Inside the Beltway – February 2020

State Exemptions Influence Vaccine Uptake in Pediatric Populations

Contributed by: Health Policy Committee Member Danielle Altares Sarik, PhD, APRN

Vaccines are a well-researched and proven method to protect against infectious disease. Since the creation of the first smallpox vaccine in 1796, experts estimate that 2-3 million lives are saved annually due to the immunity bestowed by vaccination. However, in recent years, we have seen a surge in vaccine hesitancy and a strengthening of anti-vaccine sentiment. Through the use of media platforms, individuals and groups have the capacity to spread untruths, and amplify unfounded concerns surrounding vaccine safety and efficacy.

State laws set the standards for which vaccinations are needed for children to attend school. In many ways, these laws provide a safety net by identifying those children who have not been vaccinated according to schedule prior to the start of daycare or preschool. However, some parents may choose to opt out of vaccination by taking advantage of existing exemptions. While every state offers medical exemptions, some also offer exemptions for philosophical and religious reasons. Some states, such as California, have recently required more information or oversight of exemptions, in an effort to encourage vaccination. In communities with high exemption rates, or “clustering”, there is a higher risk of losing herd immunity and having increased spread of vaccine preventable illness.

When reviewing national legislation, it appears that many states are exploring ways to encourage vaccination, and eliminate overly lenient exemption practices. In 2019, more than 300 vaccine related bills were proposed. Washington, Maine and New York enacted legislation that removes exemption for either personal or religious reasons for at least one vaccine requirement. This is significant and may be in response to the reality of rising outbreaks of vaccine preventable illnesses such as the measles outbreak of 2019. More than 1,200 cases of measles were confirmed in 31 states, representing the greatest number of cases since 1992. Importantly, the majority of those who contracted measles were not vaccinated.

As pediatric providers contemplate our own stance on vaccination in our practices, we must also consider those pediatric patients who are unable to receive vaccination for medical reasons. In situations where high vaccination rates exist in a community, the ability of diseases such as measles to spread is curtailed by the process of herd immunity. However, when vaccination rates dip, vaccine preventable diseases can find susceptible hosts and spread, placing vulnerable patients at risk. Legislation at the state or national level may influence vaccination rates and guide pediatric practice as well.

Learn more about your state’s laws and connect with your chapter legislative chair to learn more about pro- and anti-immunization focused bills being introduced in your state legislature that you could affect your patients and their families.

FDA E-Cigarette Guidance Leaves Flavored E-Cigarettes on Market

The Trump administration released its long-awaited policy on flavored e-cigarettes Jan. 2 – a limited ban on the sale of sweet and fruity flavored vape pods and cartridges that allowed gas stations and convenience stores to continue selling menthol cartridges and vapes as well as permitting vape shops to sell a broad range of e-cigarette liquids in “open-tank” vaping systems. The plan was far less extensive than President Trump’s promise last September to outlaw all flavored vaping products in response to the alarming rise in teenage vaping. FDA Center for Tobacco Products director Mitch Zeller said that the agency would consider restricting the sale of menthol-flavored vaping products if teen use of them increases as other flavors are banned, a day after HHS Sec. Alex Azar said the administration allowed tobacco and menthol flavors to stay on the market because they were “less appealing” to kids.

In releasing his agency’s 34th report on smoking cessation Jan. 23, Surgeon General Jerome Adams said that not enough evidence exists to determine whether e-cigarettes help smokers quit or ultimately improve public health. He added that the increasing availability of e-cigarettes and their popularity among teens “raise questions about the potential impact that such products could have on efforts to eliminate disease and death caused by tobacco use” and that it is difficult to make generalizations about how useful they can be for smokers trying to quit traditional cigarettes.

NAPNAP, Nursing Groups Urge CMS to Eliminate Practice Barriers

Responding to a Dec. 26 Centers for Medicare and Medicaid Services request for comments, NAPNAP and other nursing organizations called on the agency to follow through on the executive order issued by President Trump last October and propose regulations this year that remove barriers in the Medicare program that prevent nurses and advanced practice registered nurses from practicing at the full extent of their education and clinical preparation. NAPNAP also issued a Call to Action encouraging members to submit their own ideas for rules that restrict practice and access to care for patients.

The CMS request sought recommendations on the elimination of specific Medicare regulations that require more stringent supervision than existing state scope of practice laws or that limit health professionals from practicing at the top of their license. Groups are hopeful that policy changes will be included in the agency’s annual updates to Medicare policies to be proposed later this year.

“Public Charge” Rule Goes into Effect After Court Ruling

In a split 5 to 4 ruling Jan. 27, the Supreme Court allowed the Trump administration to start enforcing the Homeland Security “public charge” rule intended to screen out green card applicants seen as being at risk of becoming dependent on government benefits. The court blocked a New York federal appellate judge’s injunction that stopped the policy from taking effect while a legal fight went forward. The Homeland Security Department said it would begin enforcing the rule Feb. 24, meaning that benefits received on or after that date would count toward the “public charge” determination. Medicaid and CHIP coverage for children aren’t included, but advocates worry that immigrant families won’t apply for benefits they are eligible to receive out of fear that their status will be examined.

Under the rule finalized last year, immigrants will be considered “public charges” if they are deemed likely to receive such public benefits as Medicaid, public housing assistance or food stamps for more than 12 months over a 36-month period. Officials can consider a list of factors, including age, health, education, English-language proficiency, family size, wealth, and credit score.

Worried Lawmakers Monitor Coronavirus Response

As China struggles to cope with the epidemic spread of the Wuhan coronavirus, concerned members of Congress questioned the responses of both the Chinese and U.S. governments. At a Feb. 5 hearing, some members of the House Foreign Affairs Subcommittee on Asia challenged the effectiveness of the administration’s quarantines and travel bans, while others railed against the Chinese government for acting too slowly and secretively. The Centers for Disease Control and Prevention said Feb. 13 that some of the coronavirus testing kits sent to state laboratories around the country had flaws and didn’t work properly, meaning that states encountering problems would have to rely on the CDC’s central lab, causing delays in getting test results.

The Trump administration declared a public health emergency in the U.S. Jan. 31, closing the borders to foreign nationals who had recently been to China and imposing a mandatory two-week quarantine on citizens returning from the Hubei province at the center of the outbreak.

President’s Budget Proposes Deep Cuts in Nursing Programs

Less than a week after his State of the Union address to Congress, President Trump sent a $4.8 trillion budget for fiscal year 2020 to Capitol Hill Feb. 10 that proposed virtually wiping out federal funds for nursing workforce programs. “A Budget for America’s Future” proposed to cut funds for the Department of Health and Human Services by $9.4 billion, a 9 percent reduction from current funding, and entirely eliminate funding for Title VIII nursing workforce programs except the NURSE Corps, whose funding would be reduced by $5.5 million. A nearly $3 billion cut in funding for the National Institutes of Health included reducing spending on the National Institute of Nursing Research by more than $12 million. Among legislative proposals, the budget called for revising the Medicare Shared Savings Program to authorize patients seen by nurse practitioners to be assigned to Medicare accountable care organizations, saving the government $80 million over a decade.

Congress is likely to largely dismiss the administration budget, although it outlines priorities that will influence spending negotiations later this year. NAPNAP joined other nursing organizations in urging Congress to retain the Title VIII programs and increase their funding to a total of $278 million, a boost of nearly 7 percent, and increase funds for the National Institute of Nursing Research to $182 million.

Administration Offers Medicaid Block Grant Option to States

The Trump administration on Jan. 30 released its long-expected guidance to state Medicaid directors on how to convert their traditionally open-ended Medicaid funding into capped block grants in exchange for greater flexibility in changing enrollment and coverage policies. Labeled the “Healthy Adult Opportunity,” the guidance would waive requirements such as retroactive coverage periods and allow them to impose work requirements and “nominal” premiums and cost-sharing. Children, pregnant women, and people enrolled in Medicaid due to disability or long-term care would be excluded, although Medicaid advocates said capping federal funding could force states to eliminate optional coverage including early and periodic screening, diagnostic and treatment (EPSDT) for older children.

The block grant plan is an option for states, not a requirement, but Oklahoma Republican Gov. Kevin Stitt, who joined administration officials at the event announcing the new guidance, said he will roll out a plan to expand Medicaid based on the new policy. Supporters of Medicaid expansion in Oklahoma have gathered enough signatures to get an amendment to the state constitution expanding coverage issue on the fall election ballot.

In Other News…

Impeachment Stalls Senate Action on Title VIII Reauthorization
Legislative action in the Senate ground to a halt during President Trump’s impeachment trial, including efforts to have the chamber vote on the “Title VIII Nursing Workforce Reauthorization Act of 2019” (H.R. 728/S. 1399), which passed the House last fall and was approved by the Senate Health, Education, Labor, and Pensions Committee. Senate sponsors are hoping to work out minor differences between their bill and the House-passed version in the coming weeks and have both chambers pass the agreement and send it to the White House.

Administration Proposes to Roll Back Nutrition Guidelines for School Meals
The Department of Agriculture proposed new rules for the Food and Nutrition Service Friday Jan. 17 that would allow schools to cut the amount of vegetables and fruits required at lunch and breakfast while giving them license to sell more pizza, burgers and fries to students. Deputy Under Secretary Brandon Lipps said the changes would help address what he described as unintended consequences of the regulations implementing former first lady Michelle Obama’s plan establishing stricter nutritional standards for school breakfasts and lunches. Nutrition advocates said the proposed rules, if finalized, would create a huge loophole in school nutrition guidelines, paving the way for children to choose foods high in calories, saturated fat or sodium in place of balanced school meals.  The agency is responsible for administering nutritional programs that feed nearly 30 million students at 99,000 schools.

Supreme Court Considers Hearing Case to Eliminate ACA
In a closed-door conference Feb. 21, Supreme Court justices are expected to decide whether they will take charge of the lawsuit brought by Republican state attorneys general seeking to strike down the Affordable Care Act, after a federal appeals court referred the case back to a Texas district court. Democratic state attorneys general urge the Supreme Court to take up the case during its current term, which ends in June, but even if they choose to take the case the justices may not be able to hear arguments and render a decision until their next term, after the November general election.

The justices agreed Jan. 17 to revisit the issue of whether employers must guarantee free birth control coverage for their workers – marking the third high court review of the ACA contraceptive coverage mandate, but the first since conservative Justices Neil Gorsuch and Brett Kavanaugh joined the court. Both Gorsuch and Kavanaugh considered similar cases while appellate court judges, sympathizing with religious groups seeking exemptions from the requirement on moral grounds.

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