The CHEAC Office will be closed tomorrow, Friday, March 29 in observance of Cesar Chavez Day. We will resume normal operations on Monday, April 1.
March 28, 2019 Edition
CHEAC is excited to again offer expanded workshops to our 2019 Annual Meeting attendees through collaborating with key partners to host workshop sessions. Recall, the 2019 CHEAC Annual Meeting will be held on October 9-11, 2019 in Pasadena and will provide local health department leadership and staff throughout California with networking and learning opportunities. This year’s theme is “Strengthening the Public Health Infrastructure” and will once again include keynote sessions with guest speakers, as well as a myriad of workshops intended to stimulate best practice sharing and/or discussion around issues impacting public health.
CHEAC invites you as key partners to submit workshop abstracts should you wish to host a workshop sessions. Roughly 15 workshops will be hosted between 10:00 am and 4:00 pm on Wednesday, October 9 and Thursday, October 10. Those interested in submitting a workshop abstract can find additional information on our CHEAC website here. All workshop abstract proposals are due to CHEAC via email by COB tomorrow, Friday, March
We are pleased to announce that San Bernardino County Department of Public Health was awarded accreditation status by the Public Health Accreditation Board (PHAB) this week. San Bernardino County becomes the 14th local health department awarded PHAB recognition in California, in addition to the California Department of Public Health (CDPH).
Please join us in congratulating all of the hard work of our colleagues in San Bernardino County. Additional information on PHAB, as well as the press release, is available here.
The California Legislature maintained a robust pace of committee hearings this week as it continues to shift from informational hearings to more substantive bill hearings. Two weeks remain before the Legislature’s 10-day Spring Recess which is set to begin on April 11.
Notably this week, Senator Richard Pan gutted and amended SB 276 which would require physicians to submit a CDPH-developed statewide standardized immunization medical exemption request form and require the state public health officer or public health officer’s designee to approve or deny the request upon determining sufficient medical evidence that the immunization is contraindicated utilizing guidance from the U.S. Centers for Disease Control and Prevention (CDC). The California Department of Public Health (CDPH) would be required to create and maintain a database of approved medical exemption requests and make available the database to local health officers. The state public health officer and local public health officers would be authorized to revoke a medical exemption if it is determined that the exemption is fraudulent or inconsistent with applicable CDC guidelines.
In a statement, Senator Pan discussed how the measure would strengthen oversight of the medical exemption process and increase public health and safety. The measure is sponsored by the California Medical Association, the American Academy of Pediatrics, California, and Vaccinate California. Recall, Pan carried SB 277 (Chapter 35, Statutes of 2015), which removed the personal belief exemption for required immunizations for school and daycare admission.
Below, we highlight several actions taken on bills this week of interest to CHEAC Members. The full CHEAC Weekly Bill Chart is available here.
Chronic Disease Prevention and Wellness Promotion
SB 347 (Monning) as introduced on February 19, 2019 – SUPPORT
SB 347 by Senator Bill Monning was heard in the Senate Health Committee on Wednesday. The measure would require labels of sugar-sweetened beverages (SSBs) to bear the safety warning, “STATE OF CALIFORNIA SAFETY WARNING: Drinking beverages with added sugar(s) contributes to obesity, type 2 diabetes, and tooth decay.” The safety warnings would be required for vending machines, dispensing machines, and points of purchase for any unsealed SSBs. CHEAC previously supported identical measures, carried by Senator Bill Monning in Assembly Member Rob Bonta in 2017, which were both unsuccessful. After extensive discussion around whether SB 347 is the right approach to curbing SSB consumption, the measure was advanced out of the Senate Health Committee on a 5-1 vote with three members not voting. The measure now heads to the Senate Appropriations Committee.
AB 1500 (Carrillo) as introduced on February 22, 2019 – SUPPORT
Assembly Member Wendy Carrillo’s AB 1500 was heard in the Assembly Environmental Safety & Toxic Materials Committee on Tuesday. AB 1500 would strengthen local enforcement authority in instances of hazardous substance release. Local health officers would be authorized to issue orders against responsible parties and unified program agencies (UPAs) would be authorized to suspend, revoke, or withhold facility permits under specified circumstances. The measure is co-sponsored by Los Angeles County and the California Association of Environmental Health Administrators (CAEHA). AB 1500 was advanced to the Assembly Appropriations Committee on a 6-0 vote with three members not voting.
Health Coverage/Health Care Reform
AB 848 (Gray) as introduced on February 20, 2019 – SUPPORT
AB 848 by Assembly Member Adam Gray was heard in the Assembly Health Committee on Tuesday. This measure would add continuous glucose monitors (CGMs) and related supplies as a Medi-Cal covered benefit when medically necessary for the treatment of diabetes. The measure was advanced unanimously from the Assembly Health Committee to the Assembly Appropriations Committee.
AB 645 (Irwin) as amended on March 6, 2019 – SUPPORT
Assembly Member Jacqui Irwin’s AB 645 was heard in the Assembly Public Safety Committee on Tuesday. AB 645 would add to existing warning labels on firearms and signage at licensed firearm dealer premises language stating, “If you or someone you know is contemplating suicide, please call the National Suicide Prevention Lifeline,” with the applicable phone number. The measure would also require the Department of Justice (DOJ) firearm safety certificate course and written acknowledgement to cover the topic of suicide prevention. CHEAC supports this measure as a means to increase the availability of information on suicide prevention resources. AB 645 was advanced unanimously from the Assembly Public Safety Committee to the Assembly Appropriations Committee.
SB 38 (Hill) as introduced on December 3, 2018 – SUPPORT
SB 38 by Senator Jerry Hill was heard on Wednesday in a packed Senate Health Committee. The measure, co-authored by nearly 20 legislators, would prohibit a tobacco retailer from selling or offering to sell any flavored tobacco product. In his presentation, Senator Hill cited the alarming increase of flavored tobacco products among California youth as the need for the measure, and supporters included a significant number of children and youth from across the state. Those in opposition to the measure largely consisted of business interests, tobacco-related industry representatives, and retailers. CHEAC supports SB 38 to reduce the availability and access of tobacco products. SB 38 was advanced from the Senate Health Committee to the Senate Appropriations Committee on an 8-1 vote.
SB 39 (Hill) as introduced on December 3, 2018 – SUPPORT
SB 39 by Senator Hill was also heard in the Senate Health Committee on Wednesday. SB 39 would strengthen existing STAKE Act provisions by requiring mail-order tobacco products to be packaged in a container with specified conspicuous labeling and by requiring the signature of a recipient 21 years of age or older upon delivery of mail-order products. These provisions are similar to existing statute governing alcohol delivery. SB 39 was unanimously advanced from the Senate Health Committee to the Senate Appropriations Committee.
On Monday, Assembly Budget Subcommittees No. 1 on Health and Human Services and No. 2 on Education Finance convened a joint informational hearing entitled, “Meeting the Demand for Health: Final Report of the California Future Health Workforce Commission.” Recall, the California Future Health Workforce Commission released its final report in February, which assessed the current state of California’s healthcare workforce and identified strategies to increase capacity, education, and training.
Monday’s hearing featured presentations by and discussions with key medical professionals and stakeholders involved in the commission report and delivery of health services. Sandra Hernández, President and CEO, of the California Health Care Foundation began the hearing by providing an overview of the landscape of California’s current health care system and health workforce, pointing to California’s uninsured rate, access issues, and severe workforce shortages and provider mismatches. As California’s population is projected to grow older and become more diverse over the next several decades, its workforce shortage is also expected to worsen. These issues, according to Dr. Hernández and the commission, comprise a “looming crisis,” posing a significant threat to the health and medical care of all Californians.
The first panel featured presentations on the 10 priority recommendations by the California Future Health Workforce Commission, which largely focus on recruitment and expansion of workforce development and training opportunities. The 10 priority recommendations carry a price tag of approximately $3 billion over a 10-year period; this amount is less than one percent of what Californians are projected to spend across the entire health care system in 2019 alone. Key examples of the top 10 priorities identified by the California Future Health Workforce Commission include:
- Expanding and scaling pipeline programs to recruit and prepare students from underrepresented and low-income backgrounds for health careers
- Supporting scholarships for qualified students who pursue priority health professions and serve in underserved communities
- Expanding the number of primary care physician and psychiatry residency positions
- Establishing and scaling a universal home care worker family of jobs with career ladders and associated training
- Scaling the engagement of community health workers, promotores, and peer providers through certification, training, and reimbursement
Assembly Member Jim Wood, who played an active role in the commission’s report, shared his perspective on his district’s healthcare workforce shortages, as well as the increasingly aging workforce in his district. Other committee members queried panelists on how the commission’s priority recommendations should be scaled up and phased in throughout the state, as well as how the recommendations should be financed.
The second panel included presentations by representatives from the University of California, California State University, and California Community Colleges on how to meet the educational and training demands in order to implement the recommendations identified by the commission. Educational officials discussed efforts currently underway, as well as planned initiatives to augment healthcare workforce training programs, develop a team-based medical approach, and increase allied and associated health care professional availability in California. Of note, Alison Wynn, Interim Assistant Vice Chancellor and Interim State University Dean of the California State University, and other panelists indicated the need to partner with schools of public health and local health departments to broaden the health care focus and address social determinants of health, health inequities, and health disparities. Panelists discussed various educational and training pipeline initiatives in place increase workforce placement and development in healthcare professions.
Last, the Legislative Analyst’s Office (LAO) discussed key programs currently in place related to healthcare workforce development, as well as proposals included in Governor Gavin Newsom’s January budget. New investments to strengthen workforce proposed by the Newsom Administration are focused on physician placement programs, mental health workforce, and state agency workforce shortages, and specifically include an ongoing $33 million General Fund to continue support of the current Office of Statewide Health Planning and Development (OSHPD) healthcare workforce development initiatives and a proposed one-time $50 million General Fund to increase training opportunities for mental health workforce programs. Committee members asked LAO representatives for input on how workforce development funding should be prioritized and directed to different vocations and areas of the state.
During public comment, CHEAC Executive Director Michelle Gibbons acknowledged the importance of increasing healthcare workforce capacity but called attention to the need to address public health workforce challenges, particularly as it relates to public health nurses, epidemiologists, disease investigators, and public health laboratory staff. Highlighting the challenges experienced in recruiting and retaining specialized public health professionals, Michelle Gibbons urged consideration of the role of the public health workforce in promoting prevention and upstream interventions in the broader health and medical arenas.
On Monday, Assembly Budget Subcommittee No. 1 on Health and Human Services heard items related substance use disorder prevention and addiction treatment from the California Department of Public Health (CDPH) and Department of Health Care Services (DHCS).
State Public Health Officer and CDPH Director Dr. Karen Smith provided an overview of CDPH programs and activities related to substance use and addiction, including opioid surveillance and overdose prevention initiatives, cannabis education, and tobacco control activities. Dr. Smith highlighted the most recent data on various substance use-related deaths and emergency department visits, indicating that alcohol and pharmaceutical drugs remain the most common substance causing deaths and nonfatal injuries across the state.
Dr. Smith discussed progress of the Statewide Opioid Working Group and cross-sector collaborations undertaken to decrease the number of opioid prescriptions and opioid overdose deaths in California. Further, Dr. Smith and Center for Health Communities Deputy Director Monica Morales provided an update on the naloxone distribution program, through which nearly 70,000 doses of naloxone were distributed to 60 local health departments.
While California’s opioid use and overdose rates remain among the lowest in the country, Dr. Smith expressed significant concerns with rising rates of heroin and synthetic opioids such as fentanyl uses and the need to expand its focus on partnerships with law enforcement to control access to illicit substances. Dr. Smith provided an overview of funding received by CDPH to conduct its opioid-related programming and services, which has been nearly entirely provided through federal grants.
CDPH provided other updates within other divisions, including on the Let’s Talk Cannabis educational campaign, cannabis regulatory and licensing activities, tobacco control, and problem gambling services.
Subcommittee members queried panelists on strategies being employed by CDPH and local health departments related to youth electronic cigarette and tobacco use, the lack of programming to address alcohol addiction, and opioid prevention activities to specified target populations.
The hearing’s second panel featured DHCS Director Jennifer Kent to provide an overview on key DHCS delivery systems and services related to substance use disorders. Director Kent detailed the Drug Medi-Cal Waiver operating in 25 counties in California and indicated a goal of 40 participating counties which would reach approximately 95 percent of the state’s population.
Related to opioids, Director Kent provided an overview of the $230 million in federal grants for a variety of activities including the medication assisted treatment (MAT) expansion project (Hub & Spoke System), emergency department peer navigators, and naloxone distribution efforts. A representative from Santa Barbara County provided a local perspective of opioid overdose prevention activities, delivery of substance use disorder treatment services, and the nexus with target populations, such as individuals experiencing homelessness and those involved in the criminal justice system, at the county level.
Given that all items were oversight issues, the subcommittee took no action on the items presented and discussed. The full hearing agenda and materials are available here.
Newsom Issues State of Emergency on Wildfires, Releases Additional Details on Emergency Preparedness Campaign
Last Friday, Governor Gavin Newsom declared a statewide emergency on wildfires and directed his Administration to expedite forest management activities to protect 200 communities at an elevated wildfire risk ahead of the upcoming fire season. Newsom’s executive order provides waivers of administrative and regulatory requirements and allow action to be taken in the next 12 months to allow specified entities to forego certain environmental reviews and expedite competitive bidding for contracts. Friday’s executive order follow’s Newsom’s previous order, issued on his first day in office, directing the California Department of Forestry and Fire Protection (CAL FIRE) to recommend immediate, medium-, and long-term actions to prevent destructive wildfires.
Additionally, on Friday, Governor Newsom announced additional details on the $50 million California for All Emergency Preparedness Campaign, which is a joint initiative between Cal Volunteers and the Governor’s Office of Emergency Services (OES). The campaign will augment efforts of first responders by ensuring that at least one million of the most vulnerable Californians are connected to culturally- and linguistically-competent support during emergencies. Specifically, the emergency preparedness campaign will provide:
- $24.25 million in grants to community-based organizations to prepared residents for natural disasters through education and resources
- $12.6 million to support community efforts to build resiliency and respond to disasters by dispatching expert disaster teams to key regions and expanding citizen emergency response teams (CERT)
- $13.15 million to assist community groups in the development of a linguistically- and culturally-appropriate public awareness and outreach campaign, directed specifically at the most vulnerable California communities
Recall, funding for the California for All Emergency Preparedness Campaign was provided through AB 72 (Chapter 1, Statutes of 2019) signed into law by Governor Brown last month.
The Newsom Administration also issued on Friday Emergency Alert and Warning Guidelines pursuant to SB 833 (Chapter 617, Statutes of 2018), which aim to assist local jurisdictions with clear guidance on communication procedures and protocols in emergencies.
The full announcement from Governor Newsom is available here.
On Monday, the Trump Administration reversed its previous position on ongoing litigation related to the Affordable Care Act (ACA), asking a federal appeals court to strike down the act in its entirety.
Recall, in December 2018, U.S. District Judge Reed O’Connor of Texas ruled in favor of a group of Republican attorneys general and governors, determining that the ACA in its entirety was unconstitutional because the individual coverage mandate tax penalty was removed as part of the 2017 tax reform measure passed by Congress. After his initial ruling, Judge O’Connor then issued a stay on his ruling upon request by a group of Democratic attorneys general and governors, led by California Attorney General Xavier Becerra, allowing the ACA to stand while O’Connor’s judgement underwent an appeal.
At the time, the Trump Administration declined to support the Republican plaintiff’s argument, and instead argued that other key components of the ACA, such as Medicaid expansion, could survive because they could be considered legally distinct from the individual mandate and other consumer protections such as prohibitions on charging more or refusing coverage for individuals with preexisting conditions.
However, in a two-sentence letter on Monday to the appeals court handling the case, a federal official indicated, “The Department of Justice has determined that the district court’s judgment should be affirmed.” With this submission to the court, the Trump Administration has formally endorsed the elimination of the ACA in its entirety, no longer maintaining its stance that other key components of the ACA could stand without the individual mandate and certain consumer protections.
California Attorney General Xavier Becerra, leading a coalition of 21 attorneys general, swiftly filed an opening brief on the recent developments of the case, arguing that every provision of the ACA remains valid. Declaring the lawsuit and federal position reversal “as dangerous as it is reckless,” Becerra further argued that plaintiffs do not have standing to challenge the individual mandate provision because the plaintiffs are not injured, there is no evidence that plaintiffs will be required to spend more money, and that the district court wrongly concluded that the individual mandate was unconstitutional.
The opening brief also describes the potential dire impacts on the entire U.S. healthcare system and its residents if the district court’s decision that the ACA is unconstitutional is affirmed, indicating that over 133 million Americans, including 17 million children, with preexisting conditions, over 12 million Americans who gained coverage through Medicaid expansion, and over 12 million older adults who receive a Medicare benefit for prescription drugs would be harmed.
In addition to the legal response filed by Becerra and other attorneys generals, Congressional Democrats introduced legislative package on Tuesday afternoon which would seek to reduce healthcare coverage costs and protect consumers with preexisting conditions. Though, with split chambers of Congress, the measures likely face a difficult road ahead. It remains to be seen how the Trump Administration’s reversal in opinion will impact the ongoing appeal to Judge O’Connor’s ruling on a matter that is increasingly likely to end up in front of the U.S. Supreme Court.
On Wednesday, a U.S. District Court Judge in the District of Columbia issued a dual-ruling, striking down Medicaid work requirements in Arkansas and Kentucky. Judge James Boasberg determined that the U.S. Department of Health and Human Services (HHS) failed to adequately consider impacts of work requirements, writing, “The Court cannot concur that the Medicaid Act leaves the Secretary so unconstrained, nor that the states are so armed to refashion the program Congress designed in any way they choose.”
In this week’s ruling, Judge Boasberg rejected for a second time Kentucky’s proposed work requirements after previously ordering HHS last June to reevaluate its plan. Once again, Boasberg determined that HHS had not adequately considered whether the state’s proposed work requirements would continue to allow beneficiaries adequate access to health coverage. Kentucky’s proposed work requirements were a component of a broader overhaul of the state’s Medicaid program which was projected to decrease enrollment in the program by over 95,000 individuals. Boasberg, in his ruling invalidating the state’s proposed program, indicated the demonstration shall not move forward because HHS officials “did not consider the health benefits of the project relative to its harms to the health of those who might lose their coverage.”
The ruling on Arkansas’ Medicaid work requirements are expected to have a more immediate impact, particularly given that over 18,000 Medicaid beneficiaries lost coverage last year for failing to meet newly-imposed work requirements. Arkansas, as part of its state Medicaid demonstration, required beneficiaries to work or participate in other employment-related activities for at least 80 hours per month to retain their coverage.
This week’s ruling has potential impacts on the six other states that have already received approval, as well as seven other states seeking approval, to implement similar employment-conditional requirements for Medicaid coverage. As legal challenges increasingly mount against those states, U.S. Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma reaffirmed the Trump Administration’s commitment to defending efforts of states to implement such requirements and help people “rise out of poverty and government dependence.” Pending legal challenges are expected to continue to play out over the coming months, leaving in limbo states’ work requirements and beneficiaries’ coverage.
On Monday, the U.S. Centers for Medicare and Medicaid Services (CMS) issued its Health Insurance Exchanges 2019 Open Enrollment Report, finding that approximately 11.4 million consumers selected or were automatically reenrolled in coverage during the 2019 enrollment period. This figure is a decrease from 11.8 million consumers during the 2018 enrollment period. 24 percent of consumers that selected a plan for 2019 were new to the Exchange, representing a decrease from 27 percent during the 2018 enrollment period.
While state-based exchanges were found to hold relatively steady for 2019, enrollment through the federal HealthCare.gov system realized greater declines. Experts point to a likely combination of factors that resulted in decreased enrollment, including the removal of the federal individual mandate tax penalty and reduced federal funding for advertising and enrollment assistance. The full CMS report is available here.
On Tuesday, the Oklahoma Attorney General announced a $270 million settlement deal that was reached with Purdue Pharma, manufacturers of OxyContin, and its owners, just two months before a trial was set to begin. The lawsuit was being watched closely throughout the country as a number of other U.S. states and local governments pursue legal action against opioid manufacturers.
In the Oklahoma settlement, Purdue Pharma will pay over $100 million to establish a new addiction treatment and research center at Oklahoma State University; the Sackler family, owners of Purdue Pharma, will also contribute an additional $75 million over five years to the center. Over $70 million will be paid to Oklahoma counties, cities, and tribes for litigation costs and expenses incurred from opioid use disorders and overdoses. $20 million will be utilized for addiction treatment and medical services. Purdue Pharma also agreed not to promote opioids in the state of Oklahoma.
Legal action in Oklahoma against other pharmaceutical manufacturers, including Johnson and Johnson, is still set to occur in late May. The deal reached with Purdue Pharma is significantly greater than its previous settlements with other states; Purdue settled with West Virginia in 2004 for $10 million and with Kentucky in 2015 for $24 million.
It remains to be seen how the Oklahoma-Purdue Pharma settlement deal with impact other pending litigation and legal actions being pursued by other state and local governments throughout the U.S.
This week, the Public Health Institute (PHI) announced that it will be hosting the National Opioid Leadership Summit on Tuesday, June 25 in Sacramento. The event will provide opportunities for attendees to learn about, share, and collaborate on solutions to the opioid crisis that bridge criminal justice, health care, and public health sectors. U.S. Surgeon General Jerome Adams will deliver the keynote address, and the event will feature other TED-style talks, keynote addresses, and interactive breakouts. To receive additional details, early-bird pricing, and event registration information, sign up here.
On Monday, the American Academy of Pediatrics (AAP) and the American Heart Association (AHA) released a joint policy statement endorsing a suite of public health-related public policy approaches designed to reduce consumption of sugar-sweetened beverages (SSBs) among children. Citing an alarming increase in consumption of SSBs, AAP and AHA called for a comprehensive strategy to reduce appeal of these products in an attempt to prevent serious chronic disease conditions, including tooth decay, diabetes, obesity, and heart disease.
In its joint policy statement, AAP and AHA recommend:
- Local, state, and national policymakers should consider raising the price of SSBs, such as through an excise tax, along with an accompanying educational campaign. Tax revenues should go, in part, toward reducing health and socioeconomic disparities.
- Federal and state governments should support efforts to decrease SSB marketing to children and teens.
- Health drinks, such as water and milk, should be the default beverages on children’s menus and vending machines, and federal nutrition assistance programs should ensure access to healthy food and beverages and discourage consumption of SSBs.
- Children, adolescents, and their families should have ready access to credible nutrition information, including nutrition labels, restaurant menus, and advertisements.
- Hospitals should serve a s a model to establish policies to limit or discourage purchase of SSBs.
In developing their public policy recommendations, AAP and AHA reference lessons learned from decades of work on tobacco control efforts, which have included excise taxes and limitations on marketing. The two organizations point to successful initiatives undertaken by local governments, including several jurisdictions in California, to reduce SSB consumption and direct excise tax revenues to community health-based programs.
Notably, the California Legislature has already passed or proposed a number of the AAP- and AHA-recommended policies, including requiring water and milk to be the default beverages of children’s meals. Other recommended policies have been proposed this legislative session through a package of bills that aim to impose an SSB fee, limit marketing and promotional incentives, and add warning labels to SSBs.
The full AAP- and AHA-endorsed public policies are available here.
This week, the U.S. Health Resources and Services Administration (HRSA) announced a funding opportunity to support one-time infrastructure enhancements to improve new or existing high-quality, integrated oral health services in health centers. Up to 250 grants up to $300,000 each are expected to be awarded nationwide by September 2019. Funding is available to support one-time physical infrastructure investments (e.g. minor alternation and renovation, equipment purchases) and organizational infrastructure investments (e.g. training, consulting, and health information technology), including those provided via telehealth and virtual dentistry.
Applications are due to HRSA by May 21, 2019. The HRSA notice of funding opportunity is available here.