Public Health Feature - August 2009
Tex Med . 2009;105(8):29-33.
By Crystal Conde
Physicians who turned out in record numbers for First Tuesdays at the Capitol this year shared with lawmakers an aggressive public health legislative agenda to protect Texans from cigarette smoke, improve immunization rates, and curb obesity.
On some issues, the legislature got the message and passed key bills that will help physicians accomplish some of those goals. On one big one - smoking - it didn't.
Herminia Palacio, MD, MPH, chair of the Texas Public Health Coalition , of which the Texas Medical Association is a charter member, says the coalition's legislative priorities fared "moderately well" this session.
Legislators passed many of the healthy eating and physical activity bills the group endorsed, and Gov. Rick Perry signed each of them into law. In addition, he signed coalition-supported legislation to improve the state's immunization rates.
The legislature also endorsed a bill improving the infrastructure of the operations of the Cancer Prevention and Research Institute of Texas (CPRIT), created by the 2007 legislature. The legislation also appropriates $450 million for the next two years to fund grants for cancer research and prevention. (See " CPRIT Funding a Priority for Legislature .")
Not every bill the coalition backed gained approval. Unfortunately, Dr. Palacio says, the coalition may need to ramp up efforts to inform the legislature and the public of the health benefits of a law that protects the entire state from the harmful effects of tobacco smoke in workplaces and in public venues.
In spite of the political highs and lows of the session, Dr. Palacio applauds the coalition's work and TMA's expertise and support.
"TMA was an invaluable asset to the coalition and made generous contributions in terms of production and distribution of the legislative briefing documents and other materials," said Dr. Palacio, executive director of the Harris County Health Department.
Bills Stubbed Out
One of the coalition's biggest disappointments was the legislature's failure once again to pass a bill outlawing smoking in public facilities and indoor workplaces.
James Gray, American Cancer Society legislative and government relations director, High Plains Division, says House Bill 5 by Rep. Myra Crownover (R-Denton) and its companion, Senate Bill 544 by Sen. Rodney Ellis (D-Houston), were more successful this time around than in previous sessions.
For the first time, SB 544 emerged from the Senate Health and Human Services Committee intact as a comprehensive bill. Plus, more than half of the members of the House backed HB 5.
However, that didn't generate enough momentum to pass the bills. Mr. Gray, also a member of Smoke-Free Texas, a coalition of public health organizations working for statewide and community smoke-free ordinances, said the bill died because supporters could not secure a two-thirds majority of the 31 senators needed to allow the bill to come up for a floor vote.
Some lawmakers offered a watered-down version of the House bill. The weakened form of HB 5 would have exempted 226 of the state's 254 counties, as well as cigar bars, tobacco shops, and other businesses and facilities. Thus, Mr. Gray says, proponents of comprehensive legislation refused to support it.
"We walked away from a bill that was getting amended to a point that it would have been ineffective," he said.
He adds that the tobacco industry worked to kill the bill. According to the Texas Ethics Commission, Big Tobacco hired 40 lobbyists for the session.
Joel Dunnington, MD, a Houston radiologist and consultant to the TMA Council on Public Health, says regardless of the overwhelming support HB 5 received from House members and their constituents, tobacco lobbyists proved too cunning this session.
Senator Ellis says the tobacco lobby had a strong but furtive presence at the capitol and the lobbyists "were able to hide behind private property rights as a cover for their dirty work. I understand that Texans value their independence, but when it comes to behavior that threatens the health of those around you, there is no right to engage in that harmful behavior," Senator Ellis said.
Representative Crownover echoes his sentiment and adds that it's necessary to inform people about the dangers of secondhand smoke, which accounts for the deaths of 3,600 adult nonsmokers in Texas each year, according to the Campaign for Tobacco-Free Kids .
"It will be up to us to educate the public and members of the legislature because the moment someone realizes the true threat of secondhand smoke, the personal freedom and property rights arguments lose all validity," she said.
Mr. Gray hoped comprehensive smoke-free legislation would pass this year.
"We thought it would happen this session. There are some legislators who still need to be convinced this is a significant public health threat," Mr. Gray said. "The public will is there, but the political will isn't."
That's despite the 68 percent of Texans polled this year who indicated they favored a smoke-free state. Texas is one of 23 states without statewide smoke-free legislation. This year, Wisconsin and North Carolina passed smoke-free laws, bringing the total to 27 states.
According to Smoke-Free Texas , the state now has 28 cities with comprehensive ordinances that prohibit smoking in public places and worksites, including restaurants and bars. Smoke-free ordinances protect 36 percent of the Texas population, or nearly 7 million Texans. Mr. Gray says Smoke-Free Texas will continue its mission to help local communities adopt ordinances before the 2011 legislative session.
Perseverance is crucial for generating support for high-priority public health concerns, says Dr. Palacio.
"We're going to make this [smoke-free legislation] an issue candidates running for office care about and talk about. We want the public to carry this issue to their local leaders," Mr. Gray added. "This bill has broad support and no financial cost to implement. It's a win-win for Texas lawmakers."
In the meantime, Senator Ellis vows that he will file the statewide smoke-free bill again next session.
"It is too important to the health of Texans not to try again. Representative Crownover and I will start our campaign early," Senator Ellis said. "We will show our colleagues that more and more of their constituents want this bill to pass. And come next session, our colleagues will have to make the decision to either listen to their constituents or do the bidding of the tobacco lobby."
He praised the Public Health Coalition's efforts and encouraged more physicians to make passage of statewide smoke-free legislation a top priority.
"Physicians have a lot of influence in our society. They need to join our campaign for this issue during the interim by lobbying their representatives in the capitol and writing letters and editorials to their local papers," Senator Ellis said.
Shot of Health for Texas
When physicians showed up at the capitol to spread the message that Texas needs to improve immunization rates, legislators listened. Governor Perry signed three TMA- and coalition-backed immunization bills that passed early in the session.
The first creates a lifelong immunization registry. SB 346 by Sen. Jane Nelson (R-Lewisville) directs the Health and Human Services Commission to develop guidelines for informing the public that once individuals turn 18, they or their parents may consent in writing to have their immunization records remain in ImmTrac, the state immunization registry.
Children who turn 18 will have one year to consent to the Texas Department of State Health Services (DSHS) to maintain their immunization histories in the registry. DSHS will no longer maintain the data if it does not receive consent after a year has expired.
DSHS and the Texas Education Agency will collaborate to inform local school districts of the immunization registry consent requirements. SB 346 also allows health care payment plans and physicians to submit to ImmTrac immunization data for adults.
Jeffery Levin, MD, MSPH, chair of TMA's Council on Public Health, says sustaining a lifelong immunization registry in Texas can only benefit the public's health.
"Having a lifelong registry helps doctors offer better care to the public in terms of maintaining immunizations at recommended levels," he said. "We've had a focus on childhood immunizations, which are important, and now we can ensure adults are protected from preventable disease, also."
The second bill the governor signed, SB 347 by Senator Nelson, allows the state to share immunization data with other states when emergencies, such as hurricanes or other natural disasters, force Texas residents to evacuate. Likewise, DSHS may receive immunization information from the health authority of another state if its residents relocate to Texas because of a disaster.
Passage of these bills into law is pivotal to protecting Texans' health in an emergency, according to Senator Nelson. She says the laws reinforce and support Texas' stressed emergency response system, allowing Texas to share immunization information with other states and making it possible for physicians to access adult immunization information.
"These bills enhance what we are already doing in terms of preparing our medical community for disaster situations, which will help protect the health of our citizens," she said.
SB 346 and SB 347 will take effect Sept. 1.
The third bill, SB 1328 by Senator Nelson, requires DSHS to study the vaccination needs of first responders and their families during a disaster such as a hurricane or flood. Dr. Levin says SB 1328 is important because DSHS will be able to assess the types of vaccinations that first responders need when helping disaster victims and make sure they receive those immunizations. He says emergency workers could be at increased risk of injury and require specific vaccinations, such as tetanus.
DSHS will assess the vaccination status of first responders and their immediate family members; examine their workplace immunization policies and insurance coverage; and make recommendations on educating first responders and their immediate families about available options to obtain immunization services, regardless of insurance coverage.
Senator Nelson championed all of these bills, which have a strong emphasis on preparing the state for a disaster or public health crisis.
"As the H1N1 virus hit during the final weeks of the session, the legislature was reminded how important it is for us to be ready to respond to large-scale emergencies, which include having an infrastructure in place to access information about vaccines," she said.
Getting Texans Moving
The legislature also passed several Public Health Coalition-supported bills to prevent obesity.
Among them is SB 282 by Senator Nelson, which allows the Texas Department of Agriculture to award grants to public schools and early childhood education facilities for children aged 3 and 4 years to implement best practices in nutrition. For example, schools could use grants to add fresh produce to meals in innovative ways or to add salad bars in their cafeterias.
Another Senator Nelson-authored bill, SB 870, directs Medicaid and the Children's Health Insurance Program (CHIP) to implement pilot programs to help reduce childhood obesity among enrollees. Such programs aim to improve the nutritional choices and increase the physical activity levels of CHIP enrollees and Medicaid recipients and reduce CHIP and Medicaid costs caused by obesity.
Developing pilot studies and implementing effective programs based on their results are vital to making a difference in the fight against the obesity epidemic in Texas, says Kimberly Edwards, MD, an Austin pediatrician and chair of the Texas Pediatric Society Obesity Committee. She says SB 870 has the power to reduce obesity rates in the lower socioeconomic strata of our society.
An additional bill by Senator Nelson, SB 891, establishes a standard definition of physical education (PE) curriculum across the state and sets PE teacher-to-student ratios to ensure the safety of students participating in PE.
SB 891 requires a school PE curriculum to enable students to develop the skills and confidence to participate in physical activity for the rest of their lives. Each school district would have to establish specific objectives and goals for a program. Fifty percent of each week's PE classes must involve moderate or vigorous physical activity.
Dr. Levin says passage of antiobesity bills illustrates that lawmakers understand the need for immediate action. He says improving children's nutrition choices and increasing their physical activity levels now will lead to measurable overall health gains among the population over time.
Obesity projections presented by Texas State Demographer Karl Eschbach, PhD, late last year indicate the need for population-based interventions to reverse the rise in obesity. Moderate projections estimate that the number of obese Texans will reach approximately 14.65 million, or nearly 42 percent of the population, by 2040.
Overall, Dr. Edwards is pleased with the legislature's actions to increase healthy eating and exercise among Texans.
"There's always room for improvement, but I think the legislature really heard everyone very well that obesity prevention has to be a priority for our state if we want to ensure a healthy population for years to come," she said.
Senator Nelson says passage of legislation that improves healthy eating and physical activity and other important public health issues that affect the state is due in large part to the advocacy of physicians.
"In order to make informed decisions, we need to hear from actual physicians in our districts regarding how our state health policies affect their practices and their patients. First Tuesdays at the Capitol also are effective because we see the doctors making the rounds, advocating on behalf of public health, and it reminds us that physicians are engaged in the process," she said.
Dr. Edwards, who testified in support of SB 282 and SB 283, applauds TMA for its focus on creating dialogue and collaboration between doctors and the legislature.
"Physicians have powerful voices. Without physician involvement, it would have been harder to pass some of this legislation," she 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 e-mail at Crystal Conde .
CPRIT Funding a Priority for Legislature
Nearly two years after Texas voters approved Proposition 15, a constitutional amendment allowing the state to issue $3 billion in general obligation bonds over 10 years to fund grants for cancer research and prevention, the legislature passed a bill that funds the Cancer Prevention and Research Institute of Texas (CPRIT) and outlines more clearly how it will operate.
House Bill 1358 by Rep. Jim Keffer (R-Eastland) and Rep. Patrick Rose (D-Dripping Springs) clarifies the peer review process, gives CPRIT the necessary tools to ensure appropriate investment of taxpayer money, and strengthens the institute's conflict-of-interest guidelines.
Leonides Cigarroa Jr., MD, a member of CPRIT's Scientific and Prevention Advisory Council and a member of the TMA Council on Public Health, says the infrastructure improvements will make the institute more transparent and efficient in its operations. He says the diverse membership makeup of the Oversight Committee and the Scientific and Prevention Advisory Council gives CPRIT an advantage in cancer prevention and research.
"I know how to see a patient and diagnose a cancer. I don't know how to fight political fights. People with political savvy are at the table along with physicians working on the front lines. This will be a group that truly fights the fight to prevent and eventually cure cancer," he said.
The Scientific and Prevention Advisory Council advises the Oversight Committee on promising areas for investing state dollars in cancer prevention and research. At press time, according to Dr. Cigarroa, the advisory council was developing investment recommendations for the Oversight Committee.
CPRIT received an appropriation of $450 million for the next two years to fund grants for cancer research and prevention, expedite innovation in cancer treatment, and expand cancer prevention and treatment capabilities. The legislature could have allocated $600 million for the biennium.
Despite disappointment over the legislature's decision not to fully fund CPRIT the first two years, Dr. Cigarroa says CPRIT will make the most of the $450 million, ensuring that cancer prevention and control is a priority.
Lewis Foxhall, MD, chair of TMA's Physician Oncology Education Program Steering Committee, is optimistic for CPRIT in terms of furthering cancer prevention and treatment at the practicing-physician level.
"We want to focus on implementation of evidence-based programs. The research is extremely important, but we need to use the fruits of the research we've already done and put that into practice immediately at the doctor's office level," Dr. Foxhall said.
CPRIT will begin calling for research proposals as early as this month, Dr. Cigarroa says.
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