Doula Services Improve Maternal and Child Health Outcomes

Medicaid Programs Increasingly Reimbursing for Doula Services

Doulas are professionals who provides physical, emotional, and informational support to a woman throughout pregnancy, childbirth, and postpartum. Doula’s act as a facilitator between the laboring women and her physician by ensuring that mom and dad get the information they need in a way that they understand so they can make informed decisions. 

Evidence suggests that support from doulas is linked to lower c-section rates and fewer complications. Medicaid finances more than half of all births each year in 25 states, indicating that Medicaid reimbursement policy can be a particularly effective lever to improve maternal health outcomes. Two states have enacted legislation to provide reimbursement for care by doulas as a way to improve maternal health outcomes and address existing maternal mortality disparities.

Currently, Minnesota and Oregon take advantage of the fact that doulas can reduce healthcare costs while improving outcomes in their state Medicaid programs. In the 2018 budget, Minnesota increased the reimbursement rates for doulas.  The new law also requires Oregon’s coordinated care organizations (which deliver Medicaid services) to provide information about how to access doula services online and through any printed explanations of benefits. The law tasked Oregon Medicaid with facilitating direct payments to doulas, which was addressed through rulemaking.  

New Jersey recently enacted legislation to improve maternal health among disproportionately affected groups of women by permitting the state to seek a state plan amendment or waiver that establishes Medicaid reimbursement for doula services. The legislation follows a recently piloted state doula program aimed at reducing health disparities in communities with high infant mortality rates.

Indiana also enacted legislation ensuring that pregnancy services covered by Medicaid also include reimbursement for doulas. The law incorporates doula services into the state’s obstetrician navigator program through the department of health, as well as the family and social services administration, allowing Medicaid reimbursement for services provided by doulas. Like in New Jersey, this legislation allows the state to apply for a state plan amendment or waiver necessary to implement doula reimbursement in Medicaid.

There’s growing momentum to conduct comprehensive reviews of maternal mortality data, which could help better understand the underlying causes of health disparities. Using a health equity lens to develop policy and design clinical interventions could also prove valuable by ensuring that services are culturally competent, affordable, and accessible by populations who need them most. 

Twenty-nine states (including Arizona) have committees that review maternal deaths and make public policy recommendations.  Arizona took a big step forward this last legislative session with the passage of SB 1040 Maternal Mortality Report which establishes a Maternal Fatalities and Morbidity Advisory Committee to explore public health policy interventions to improve maternal outcomes.

Perhaps the Advisory Committee, which meets on Friday August 30 from 9:30am to 12:30 pm at the Arizona State Laboratory, will explore the role that Doulas can play in improving birth outcomes and make some evidence based recommendations to better use their services in Arizona’s care network (our Board President Mary Ellen Cunningham will be representing AzPHA on the committee).

Will Humble Early Childhood, Maternal Health, Medicaid, Prevention, Wills Blog

Addressing Postpartum Depression with Public Health Policy

As Arizona embarks on an in-depth look at maternal mortality in the coming months no doubt that postpartum depression will be part of the discussion.  

Moms with postpartum depression can have feelings of sadness, anxiety, and exhaustion that may make it difficult to care for themselves and their kids.  Data from the CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS) show that one in nine U.S. women experience symptoms of postpartum depression.

While there’s not a single cause of postpartum depression—it likely results from a combination of physical and emotional factors—women are at greater risk for developing postpartum depression if they have one or more of the following risk factors:

  • Symptoms of depression during or after a pregnancy.

  • Previous experience with depression or bipolar disorder.

  • A family member who has been diagnosed with depression or other mental illness.

  • A stressful life event during pregnancy or shortly after giving birth.

  • Medical complications during childbirth.

  • Mixed feelings about pregnancy.

  • Lack of strong emotional support from a partner, family, or friends.

  • Alcohol or other drug use problems.

Legislative approaches to address maternal mental health conditions and postpartum depression include increasing awareness of risk factors for and effects of postpartum depression, increasing access to prenatal and postpartum screening for these risk factors, and increasing access to treatment and support services for women at high risk for postpartum depression.

Below is an overview of state legislative activity in 2019 to address the screening and treatment for maternal mental health conditions and postpartum depression.

Texas passed 2 bills addressing postpartum depression. One (HB 253) requires their health and human services commission to develop and implement a five-year strategic plan to improve access to postpartum depression screening, referral, treatment, and support services.  The other bill (SB 750) instructs the commission to develop and implement a postpartum depression treatment network for women enrolled in the state’s medical assistance program.

In Oklahoma, SB 419, directs the state licensing boards to work with hospitals and healthcare professionals to develop policies and materials addressing education about and assessment of perinatal mental health disorders in pregnant and postpartum women.

Illinois passed HB 2438 which requires that mental health conditions occurring during pregnancy or postpartum be covered by insurers.  HB 3511 (the Illinois Maternal Mental Health Conditions, Education, Early Diagnosis, and Treatment Act) requires their department of human services to develop educational materials for health care professionals and patients about maternal mental health conditions and requiring birthing hospitals to supplement the materials with relevant resources to the region or community in which they are located.

Virginia passed HB 2613, which adds information about perinatal anxiety to the types of information licensed providers providing maternity care must provide to each patient (including postpartum blues and perinatal depression).

Arizona will be exploring strategies to improve maternal health outcomes as part of the implementation of SB 1040 Maternal Mortality Report – which established a Maternal Fatalities and Morbidity Advisory Committee to explore public health policy interventions to improve maternal outcomes.

Perhaps the Advisory Committee, which meets on Friday August 30 from 9:30am to 12:30 pm at the Arizona State Laboratory, will explore the role public policy can play in reducing the public health impact of post-partum depression. Our Board President Mary Ellen Cunningham will be representing AzPHA on the committee.

Will Humble Oral Health, Wills Blog

AHCCCS Accepting Public Comments on their Oral Health Policy Manual

These Polices are Important in Reducing Health Disparities

AHCCCS is in the process of accepting comments on their oral health policy manual for their EPSDT program- so this is your opportunity to do some administrative advocacy and provide them with your insight and comments.

Here’s a link to the Manual and comment page: AMPM 431 – Oral Health Care for Early and Periodic Screening, Diagnosis and Treatment Aged Members

A Stakeholder group organized by First Things First staff (and AzPHA members) Kavita Bernstein and Vince Torres met last week and developed some priority recommendations that would improve children’s oral health.  Those recommendations are listed below.

You can use This Link to get to their comment page. Below are some of the recommendations for you to consider submitting.  Please use your own voice and incorporate your own perspective.  Personalized comments have more impact than block-copy-paste ones.

The sample comments below state the page number in the Manual that the comment goes with. Please ensure to include the Policy Page Number relating to each comment.

Remember that our collective voice is stronger than one…  so please take some time to submit your comments in the next couple of weeks.  The comment period ends right after Labor Day.

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Recommendation for AHCCCS to expand provider types who can provide oral health screenings within pediatric settings to include RN, RDH and APDH. This would allow for co-location models, as well as, more flexibility for pediatric clinics in service delivery.

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Recommendation for AHCCCS to consider the use of the definitions for ‘urgent’ and ‘routine’ from the Association of State and Territorial Dental Directors (ASTDD). This would allow for a consistent approach to screening and referral across health plans and providers.

Recommendation that AHCCCS consider a tighter timeline for urgent referrals given that three business days could span over a weekend and may be too long for a child exhibiting signs of pain, infection and swelling.

Recommendation for AHCCCS to expand provider types that can apply fluoride varnish within a pediatric setting, to include MAs.

Page 4

Recommendation for AHCCCS to consider allowing reimbursement for nutrition counseling by a dental home to align with the requirement to provide this specific service.

Page 5

Recommendation for AHCCCS to consider stronger, clarifying language that defines ‘medical necessity’.

Recommendation for AHCCCS to consider language that permits and reimburses for sealants on primary teeth as evidenced by positive outcomes seen by IHS and would be in alignment with the AAPD Dental Sealant Policy and Recommendation.

Recommendation for clarity on the definition of a dental provider – in addition, there is no definition in AMPM 100 to which health plans and providers can align.

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Recommendation for AHCCCS to consider the impact of a two tiered consent process on dental mobile clinics

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Recommendation for AHCCCS to clarify who ‘all providers’ are in new bullet point #7. In addition, recommendation for AHCCCS to assess the feasibility of pediatric clinics (and families) scheduling a child to come into the clinic solely for a dental screening. Recommendation for AHCCCS to consider language that indicates that providers should schedule the dental screening within the next EPSDT visit (if at a primary care clinic) or at the next dental visit (if at a dental home)

Will Humble Health Insurance, Immigration Policy, Social Determinants, Wills Blog

Homeland Security Establishes Final “Public Charge” Rules

Here’s my Best Shot at Explaining What the New Rules Will Do

I’m sure you’ve the flurry of reports about the Department of Homeland Security (DHS) “public charge” final rule. There will be lawsuit(s) challenging the new rules, but for now the new regulations are scheduled to kick in October 15, 2019.

The bottom line is that the new regulations will change the criteria the federal government uses to make decisions about legal permanent resident applications. The final rules will block legal immigrants from extending their temporary visas or gaining permanent residency if the government decides the applicant is likely to rely on public benefits in the future.

The Feds already consider whether applicants for legal permanent residency receive Temporary Assistance for Needy Families or Supplemental Security Income (SSI) when they evaluate applications for permanent resident status.

When the new Rules take effect on October 15 they’ll also consider whether applicants receive Medicaid (AHCCCS), the Supplemental Nutrition Assistance Program (food stamps), or Section 8 Housing assistance. 

The definition of a “public charge” in the final Rule is: “an individual who receives one or more designated public benefits for more than 12 months in the aggregate within any 36-month period”.

The draft rules released last year had included criteria that would have applied these standards to kids and adults. The final Rule won’t consider whether benefits were used by an applicant’s children. Likewise, if lawfully present kids receive benefits (e.g. Medicaid) that fact won’t be considered against them if the child later applies for legal permanent residency (a “green card”).

Here are some things to remember about this new Rule

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

  • This doesn’t directly impact current legal permanent residents (current green card holders). The public charge test won’t be applied to legal current residents (green card holders) applying for citizenship;

  • The new rule isn’t retroactive – meaning public benefits received before 10/15/19 won’t be counted as a public charge; and

  • The new rules don’t apply to refugees. Existing statute prevents DHS from using these criteria for refugees.

Even though the final Rule excludes benefits received by children, this policy will still have a significant impact on children’s health as well as the health of their families and our communities.

Public health note:  We know from both national reports and from assistors and community organizations working in Arizona, that families are afraid and withdrawing from or reluctant to participate in benefits for which they or their children are legally eligible. Nationally, nearly one in four children have an immigrant parent, and almost 90% of them are US citizens.  Missing out on safety net programs for which folks are entitled can result in bad health outcomes because of social determinants that won’t be addressed and missed doctor’s appointments which could result in missed developmental screenings and interventions.

The US government has made their decision – and the new policy will be implemented unless overturned by the courts. There’s nothing short suing that will undo this decision for now.

What we can do is to get the word out to families in this category that signing up their kids for safety net benefits to which they’re entitled won’t count against them when they apply for legal permanent status- nor will it count against their kids if they eventually apply for a green card. We can minimize the public health impact of this decision if the public health system is effective in ensuring that families know this important information! 

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