Author: Will Humble

Actually, They Weren’t Even Heard

Several bills that addressed various aspects of firearm violence were proposed last legislative session. None were successful. In fact, a quick perusal of the bills will reveal to you that none were even given a hearing. Sad state of affairs, don’t you think?

SB 1219 Domestic Violence Offenses & Firearm Transfer (Carter)

Persons that have been adjudicated and the court rules that they may not possess a firearm must surrender their firearms to a law enforcement agency.  The law enforcement agency may then dispose of the firearm(s) in accordance with law.  People that have an Order of Protection against them must also surrender their firearms, although the law enforcement agency must return the firearm when the Order expires (after a background check).

HB 2247 Bump Stocks (Friese)

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

HB 2248 Firearm Sales (Friese)

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

HB 2161 Order of Protection (Hernandez)

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

HB 2249  Mental Health and Firearm Possession (Friese)

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

Arizona and 47 other states have programs called Area Health Education Centers that focus on enhancing access to quality healthcare (especially particularly primary and preventive care) by improving the supply and distribution of healthcare professionals through academic-community educational partnerships in rural and urban medically underserved areas.

Arizona’s state Area Health Education Center (AzAHEC) is housed at the University of Arizona.  Like the AHECs in most other states, Arizona’s statewide AzAHEC focuses on developing health professions workforce education programs that emphasize primary care and increasing access to care in rural and underserved communities.  Many of the strategies to accomplish this include improving the supply, quality, diversity and distribution of the health professions workforce.

The state AHEC program at the UA works in collaboration with the 5 statewide Arizona AHEC regional centers which are independent non-profit organizations that work in coordination with the state program:

• Eastern Arizona Health Education Center

• Central Arizona Health Education Center

• Northern Arizona Health Education Center

• Southeast Arizona Health Education Center

• Western Arizona Health Education Center

The 5 regional centers each have their own unique strategies to improving the supply, quality, diversity and distribution of the health professions workforce.  Many of the regional strategies include strategies to develop health professions students and health professions workforce, recruiting and retaining a health professions workforce, and inter-professional training.  The regional centers also support many health careers programs including students in medicine, nursing, pharmacy, public health, dentistry, and allied health.

As of July 1, 2019 the Central Arizona Health Education Center took over as the Area Health Education Center for Central AZ.  For many years, Empowerment Systems dba the Greater Valley Area Health Education Center had been the Central Regional AHEC.  Sean Clendaniel is busy getting the business model and systems up and running as you read this. I’ll be updating the happenings in the Central AHEC in the coming months.

The combined work of the 5 regional centers and the state program are far too wide-ranging to capture here- but you can get an idea of the particulars by reading the state program Annual Report which includes summaries of the priority programs at the state program (UA) as well as the regional AHECs.

How it’s Funded

Funding for Arizona’s AzAHEC system is voter protected. The statute authorizing and funding the state system was approved by Arizona voters as Proposition 203 (in 1996) (aka Healthy Arizona 1) which required the Arizona State Lottery to allocate funds including the state AzAHEC programs [A.R.S. §5-522(E)] when annual Lottery revenues reach a specified threshold.

The system really matured in 2000 when voters passed Proposition 204 (aka Healthy Arizona 2) which expanded eligibility for the AHCCCS to 100% of the federal poverty level guidelines…  but also included a directive to distribute $4M annually to the AzAHEC system. 

It’s rare to have a state program that has a guaranteed source of income that doesn’t require an appropriation authorization from the state legislature, which is a real source of strength and stability. Also, because the funds are voter protected, if money is still available at the end of the fiscal year the reserves aren’t swept (like they are in most other state government programs).  As a result, the system has accumulated some carry-forward funds that are available for use in future years.  FY 2016 began with an effective carry-forward balance of approximately $7.5M.  Annual reports after 2016 didn’t disclose carry forward balances- so I’m not sure what the current carry forward is.

Leadership Change at the State Level & Moving Forward

Earlier this month, Dr. Sally Reel decided to step down from her role as the head of the AzAHEC system. Dan Derksen, MD, has agreed to serve as acting director as the U of A conducts a search for a successor.  As is the case with any leadership change- this will provide an opportunity to take a fresh look at the direction and priorities of the AzAHEC system including mission priorities and allocation of the funds.

With this leadership change, the state program moved out of the administrative control of the College of Nursing where it has been for many years to the office of the Senior Vice President for Health Sciences at the UA.  This administrative change will also provide some additional opportunities to better develop cross program inter-professional training opportunities.

Another opportunity for the state AzAHEC system is the implementation of new budget items that were in this year’s state budget- especially the addition of $12.5M more for Graduate Medical Education ($7M rural and $4.5M urban) in the coming year.  Graduate Medical Education is important because Residency programs have a huge impact on retaining primary care physicians and other allied health professionals- a big leverage point for driving healthcare professionals toward rural and underserved areas of AZ.

While Arizona has some pretty robust Medicaid GME spending already, those residencies are generally distributed in urban areas.  That’s because the money used to draw down the federal matching funds comes mostly from urban area hospitals – and the residencies go to those areas.  Also, those residency slots are generally for subspecialists – not primary care (which has the greatest need).

The new state AzAHEC program will now be in a position to influence the decisions to allocate the new $12.5M in Graduate Medical Education funding- that’s great because of the expertise within the program and at the AZ Center for Rural Health at the UA.

Other opportunities for program include soliciting input from regional AzAHEC office which could result in new innovative strategies that could be implemented either by the regional AHEC offices of the statewide AzAHEC.  Perhaps this could best be accomplished by convening a statewide primary care workforce forum to get input from a cross section of Arizona Stakeholders regarding strategic planning options and use of state AzAHEC funds.  An independent entity such as AzPHA could convene the forum, which would solicit ideas presented by participants including local AzAHEC programs.

More to come.

108 years ago, Arizona’s founders protected ordinary voters with a state constitution that guaranteed AZ residents the power of referendum, recall and initiatives.  Many of the bold moves to improve public health policy have come via citizens initiatives. A few examples are:

• The Smoke Free Arizona Act;

• The TRUST Commission for tobacco education and prevention;

• First Things First;

• Proposition 204 (from 2000) which extended Medicaid eligibility to 100% of federal poverty

The next set of Voter Initiatives (if any qualify for the ballot given the new restrictions and requirements) will be on the ballot in November of 2020- and the deadline for filing the required signatures is July 2, 2020.  Because it takes a long time to get the required signatures (and because of the new restrictions) folks that want to run voter initiatives need to start collecting signatures pretty soon.

Several entities have filed to notice their intent to get on the ballot so far (here’s that list on the Secretary of State’s website) but the only one that looks legit so far is one called the “Voters’ Right to Know Amendment”.  Terry Goddard is the Applicant and Chair for that one.  Here’s a link to the voter initiative language and here’s the summary from the site:

Under this Amendment, it will no longer be possible to hide from public view the true sources of campaign spending. Anyone spending more than $20,000 on a statewide campaign or $10,000 on a local campaign must disclose contributions of $5,000 or more used to fund campaign expenditures. Major contributions must be tracked to their original sources. Violators are subject to fines. 

Because elections can have a profound impact on public health policies- we’ll be diving into the details of this Initiative to determine whether and how to support this effort.  More on that in a future update.

No doubt additional Initiatives that will have an impact on public health policy will be filed soon (including one that will legalize the retail sale of Cannabis).  We’ll continue to watch for those and will dive into the details after they’re released – probably in next week’s Policy Update.

Here’s the Public Health Impact

The US House and Senate passed the “Bipartisan Budget Act of 2019” this week.  The president is expected to sign this bill into law soon.  Here’s what the budget bill will do:

• Discretionary Spending: Increases the allocation for non-defense discretionary spending to $621.5 billion for FY20, which is an increase of $24.5 billion from FY19 non-defense discretionary caps. It also provides $626.5 billion for FY21, which is a $5 billion increase from FY20.

• Census: Provides $2.5 billion for the 2020 Census.

• Offsets: This legislation includes $77 billion in offsets achieved through increased fees and extending the sequestration cuts for non-exempt mandatory programs such as the Prevention and Public Health Fund through FY29. In other words- the Prevention and Public Health Fund won’t be cut this fiscal year – but the budget agreement contemplates cutting the fund in future years.

In Arizona the Prevention and Public Health Fund investments include immunizations, smoking cessation, diabetes prevention, opioid treatment, and more.  Here’s a report we wrote that summarizes what the Fund does here in Arizona.

It’s been awhile since I mentioned out Upcoming Events public health calendar.  Our website at http://www.azpha.org/upcoming-events contains a listing of upcoming webinars and meetings that might be of interest to our members- so make sure to bookmark it and visit the site from time to time. 

Also, let me know when you see something interesting that’s coming up at willhumble@azpha.org and I’ll add it to the calendar.

A light rail extension on Central Avenue in South Phoenix will have a long-lasting, positive impact on community health in South Phoenix.  That’s not just an opinion, that comes from a scientific and detailed 2015 Health Impact Assessment by the Maricopa County Department of Public Health and the Arizona Alliance for Livable Communities.

The South Central Neighborhoods Transit Health Impact Assessment concludes that a thoughtfully planned transportation plan that includes a light rail extension in South Phoenix will result in positive long-term health outcomes for residents, including lowering rates of chronic disease, improving pregnancy outcomes, and reducing violent deaths.

The City of Phoenix’s current transportation plan has been developed over a decade and approved by voters 3 times.  The public has been heavily engaged in this planning effort which has included more than 500 public meetings held to gather input.

Proposition 105 will dismiss this planning and prohibit Phoenix from investing in any kind of rail project – including light rail, commuter rail, or other potential train connections despite the fact that light rail extension have a long-lasting positive public health impact and reinforce the positive aspects of the community.

The Existing Transportation Plan is Good

Four years ago, Phoenix voters passed Proposition 104, a comprehensive transportation plan that included input from public health stakeholders.  The plan incorporated evidence-based provisions to improve many facets of transportation – including things to make transportation easier for folks with disabilities and improving opportunities for physical activity with more walkable and bike-able transportation options.

The voter approved plan extended Phoenix’s existing 4/10ths of a cent transportation sales tax (originally passed in 2000) and increased it by 3/10ths of a cent to:

• Greatly enhancing Dial-a-Ride for persons with disabilities;

• Add 1,150 new bike lanes;

• Add 170 miles of new sidewalks;

• Increase bus frequency by 70%;

• Increase transit hours of operation by 20%;

• Invest $280 million for new roads and bridges;

• Repair 750 miles of asphalt streets; and

• Increase investments in light rail.

Phoenix’s existing Plan is well-balanced to provide various services based on differing community needs, contributing to improved transportation flexibility options and improving social determinants of health related to transportation.

For example, the existing transportation plan includes substantial investment in new transportation options in South Phoenix including a light rail extension.  That’s important because South Phoenix households are four times more likely to not have a car compared to other households throughout the Valley. 

The existing plan also enhances public transit services to South Phoenix and provides families with convenient access to key destinations such as work and school. In fact, over 70% of South Phoenix residents voted in favor of the current transportation plan. 

For all these reasons the Arizona Public Health Association urges Phoenicians to VOTE NO on Proposition 105.  Our health depends on it.

We’ve had a terrific FY-19 as an organization.  Our membership has grown more than 30% in the last two years and we’ve been increasingly becoming a force for positive public health policy development.  We also have a growing list of Organizational Membership supporters- which you can view on our Supporters Page: http://www.azpha.org/oursupporters 

Here’s a link to our end of FY-19 MEMBERSHIP REPORT and some current membership SUMMARY CHARTS.  As a refresher- here’s a link to our PowerPoint Summary of the 2019 Legislative Session (PDF)

The US has the highest maternal mortality rate of any developed country.  Sadly, it’s getting worse each year.  About 800 American women die and 65,000 almost die during pregnancy or childbirth. The number of deaths in AZ jumped from around 10 in 2015 to about 30 in 2016 (the last year for which ADHS has data posted- the numbers are cell-suppressed to protect confidentiality). 

Nationally, back women die from pregnancy-related causes at three to four times the rate of white women, even after controlling for social determinants. Women in rural areas also have higher maternal mortality rates than urban women.  Here’s a story that highlights some of the issues in an easy to read way.

Evidence-based policy making is a key.  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 will establish an Advisory Committee on Maternal Fatalities and Morbidity.

It requires ADHS and the Committee to hold a public hearing to receive public input regarding the recommended improvements to information collection concerning the incidence and causes of maternal fatalities and severe maternal morbidity and complete a report (including recommendations) by the end of this year.

Arizona Law is Having Chilling Effect

The opioid epidemic is one of the greatest public health crises of our time.  The roots that caused the epidemic are deep and the public health interventions that will be needed to ease the crisis are many.  Those interventions include dramatic changes to prescribing practices, things like the distribution of naloxone, more robust treatment options including Medically Assisted Treatment, and harm reduction and engagement strategies like Syringe Services.

We need all those tools working together in order to mount an effective response.  Last year’s Arizona Opioid Epidemic Act was an important new law that is addressing many of those factors- but not all.  A real outlier is that the Act didn’t make an important change that is needed in Arizona – decriminalizing syringe service programs. As this excellent report by Stephanie Innes in the Republic this week shows, needle exchange efforts in Arizona have been impaired because some of the things that syringe service programs do are considered felonies under state law.

Syringe services programs are community-based prevention efforts that offer a range of interventions. They provide access to and disposal of sterile syringes and injection equipment, linkage to substance use disorder treatment, and naloxone distribution.  People who use syringe service programs gain access to other vital services including vaccination, testing, and linkage to care and treatment for infectious diseases including viral hepatitis and HIV. 

Nearly 30 years of research shows that comprehensive syringe service programs are safe, effective, and reduce overall health costs. They play an important role in reducing the transmission of viral hepatitis, HIV, and other infections and are a major component of the Ending the HIV Epidemic: A Plan for America initiative. The U.S. Surgeon General determined that syringe service programs don’t increase the illegal use of drugs by injection. Studies also show that they protect the public and first responders by providing safe needle disposal.

Sadly, syringe service programs in Arizona are illegal because syringes are considered drug paraphernalia under Arizona law (a class 6 felony). While arrests, indictments and convictions of workers that operate syringe service programs are rare- the fact that syringe service programs are illegal has a marked chilling effect on the ability of organizations and individuals to operate and fund these important programs. 

After all- it’s pretty hard to get a grant award if you need to disclose to the funder that you intend to commit felonies with the money!

A cohort of public health organizations led by Sonoran Prevention Works have been trying for the last few years to simply decriminalize syringe service programs.  Pretty simple, right?

Sadly, the effort has been unsuccessful. 

In 2018 HB 2389 Syringe access programs; authorization passed the full House of Representatives, was dramatically weakened by a poor amendment in the Senate but ultimately failed to come out of a Conference Committee.  This year, HB 2148 Syringe Services Programs failed to even make it to the House Floor for a vote.

Public health stakeholders will continue to try to get our Legislature to pass a bill that will decriminalize this important evidence-based public health practice.

By the way, the CDC has released materials that health departments can use to provide information on the critical role of SSPs in prevention and treatment, including:

• A summary of information on the safety and effectiveness of SSPs in reducing viral hepatitis and HIV;

• A fact sheet outlining the various ways syringe service programs can prevent transmission of blood-borne infections and link people to care, reduce and treat substance use, and enhance public safety;

• A fact sheet for health departments and community partners that defines syringe service programs and their public health impacts; and

• Frequently asked questions and answers about syringe service programs.

All of these materials are available to you online on the CDC’s Syringe Services Programs website.

Here’s a statement from the CDC on the subject: “It is our hope that by sharing these materials with you, we will engage the full strength of the nation’s public health and community infrastructure to reduce the toll of opioids and infectious diseases in our communities. We have the tools. We have the science. We can work together to improve the health and security of current and future generations.”