Inside the Beltway - April 2023

The Climate Crisis: An Environmental Justice Lens

Contributed by Health Policy Committee member Sarah Green, DNP, CPNP-AC

As we celebrate Earth Month, April provides an opportunity to draw awareness to federal policy efforts seeking to address the climate crisis from an environmental justice lens. In its position statement, the National Association of Pediatric Nurse Practitioners recognizes that climate change disproportionately impacts children and vulnerable populations, specifically economically disenfranchised and communities of color. These impacts include environmental hazards and lack of green spaces in the communities in these communities. The concept of environmental justice is focused on the “equitable treatment and meaningful involvement regardless of race, color, national origin, or income, with respect to the development, implementation, and enforcement of environmental laws, regulations, and policies.”

On March 22, 2023, in the 118^th Congress, House of Representatives members Raul M. Grijalva, and Barbara Lee, and Senators Tammy Duckworth and Cory Booker reintroduced the A. Donald McEachin Environmental Justice for All, (H.R. 1705), sponsored by a collaboration of more than 300 grassroots, youth advocates, and environmental justice leaders from around the nation. The bill had its beginnings back in 2018, when the late Representative A. Donald McEachin and Representative Grijalva initiated a community led, driven, and crafted environmental justice bill. This piece of legislation is described as the first comprehensive environmental justice legislation to pass through a House Committee.

Key features of the bill include:

Amending and Strengthening of the Title VI of the Civil Rights Act of 1964, treating environmental justice as a civil rights issue.
Requiring analysis of the cumulative impact of toxic pollution, and demonstrating that with reasonable certainty that there will be no harm to human health.
Codifying and bolsters the 1994 Executive Act requiring that federal agencies development and report on implementation of environmental justice strategies and include diverse communities in research, data collection, and analysis.
Requiring that federal agencies engage in meaningful community involvement under the National Environmental Policy Act, when a proposed action will impact an environmental justice community.
Funding research grant programs focused on investigating personal and childcare products that contain products linked with adverse health products.
Promoting equitable access to parks and recreational opportunities, with a focus on underserved and urban communities.
Authorizing $75 million annually for grants that support projects dedicated to environmental and public health issues in environment justice communities.
Establishing a Federal Energy Transition Economic Development Assistance Fund to support communities and workers seeking to move away from greenhouse gas-dependent economies.

H.R. 1705 is a comprehensive environmental justice bill that aligns with NAPNAP’s priority to optimize child and family health by responding to the adverse health impacts associated with climate change. Additionally, it can serve as a model for environmental justice legislation efforts at state and grassroots levels. As experts in pediatrics and advocates for children, there are many ways that you can impact environmental justice policy.

These are the highest priority actions that you can take:

Call, email or schedule a virtual meeting with your Congressional representative to request their support of H.R. 1705 as an individual clinician constituent or NAPNAP chapter legislative representative.
Get the word out on social media to support H.R. 1705.
Seek out state and local legislative efforts that focus on using community-centered approaches to respond to climate-related health crises including advocating for increase in green spaces.
Join, as an individual or NAPNAP chapter representative, a local, state, or national organization focused on environmental health issues and policy change. One nursing focused organization is the Alliance of Nurses for Healthy Environments.

For more information about environmental impacts on children’s health, visit the Journal of Pediatric Health Care’s Planetary Health, Environmental Justice, and Child Health special edition.

We Want You!

Your Health Policy Committee is seeking new members to start July 1. This is your chance to work with fellow members dedicated to advocating for children’s health while enhancing your leadership skills and building your professional resume. Applicants can learn more and apply by the May 21 deadline.

Challenges to Abortion Medication May Reach Supreme Court

The ability of women to access medication for abortions and miscarriages was cast into uncertainty April 7 when two federal district judges issued contradictory rulings, with one jurist blocking federal approval of mifepristone, the medication used in more than half of all abortions in the U.S., while another said the drug should remain available in a swath of states. A three-judge panel of the 5th Circuit Court of Appeals on April 12 agreed to maintain the availability of an abortion pill but only under strict conditions that prohibit its use beyond seven weeks of pregnancy and bar its distribution by mail. The dueling opinions from Texas and Washington state appeared to set the issue on course to reach the Supreme Court, which overturned the constitutional right to abortions last year. Meanwhile, states are stocking up on the available supply of mifepristone pending the outcome of the litigation.

The April 7 ruling from Texas District Judge Matthew Kacsmaryk put on hold the Food and Drug Administration’s approval of mifepristone, which was cleared for use in the U.S. in 2000, marking the first time a judge has suspended longtime agency approval of a medication despite opposition from the government and the drug’s manufacturer. Later the same day, Washington state District Judge Thomas Rice ruled that the drug is safe and effective and ordered the FDA to preserve “the status quo” and retain access in the 17 states and the District of Columbia that filed the second lawsuit seeking to protect medication abortion.

Biden Ends COVID Emergency As States Reassess Eligibility for Health Coverage

President Biden on April 10 signed a resolution formally ending the coronavirus national emergency first enacted in March 2020. Although Biden announced plans to end the emergency in May, House Republicans passed the measure terminating the national emergency under the Congressional Review Act, which allows Congress to overturn rules by federal agencies with a simple majority vote. The resolution doesn’t affect the public health emergency declared by the Department of Health and Human Services, which is still set to expire on May 11 along with many flexibilities linked to the designation.

At the same time, at least five states indicated that they planned to start dropping individuals who are no longer eligible for Medicaid and Children’s Health Insurance Program coverage on April 1, the first day states can resume standard enrollment assessments and drop beneficiaries if they’re found ineligible for various reasons. States kept Medicaid beneficiaries continuously enrolled during COVID-19 in order to receive a 6.2 percent increase in federal Medicaid matching funds, but the 2023 Consolidated Appropriations Act ended the “maintenance of effort” requirement April 1. Officials in Arizona, Arkansas, Idaho, New Hampshire, and South Dakota said they planned to start disenrolling ineligible participants immediately, and two of those states plan to complete their eligibility reviews in eight months. The Department of Health and Human Services estimated that roughly 15 million people could be dropped from Medicaid when the continuous enrollment requirement ends.

NAPNAP Raises Concerns About Proposed Tele-Prescribing Rules

NAPNAP joined other national provider organizations in urging the Drug Enforcement Administration (DEA) to reconsider reimposing restrictions on the ability of pediatric advanced practice registered nurses and other clinicians to prescribe some controlled substances and buprenorphine for substance abuse cases. The DEA proposed two regulations Feb. 24 to reinstate requirements that patients have in-person visits with clinicians to get prescriptions for some medications that the agency had waived during the COVID pandemic.

The rules, which will take effect when the public health emergency ends in May if the agency finalizes them, would require patients seeking Adderall to treat attention-deficit/hyperactivity disorder or Oxycontin for pain relief to a prescriber’s office before they can start taking the drug. Patients who need buprenorphine for opioid use disorder, testosterone for gender-affirming care, or ketamine for depression, could get an initial 30-day supply via telehealth service, but would need to visit a clinician’s office to continue taking those medications. The proposed rules would give patients who started medications during the pandemic a 180-day grace period to comply with the in-person visit requirement.

Biden Moves To Extend ACA, Medicaid/CHIP Eligibility To DACA Recipients

The Biden administration is reviewing new rules that propose to would allow immigrants covered by the Deferred Action for Childhood Arrivals program to qualify for health insurance through Medicaid, the Children’s Health Insurance Program, and Affordable Care Act marketplaces, the White House announced April 13. The plan, which the White House says would benefit up to 580,000 young people brought to the U.S. as children, would broaden the definition of who qualifies for the insurance programs, expanding who is considered lawfully present as it applies to Medicaid, CHIP, and ACA marketplace eligibility so that it includes DACA participants.

The effort to make health coverage more accessible to these young people is part of a sharp policy reversal between the Biden administration and its predecessor. The Trump administration sought unsuccessfully to dismantle the program, which was created in 2012 and protects people who entered the country as children and remained here unlawfully. In contrast, President Biden has been pressing Congress to create a path to citizenship for this group, unsuccessfully so far.

Judge Strikes Down Preventive Services Coverage Requirement

On March 30, Texas federal District Judge Reed O’Connor overturned a key provision of the Affordable Care Act that requires insurers and employers to cover preventive services for free, including cancer screenings and HIV drugs. The ruling by Judge Reed O’Connor – who previously struck down the entire Affordable Care Act before it was upheld by the Supreme Court – applies nationwide, immediately jeopardizing access to treatment for the roughly 100 million Americans who use free preventive services annually and leaving the door open for insurers to impose deductibles and copays for potentially life-saving screening tests. O’Connor indicated last year that he felt the preventive services mandate was unconstitutional, but at the time waited to decide on the scope of remedy.

Specifically, the ruling states bars the federal government from requiring health plans to cover services recommended or updated by the U.S. Preventive Services Task Force on or after March 23, 2010. The ruling doesn’t affect coverage requirements for services recommended by the Task Force prior to that date, including some immunization requirements. The federal government has appealed the decision to the 5th Circuit Court of Appeals, but it’s not yet clear if district court ruling will be stayed while the litigation continues.

Administration Proposes Rule on Transgender Athletics

Schools and colleges across the U.S. would be forbidden from enacting outright bans on transgender athletes under a proposal released April 6 by the Biden administration, but teams could create limits in some cases, such as ensuring fairness. Under the Education Department’s proposed rule, which still faces public comment and likely legal challenges, no school or college that receives federal funding would be allowed to impose a “one-size-fits-all” policy that categorically bans trans students from playing on sports teams consistent with their gender identity, which would be considered a violation of Title IX, the landmark 1972 gender equity law. The proposal leaves room for schools to develop team eligibility rules that could ultimately result in restrictions around trans athletes’ participation only if they serve “important educational objectives” such as fairness in competition and reduction of injury risks.

In Other News…

Congress, White House Try to Move Ahead on Budget, Debt Limit
Facing sharp partisan divisions and narrow majorities in both chambers, congressional leaders are preparing to start voting on bills to fund the federal government in fiscal year 2024 while also facing a potential default on the nation’s $31.4 trillion national debt this summer. House and Senate appropriators continue to hold hearings following President Biden’s March 9 release of his $6.9 trillion fiscal 2024 budget plan, which includes a proposed $49.5 million increase for nursing workforce development programs under Title VIII of the Public Health Service Act. It’s unclear if either House Republicans or Senate Democrats will vote on a budget resolution, and leaders have yet to agree on topline spending for defense and domestic programs – the essential first step for appropriators to draft the 12 separate bills to fund federal agencies and programs. NAPNAP joined national nursing groups in urging Congress to recognize the critical need to increase funding to address workforce shortages, requesting a total of $530 million for the Title VIII programs while recognizing the wide gap between the White House and House Republicans on federal spending priorities.

At the same time, efforts to reach an agreement to raise the federal debt limit have ground to a halt, with congressional Republicans seeking to cut and cap nondefense spending, recapture unspent COVID relief funds and establish new work requirements for federal benefits including Medicaid, along with energy and border security legislation. The President and Democrats on Capitol Hill refuse to discuss those cuts, demanding that Congress pass a “clean” bill raising the debt limit without other policy changes.

Tougher Rules Issued for Mercury, Air Toxics, Sterilizing Chemicals
The Environmental Protection Agency ramped up proposed regulations on coal April 5, seeking stronger limits on mercury and other toxic air pollutants from power plants as part of a wider attempt to crackdown on pollution and greenhouse gas emissions. The administration proposed the most stringent update on limits to mercury from smokestacks since the Obama administration first issued Mercury and Air Toxics Standards in 2012, saying it expects the standards to reduce by more than two-thirds the mercury emissions from plants that burn lignite, also known as brown coal, and emissions that contain nickel, arsenic and other metals from other plants.

Separately, responding to community health experts and environmental justice advocates, the EPA released tougher proposed standards April 6 on pollution from several toxic chemicals, including ethylene oxide, widely used for sterilizing medical equipment and other purposes. Environmental groups and EPA officials said the tougher rules are needed because far too many Americans are burdened by pollution from ethylene oxide, which the agency identifies as a carcinogen. However, parts of the health care and chemical industries warned that the changes could disrupt the supply of safe medical equipment, affecting hospitals and clinics nationwide.

Administration Seeks to Reduce Sodium in Processed Foods
Following up on pledges to implement President Biden’s recommendations during the White House Hunger, Nutrition and Health conference last fall, the Food and Drug Administration on March 24 proposed steps to reduce sodium content in processed foods and offer food manufacturers guidance to better inform consumers about what they’re eating. If finalized, the new standards will allow foods that include salt to use “safe and suitable” salt substitutes. The agency also issued draft guidance that would offer guidance to food manufacturers on “how and when they can use Dietary Guidance Statements on food labels to help inform consumers about their products and how they can contribute to a nutritious diet,” according to the FDA.