Health Matters in Texas

"Health Matters in Texas": Legislature Enhances Public Health System 

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Public Health Feature – August 2013 

Tex Med. 2013;109(8):41-45.

By Crystal Zuzek 
Associate Editor 

Physicians who turned out for First Tuesdays at the Capitol this year and who testified before legislative committees presented an aggressive public health agenda to shield Texans from cigarette smoke, protect them from vaccine-preventable diseases, curb the obesity rate, and support cancer prevention and research. Thanks to their voices and the work of the Texas Medical Association and the Texas Public Health Coalition (TPHC), the legislature got the message and passed many key bills that will help physicians accomplish some of those goals.

Joel Romo, senior director of government relations for the American Heart Association Southwest Affiliate, chairs TPHC's obesity subcommittee. He says the coalition's coordinated messaging had a positive impact in the 2013 legislative session.

"Although we weren't 100-percent successful, we were able to advance some of our proposals and fend off efforts to weaken others. We had a diverse agenda, and I think we made an impact on public health and can build upon that for the 2015 legislative session."

TPHC won passage of several innovative immunization policies. One of them, Senate Bill 63 by Sen. Jane Nelson (R-Flower Mound) and Rep. J.D. Sheffield, DO (R-Gatesville), allows pregnant minors and minor parents to consent to their own vaccination. Currently, minor parents can consent to their child's vaccination but not their own. That law takes effect on Sept. 1.

"All parents of newborns, regardless of their age, need to be protected from vaccine-preventable diseases that they might transmit to their babies. This law will enhance the protection that these vulnerable children need," said Jason Terk, MD, past chair of the TMA Council on Science and Public Health, who testified in favor of the bill.

SB 63 is one of many immunization-related bills that will enhance physicians' ability to vaccinate more people.

In addition, the legislature approved more than $332 million in new money for mental health and substance abuse services and added $100 million to women's health services funding.

Texas Department of State Health Services (DSHS) Commissioner David Lakey, MD, says support from TPHC, TMA, and other health organizations, as well as physicians' presence at the Capitol, were invaluable this session.

"Our voices were heard. Health matters in Texas. The successes were a team effort, and I greatly appreciate the doctors, health organizations, and advocates who set aside time to make sure health was visible and well represented at the Capitol," Dr. Lakey said.

DSHS Gets More Money 

DSHS emerged from the legislative session without having its budget reduced. The department requested $5.75 billion in funding for the 2014-15 biennium. Lawmakers appropriated $6.23 billion for 2014-15. That amount represents an increase over the department's $5.8 billion 2012-13 budget.

DSHS received additional funds to cover behavior health services.

Health department funding includes $168.5 million to provide adult and child immunizations, $42.9 million for chronic disease prevention, and $29.7 million to fund the tobacco program. An additional $11.7 million will cover initiatives such as increasing tobacco prevention and cessation for Quitline counseling services and preventing smokeless tobacco use among children in rural counties.

Dr. Lakey says the new programs and expansions made possible by the additional dollars will allow the department to focus on enhancing services to improve the health of Texans.

"The legislature put significant dollars forward for public health. That support can best be seen in the numbers. Our budget for the next biennium will be almost a half-billion dollars more than our current budget," he said. "With an additional $332 million in mental health and substance abuse funding over the base budget bill, we can improve services by reducing waiting lists for community mental health services and expanding treatment options."

Mental health funding includes $4 million to improve mental health services for veterans; $5 million to enhance prevention and early identification of mental illness in school-age children; $25 million for additional crisis services to be provided by local mental health authorities; and $25 million to promote public-private partnerships to improve mental health care delivery and services.

The 2014-15 budget adds $100 million to women's health services. The legislature appropriated $126.3 million to fund the Primary Health Care Program, which contracts with community health clinics and nonprofit organizations to provide services for uninsured, poor Texans who do not qualify for other state health programs. Additional funds in the program will allow DSHS to serve approximately 250,000 Texans annually by providing well-woman checks, cancer screenings, and family planning.

The legislature included $43 million for services such as sexually transmitted disease testing and treatment, contraception, health exams for men and women, clinical breast exams, Pap tests, and cholesterol and diabetes screenings.

Lawmakers also provided $73 million to fully fund the Texas Women's Health Program, operated by the Texas Health and Human Services Commission. The program provides low-income women aged 18 to 44 with access to birth control, basic preventive health screenings, and treatment for sexually transmitted diseases. Before 2013, the federal government provided 90-percent funding for the program, but last year the state opted to forgo federal funding to exclude Planned Parenthood from the program.  

Lawmakers Focus on Immunization 

Dr. Terk testified in support of Senate Bill 64 by Senator Nelson and Rep. John Zerwas, MD (R-Richmond). The law takes effect Sept. 1 and requires licensed child care facilities to create a vaccination policy for their employees. Dr. Terk says the law is modeled after the health care worker vaccination bill passed in the 2011 session. (See "Lifesaving Shots," Texas Medicine August 2012, pages 25-29.)

He explained to the House Public Health Committee in April that SB 64 does not dictate what must be included in each facility's policy.

"We want to be sure each facility has the freedom to make the decision on how best to balance the safety and health of its employees and the children in their care with the cost associated with certain vaccinations," he said.

Representative Zerwas, an anesthesiologist, says he didn't hesitate to sponsor SB 64 because immunizing child care workers is a crucial step in preventing the spread of disease and improving the population's health.

"Immunization policy is really easy to get behind because it's just good public health policy. Anything we can do to facilitate the use of vaccines is in everyone's interest," he said.

Dr. Zerwas is pleased many immunization policies supported by TMA, TPHC, and other health organizations passed this session.

"I'm not sure why so many of these bills had traction this year. It may be that legislators have become more aware of the sound scientific evidence surrounding immunizations in terms of public health policy," he said.

Physicians received some tax support in regard to immunizations, as well. Rolled into an omnibus franchise tax bill, House Bill 500, is relief that will help primary care physicians provide vaccinations by allowing them to deduct from their taxable revenues the cost of purchasing and stocking vaccines. The business franchise tax levies a 1-percent tax on vaccine payments that Dr. Terk says "erodes an already thin margin on the economics of providing vaccines for physicians in private practice" and "threatens the infrastructure that supports vaccination for the majority of children and adults in the state."

TMA headed back to the Capitol this session to address meningococcal vaccine requirements for college students and succeeded in advocating passage of Senate Bill 62, designed to target immunization at those with the greatest risk of disease and reduce the volume of students seeking conscientious exemptions. In 2011, the legislature passed Senate Bill 1107, which required entering college students up to age 29 to be vaccinated against bacterial meningitis.

Donald Murphey, MD, medical director of infectious disease at Cook Children's Health Care System in Fort Worth, testified on behalf of TMA and the Texas Pediatric Society (TPS) for SB 62 by Senator Nelson and Rep. Jodie Laubenberg (R-Parker). He explained to the Senate Higher Education Committee that the 2011 law created numerous challenges for young adults seeking college admission. He says many college students don't have a primary care physician or health insurance and have difficulty getting vaccinated.

"Colleges have also faced challenges in implementing this legislation. We want students vaccinated against bacterial meningitis. We don't want this vaccination requirement to become a barrier for a student enrolling in school," he told the committee.

Dr. Murphey says the new law, which takes effect Jan. 1, 2014, helps address some of the challenges SB 1107 created by aligning the targeted immunization population more closely with Centers for Disease Control and Prevention (CDC) meningococcal vaccine recommendations. CDC's Advisory Committee on Immunization Practices (ACIP) recommends routine meningococcal vaccination of children aged 11 through 12 years and one-time booster doses between ages 16 and 18, depending on the child's age at the time of initial vaccination. Click here for ACIP's meningococcal vaccine recommendations.

SB 62 requires vaccination of students aged 21 and younger and establishes a DSHS online exemption form, which Dr. Murphey says represents "a reasonable compromise for students seeking an exemption."

He adds that the department's online exemption portal features educational information on bacterial meningitis and the vaccine.

Despite strong support from TMA and other health organizations, not all of the coalition-backed immunization bills made it to the governor's desk. House Bill 772 by Rep. Donna Howard (D-Austin), regarding the consent process for ImmTrac, the state's immunization registry, passed in the House, but the Senate Committee on Health and Human Services did not consider it. Passage of the bill would have changed the consent process for ImmTrac to opt out rather than opt in.

House Bill 771 by Representative Howard would have allowed patients to consent to their vaccination records remaining in ImmTrac until they reach age 26. The bill remained in the House Committee on Public Health. 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. TMA and TPHC supported the legislation because it would help prevent immunization data from being expunged, as many 18-year-olds don't know about the ImmTrac consent period.  

 Legislation Up in Smoke 

Once again, lawmakers failed to pass a comprehensive smoke-free indoor workplace policy. TMA backed House Bill 400 by Rep. Myra Crownover (R-Denton) and Senate Bill 86 by Sen. Rodney Ellis (D-Houston) to prohibit smoking in workplaces.

Debra Patt, MD, past chair of the TMA Committee on Cancer, says such a policy costs nothing up front and would improve health and save the state money in the long run.

"The failure to pass a statewide comprehensive smoke-free policy is less about economics and more about personal liberty. There has not been enough support within Texas government for a comprehensive statewide smoke-free policy largely due to the concern about infringement on the personal liberty of Texas smokers," Dr. Patt said.

Physicians say the failure to pass statewide smoke-free workplace legislation puts many Texans' health at risk. Comprehensive smoke-free workplace ordinances now cover 36 Texas cities. Twenty-nine states are smoke-free.  

"In the long term, lack of a comprehensive smoke-free policy will leave many areas in Texas unprotected. Children and workers will continue to have little control over exposure to tobacco smoke," Dr. Patt said.

Representative Crownover says thousands of Texas workers will unnecessarily be exposed to benzene, formaldehyde, arsenic, and other carcinogens because HB 400 didn't pass. For that reason, she intends to file the legislation again in 2015.

"We need to educate the Senate. They need to understand how much money is wasted and how many lives are being lost due to inaction. They need to hear from the voters about our individual rights to breathe clean air. They need to understand that the pregnant mother working two waitressing jobs can't afford to choose between the health of her unborn child and her paycheck," she said.

To pass the smoke-free workplace legislation, Representative Crownover says physicians must speak to their elected officials during the interim about the dangers of secondhand smoke.

"Don't wait until the legislature comes back to Austin in two years. Go to the town hall meetings and campaign events, and ask your senators where they stand on the issue. Make sure they understand that 74 percent of the voters in Texas support the right to breathe clean air," she said.

Eduardo Sanchez, MD, American Heart Association deputy chief medical officer, is disappointed the legislature didn't pass HB 400.

"Tobacco continues to be the single biggest factor contributing to preventable premature death and disease and the avoidable associated costs. TPHC will be back in two years with some of the same priorities related to tobacco use, immunizations, and childhood obesity if our state's health trends continue on their projected paths," said Dr. Sanchez, a TPHC member.

Obesity Assessment Debated 

The FITNESSGRAM was a hotly debated topic this session. Sen. Bob Deuell, MD (R-Greenville), filed Senate Bill 684 to make FITNESSGRAM testing optional for schools, and Rep. Dennis Bonnen (R-Angleton) filed House Bill 1156 to eliminate FITNESSGRAM testing in schools. Neither bill passed.

The FITNESSGRAM is a physical education assessment and reporting program required under current law for children in grades 3 through 12. It measures a child’s aerobic capacity, muscular strength, muscular endurance, flexibility, and body composition

TPS President Kimberly Avila Edwards, MD, a pediatrician at Austin Regional Clinic, is happy the FITNESSGRAM remains intact.  

"The long-term data this assessment provides will continue to help identify areas of increased prevalence of overweight and obesity that can help determine where initial targets for prevention and intervention should be focused. The FITNESSGRAM will also help identify successful interventions that are influencing long-term decreases in overweight and obesity and that should be replicated."

The FITNESSGRAM may have generated debate this session due to budget struggles among Texas schools, Dr. Avila Edwards says. 

"Given the cuts to school funding in 2011, it is reasonable to try to limit unfunded mandates. Lawmakers want to help school districts cut costs, but cutting the FITNESSGRAM should not be a target, as it is necessary for their students' health and related academic success," she said.

Lisa Swanson, MD, a Mesquite pediatrician and a member of the TMA Committee on Child and Adolescent Health, testified against SB 684 before the Senate Education Committee on behalf of TMA, TPS, and TPHC. She asked committee members to help schools implement the FITNESSGRAM and to allow them to continue capturing critical data that can be used to fight Texas' costly obesity epidemic.

TMA and TPHC successfully lobbied for additional money in the state budget to keep the FITNESSGRAM assessment alive in schools and to collect data to address the state's obesity epidemic.

Despite support from TMA and TPHC, lawmakers failed to pass some obesity prevention bills during the session.

TPHC again advocated restoring a half-credit of health and physical education (PE) as a requirement for graduation. Senate Bill 134 by Senator Nelson would have increased PE and health education requirements for students. Senate Bill 65, also by Senator Nelson, would have recognized public schools with successful health and fitness programs. The bills never made it out of committee.

Failure to pass SB 134 will have a detrimental long-term impact on adolescents' health, according to Dr. Avila Edwards. 

"Our schools play a critical role in educating adolescents about health, high-risk behaviors, and the long-term impact of poor health choices. It is a disservice for our children to go through their high school education without health and physical education," Dr. Avila Edwards said. "Reinvesting in their health and physical education is an investment in their future."

CPRIT Survives Session 

Reforming business operations at the embattled Cancer Prevention and Research Institute of Texas (CPRIT) received a great deal of attention from lawmakers this session. TPHC supported the institute's funding request for cancer prevention and research while ensuring a transparent funding process that includes an independent, robust scientific review on the merit of all projects. The institute is mired in controversy over allegations it mishandled three large grants totaling $56 million.

The legislature approved $600 million in bond proceeds for 2014-15 and required a transfer of $6 million in bond proceeds to DSHS to support the Texas Cancer Registry. This amount does not differ from funding appropriated in 2012-13. By law, CPRIT can allocate a maximum of 10 percent of total annual grant awards to prevention. That means up to $30 million per year for 2014 and 2015 will be available to fund prevention initiatives.

Wayne Roberts, CPRIT interim executive director, says prevention funds will cover evidenced-based clinical services; education projects; primary prevention interventions such as tobacco control; early detection, screening, and diagnostic services; and survivorship programs that provide services like physical rehabilitation and therapy.

TMA and TPHC supported Senate Bill 149 by Senator Nelson to help ensure a transparent funding process within CPRIT. TMA told the Senate Health and Human Services Committee the bill takes important steps to address concern over how CPRIT conducts business. The bill modifies CPRIT's structure, establishes salary restrictions, and changes the composition of the oversight committee. SB 149 also establishes conflict-of-interest rules that govern institute committees and employees. The bill requires the oversight committee to adopt a code of conduct applicable to the members of the oversight and program integration committees and CPRIT employees.

Senator Nelson considers the deliberation over CPRIT funding to be one of the biggest challenges public health faced in the legislature.

"The lapses in oversight at CPRIT seriously damaged the public's trust in what should be one of our proudest endeavors. The funding for this institute and its important research and prevention efforts were very much in jeopardy when the session began," she said.

"SB 149 sets up an iron-clad system of checks and balances at CPRIT and ensures oversight, both within the institute and outside it," Senator Nelson said.

Mr. Roberts says CPRIT has taken additional steps to lend transparency to its processes.

"CPRIT is already implementing efforts to increase transparency for its entire grant program, from the application review and award process to its post-award monitoring activities. CPRIT will publish information about all reported conflicts of interest requiring recusal during the review process, any investigations into unreported conflicts of interest, and any waivers granted for the conflict of interest rules," he said.

Mr. Roberts adds that CPRIT's chief executive officer will submit a written affidavit for each grant application recommended for an award that certifies the information related to the peer review process. In addition, every grant award contract made by CPRIT is a public document, and grant monitoring and compliance activities will be publicly reported to the oversight committee at public meetings.

Dr. Sanchez says he hopes the provisions in SB 149 lead to better stewardship of CPRIT funds and more transparency regarding fund allocation. He says all Texans benefit from CPRIT's work in preventing and treating cancer.

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


August 2013 Texas Medicine Contents
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