Sept. 20, 2019: National Advocacy Update

The AMA and Manatt Health released a national opioid policy roadmap to provide best practices and evidence on how policymakers can help end the nation's opioid epidemic. That national roadmap was developed as part of an 18-month effort, including an in-depth analysis of the response to the opioid epidemic in four states: Colorado, Mississippi, North Carolina and Pennsylvania.

The analysis (PDF) focuses on state efforts in six key areas to identify best practices and provide a plan for all states to follow in order to increase access to high-quality, evidence-based treatment for persons with a substance use disorder (SUD) or who need comprehensive, multidisciplinary, multimodal pain care, and to increase access to naloxone to save lives from overdose.

Four key themes emerged:

States must be willing to use their oversight and enforcement authority. State regulators have differing degrees of authority to pursue policies and changes that can have a significant impact on reducing barriers and improving patient care, but the extent to which they use these tools to increase access to evidence-based treatment or hold payers and others accountable for impeded access varies considerably.

Medicaid is leading the way. Medicaid is on the front lines and often provides more comprehensive care for substance use disorders than the commercial insurance market does; there may be opportunities to extend Medicaid successes to commercial coverage. Expanding Medicaid would help even more patients. states that have expanded Medicaid coverage to low-income adults are, at baseline level, far ahead of those that have not expanded in terms of addressing this epidemic. All states should expand their Medicaid programs as allowed under the Affordable Care Act (ACA) as a key step in addressing the epidemic.

Grants are helpful, but long-term implementation needs long-term, sustainable funding. Many best practices that are helping save lives are grant-funded and need long-term, sustainable funding to continue benefiting patients. Without reliable funding streams, programs that help save lives will simply go away. "We have a huge population of uninsured that can receive treatment from these funds, but how are they going to continue to receive treatment?" said Susan Kansagara, Chronic Diseases Section Chief at the North Carolina Department of Health and Human Services, during a media call. "We know [opioid abuse] is a condition that requires many years, if not a lifetime, of treatment and recovery support. It's hard to tell a practice to hire two more physicians if I don't know if funding is going to continue to come in after two years."

The process of evaluating what works is just starting. Some states have undertaken efforts to evaluate current policies and programs to determine what is actually working; most of these evaluations are just beginning. Comprehensive analysis is essential in order to focus resources on successful interventions—and to revise or rescind policies that are having unintended consequences.

The report also identifies six key areas where regulators, policymakers and other key stakeholders can take action.

Access to evidence-based treatment for opioid use disorder. Remove prior authorization and other barriers to medication-assisted treatment (MAT) for opioid use disorder—and ensure MAT is affordable.

Parity enforcement. Increase oversight and enforcement of mental health and substance use disorder parity laws.

Network adequacy/workforce enhancement. Ensure adequate networks that allow for timely access to addiction medicine physicians and other health care professionals; this includes payment reforms, collaborative care models and other efforts to bolster and support the nation's opioid use disorder treatment workforce.

Pain management. Enhance access to comprehensive, multidisciplinary, multimodal pain care, including non-opioid and non-pharmacologic pain care options.

Access to naloxone. Reduce harm by expanding access to naloxone and coordinating care for patients in crisis.

Evaluation. Evaluate policies and outcomes to identify what is working, so as to build on the most successful efforts, and also to identify policies and programs that may need to be revised or rescinded.

The AMA stands ready to work with all stakeholders to implement the recommendations in this national roadmap.

Visit end-opioid-epidemic.org to learn more about what the AMA is doing to end the opioid epidemic.

AMA President Dr. Patrice Harris testified before the House Energy and Commerce Subcommittee on Health on Sept. 10, regarding legislation to address the nation's high maternal mortality rate. At the hearing, Dr. Harris highlighted the following factors (PDF) as contributing to rising maternal mortality rates in the United States, including the disproportionately high maternal mortality rates for Black women and Native American/Alaska Native women:

• Lack of insurance or inadequate coverage prior to, during and after pregnancy
• Increased closures of maternity units in rural and urban communities
• Lack of inter-professional teams trained in best practices
• Structural determinants of health, such as public policies, laws and racism that produce inequities in the social determinants of health, such as education, employment, housing and transportation
• Stress exacerbated by discrimination that can result in hypertension, heart disease and gestational diabetes during pregnancy
• Clinicians not listening to black women, resulting in missed warning signs and delayed diagnosis

She expressed the AMA's support for H.R. 1897/S. 916, the "Mothers and Offspring Mortality and Morbidity Awareness (MOMMA's) Act", which would improve data collection, disseminate information on effective interventions, and expand access to health care and social services for postpartum women. The bill would enhance federal efforts to support states in collecting, standardizing, and sharing maternal mortality and morbidity data, and authorizes and expands existing federal grant programs dedicated to scaling best practices to improve maternity care. The MOMMA's Act would also authorize states to expand coverage under Medicaid, CHIP, and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) for 12 months postpartum, and it would ensure improved access to culturally-competent care training and workforce practices throughout the care delivery system.

Dr. Harris spoke about the AMA's new Center for Health Equity and the organization's commitment to champion health equity and promote greater diversity within the medical workforce. She also expressed the AMA's continued support for legislation signed into law last year, H.R. 1318 (P.L. 115-344), the "Preventing Maternal Deaths Act," which strengthened federal support for state maternal mortality review committees that review individual maternal deaths and recommended specific ways to prevent them in the future.

Last week, the House Committee on Small Business held a hearing on step therapy and prior authorization. Chairwoman Nydia Velázquez (D-NY) and Rep. John Joyce, MD (R-PA), were especially strong in their message that physicians are trying to provide the "highest quality clinical care" and that prior authorization and step therapy are leading to delays in care. When doctors spend hours dealing with paperwork or cannot treat a patient because a health insurance company will not approve a treatment, patients suffer.

Dr. Joyce and the witnesses offered clear-cut examples, including stories of physicians having to seek prior authorization during the middle of surgery and often being denied. There was consensus that prior authorization processes must be streamlined and that greater clarity is needed regarding which services are subject to it. The witnesses made compelling arguments that the health insurance representatives providing prior authorization should be physician peers who understand the underlying medical conditions and the appropriate standard of care.

Earlier this week, the AMA and 369 other patient, physician and health care professional organizations sent a letter (PDF) to members of Congress asking them to cosponsor H.R. 3107, the "Improving Seniors' Timely Access to Care Act," which was introduced this summer by Reps. Suzan DelBene (D-WA), Mike Kelly (R-PA), Roger Marshall, MD (R-KS), and Ami Bera, MD (D-CA). The legislation is based on the Consensus Statement on the Improving Prior Authorization Process (PDF) adopted by leading national organizations, including the AMA, representing physicians, medical groups, hospitals, pharmacists and health plans.

The AMA weighed in (PDF) on the U.S. Citizenship and Immigration Services' (USCIS) previously announced revocation of the nation's medically deferred deportation policy for critically ill individuals. About 1,000 undocumented immigrants, many of whom are seriously ill children with conditions like cancer, muscular dystrophy and rare genetic disorders, apply for deferred action on their immigration status in order to continue their treatment. In August, the USCIS informed hundreds of patients they had 33 days to leave the country or be deported. After public outcry, U.S. immigration officials subsequently announced they would pause those deportations and reconsider the policy change.

This change in policy would have needlessly endangered immigrant children with serious illnesses and their families and, accordingly, sent a letter (PDF) to USCIS on Sept. 6 strongly urging the agency to reverse the policy change. The AMA subsequently shared its letter with the House Oversight and Reform Committee in advance of a subcommittee oversight hearing on the new policy.

On Sept. 19, in response to the outrage expressed by the AMA and other health care groups, the USCIS announced it will process deferred action bids again. Meaning the Administration will immediately resume processing requests for deportation relief from immigrants without legal status, including those with serious medical conditions receiving life-saving treatments in the U.S. The AMA will continue to monitor the situation closely to ensure that this policy is properly reversed and seriously ill children and families receive the medical care they need.

Last week, in accordance with policy adopted during the 2019 AMA Annual meeting, the AMA strongly urged (PDF) the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Homeland Security (DHS) to allow asylum-seekers to receive all medically-appropriate care, including vaccinations, in a patient-centered, language- and culturally-appropriate way upon presentation for asylum regardless of country of origin.

"Asylum-seekers are a vulnerable group that often face circumstances in which their health and well-being may have been compromised during their journey to seek safety. It is our understanding that the U.S. Customs and Border Protection (CBP) will not provide influenza vaccinations to migrants in its custody, even though flu outbreaks have been reported in CBP facilities. We believe that the current living conditions facing many children and families detained in CBP custody may aggravate the spread of infectious diseases such as the flu. The flu season will begin shortly, and we believe that it is in the best interest of public health for vaccinations to be given as soon as possible," wrote AMA CEO and EVP James L. Madara, MD.

According to the U.S. Centers for Disease Control and Prevention (CDC) the burden of illness during the 2017–2018 season was high with an estimated 48.8 million people in the U.S. getting sick with influenza, 22.7 million people going to a health care provider, 959,000 hospitalizations, and 79,400 deaths from influenza. The number of cases of influenza-associated illness that occurred last season was the highest since the 2009 H1N1 pandemic, when an estimated 60 million people were sick with influenza.

The House passed the "Humanitarian Standards at the Border Act" (H.R. 3932) on July 25 by a majority party-line vote, 233-195. All democrats and one republican voted for the measure. The AMA has weighed in extensively on this issue; the AMA called on (PDF) the U.S. Department of Homeland Security (DHS) and U.S. Customs and Border Protection (CBP) to address the condition of their facilities at the southern border, which are inconsistent with evidence-based recommendations for appropriate care and treatment of children and pregnant women. The AMA also issued a letter (PDF) to the House Committee on Oversight and Reform in advance of the upcoming hearings entitled, "Kids in Cages: Inhumane Treatment at the Border," and "The Trump Administration's Child Separation Policy: Substantiated Allegations of Mistreatment." In addition the AMA issued a letter (PDF) of support to the House Judiciary Committee in advance of its mark-up of the legislation.

"Conditions in CBP facilities, including open toilets, constant light exposure, insufficient food and water, extreme temperatures, and forcing pregnant women and children to sleep on cement floors, are traumatizing. These facilities are simply not appropriate places for children or for pregnant women. We strongly urge the administration and Congress to work with the medical community to develop policies that ensure the health of children and families is protected throughout the immigration process," wrote AMA CEO and EVP James L. Madara, MD. The bill has been referred to the Senate Judiciary Committee where it awaits action.

In September the administration released a proposed rule expanding the long-term detention of migrating families. Consistent with policy adopted during the 2018 AMA Annual Meeting, the AMA submitted a comment letter (PDF) opposing the proposed rule and its impact on the health and well-being of migrating families. The AMA has been, and will continue to be, aggressive (PDF) in demanding oversight of these detention facilities and will continue to voice its concern (PDF) and advocate for the health and safety of migrating children and families.

Three bills were marked up by the House Judiciary Committee in response to the latest mass shootings. H.R. 1186: the "Keep Americans Safe Act" (Rep. Deutch (D-FL)), would ban high capacity ammunition magazines; H.R. 1236, the "Extreme Risk Protection Order Act of 2019" (Rep. Carbajal (D-TX)) would authorize grants to incentivize states to establish red-flag laws to allow family members or law enforcement to petition a judge to temporarily remove guns from a person considered a threat to themselves or others while also creating a federal pathway for red flag cases to be brought; and H.R. 2708 (Rep. Cicilline (D-RI)) would prohibit people convicted of a misdemeanor hate crime from possessing a firearm. The bills await consideration before the full House.

Of the three bills, H.R. 1236, the "Extreme Risk Protection Order Act of 2019," aka "Red Flags," is the only issue the Senate has considered on gun violence prevention. Chairman Lindsey Graham (R-SC) of the Senate Judiciary Committee held a hearing on this issue this past March, and the AMA submitted a letter (PDF) of support for the concept of providing grants to states to establish red flags law to the Committee in advance of that hearing. The House previously passed on Feb. 28, H.R. 8, the "Bipartisan Background Checks Act of 2019" and H.R. 1112, the "Enhanced Background Checks Act of 2019." The AMA sent a letter of support for H.R. 8 to bill sponsors and it is currently awaiting consideration in the Senate.

New research shows that 40.5% of high-school seniors have tried nicotine vaping, adding urgency to President Trump's announcement that the Food and Drug Administration (FDA) will take action to ban the e-cigarette flavorings that have proved so attractive to teens and young adults. Meanwhile, federal health agencies are encouraging physicians to report detailed information on cases of vaping-associated lung illnesses. Here's what doctors need to know.

• Vaping is taking off among kids. A national survey of 42,531 eighth–12th graders finds that 25.4% of high-school seniors have vaped nicotine in the last month, while 20.2% of 10th graders and 9% of eighth-graders have done so.
• It's way past time to eliminate e-cigarette flavorings. The AMA has long called on the FDA "to regulate e-cigarettes, particularly banning flavors and marketing practices that enhance the appeal of e-cigarette products to youth," said Patrice A. Harris, MD, MA, the Association's president. The AMA House of Delegates has declared the skyrocketing use of e-cigarettes to be an "urgent public health epidemic" and urged the FDA to take action to address it. Dr. Harris also lauded recent actions by Michigan and New York to ban e-cigarette flavorings.
• Vaping-related lung illnesses have struck hundreds, killing seven. The CDC has reported 530 cases of lung injury in 38 states and one U.S. territory. The CDC has confirmed seven deaths in six states: California, Illinois, Indiana, Kansas, Minnesota and Oregon. While most of the patients affected used e-cigarette products with tetrahydrocannabinol (THC), some of the patients reported vaping only nicotine. The CDC is regularly providing updates on the outbreak.
• The CDC and FDA are telling physicians: Report what you see. The CDC says physicians and other clinicians should "report cases of severe pulmonary disease of unclear etiology and a history of e-cigarette product use within the past 90 days to your state or local health department." Learn more by reading the CDC's health advisory, "Severe Pulmonary Disease Associated with Using E-Cigarette Products." The FDA, meanwhile, has developed a portal to report safety problems with tobacco products. The agency says it wants reports from health professionals about tobacco products that are damaged, defective, contaminated, smell or taste wrong. The FDA reviews the reports to identify concerning trends.

Read more.

• Sept. 20, 2019: Advocacy spotlight on 10 states with the least competitive health insurance markets 
• Sept. 20, 2019: State Advocacy Update 
• Sept. 20, 2019: Judicial Advocacy Update