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"Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity." - World Health Organization

Updates from the States

Alabama:

Lea G. Yerby

• For the 11th year in a row, State Senator Vivian Figures (D-Mobile), sponsored a bill to prohibit smoking in places of employment and public places, and to provide penalties for violations of the proposed law. The definition of public place included restaurants, bars, and sports arenas, among many other locations. Penalties for violation of the act included individual fines of up to $500 per violation. Despite strong statewide collaboration and endorsement of the bill, it did not make it out of the Senate. Here is to a strong and successful 12th attempt!
• State Senator Larry Means (D-Atalla) introduced measure SB113 that would prohibit the sale of tobacco products through a self-service display, or vending machine, and increase restrictions regarding the sale of tobacco product to minors. While this bill was reported by the Committee on Judiciary, it was indefinitely postponed in the Senate.

Arizona:

Nicole Olmstead

Arkansas:

Kevin W. Ryan

New and developing areas related to tobacco prevention and cessation in Arkansas:

• Arkansas reported this week a notable decrease in tobacco use. From 2002 when 25.1% of adults in the state reported using tobacco, recently released data shows that this has decreased to 20.7%, or about 100,000 fewer adults smoking.
• Staffed by Arkansas SHPI HPPE Kevin W. Ryan, Arkansas Surgeon General Dr. Joe Thompson provided testimony before the Arkansas Legislature regarding efficacy of tobacco prevention and cessation programs in Arkansas, the relationship between tobacco use and substance abuse, and import of retaining tobacco settlement funding of current tobacco related programs.
• Kevin Ryan has begun a series of meetings with key legislators and stakeholders related to retention of tobacco settlement proceeds funding of prevention and cessation programs in the state.

California:

Omar Sahak

As with the rest of the country, California is combating fiscal difficulties of unprecedented proportions. The "State Budget Crisis" of 2009 followed last year's legislative delay of several months in passing a state budget. For the past few months, the state has been issuing billions of dollars in IOUs in light of its financial difficulties.

The current budget cuts are severely impacting health and human services and the California healthcare safety net. In July 2009, Medi-Cal, the state Medicaid program, eliminated reimbursement for certain "optional" benefits, including podiatry services, optician/optical laboratory services, optometry services, adult dental services, chiropractic services, acupuncture services, incontinence creams and washes, psychology services, and speech therapy and audiology services. Several demonstrations and protests took place to prevent the elimination of crucial adult dental, podiatry and optometry services, and a lawsuit was filed by the California Primary Care Association and partners. The courts decided with the state, and the cuts went through as planned. Hundreds of communities are now contending with this attack on their economic and social viability.

Budget cuts are forcing the closure of many clinics and hospitals serving low-income populations, as well as forcing the closure of state parks and schools. The State budget passed in late July 2009 with enormous cuts to programs and services for children, HIV/AIDS prevention and treatment, in-home support services, and others. Funding for Medi-Cal was reduced by $323.2 million. Other cuts included $2.2 million from Rural Health Services, $1.9 from Seasonal Migratory Worker Program, $1.5 million from Indian Health Program, $8.4 million from Expanded Access to Primary Care Program, $18 million from the Immunization Program, $2.9 million from the Children's Dental Disease Prevention Program, $35 million from the AIDS Drug Assistance Program and other Office of AIDS programs, $3 million from the California Poison Control System.

Healthy Families, California's version of SCHIP, saw its budget slashed by $190 million. The First 5 commission voted in August to provide $81 million to Healthy Families, leaving a funding gap of $120 million, which would still eliminate coverage for over 600,000 children. SB 1442 was recently passed to protect the enrollment of these children in the program, and fill the $120 million funding gap.

Health promotion legislation updates include SB 400, seeking to allow only adults to purchase e-cigarettes, which produces a nicotine vapor and comes in flavors that might appeal to youth. This bill is currently in the Senate Committee on Health. AB 1478 seeks to require that doctors discuss nutrition as an alternative to standard treatments for diabetes and heart disease in nonemergency cases. This bill is currently in suspense until January 2010. AB 513 recently passed, and mandates that health care service plans and insurers include coverage for lactation consultations and for the rental of breast pumps as part of their contracts and policies.

Other legislation currently under consideration are AB 346, which expands joint use projects, SB 257, which requires state departments to notify women nearing maternity leave of breastfeeding accommodations in the workplace, AB 627, which requires basic nutrition and activity requirements for child care licensing.

Colorado:

Kyle Legleiter

The 2009 Colorado legislative session concluded on May 7th and focused on proposals to balance the state's budget in the face of declining revenues from all sources. Fiscal year 2009-2010 revenue projections estimated a gap of $786 million in the state's General Fund that needed to be filled by a combination of budget cuts and revenue increases. As a result, a 2/3 majority of both houses voted to declare a fiscal emergency for the state (SJR35). This move allowed the legislature to transfer revenues from the state's tobacco taxes into the General Fund. Without the declaration of a fiscal emergency, Colorado's Amendment 35 would require that these revenues be dedicated to programs for tobacco education and cessation, primary care services at safety net clinics, and cancer, cardiovascular, and pulmonary disease grant programs. As a result, SB269 instituted a small percentage cut to these programs by capping their total FY 09-10 funds at $100 million. SB271 then dedicated $20 million of the remaining tobacco tax revenues to covering the costs of increased enrollment in Colorado's Medicaid program.

In addition to these moves to balance the state's budget, the Colorado legislature also passed several pieces of legislation during the 2009 session with potential impacts on public health and chronic diseases:

• HB 1012 allows health insurers to offer incentives for participation in wellness and prevention programs, including activities that support healthy eating, physical activity, and tobacco cessation
• HB 1342 eliminated a sales tax exemption on cigarettes. This is expected to raise the price of a pack of cigarettes by approximately 15 cents and to increase the state's sales tax revenues by $31 million annually
• SB 148 improves safety for bicyclists on Colorado's roads and highways by requiring that drivers pass cyclists with adequate space. It also creates new misdemeanor offenses for threatening or harassing cyclists.
• HB 1204 requires health insurance plans to cover certain preventive healthcare services with limited copayment or coinsurance amounts, including cholesterol screenings, tobacco use screenings and interventions, cervical cancer screenings, and childhood immunizations.
• SB 3 expanded Colorado's enhanced emissions standards to improve air quality. These standards will now include parts of Larimer and Weld counties in northern Colorado.

Public health advocates did encounter setbacks during this session with the defeat of two bills aiming to decrease childhood obesity. SB 46 would have imposed minimum nutritional standards for foods sold in school vending machines, and SB 131 would have created minimum weekly requirements for physical activity in schools. However, opposition from school districts concerned about the costs and administrative burdens of implementing the measures ultimately led to the defeat of these bills in 2009.

Illinois:

Michele Pfeilschifter

• Training Opportunity: Building Blocks for Chronic Disease Prevention and Health Promotion in State Policy - Monday, August 3, 2009 from 1pm - 4pm, Illinois State University in Normal, IL; More information will be on the ISOPHE website (www.isophe.org) or contact Michele Pfeilschifter at mpfeilschifter@arthritis.org or (312) 372-2080 x 27
• HB 3767: Creates the Obesity Prevention Initiative Act
  Illinois Department of Public Health to organize at least 6 hearings on the health effects and costs of obesity and the need to address the obesity epidemic Passed both House and Senate - now goes to Governor for action (last action 5/30/09)

Kentucky:

Emily Beauregard

Earlier in the year, the Kentucky Legislature failed to pass a bill to increase the cigarette tax by $0.70, although a tax of $0.30 was approved. This tax was largely aimed at increasing tax revenues for the State budget, although there would have been significant public health benefits gained, as well. In another attempt to create an additional source of revenue, Governor Beshear convened a special session in June to consider economic development bills that would generate more revenue for the horse racing industry, Kentucky schools, and the Kentucky general fund, and to create jobs for Kentucky residents. The "slots" bill did not pass, so there will be no opportunity to generate revenue from slot machines at horse tracks. Without this additional revenue, Kentucky faces a $1 billion budget shortfall. To balance the budget Governor Beshear made cuts of 2.6% or more to all government services, but did make a few exceptions for education and health services. In addition to these protected health services, Kentucky's $3 billion in stimulus funding will be largely invested in health care, with $1 billion going to Medicaid and almost $300 million going toward "health and welfare" services. The Governor has also recently committed to increasing KCHIP enrollment numbers and signed legislation to mandate the inclusion of mammograms in all basic insurance plans offered in Kentucky.

Other stimulus funds are also coming into the State through grants to expand services at federally qualified health centers like mine. At Family Health Centers, we are currently expanding primary care and dental services with the addition of new staff and hope to expand two of our clinic sites through proposed construction projects.

Louisiana:

Christine Brennan

Maine:

Heather Davis

The 124th Maine Legislature enacted several bills related to chronic disease prevention this session. Among the bills:

• LD 319 An Act To Track the Prevalence of Childhood Obesity in Maine
  Public Law 2009, chapter 407 requires the Department of Health and Human Services, Maine Center for Disease Control and Prevention to create a protocol for school nurses and trained screeners to follow in the collection of body mass index data from children and provide a method for uniform reporting to the department. It also allows a student to be exempt from this collection of data if the student's parent or guardian objects on religious or philosophical grounds. The law provides that body mass index data collected by school administrative units are confidential except that data may be reported in the aggregate to the Department of Health and Human Services, Maine Center for Disease Control and Prevention. Data reported in this manner may not identify an individual student. The collection and reporting of data by the school administrative units is contingent upon the availability of federal funds.
• LD 1259 An Act To Increase Access to Nutrition Information
  Public Law 2009, chapter 395 requires a chain restaurant, which is a restaurant with the same trade name and the same type of food, meals and menus as 20 or more restaurants at least one of which is in Maine, to provide accurate calorie information on its menus, menu boards and food display labels for the food and beverage items it regularly sells, not including limited-time offers, condiments, items in sealed manufacturer's packaging with nutrition information or custom orders. The law also requires a chain restaurant to state on its menu and menu boards: "To maintain a healthy weight, a typical adult should consume approximately 2,000 calories per day; however, individual calorie needs may vary." This law allows a chain restaurant to state on its menu and menu boards: "Nutrition information is based upon standard recipes and product formulations; however, modest variations may occur due to differences in preparation, serving sizes, ingredients or special orders." The law provides a definition for "calories per serving," the law exempts limited time offerings to 90 days per year. It exempts from the definition of "chain restaurant" a movie theater and a hotel or motel that contains a separately owned eating establishment but applies the provisions of the bill to that separately owned eating establishment. It exempts food items provided at a self-service salad bar or buffet. It establishes a separate caloric labeling requirement for beer, wine and spirits. It specifies that enforcement is by the Attorney General against the owner or franchisee of the eating establishment and that there are no private remedies. The law states that state regulation of nutritional information by chain restaurants occupies the whole field of regulation and prohibits municipalities from enacting any ordinance regulating the dissemination of such information. The law takes effect February 1, 2011.
• LD 67 An Act To Protect Maine's State Parks and State Historic Sites
  Public Law 2009, chapter 65 prohibits smoking in, on or within 20 feet of a beach, playground, snack bar, group picnic shelter, business facility, enclosed area, public place or restroom in a state park or state historic site. This bill was enacted as an emergency measure effective May 1, 2009.
• LD 820 An Act To Prohibit Smoking in Outdoor Eating Areas
  Public Law 2009, chapter 140 prohibits smoking in outdoor eating areas of eating establishments. It requires eating establishments to notify their patrons of the prohibition on smoking and to request that persons in the outdoor eating area comply with the law.
• LD 1230 An Act To Prohibit the Delivery of Tobacco Products to Minors
  Public Law 2009, chapter 398 prohibits delivery sales of tobacco products in the State to anyone other than a licensed tobacco distributor or a licensed tobacco retailer but exempts premium cigars. For premium cigars it retains current law on shipment of tobacco products, narrowing it beginning October 1, 2009 to apply to premium cigars, and retaining the requirement that shippers of premium cigars into the State be licensed as tobacco retailers. It repeals a provision of the law that has been enjoined by the federal court and a provision that does not apply to premium cigars. Public Law 2009, chapter 398 takes effect October 1, 2009.
• LD 1429 An Act To Strengthen the Workplace Smoking Laws and Other Laws Governing Smoking
  Public Law 2009, chapter 300 does the following:
  1. It prohibits designated smoking areas indoors in places of employment and provides a definition of permitted outdoor designated smoking areas; 2. It repeals the laws on smoking in hospitals, nursing homes and jury rooms that differed from the public place and workplace laws; 3. It clarifies in the laws governing workplace smoking that "business facility" may include a private residence or unit or apartment within a residential facility during the period of time that the private residence or unit or apartment is a place of employment; and 4. It clarifies that "residential facility" means a facility licensed by the Department of Health and Human Services.

In addition, the 124th Maine Legislature adopted a bill to establish a Universal Wellness Initiative:

• LD 1363 An Act To Establish and Promote Statewide Collaboration and Coordination in Public Health Activities and To Enact a Universal Wellness Initiative
  Public Law 2009, chapter 355 coordinates and streamlines the public health system in this State. It prepares the state public health system for national federally recognized public health accreditation and ensures the effective, efficient and evidence-based delivery of essential public health services. The law recognizes and formally establishes Healthy Maine Partnerships, district coordinating councils for public health and the Statewide Coordinating Council for Public Health. The law also establishes a universal wellness initiative using the existing resources of the public health infrastructure. The law requires the development and distribution of a resource toolkit for the uninsured and a health risk assessment for all people of the State with a focus on the uninsured and those facing health disparities. It also requires the Department of Health and Human Services, Maine Center for Disease Control and Prevention to issue an annual report card on health for each public health district in the State and for the state health plan to publish the report cards. The law allows municipal health departments to enter into data-sharing agreements with the Department of Health and Human Services if the agreement protects the confidentiality and security of individually identifiable health information.

Maryland:

Liany Arroyo

With the Maryland legislative session over until January 13, 2010, there is not much to report on except for budget cuts. The current economic situation of the country has also affected Maryland and its counties negatively with the state facing a more than $700 million budget shortfall. With a commitment to spare K-12 funding, Governor O'Malley has his hands full trying to find savings in the budget. While federal stimulus funding is helping to close the deficit, Medicaid, aid to local governments, and transportation are taking the biggest hits. Also cuts in state personnel, with health and public safety bearing the brunt of those cuts, are providing additional budget savings. Unfortunately, local health departments and public hospitals will face more challenges in meeting community needs at a time when more individuals need their services.

There is still time to act before another expected round of cuts takes place prior to the next legislative session in January 2011.

Michigan:

Jaye I. Bond

State Budget Crisis
The state of Michigan is enthralled by an unprecedented financial crisis. With the decline of the American automotive industry, Michigan was especially hard hit by monumental decreases in state revenue as the collectable sales and income taxes dwindled down. Unfortunately, many of the cuts being proposed are in the areas of health and human services. In Michigan, the Healthy Michigan Fund, which supports many preventive services including maternal and child health, lead poisoning prevention, smoking cessation, and family planning services, is at risk of losing $8.3 million in funding. The Medicaid program was slashed by $53 million. In Michigan, the Democrat-run House of Representatives approved of the restoration of these funds, but the Republican majority of the Senate opposed. It is most likely that reconciliations between the House and Senate will be made through Committees. These decision-making groups are expected to meet in the next few weeks as a final budget must be in place by September 30 to avoid a government shut-down. Advocacy groups are working incessantly to reinstate the proposed cuts. Many are proposing new taxes, including taxes on services (e.g. massages, golfing, etc.) and increases on liquor and tobacco taxes, to make up for losses in sales tax, income tax, and other tax loopholes.

Michigan's Blues
Blue Cross Blue Shield of Michigan is in serious negotiations to raise health insurance rates by 22% for 163,000 people who buy their own coverage. In early August, they reached an agreement with the Michigan Attorney General that would allow the rate hike. Attorney General Mike Cox did not, however, agree to allow the non-profit insurance agency to raise rates by 31% for 210,000 seniors with supplemental Medicare plans. The Blues, which originally requested a 56% increase for non-seniors and 41% increase for seniors, claim the rate hikes are needed to offset an estimated $1 billion in losses through 2011 on individual policies. The Blues are also requesting that the state require more commercial insurers to accept all applicants, as it is required to do. The Attorney General disagrees, saying that the insurance company can offset the increases by using money from its $2.4 billion surplus. The case regarding seniors will be heard in mid-September by an administrative law judge in Lansing. The hike facing non-seniors must be approved by Michigan's Office of Financial and Insurance Regulations before taking effect.

Minnesota:

Patrick Stieg

The latest big news is the Statewide Health Improvement Program (SHIP). SHIP is an important part of Minnesota's health reform initiative, which was adopted by the state legislature and signed into law by Governor Pawlenty in May 2008. Funds were appropriated for the first two years of SHIP at $47 million, beginning July 1, 2009. With the state facing a $2.7 billion budget shortfall, the public health community was quite fearful that the 2009 legislative session would result in the SHIP funds being un-appropriated. On June 18th we learned that the legislature and the Governor were able to obtain a balanced budget without using any of the previously designated SHIP funds.

SHIP is designed to reduce the burden of chronic disease in Minnesota by decreasing obesity, and tobacco use & exposure. The approach will be to make sustainable policy, systems, and environmental changes in local schools, worksites, healthcare settings and other community settings, by focusing on nutrition, physical activity and tobacco issues. Local public health departments and tribal health departments were eligible to apply for funding to do this work. I am very happy to report that more than 40 local departments will be funded (including my own in suburban Minneapolis-St. Paul!), to ensure we truly have a statewide program working for our residents. Other states are already looking at Minnesota as a model for health reform and chronic disease prevention, so I hope we can deliver!

Missouri:

Karley King

May 15, 2009 marked the end of the 95th Missouri General Assembly. While some progress was made during the session, some advocates saw many missed opportunities.

2009 Progress

Presumptive Eligibility for Children's Health Coverage Funded: This is an option that allows health care settings - such as state's children's hospitals, federally qualified health centers and rural health clinics - to provide immediate but temporary enrollment into state health coverage to children who appear to meet program eligibility requirements. The presumption is based on a preliminary income check by health care staff and allows the child to receive needed health care at the time of the initial visit, rather than waiting for the completion of a full eligibility determination. The family can then complete the necessary application to continue coverage after the initial visit.

Legislation to Create Regional Autism Projects Passes (HB 525 and SB 157): Both pieces of legislation will require the Division of Developmental Disabilities within the department of Mental Health to establish programs and services for individuals diagnosed with autism, and to enhance a family's ability to meet the developmental and training needs of a family member with autism.

Early last month the Missouri House passed legislation that made helmet use optional for riders age 21 and over. This legislation repealed Missouri mandatory motorcycle helmet law. Riders under the age of 21 would still be required to wear helmets. This law has provoked several debates / discussions to address public safety against freedom argument.

2009 Missed Opportunities:

Public Health Coverage for Kids: Would eliminate premiums for children living in families with incomes between 150 and 225 % of the federal poverty level.

Health Coverage to Low-Income Parents Expansion: Would extend Medicaid benefit to 35,000 low-income parents

Outreach and Enrollment Legislation: Would require Missouri public school districts to provide, at the time of enrollment, information to parent on MO children's health insurance program.

Home Nursing Visits for Newborns and Autism Insurance: Would include home nursing visits for newborns as a MO Healthnet benefit, and would allow at-risk infants to receive home visits by registered nurses.

New York:

Adrienne Wald

In July 2009, Governor David A. Paterson signed into law three Governor's Program bills that will make health insurance more affordable and improve access to health care for New Yorkers. The first bill signed into law extends the period of time for COBRA coverage from 18 to 36 months; the second permits families to cover their young adult dependents through age 29 under their job-based insurance; and the third enacts a series of managed care reforms to make health insurance work better for consumers and permit timely access to necessary health services.

North Carolina:

Shelley Golden

Two topics have generated the most attention in public health circles in North Carolina:

• On Tuesday, May 19, Governor Bev Perdue signed into law a ban on smoking in all North Carolina restaurants and bars. While the bill was a compromise by public health advocates, who hoped for a ban in all public places (private clubs and cigar bars were excluded), it is still considered historic, given the strong history of the tobacco industry in the state.
• Like most states, North Carolina is facing a significant budget shortfall ($4-5 billion estimated). The House is in the process of drafting a budget; the governor has already drafted one. Both processes contain numerous rumors about which social services will be on the chopping block, resulting in many emergency legislative updates, and perceived pitting of certain services against others. Furthermore, the state announced mandatory furloughs for all state employees, and most counties are cutting staff, instituting furloughs, or, at best, maintaining current salaries and not filling empty positions. The North Carolina Public Health Association and other public health groups are now advocating for revenue generation as a means of addressing the shortfall. In particular, many groups are calling for an increase in the cigarette excise tax by $1. Resistance to such an initiative by many politicians, including the governor, is anticipated.

Ohio:

Beth Canfield-Simbro

Three topics that have generated the most attention in public health circles in Ohio:

• On August 11, Judge Fais ruled against Governor Strickland and the Ohio legislature, who removed $230 million from an endowment to reduce tobacco use; the ruling states those funds must be used to prevent children from smoking and to help current smokers quit smoking. However, the ruling is for a tobacco foundation that was dissolved a year ago. Gov. Strickland is poised to mount an appeal to the ruling.
• Results of the 2008 Family Health Survey have been released; the data is available to Ohio researchers and the public. Policy briefs for legislators have been created to better inform them of issues facing Ohio families, such as higher numbers of uninsured adults.
• Ohio will receive $32 million as a result of the Pfizer multi-state and federal settlement for illegally advertising drugs for unapproved uses.

Jennifer Scofield

• Ohio Survey Shows Fewer Uninsured Children; More Uninsured Adults
  More Ohio children have health care coverage now than in 2004, according to results from the 2008 Ohio Family Health Survey. The number of children without insurance dropped to 4 percent in 2008 from 5.4 percent in 2004. Source: Health Policy Institute of Ohio 2009.
• The Center for Public Health Statistics and Informatics, housed at the Ohio Department of Health, seeks to help solve health care problems by empowering policy and decision makers with data about the health issues in their local communities. In Ohio, community health profiles are available outlining the factors impacting a community's disease and injury burden include socioeconomic status, access to health care, age distribution and lifestyle behaviors.
• Medworks' Weekend of Free Medical Treatment to Build Foundation for Ongoing Care in Cleveland;- July 25-26 event at University Circle's Walker Center.
• CLEVELAND, Ohio - July 13, 2009 - Medworks (http://www.medworksusa.org/) will provide free access for the uninsured and underinsured to a wide range of health care providers from 8 a.m. to 4 p.m. Saturday and Sunday, July 25 and 26, at the W.O. Walker Center, 10524 Euclid Ave. Replacing May's cancelled health care program at the Cuyahoga County Fairgrounds, Medworks has changed the format of the July event to be a pre-scheduled appointment only event. Those interested in scheduling vision or medical treatment should call a phone bank hosted by Channel 3 WKYC, starting July 13th, at 216-858-6250 or 877-790-7370.

Washington:

Sandra Ripley Distelhorst

In April the final budget for Washington State was approved, which included $4.4 billion in reductions over three years. Cuts to health care programs included reduced public awareness activities on tobacco use prevention and control; reduced funding for local community and school programs; and elimination of funding for the State Supplied Vaccine Program beginning May 1, 2010 (or when state funds exhausted). Children with private health insurance will no longer be eligible for any state supplied vaccines after May 1, 2010. However, state will continue to use federal funds to provide vaccines for children with Medicaid or who do not have private health insurance. In addition the state will no longer be a universal vaccine purchaser for the human papillomavirus (HPV) vaccine.

Health care coverage also took a big hit, with 43% budget reduction in the state Basic Health Plan that services over 100,000 working poor. To avoid losing approximately 40,000 current enrollees, the Health Care Authority choice instead to increase monthly premiums from an average of $36 per month to $61.60 per month; increase the deductible from $150 to $250; and to temporarily suspend new enrollments.

With a focus on budget cuts, only a few health-related bills were passed. They included MRSA bill that will require hospitals to adopt a MRSA screening policy by Jan. 1, 2010 for elective surgery patients as well as other infection MRSA prevention measures The Centers for Disease Control and Prevention reported in 2007 that MRSA infections have become epidemic and kill at least 18,000 people a year, more than AIDS.

Wisconsin:

Frederick Petillo

Federal Level Updates

SOPHE Resolutions on Chronic Disease and Health Disparities