Healthy Priorities

Public Health Group Sets 2013 Goals 

 Texas Medicine Logo 

Tex Med. 2013;109(2):27-33.

By Crystal Conde 
Associate Editor 

Debra Patt, MD, sees tobacco's destructive impact daily in her Austin oncology practice.

"I can tell you that just less than an hour ago I was treating tobacco-related disease on the back end. It's much easier to treat it on the front end. In the words of Benjamin Franklin: 'An ounce of prevention is worth a pound of cure,'" Dr. Patt told attendees at a University of Health forum in November. Dr. Patt, chair of the TMA Committee on Cancer, spoke on the fiscal and physical costs of tobacco use.

Last year, the Texas Public Health Coalition (TPHC) hosted four University of Health programs to educate legislators and their staff members and state agency staff members about key public health issues affecting the state.

The forums, held at the Texas Medical Association building, addressed how public health affects the state's economy and the impact immunizations, obesity, and smoking have on physical and fiscal health.

Program presenters polled forum attendees about each forum's subject matter. TPHC will analyze and use the responses to help provide direction for policy and legislative strategy during this legislative session.

Herminia Palacio, MD, chair of TPHC, says the forums are part of a new approach aimed at engaging lawmakers before the 2013 legislative session.

"In addition to educating legislators in our University of Health programs, the coalition has also been posting blog entries related to our public health priorities on TMA's blog, MeAndMyDoctor, to generate buzz," Dr. Palacio said.

TPHC consists of more than 20 organizations dedicated to advancing core public health principles at the state and community levels. TMA is a charter member.

In December, TPHC unveiled its legislative priorities on immunizations, tobacco use, obesity, and cancer prevention for the 2013 session. Member organizations are focusing on some familiar territory – increasing the amount of required physical activity in Texas schools and supporting comprehensive statewide legislation that eliminates exposure to secondhand smoke in all indoor workplaces throughout Texas, for example.

The coalition also is pushing for new, innovative immunization policies. They include: 

  • Giving minor parents, who can consent to their child's vaccination, the ability to consent to their own vaccination.
  • Supporting a statewide disease prevention and health quality initiative to improve vaccination rates among employees of state-licensed day-care and early child-care facilities.
  • Allowing patients to consent to their vaccination records remaining in ImmTrac, the state's immunization registry, until they reach age 26. ImmTrac currently stores vaccination records until a person's 18th birthday and gives the person a year to consent to having the records stored there. Dr. Palacio says that many 18-year-olds don't know about the ImmTrac consent period, and their immunization data are expunged.  

For a full list of TPHC legislative priorities and for information on the group's members, mission, and advocacy areas, visit the TMA website.

Sen. Jane Nelson (R-Flower Mound), chair of the Senate Health and Human Services Committee, says recommendations from groups like TPHC help her make the case for important public health legislation each session.

"The ideas are thoughtful and well-researched, and I greatly appreciate the time and effort that went into developing an agenda that aligns very closely with my own goals for the legislative session," she said.

Jason Terk, MD, chair of TMA's Council on Science and Public Health, says the TPHC legislative recommendations "reflect the combined wisdom of stakeholders representing many organizations concerned with the health of Texans" and dovetail with the council's priorities.

Texas Department of State Health Services (DSHS) Commissioner David Lakey, MD, says it's important for health organizations to have a unified message.

"We need to work together to make progress in the areas of tobacco use, obesity, and vaccine-preventable diseases – not just because of the economic benefits for the state, but more importantly because those efforts would improve the health of people in Texas," he said. 

Save Lives, Save Money 

Dr. Palacio stepped into the role of TPHC chair in 2008, just in time to lead it into the 2009 legislative session. At the time, the economy had crashed, and attempting to get state funding for public health initiatives was an uphill battle. Dr. Palacio, executive director of the Harris County Health Department, learned a lot during her first session as TPHC chair.

"I learned in 2009 that putting forward an agenda calling for new or realigned public health expenditures in the wake of a budget deficit was a difficult endeavor. Since then, the coalition has been more mindful of making the connection between saving lives and saving money, focusing on the return on investment the state achieves by putting money in public health," she said.

One initiative TMA supported during the 2011 session and will advocate again this session costs nothing up front and would improve health and save the state money in the long run. TMA backed House Bill 670 by Rep. Myra Crownover (R-Denton) and Senate Bill 355 by Sen. Rodney Ellis (D-Houston) to prohibit smoking in workplaces. The smoking ban ended up as an amendment to another bill, but opponents blocked the legislation when it reached the Senate, and it failed to pass during the regular session. The legislation staged a comeback during the special session, but the newest incarnation, Senate Bill 28 and House Bill 46, didn't survive.

The American Lung Association gave Texas an "F" in tobacco prevention and control spending in its report titled State of Tobacco Control 2012. According to the report, in fiscal year 2012, Texas spent $5.45 million on tobacco control programs. The Centers for Disease Control and Prevention (CDC) recommends Texas invest $266 million in tobacco control programs, but the state spends only 4.6 percent of the recommendation. (See "Tobacco's Toll on Texas.")

Comprehensive smoke-free workplace ordinances now cover 36 Texas cities. Twenty-nine states are smoke-free. In a 2011 Baselice & Associates Inc. survey, 70 percent of Texans supported prohibiting indoor smoking, including in restaurants and bars.

Dr. Patt says the TPHC-sponsored University of Health event gave her a platform to educate legislative staff on the benefits of a comprehensive smoke-free indoor workplace policy.

"The natural consequence of this policy would be improved health among Texans, improved productivity, and decreases in health care spending," she said.

A DSHS analysis of smoking ordinances in El Paso County and Travis County – areas with populations of at least 50,000 that have the most restrictive smoking ordinances passed since 2005 – reveals reductions in potentially preventable hospitalizations (PPHs) from 2005 to 2009.

According to the DSHS Center for Program Coordination, during the five-year period, El Paso County adult residents experienced a reduction in the chronic obstructive pulmonary disease PPH rate that was 50 percent less than the state rate. Residents' congestive heart failure PPH rate fell to 22 percent less than the state rate, while the bacterial pneumonia PPH rate was 16 percent less than the state rate.

From 2005 to 2009, Travis County adult residents' asthma PPH rate was 22 percent less than the state rate. The chronic obstructive pulmonary disease PPH rate was 56 percent less than the state rate, while the congestive heart failure PPH rate was 43 percent less than the state rate. Residents' bacterial pneumonia PPH rate was 47 percent less than the state rate.

Dr. Patt adds that it's "important for legislators to understand the positive economic impact from strong smoke-free laws. Time and again, restaurants and bars have shown stable and sometimes even increased revenue when smoke-free policy is enacted."

In fact, a DSHS 2000 analysis of sales tax data from 1987 to 1999 in four smoke-free Texas cities – Austin, Arlington, Plano, and Wichita Falls – found smoke-free policies don't affect restaurant revenue or the sale of alcoholic beverages in bars.

Dr. Patt explains that by not having a comprehensive smoke-free indoor workplace policy at the state level, many employees continue to be exposed to unacceptable levels of carcinogens and toxins on the job each day. Opponents of such a law commonly cite infringement on the personal liberty of the smoker as an argument against passage.

"By not limiting toxic exposure to Texas workers, absence of a comprehensive smoke-free policy is an infringement of their civil liberty. No one should have to choose between a paycheck and their health," Dr. Patt said.

Trim Waistlines, Trim Costs 

State officials estimate that obesity costs Texas businesses $9.5 billion annually. If the obesity rate and the cost of health care continue to increase as projected, the cost to businesses could reach $32.5 billion per year by 2030, according to a 2011 report released by Comptroller Susan Combs.

The price tag for obesity is nearly three times the estimate Ms. Combs released in 2007. In February 2011, the comptroller released a report, Gaining Costs, Losing Time: The Obesity Crisis in Texas. It calculates the cost of obesity-related health care, absenteeism, decreased productivity, and disability to Texas employers.

The report estimates Texas employers paid $4 billion in direct health insurance costs related to obesity in 2009. Indirectly, obesity cost employers an estimated $5.4 billion in 2009, including $1.6 billion for obesity-related absenteeism, $3.5 billion for reduced work productivity, and $320 million for obesity-linked disability.

Dr. Terk says TPHC's support of improvements to the nutrition and physical education policies affecting young Texans in schools "is critical to turning around the crisis of obesity that continues to affect our population."

In 2011, lawmakers failed to pass many obesity prevention bills during the regular session, including Senate bills 185, 186, 224, and 225 by Senator Nelson.

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 summarize the districts' compliance with the physical education (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.

TPHC is again advocating for restoration of a half-credit of PE and health education as a requirement for graduation. The coalition's obesity priorities also call for strengthening the Texas Education Agency's (TEA's) prekindergarten health standards related to nutrition and physical activity and allocating a specified percentage of the Texas Department of Agriculture's health and nutrition grants toward programs serving young children.

Senator Nelson says she will continue to "fight for more physical education in our schools."

"Healthy habits mean Texans will live longer, better lives and incur fewer costs related to chronic illnesses associated with unhealthy behavior," she said.

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. Children who were more physically fit achieved higher standardized test scores than students who were not. In addition, schools with a higher percentage of fit students earned better state performance ratings than those with a lower percentage of fit students. 

Funding a Likely Challenge 

DSHS requested $5.75 billion in funding for the 2014-15 biennium, about $40 million less than the 2012-13 estimated budget. The department is asking for about $179 million to fund adult and child immunizations and for approximately $16 million for chronic disease prevention and $23 million for tobacco program funding for the next biennium.

In June, the Legislative Budget Board informed Texas state agencies their baseline requests for general revenue funds and general revenue-dedicated funds can't exceed the amounts expended in fiscal year 2012 and budgeted in fiscal year 2013. Exceptions to the baseline request limitation include amounts necessary to "maintain benefits and eligibility in Medicaid entitlement programs, the Children's Health Insurance Program, the foster care program, the adoption subsidies program, and the permanency care assistance program."

Agencies also must submit a supplemental schedule detailing how they would reduce the baseline request by an additional 10 percent. In its Legislative Appropriations Request, DSHS proposes reducing general revenue, in part, by eliminating some full-time administrative positions and jobs in some safety net and public health programs.

Dr. Lakey says DSHS's strategy to continue to improve public health in Texas in the face of general revenue reductions involves continuing to use "methods that can provide the greatest return for the dollars we're entrusted with by focusing on prevention and building partnerships with other organizations at the federal, state, and local levels. In addition to state general revenue, we receive federal funding and will continue to pursue other funding opportunities."

He says different parts of the department are also working together to leverage resources. For instance, the DSHS tobacco program is working with the department's chronic disease prevention, community health, and substance abuse prevention and treatment programs to reduce tobacco use in Texas.

"Return on investment, especially in the state budget, is critical to working with limited resources. We focus on interventions that bring the most value for the dollars spent. We use continuous quality improvement to improve our processes, create efficiencies, and identify effective programs," Dr. Lakey said.

The budget board added that funding requests for other purposes that exceed the baseline spending level may be submitted as exceptional items. DSHS exceptional items requests total about $352 million for the upcoming biennium.

One of the health department's exceptional items requests pertains to tobacco cessation and chronic disease prevention. DSHS is asking for $8.57 million for 2014-15 to fund initiatives such as increasing tobacco prevention and cessation funding for Quitline counseling services, preventing smokeless tobacco use among children in rural counties, and expanding the department's efforts to implement chronic disease reduction and prevention efforts in urban areas.

DSHS reports that in fiscal year 2011, the Quitline took 26,183 calls and provided 12,113 people with smoking cessation counseling and 6,305 people with nicotine replacement therapy.

Senator Nelson says she expects funding to pose a major challenge for public health legislation this session.

"As a member of the Senate Finance Committee, I will continue to make health and human services a priority and fight for … important programs, including many public health initiatives," Senator Nelson said.

Dr. Patt, like many physicians, anticipates challenges to public health legislation with a fiscal note this session. She encourages physicians to speak out in favor of public health legislation that would cut costs and improve Texans' health.

"As doctors, we need to continue to tell our story. We need to understand that our policymakers have the best intentions to facilitate good health among Texans in a fiscally responsible and autonomous way. Sometimes they need our guidance and understanding on how health policy will affect our patients and their constituents. It is our job to help legislators respect our liberties and work together to improve the health of all Texans," she said.

Dr. Terk says physicians can help overcome challenges to passage of public health legislation.

"We need to broadcast a clear message on these important public health priorities and not assume that anything is safe during the legislative session. When these issues come up for discussion during session, it will be we physicians who must speak for them by answering the call to testify and by writing editorials for newspapers," 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. 

 SIDEBAR 

Tobacco's Toll on Texas 

Economic costs due to smoking: $13,044,600,000
Adult smoking rate: 15.8 percent
High school smoking rate: 21.2 percent
Middle school smoking rate: 5.7 percent
Smoking-attributable deaths: 24,570
Smoking-attributable lung cancer deaths: 7,770
Smoking-attributable respiratory disease deaths: 6,324

Source: American Lung Association State of Tobacco Control 2012

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