Healthy Debate

Physicians, Lawmakers Work for Texans' Health

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Public Health Feature – August 2011

Tex Med. 2011;107(8):41-47.

By Crystal Conde
Associate Editor

 Kim Avila Edwards, MD, was one of hundreds of Texas physicians who showed up at the Texas Capitol this year to lobby lawmakers and testify before committees on an aggressive public health agenda. Dr. Edwards, medical director of the Healthy Living Happy Living obesity intervention program at Dell Children's Medical Center of Central Texas in Austin, counts creation of a system to map and identify areas of Texas where children are at greater risk of becoming obese and then target those areas for obesity prevention strategies as a public health victory this session.

Physicians advocated passage of legislation to decrease the burden of vaccine-preventable disease, bolster cancer prevention and research, protect Texans from cigarette smoke, and curb obesity. The Texas Medical Association and the Texas Public Health Coalition supported bills in this year's budget-conscious session that also would reduce health care costs and decrease the toll of disease.

On some issues, the legislature took the message to heart and passed legislation that will aid physicians in accomplishing some public health priorities.

Dr. Edwards says Rider 18 in the Texas Comptroller of Public Accounts' budget is a victory for public health. It allows for appropriation of $2 million for the biennium to identify data that can be used to help influence and control the total economic cost of obesity.

The rider authorizes the comptroller to create a geographic information system (GIS)-driven obesity data set for the state to map areas where children are at risk for obesity and develop a web portal to report the data and help illustrate the link between obesity and its economic impact. The Texas Education Agency (TEA) may give the comptroller all data necessary to create GIS maps showing FITNESSGRAM results and to identify areas in which children are at risk for obesity. The FITNESSGRAM evaluates child fitness levels based on measures of body composition, aerobic capacity, muscular strength, endurance, and flexibility.

Legislators approved some of the obesity prevention and immunization bills the groups endorsed. The legislature also passed bills improving the infrastructure and operations of the Cancer Prevention and Research Institute of Texas (CPRIT), created by the 2007 legislature. And lawmakers approved legislation that appropriates a full $600 million to the institute for the next two years to fund grants for cancer research and prevention. (See "CPRIT Receives Full Funding.")

Not every bill that TMA and the coalition endorsed succeeded.

One initiative TMA supported cost nothing up front and would have improved health and long-term savings for the state. TMA again backed House Bill 670 by Rep. Myra Crownover (R-Denton) and Senate Bill 355 by Sen. Rodney Ellis (D-Houston) to prohibit smoking in public and work places. The smoking ban ended up as an amendment to another bill. Opponents blocked the legislation when it reached the Senate, and it failed to pass during the regular session. But the legislation staged a comeback during the special session. The newest incarnations of the smoking ban, Senate Bill 28 and House Bill 46, didn't survive the special session.

In spite of the political highs and lows of the session, Herminia Palacio, MD, Texas Public Health Coalition chair and executive director of the Harris County Health Department, applauds the coalition's work and TMA's expertise and support. She says the coalition was essential in communicating consensus on major preventable health issues such as tobacco use, obesity, and immunizations.

"By standing together, we make a stronger impression to members, and they can have confidence that there is broad support on an issue," she said.

She applauds the coalition's successful efforts to prohibit the state's tobacco prevention budget from being gutted and to expand the bacterial meningitis vaccine requirements for college students living off campus.

Dr. Palacio adds the coalition will meet for a post-session assessment and determine the next steps and priorities.

"We believe the coalition is gaining in familiarity with lawmakers. We hope to add to our membership and support," she said.

Smoking Ban Fails

Representative Crownover says several factors contributed to the demise of the smoking ban amendment during the regular legislative session. She says the Senate appointees to the conference committee didn't all strongly support the legislation. Plus, the Senate Parliamentarian was concerned the amendment violated the one subject rule in the Texas Constitution. The one subject rule is a principle that a statute should embrace only one topic.

"While we were very confident that the amendment was well within the bounds of the bill, in the end, the Senate conferees decided that any risk to the bill was too great," she said.

Representative Crownover says the smoking ban had wide support, including the Texas Restaurant Association and the Texas Conservative Coalition.

Failure to pass the statewide smoke-free legislation puts the health of Texas' residents at risk, Representative Crownover says.

She anticipates legislation to prohibit smoking in public places will be back in 2013. She stresses that for the results to be different, "the voters of Texas are going to have to let their senators know that this is an issue that matters to them."

The lawmaker calls on physicians to help rally support around the legislation next session.

"People understand that smoking is harmful, but they do not understand the true danger of secondhand smoke. Physicians can help by speaking out publicly about the true danger of secondhand smoke. I think once the public is educated the arguments against a smoking ban will pale in comparison to the value of human life," Representative Crownover said.

Sen. Bob Deuell, MD (R-Greenville), was among those opposed to the smoking ban.

"While I personally wish smoking would be banned in all public places, I think the decision should be that of the property owner. I think a smoking ban as proposed would be a violation of our state and federal constitutions. As a state senator, I took an oath to uphold those documents," Senator Deuell said.

He adds he thinks Texas is "headed for a smoke-free society. The good news is that it will be of free choice and not big brother government."

HB 46 was reported out of the House Committee on Appropriations. SB 28 was approved by the Senate Health and Human Services Committee and referred for consideration by the full Senate. Neither bill advanced.

Joel Dunnington, MD, a Houston diagnostic radiologist, says the legislature's failure to pass a ban on smoking in public places will have a detrimental impact on the health of Texans and the state's economy.

"In terms of Medicaid dollars and other state and county health districts, they're going to have to spend more money caring for Texans who suffer from smoking-related diseases," he said.

A Texas Health and Human Services Commission (HHSC) analysis of the effect of comprehensive smoking bans on Medicaid spending concluded they likely will reduce annual Medicaid costs of hospitalizations for heart attack, stroke, and respiratory illness in Texas by 9.2 percent in 2012 alone. HHSC found the effect of the ordinances on health outcomes increases over time.

The commission estimates the state could realize Medicaid savings of $6.4 million in general revenue funds for fiscal year 2012, with the potential for higher savings later

At the beginning of this legislative session, it looked as though state general revenue funds for tobacco prevention could be reduced from the Texas Department of State Health Services (DSHS) requested amount of $20.9 million to $0, with only $3.9 million in federal funds for the department to work with. By the time it finished its work, though, the legislature appropriated $15.7 million in tobacco prevention funds for 2012-13, compared with $27.8 million DSHS received for 2010-11.

Public Health Victories

Sen. Jane Nelson (R-Flower Mound), chair of the Senate Health and Human Services Committee, says the budget was the biggest challenge for public health. TMA supported the Senate version of the budget, which contained less severe cuts to public health than the House version.

"Fortunately, we were able to ensure that public health functions remained intact and to facilitate more efficient use of existing resources through legislation such as Senate Bill 969, which will allow local health departments to have more input into how scarce public health dollars are allocated in communities," the senator said.

SB 969 establishes the Public Health Funding and Policy Committee within DSHS. The group will consist of regional health directors, local health departments, public health authorities, and individuals from schools of public health at Texas universities. The legislation allows local health officials and others to be involved in setting policy priorities and gives them a way to communicate their concerns and suggestions to DSHS.

Another public health legislative victory Senator Nelson touts is passage of Senate Bill 229.

The bill "will ensure that we are screening all newborns for hearing abnormalities and hearing loss, which is by far the most prevalent congenital condition among Texas newborns. My hope is that ensuring that all of our babies are screened will help us catch these hearing problems early so families can seek whatever therapies or treatments are necessary for their children," Senator Nelson said.

The legislation eliminates an exemption from performing the screenings at hospitals in counties with fewer than 50,000 residents and birthing centers in counties with fewer than 50,000 residents and fewer than 100 births annually. It also requires midwives to refer parents of newborns for hearing screening.

The bill doesn't lift the newborn hearing screening exemption for military hospitals, home births, and facilities operated by a midwife.

In the fight to reduce the burden of obesity in Texas, Senator Nelson's Senate Bill 226 made its way to the governor. The legislation allows TEA to collect de-identified, individual FITNESSGRAM data submitted from schools, rather than having to aggregate the data.

"While still protecting the privacy of our students, this will allow the TEA to correlate this data with attendance and academic data. There are proven connections between children's health and their academic performance, and allowing for coordination of individual student-level data will give us a clearer picture of this connection," she said.

In fact, a 2009 TEA study indicates students who are more physically fit are more likely to perform well on tests and have fewer disciplinary problems at school.

Senate Bill 8 passed during the special session. The bill limits a school district's required annual FITNESSGRAM assessment of students in grade 3 or higher to only those students enrolled in a physical education (PE) course.

Jason Terk, MD, a Keller pediatrician and chair of the TMA Council on Science and Public Health, describes expectations for significant advances in public health this session as "muted" due to the budget outlook for many state health agencies. He says there were some bright spots for public health advocates this session.

House Bill 3336 by Representative Garnet Coleman (D-Houston) requires information on pertussis and pertussis vaccination be provided to all parents of newborns in hospitals, including the Centers for Disease Control and Prevention (CDC) recommendation that all parents of newborns receive the Tetanus, Diphtheria and Pertussis (Tdap) vaccine. Gov. Rick Perry signed the bill, and it took effect immediately.

TMA helped to achieve another "clear victory for public health," according to Dr. Terk, when the governor signed Senate Bill 1107 by Wendy Davis (D-Fort Worth) in May. It requires new college students to be vaccinated against meningococcal disease before entering college, regardless of whether they live on or off campus.

"The previous law only required meningococcal immunization for students living in residence halls or dormitories. The death of a college student who was living in an apartment off campus from meningococcal disease this past year highlighted the need to expand the requirement," Dr. Terk said.

Dr. Avila Edwards commends all of the physicians and TMA staff members who dedicated significant time to medicine's state legislative advocacy efforts.

"Although there were defeats and setbacks, the amazing effort and dedication I saw this session from so many needs to continue for public health measures to move forward next session," she said.

Other Issues

Unfortunately, some public health-related bills didn't survive the session. Senate Bill 1177 by Senator Nelson, which ordered health care facilities' to establish a policy on health care worker vaccination to protect patients from disease, passed the Senate and the House Committee on Public Health but never reached the House floor for a vote.

Legislators passed the bill in the special session, however, as part of Senate Bill 7.

The legislation says the vaccination policy must:  

  • Require workers to be vaccinated based on the level of risk they present to patients by their routine and direct exposure to patients;
  • Specify required vaccines for covered individuals;
  • Include procedures for verifying whether an employee has complied with the policy; and
  • Include procedures for health care workers to be exempt from the required vaccines for the medical conditions identified as contraindications or precautions by CDC.   

The law defines those who must be vaccinated as an employee of a health care facility; someone providing direct patient care under a contract with the facility; or someone to whom the facility has granted privileges to provide direct care. SB 7 says those exempt from the policy must follow procedures specified by the health care facility to protect patients from exposure to disease, such as using protective medical equipment, such as gloves and masks.

The policy may include, but doesn't require, procedures to exempt a person from the required vaccines based on reasons of conscience, including a religious belief.

Lawmakers also failed to pass during the regular session Senate bills 185, 186, 224, and 225 – all related to obesity prevention. Senator Nelson authored the bills.

SB 224 would have established a program to recognize schools that implement successful coordinated school health programs, improve fitness assessment results, and demonstrate active school health advisory councils (SHACs). SB 225 would have required school districts' campus improvement plans to include strategies to comply with the Texas school nutrition policy and would have required SHACs' reports to add a summary of the districts' compliance with the PE requirements.

SB 185 would have increased the required daily physical activity for students in grades 6 through 8 from four to all six semesters. SB 186 would have restored a half-credit of PE and a half-credit of health education to graduation requirements. In 2009, House Bill 3 reduced required PE credits to one.

Senator Nelson encourages physicians to remain vocal at the Capitol in support of legislation that will improve Texas' health care landscape.

"In formulating health policy, it is essential to hear the real-life perspectives of physicians and to hear how these policy changes are going to affect them and their patients," Senator Nelson said.

House Bill 574 by Donna Howard (D-Austin), regarding the consent process for ImmTrac, the state's immunization registry, didn't make it past the House Committee on Public Health. Passage of the bill would have changed the consent process for ImmTrac to opt out rather than opt in.

A Lean DSHS Budget

DSHS Commissioner David Lakey, MD, says the department is evaluating the impact of the reductions in tobacco prevention and chronic disease funding on its services and public health efforts.

"With fewer dollars for services, it stands to reason that fewer people will be served. Significant economic and human costs are associated with tobacco use and obesity. Chronic diseases, most of which are directly attributable to tobacco and obesity, are now the top drivers of medical costs in Texas. Prevention is the best way to avoid these costs," he said.

The department is exploring how to manage the resources it receives to ensure effective use of funds, he says.

Chronic disease prevention funding was cut from $29.2 million for the 2010-11 budget to $15.5 million for 2012-13. Chronic disease money covers many of the department's obesity prevention efforts. DSHS requested $36.4 million for 2012–13.

Funding for chronic disease prevention covers grants to Texas communities for physical fitness initiatives, efforts of the Texas Council on Cardiovascular Disease and Stroke, and other activities related to reducing obesity.

Total funding for DSHS was $5.7 billion for 2012-13, compared with $6.1 billion for 2010-11.

Given the leaner budget DSHS has to work with for 2012-13, Dr. Lakey says the department will continue providing essential services to Texans while refocusing some of its activities.

"We'll have as big of an impact as we can with the resources we are given. We also will continue to maintain and enhance our partnerships with key organizations such as TMA, the Texas Public Health Coalition, and other health organizations. We will also work hard to position Texas well for any additional funding opportunities," he said.

While Dr. Lakey says funding reductions could have been deeper, they are still significant, especially in the department's regulatory, chronic disease, tobacco, and family planning services.

"The reality is these reductions will have an impact. Our challenge is to address that reality. Physicians may also feel the effect of funding reductions as they work with patients who have chronic diseases and try to promote wellness and physical fitness to families," he said.

Funding for DSHS's mental health services emerged from the session "reasonably well," according to Dr. Lakey. Lawmakers maintained many of the community mental health programs and increased funding in some instances.

"Funding for mental health hospitals has increased, which means we'll be able to maintain the status quo and even make improvements in capacity and in recruiting and retaining psychiatrists."

DSHS also received funding for its patient safety, preventable hospitalizations, and healthy babies and infant mortality reduction initiative. Dr. Lakey says these interventions help improve health outcomes and save Medicaid dollars.

"And though our request for additional funds for HIV medications was not granted, the legislature provided a mechanism for us to work with HHSC to ensure this need is met," he said.

Support from the Texas Public Health Coalition, TMA, individual physicians, and other health organizations played a vital role in communicating public health issues this session, Dr. Lakey says.

"We appreciate their support of the department and of our programs. We are aligned in our ultimate goal of improving the health of Texans. We'll continue to work with them and to be good partners in our shared mission of making Texas healthier," he said.

Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.


CPRIT Receives Full Funding

In spite of the financial challenges state agencies faced this session, the Cancer Prevention and Research Institute of Texas (CPRIT) emerged with full funding.

The Texas Legislature provided $600 million for 2012-13. By comparison, the legislature approved $450 million for 2010-11.

"These additional dollars will further the chances of finding groundbreaking discoveries in cancer prevention and treatment that can be commercialized to make them available to the general public and cancer patients," said CPRIT Chief Operating Officer Heidi McConnell.

As provided by Texas law, 10 percent of the funds available – $57.4 million over the next two years – will be allocated toward prevention grants. The legislature allocated $45 million for prevention for 2010-11.

She says with full funding, CPRIT will be able to invest 33 percent more in cancer research in the next two years than it was able to in 2010-11. CPRIT will also be able to invest 32 percent more funds in evidence-based cancer prevention programs that provide needed screening services to medically underserved populations, training for health care professionals, and cancer awareness and education programs around the state, she says.

Additional legislative successes will augment CPRIT's operations.

Ms. McConnell says Senate Bill 1421 by Sen. Jane Nelson (R-Flower Mound) allows private entities to protect intellectual property submitted to CPRIT as part of an application for cancer research funding, as well as intellectual property and other proprietary technical information filed with CPRIT. SB 1421 extends that protection to the same type of information submitted to CPRIT from researchers at private universities, research institutes, and companies.

CPRIT's statute requires all grant awards to have a revenue-sharing agreement. CPRIT collects royalty and milestone payments, but SB 1421 expands the revenue-sharing options to allow the institute to take equity or securities in a company. Ms. McConnell says this option gives CPRIT more flexibility to maximize any return on the state's investment.

Governor Perry signed SB 1421, and it takes effect Sept. 1.   

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