Legislature, Governor Enact Laws to Address TMA Public Health Concerns
Public Health Feature — August 2015
Tex Med. 2015;111(8):45-51.
By Joey Berlin
The Texas Public Health Coalition (TPHC), of which the Texas Medical Association is a charter member, and diligent physicians earned significant victories during the Texas Legislature's 2015 session in reducing tobacco and electronic cigarette use and protecting schoolchildren at risk for anaphylaxis.
Lawmakers also provided the Texas Department of State Health Services (DSHS) with increased mental health and women's health funding, and a TMA-backed effort to keep children's immunization records in the state registry through their early adult years made its way into law.
San Antonio pediatrician Ryan Van Ramshorst, MD, who testified for TMA on several public health measures during the session, says he came away cautiously optimistic about the progress TMA made before the legislature adjourned in June because "there was some great stuff that happened, but there was some other common-sense stuff that didn't. And it's frustrating that despite all of our efforts, sometimes you still can't convince hearts and minds."
Success on EpiPen, E-cig Fronts
Sen. Juan "Chuy" Hinojosa (D-McAllen) authored a pair of TMA-backed measures that earned Gov. Greg Abbott's signature and stood as two of TMA's biggest public health victories of the 2015 session.
Senate Bill 66 allows school districts and open-enrollment charter schools to adopt policy on the use of epinephrine auto-injectors, known as EpiPens, and provides guidelines for districts to train school personnel on administering the injections. The bill allows physicians to give school districts standing orders to administer the injections to someone who appears to be experiencing anaphylaxis. (See "Schoolhouse Stock," November 2014 Texas Medicine, pages 53-56.)
Louise Bethea, MD, an allergist and immunologist in the Spring-Woodlands area and president-elect of the Texas Allergy, Asthma and Immunology Society, testified before both Senate and House committees on SB 66.
Dr. Bethea says the Texas Medical Practice Act doesn't clearly state that a physician can write a prescription for an entire school district. Texas schools have more than 160,000 allergic children, Dr. Bethea says, and a quarter of first-time anaphylactic reactions occur at school. But only between 25 percent and 28 percent of allergic children have access to an EpiPen at school.
"We also wanted to make sure that prescribing physicians, dispensing pharmacists, and those assisting and training or administering epinephrine auto-injectors would be immune from legal liability. These protections are provided in SB 66," Dr. Bethea said.
Senator Hinojosa also tackled the growing popularity of electronic cigarettes, known as e-cigarettes, with Senate Bill 97, a bill TMA supported. SB 97 makes it a crime to sell e-cigarettes to someone younger than 18 or to someone who intends to give e-cigarettes to a minor, just as it is illegal to do so with regular tobacco products. The new law also bans e-cigarettes from public school campuses and school events.
Although the scientific community continues to develop its knowledge of e-cigarettes' health implications, Dr. Van Ramshorst says there's enough data to support restrictions on their usage.
In April, the Centers for Disease Control and Prevention and the Food and Drug Administration's Center for Tobacco Products published data showing that in a one-year span from 2013 to 2014, e-cigarette use tripled among middle school and high school students.
"When you look at teenagers, it seems that they're less interested in traditional tobacco products, like traditional cigarettes, because they understand that they're dangerous and that they cause lung cancer," said Dr. Van Ramshorst, who testified on SB 97. "But their perception of electronic nicotine delivery systems, e-cigarettes, is that they're less dangerous and more cool — which makes e-cigs exquisitely challenging. And so I'm glad that we took some steps."
Mental health funding for DSHS received significant boosts in the legislature's 2016-17 budget. House Bill 1 allocated a total of $3.6 billion to mental health, an increase of $150 million over 2014-15 levels. The budget included nearly $6 million in additional funds for community mental health services, an increase of $20 million for state mental health hospitals, and more than $50 million extra for community mental health hospitals, including additional funding to increase community hospital beds. An increase in substance abuse funding includes about $11 million to expand prevention and treatment of neonatal abstinence syndrome.
A rider to the budget ties potential funds for tobacco cessation to federal funding in response to last year's Ebola scare. If DSHS receives more than $20.27 million in federal funding related to Ebola prevention, planning, and treatment during 2016-17, the department will transfer an equal amount of general revenue toward strategies for public health preparedness, chronic disease prevention, and tobacco cessation. DSHS will allocate those funds as it sees fit toward pediatric asthma management, potentially preventable adult hospitalizations, expanded tobacco prevention services, diabetes prevention, and funding for the Texas Emergency Medical Task Force.
The legislature also provided a healthy funding increase for women's health, according to Janet P. Realini, MD, president of Healthy Futures of Texas and chair of the Texas Women's Healthcare Coalition. Healthy Futures of Texas works to prevent teen and unplanned pregnancies.
Dr. Realini was pleased with the outcome of the budget allocations for women's preventive health care. In the 2016-17 budget, the state's Health and Human Services Commission (HHSC) will receive $262 million in general revenue funds for women's health and family planning, an increase of $47.5 million.
"Our goal, really, is for all women in Texas to have access to the preventive care, including contraception, that they need," she said. "So I think this session really was very positive toward that."
Dr. Realini says one concern is a looming consolidation of three health care programs. The budget moves two DSHS programs — the Expanded Primary Care Program and the Family Planning Program — over to HHSC, which already oversees the Texas Women's Health Program. HHSC will consolidate those three programs into two at the recommendation of the Texas Sunset Advisory Commission.
Dr. Realini says while it's unclear exactly how HHSC will handle the consolidation, she expects that the Family Planning Program will remain as is and that HHSC will consolidate the Expanded Primary Care Program and the Women's Health Program.
"We need to make sure that process and that product are things that will enhance access and enhance quality and not hurt any of the providers," Dr. Realini said.
A Longer "Trac" Record
After a similar measure failed two years earlier, Rep. J.D. Sheffield, DO (R-Gainesville), and TMA backed a bill to promote longer-lasting data in the state's ImmTrac immunization registry, with better results this time.
Governor Abbott signed House Bill 2171, which allows a person's childhood immunization records to stay in the ImmTrac database until he or she reaches age 26 if the person's parents consented before the child turned 18. ImmTrac currently keeps childhood immunization records only until a person turns 18.
The intent of HB 2171 put the bill in line with TPHC's priorities. (See "Public Health in Action.") In May, San Antonio pediatrician James Lukefahr, MD, testified in favor of the bill on behalf of TMA, telling the Senate Health and Human Services Committee that more than 90 percent of Texas parents choose to keep their children's immunization records in ImmTrac.
"However, all of these important records are deleted before our patients have a chance to use them as they approach adulthood," Dr. Lukefahr said. "Their immunization histories, typically established with their parents' consent when they were born, are simply deleted, unless our 18-year-old teen patients submit a consent form to the state. The reality is, despite our efforts to remind our teen patients, they don't make the effort to take care of their health records the way their parents did when they established the immunization record."
Dr. Van Ramshorst, who also testified in favor of HB 2171, says he thought of his younger patients when he spoke on behalf of the bill.
"I have a lot of teenagers who want to go serve their country in uniform, and I thought of those kids when I was testifying on that bill," he said. "It's going to make it easier for them to send their vaccine records on to the Army or the Marine Corps or the Air Force. So I made that argument, and the members of the committee seemed to get that."
Representative Sheffield didn't have the same success on the immunization front with another bill he sponsored, House Bill 2474. That measure would have required school districts and campuses to provide de-identified information to requesting parents about immunization exemptions in the school or district. Parents would have been able to obtain such information as the number of students in their child's school whose vaccinations aren't current, the number claiming vaccination exemptions for religious reasons, and the number claiming exemptions for medical reasons.
TMA supported HB 2474, and Dr. Van Ramshorst testified in favor of it. But after it cleared the House, the bill stalled in the Senate Health and Human Services Committee.
Dr. Van Ramshorst told the House Public Health Committee that some of his pediatric patients are immunosuppressed, and parents of those children would want to know campus-level information about the number of children exempt from vaccinations. Also, he noted, some private schools already provide that information at the campus level.
Representative Sheffield said, "What was perplexing to me [about HB 2171 and HB 2474] was how many people opposed this on the incorrect grounds that they thought we were mandating vaccines, or the next step was to force people to have vaccines, which is absolutely not in the bill or in the intent of the bill."
Veto Power Exercised
Of Governor Abbott's vetoes during his first legislative session as Texas' chief executive, perhaps none surprised TMA members more than his decision to nix Senate Bill 359 by Sen. Royce West (D-Dallas).
SB 359 would have authorized inpatient mental health facilities, hospitals, their emergency departments, and freestanding emergency medical facilities to allow physicians to detain a person who voluntarily requested treatment if the physician believes the person has a mental illness and is dangerous to self or others. The facility could hold the person for no more than four hours from the time the person either attempted to leave or expressed a desire to leave.
Les Secrest, MD, chair of TMA's Task Force on Behavioral Health, says the usual way to detain such a patient — getting the facility's on-site peace officer to do it — can become complicated in many settings. (See "Protecting Patients, Society," November 2013 Texas Medicine, pages 29-32.)
"Originally, giving peace officers that ability was to be able to allow them to intervene in situations where they could see clearly that this is bizarre and makes no sense — somebody walking down the middle of the highway inappropriately dressed or these sorts of things," Dr. Secrest said. "Those become much more obvious sorts of situations."
Currently, however, he says that unless a patient has broken the law, peace officers often feel they can't or shouldn't intervene.
Temple emergency physician Robert Greenberg, MD, says the law is antiquated in assuming any patient with mental illness needs inpatient care.
"I personally and professionally feel pretty strongly that that's a medical decision, not a legal decision, that somebody's a danger to self or others due to mental illness," Dr. Greenberg said. "And it doesn't make sense if we can make that determination, and a patient qualifies, that we shouldn't be able to hold them."
Governor Abbott did approve another TMA Task Force on Behavioral Health-backed measure on June 18 when he signed Senator West's Senate Bill 1462. That measure allows a physician to prescribe an opioid antagonist to a person in danger of experiencing an opioid-related overdose or to a family member, friend, or other person in a position to help such a person. The bill allows for potentially lifesaving prescriptions of naloxone, a common opioid antagonist.
However, before signing SB 1462, Governor Abbott vetoed House Bill 225 by Rep. Ryan Guillen (D-Rio Grande City), a similar measure that also included "Good Samaritan" language exempting certain people from prosecution for possession of a controlled substance of less than one gram. Under HB 225, a person who first requests emergency medical assistance for the possible overdose of another wouldn't face prosecution if the person did so during an ongoing medical emergency, stayed on the scene until medical assistance arrived, and cooperated with medical responders and law enforcement.
The TMA Task Force on Behavioral Health identified HB 225 as a priority recommendation. Governor Abbott's veto statement says the bill's goal was admirable, but it didn't contain adequate protections to prevent habitual drug users and dealers from abusing the law.
Dr. Secrest calls the governor's decision to instead sign SB 1462 "a consolation prize."
"One of the things that it does do is that it gets the availability of the naloxone out there, and that's one of the first steps," he said. "Whether you get over into the Good Samaritan part of that [later], as people better understand the opportunities — I think that gets to be something that can be addressed at some other point in the future."
Raw Milk, EKG Screening Bills Stall
Just four states do not completely prohibit texting while driving, according to the Insurance Institute for Highway Safety. Despite TPHC's efforts, the legislature declined to remove Texas from that list during this year's session.
Rep. Tom Craddick (R-Midland) filed House Bill 80 to implement a statewide ban on texting while driving. TPHC threw its support behind HB 80, which contained language exempting drivers who text in stopped vehicles and those who do so for emergency purposes or to report illegal activity.
In a letter to the Senate State Affairs Committee supporting the bill, TPHC notes that distracted driving caused more than 95,000 crashes in Texas in 2013, with 460 deaths. Nonetheless, HB 80 stalled in the Senate after the House passed it by a 104-39 vote.
Sen. Judith Zaffirini (D-Laredo), a sponsor of HB 80, called its failure one of the biggest disappointments of the session.
"This was the fourth consecutive session I've filed a texting bill, and the 2017 session will be my fifth," she said. "I strongly believe that texting while driving is a public health concern that needs to be addressed, especially because we can prevent more Texans from dying or being injured in texting-related crashes."
But on a more positive note, two other bills with public health implications died after physicians expressed serious reservations about their potential impact.
House Bill 91 by Rep. Dan Flynn (R-Canton) would have allowed those with a permit to sell raw milk to do so at the permit holder's place of business, the consumer's home, or at a farmers market. HB 91 was Representative Flynn's third attempt to expand raw milk sales.
In written testimony to the Senate Committee on Intergovernmental Relations, TMA says milk pasteurization was one of the United States' most effective public health practices, adding that unpasteurized milk can contain bacteria that cause gastrointestinal illness and serious diseases.
"If the state relaxes the current restrictions on the sale of raw milk, it is a fact more people will become ill from raw milk consumption," TMA wrote. "This will result in greater costs to the state and local government for investigation, inspection, and the care of those who will need to be hospitalized. These illnesses and hospitalizations are preventable."
HB 91 passed the House but didn't make it through either of two Senate committees.
Rep. Wayne Smith (R-Baytown) introduced House Bill 767, which would have required would-be student athletes to receive an electrocardiogram (EKG) before they could play University Interscholastic League-sponsored (UIL) sports. Scott Stephens, father of the late Cody Stephens, was one of HB 767's most visible backers. Cody, who had played football at Crosby High School and was set to graduate weeks later, died in his sleep from sudden cardiac arrest in May 2012.
TMA noted that the science behind EKGs doesn't support broad-scale screening and advocated on behalf of current UIL policy, which mandates a full pre-participation history and physical exam for each student athlete. HB 767 passed the House but did not make it out of the Senate Education Committee. (See "Following the Science," July 2015 Texas Medicine, pages 47-51.)
A broad new effort to improve health care materialized with Rep. Myra Crownover's (R-Denton) successful effort to establish the Texas Health Improvement Network (THIN) with House Bill 3781, which Governor Abbott signed in June. Operating as part of The University of Texas System, the network will work to reduce per-capita health care costs and improve the health care experience for patients. It will include experts in more than a dozen fields, including general public health, mental health, social work, nursing, pharmacy, social work, engineering, and computer science.
TMA, in supporting the creation of THIN, reminded the House Public Health Committee that it has testified to the legislature before about the state's "fragmented and under-resourced" public health system.
"We will be unable to sustain our vibrant economy and population if so many of our patients not only are getting sick with preventable conditions but also are getting sick earlier and are sicker for longer periods," TMA told the committee in written comments.
Another TMA-backed and Governor Abbott-approved measure to protect the state's health information exchanges (HIEs) also gives physicians a choice on how to submit health data. Rep. John Zerwas (R-Simonton) authored House Bill 2641, which allows physicians with appropriate authority to report data to and access information from DSHS-housed public health registries, such as ImmTrac and the Texas Cancer Registry. Physicians may choose to submit data either directly to DSHS or through their local HIE. TMA successfully pushed for inclusion of liability protections in this bill that will ensure physicians are not responsible for the breach of data caused by an HIE.
Joey Berlin can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email .
Public Health in Action
Gov. Greg Abbott signed measures that addressed a number of the Texas Public Health Coalition's priorities for the 2015 legislative session, including:
- Continue to store childhood immunization data for post-high school education and employment needs — House Bill 2171 by Rep. J.D. Sheffield. DO (R-Gainesville), allows for consent to store childhood immunization records in the ImmTrac registry through age 26.
- Support regulation of electronic cigarettes as tobacco products, including prevention of youth access — Senate Bill 97 by Sen. Juan "Chuy" Hinojosa (D-McAllen) criminalizes the sale of e-cigarettes to people younger than 18 or to others who intend to deliver e-cigarettes to minors.
- Preserve and support expanded funding for chronic disease prevention — House Bill 1, the budget bill for 2016-17, includes a rider tying potential chronic disease prevention funding to federal funds the Texas Department of State Health Services receives for Ebola prevention.
Tobacco Use in Texas
- High school students who smoke: 212,000 (14.1%)
- Percentage of male high school students who use smokeless or spit tobacco: 13.9%
- Kids who become new daily smokers each year: 24,200
- Packs of cigarettes kids buy or smoke each year: 64.1 million
- Adults in Texas who smoke: 3,085,500 (15.9%)
Source: Tobacco-Free Kids, October 2014
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