Heart on the Hill - May 2017

AHA Joins Other Patient, Public Health Groups in Opposing the AHCA

Earlier this month the association took a stance against the American Health Care Act (AHCA), which narrowly passed the House on May 4. Of particular concern was the eroding of protections for patients with pre-existing conditions like heart disease and stroke. The legislation permits states, under certain circumstances, to waive health status rating protections and weakens rules that prohibit insurers from charging patients with pre-existing conditions higher prices for the same services.

While the AHCA requires states that waive these patient protections to set up high-risk sharing programs such as a high-risk pool, past experience shows that these solutions often lead to higher premiums, long waits and inadequate coverage for the most vulnerable Americans. An amendment introduced by Rep. Fred Upton (R-MI) attempted to allay these concerns by providing an additional $8 billion over five years to help patients pay out-of-pocket costs or potentially higher premiums. However, the Upton amendment does not specify who would be eligible for assistance; how much of their costs would be covered; or how much they would be required to pay out of pocket for their premiums.

The AHA joined eight other patient groups in concluding that the AHCA, including the Upton amendment, was woefully inadequate for the 129 million Americans with pre-existing conditions. “There is no substitute for fundamental, unequivocal protections for people with pre-existing conditions,” the association and its coalition partners said in a joint statement.

The AHCA also allows states to waive the requirement of essential health benefits. Under the current Affordable Care Act, states are required to cover 10 essential health benefits, such as preventive and wellness services, chronic disease management and rehabilitative care. Eliminating these requirements would threaten access to preventive and other clinical services that are critical in helping prevent and manage cardiovascular diseases.

Although the version of the AHCA that passed the House has yet to receive a revised “score” from the nonpartisan Congressional Budget Office (CBO), an analysis of an earlier version of the bill by CBO predicted that 24 million people would lose coverage and it is likely that subsequent changes in the legislation will increase this number.

While the AHCA provides states with greater latitude in implementing Medicaid, this flexibility is accompanied with dramatic cuts in federal funding that would shift billions in health care costs to states making it highly unlikely that cash-strapped states will be unable to maintain essential Medicaid coverage and services.

AHA CEO Nancy Brown expressed disappointment at House members who “failed to stand up for America’s patients.”

She called on the Senate to “take a more thoughtful approach to our nation’s health care system and remember that American lives hang in the balance. “

The bill now heads to the Senate, where it is likely to undergo significant changes.

Contact: Katie Berge

NIH Sees Second Consecutive Funding Increase

On May 5, President Trump signed the 2017 Omnibus Appropriations Act into law. This act provided funding for many association priorities, including the National Institutes of Health (NIH) and Centers for Disease Control and Prevention (CDC), through September 30, 2017.

The law contains a $2 billion – or 6 percent – increase for the NIH over its current funding level. The agency also received a $2 billion boost to its budget last year, making this the first time in more than a decade that the NIH has received increased funding for two consecutive years.

Included in the appropriations for the NIH are specific increases for research on: Alzheimer’s disease, the Precision Medicine Initiative, the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative and antibiotic resistance.

AHA President Steven Houser, Ph.D., FAHA, said the NIH funding comes at a “pivotal time for research” in the United States.

Although the NIH received a needed bump, the tradeoff was cuts or freezes in funding for federal prevention programs that help Americans ward off risk factors that can put them on the path to heart attacks and strokes. The CDC’s heart and stroke prevention program was cut $30 million over its current funding level.

AHA CEO Nancy Brown said she was pleased with Congress’s commitment to NIH funding, but that we “cannot afford to let down our guard” just because of past progress.

Moving forward, “we need the dual weapons of research and prevention to wipe out the burden of CVD for every generation,” she said.

Contact: Claudia Louis

Science-Based Nutrition Under Attack in FY17 Omnibus

Despite our strong science and advocacy efforts, the 2017 omnibus funding bill included several damaging riders that threaten progress made in nutrition policy.

First, the bill included a rider to roll back nutrition standards for school meals. Unfortunately, this rider goes further than previous attempts and is coupled with efforts from the U.S. Department of Agriculture (USDA) to reopen the rule and alter the evidenced-based standards on whole grains, sodium and milk. This rider would continue the whole grains waiver, freeze the sodium standards at target one and expand milk to 1 percent flavored with no calorie limits.

Also in the bill was a provision that prohibits the Food and Nutrition Service (FNS) at USDA to conduct new research without prior congressional approval. FNS is the only research arm subject to this new oversight, and the removal of its autonomy is concerning as nutrition science continues to be attacked. Ongoing efforts to diminish nutrition science are also evident in the rider that prohibits the voluntary sodium guidelines from moving forward until the Dietary Reference Intake (DRI) update is published. While the association welcomes a DRI update, tying the guidelines to them is simply a delay tactic so those who oppose the guidelines can have more time to raise questions about the science behind sodium.

Additionally, there was a rider requiring USDA to reopen the Supplemental Nutrition Assistance Program (SNAP) retailer standards rule to redefine “variety” so that the definition is more permissive. This opens the door for unhealthy foods to qualify as staple foods. Finally, the bill once again included a rider prohibiting the Interagency Working Group on Food Marketed to Children from moving forward without a cost-benefit analysis, effectively killing this effort for yet another year.

The association anticipates these riders, and possibly others, will appear in the 2018 funding bill and we will continue to advocate for legislation without riders that are detrimental to science-based nutrition policy.

Contact: Kristy Anderson

USDA Reverses School Meals Standards

On Monday, May 1, the U.S. Department of Agriculture (USDA) announced that it will reopen the regulations for school meals nutrition standards with the intent to roll back the whole grains, sodium and milk standards, despite nearly 100 percent of schools being in compliance and evidence that the program is working. The association strongly opposes these actions.

Currently, whole grains must be 100 percent enriched, meaning all of the grain products served must be at least 51 percent whole grains. During the child nutrition reauthorization process in the last Congress, the association supported a compromise of 80 percent whole grain enriched in lieu of the current waiver process referenced in appropriations riders, but we still feel the 100 percent levels are optimal for kids’ health. USDA indicated it will continue the waiver process until the new regulations are complete.

Sodium levels, which vary based on age and meals, are currently at target one. Target two was expected to go into effect June 1 of this year, but in January USDA issued an extension for implementation until school year 2018 with additional technical assistance provided. The association supported this move. However, USDA has now said it will not go beyond target one – effectively killing targets two and three – and indicated it will reopen the rule around sodium.

With milk, USDA plans to expand the current standard to allow 1 percent flavored products with no calorie limits.

While there are certainly ongoing tweaks that can always be made to the program, and some schools might need extra technical assistance to help them get across the finish line, reopening the school meals nutrition regulation is a dangerous and unprecedented step. It provides an opportunity to further weaken the standards and creates uncertainty for schools.

The science-based nutrition standards are working, and kids are healthier because of them. The association will continue to put children’s health first and strongly advocate to protect the current nutrition standards.

Contact: Kristy Anderson

Menu Labeling Off the Table – Again

On May 1, the Food and Drug Administration (FDA) announced that it was changing the menu labeling compliance deadline from May 5, 2017 to May 7, 2018.

According to the FDA, the one year delay will allow the agency to consider ways the rule could be altered to reduce costs and provide restaurants and other retail food establishments with more flexibility in meeting the rule’s requirements.

Under the original menu labeling rule, released in December 2014, restaurants and similar retail food establishments with 20 or more locations were directed to post calorie counts on menus and menu boards, and on signs next to self-service foods on display. Additional nutrition information must be available upon request. The requirements apply to all retail food establishments that serve restaurant-type food, including restaurants, movie theaters, sports arenas, cafeterias, grocery stores and convenience stores.

In a statement, AHA CEO Nancy Brown expressed disappointment with the “FDA’s decision to push back – yet again – the deadline for food establishments to provide essential nutrition information their customers want and deserve regarding menu items” and noted that “Americans have been waiting seven years for this common-sense rule.” She also praised restaurants and other establishments with menu labeling already in place and strongly encouraged others to follow their lead.

The FDA is accepting public comments until July 3.

Contact: Susan K. Bishop

AHA Releases New SNAP Policy Statement

In March, the association released a policy statement on the upcoming 2018 farm bill, with a specific focus on keeping the Supplemental Nutrition Assistance Program (SNAP) strong and robust, while looking for opportunities to improve the diet quality, nutrition and health of beneficiaries.

The farm bill is legislation authorized approximately every five years to address agricultural policy, food issues, nutrition and hunger. The most recent bill, the Agriculture Act of 2014, is set to expire next year. The nutrition provisions are approximately four-fifths of the bill’s total expenditures, the majority of which go to SNAP.

For more than 50 years, SNAP has been an important way to address food insecurity and nutrition. Most of the 45 million SNAP beneficiaries are children, older adults or those with disabilities.

The association’s full paper outlines all the recommendations in more detail, but highlights include:

• Increasing the monthly benefit to close the end-of-the-month diet quality gap and ensure that beneficiaries can afford healthier foods throughout the entire month.
• Developing a pilot to encourage healthy choices for beneficiaries to receive a fruit and vegetable incentive, displace sugary beverages and conduct a robust evaluation.
• Crafting report language to encourage USDA to work with states on their SNAP choice waiver requests – not only to develop clear-cut definitions but to ensure that robust evaluations are being conducted so appropriate data may be collected.
• Increasing funding for SNAP-Ed and continuing support of innovative nutrition education and incorporation into programs.
• Expanding the Food Insecurity Nutrition Incentive (FINI) grants, which provide extra benefits for fruit and vegetable purchases, while ensuring the program is used for healthy foods and not for other products, such as sugary beverages.
• Continuing to expand SNAP EBT technologies at non-traditional food retailers, such as farmer’s markets and green stands, to improve access.
• Maintaining funding and preserving the integrity of the Fresh Fruit and Vegetable Program, a popular and successful program for low-income elementary school children that increases consumption of all forms of fruits and vegetables.

The Senate and House Agriculture Committees are currently holding hearings on the farm bill reauthorization. Draft bills will likely be out this fall, and legislative action will begin in 2018. The association will continue to advocate for our priorities throughout the process.

Contact: Laurie Whitsel and Kristy Anderson

Tobacco Regulations in the Crossfire

Working with our coalition partners, the AHA was able to successfully prevent several riders on tobacco regulations from being attached to the fiscal year 2017 budget bill.

Two key riders were related to the tobacco deeming rule, which gave the Food and Drug Administration (FDA) the authority to regulate e-cigarettes, cigars, hookah, pipe tobacco and dissolvables. The rule has been under attack from the tobacco industry since it was released in May 2016.

One rider would have changed the “grandfather date” for all newly deemed tobacco products. This would mean that e-cigarettes, cigars and hookah would not have to undergo a pre-market review if they were introduced to the market before August 2016, adversely affecting the FDA’s ability to examine the public health implications of these products.

Another piece of legislation would have exempted “large and premium cigars” from FDA oversight completely. This exemption would also have applied to many cheap, flavored cigars that are marketed to children.

Unfortunately, at the same time the threat from Congress was at least temporarily eliminated, the FDA announced it will delay future compliance deadlines contained in the deeming rule for three months. They include any deadline set for May 10, 2017, or later, such as those that require tobacco companies to register with the FDA, to provide a list of product ingredients, including harmful or potentially harmful constituents; to submit health documents; or seek FDA premarket approval. Meanwhile, it is likely Congress will revisit the issue in the coming months.

According to the FDA, the agency took this action in response to several lawsuits that were filed by e-cigarette and cigar manufacturers who are asking the courts to overturn the deeming rule. The new administration suggested the delay will give them time to consider issues with the deeming rule that were challenged in the lawsuits.

The FDA’s action could also indicate that the administration is considering changing how e-cigarettes, cigars, and other newly deemed tobacco products are regulated.

Contact: Alison Council and Susan K. Bishop

Physical Education Takes a Backseat in Omnibus

Another important issue that took a hit in the 2017 omnibus bill was physical education. Congress funded the Student Support and Academic Enrichment (SSAE) block grant program at only $400 million, which is just 25 percent of its intended funding. The grant program was authorized under the Every Student Succeeds Act (ESSA) at $1.65 billion.

Woefully underfunding this vital program prohibits schools from making meaningful investments in a well-rounded education. The association will continue to work with coalition partners to procure full funding in fiscal year 2018.

Contact: Kristy Anderson

AHA Volunteers Talk Pre-Existing Conditions

On March 21, the American Heart Association, in conjunction with the March of Dimes, Cystic Fibrosis Foundation, International Alliance for Pediatric Stroke and Pediatric Congenital Heart Association, sponsored a Capitol Hill briefing to educate Hill staffers and lawmakers about the challenges children with pre-existing conditions and their families face trying to purchase health coverage.

Advocates who shared their personal stories at the briefing, included pediatric stroke survivor Ryley Williams and AHA volunteer Terri Rose; congenital heart defect patient Nicholas Basken and his mom Amy (director of programs at the Pediatric Congenital Heart Association); and Mary Kay Ballasiotis, AHA volunteer and co-founder of the International Alliance for Pediatric Stroke. Balllasiotis’ daughter suffered a stroke before she was born.

Other panelists included Katherine Hayes of the Bipartisan Policy Center, Jaclyn Strube and her son Major, who lives with cystic fibrosis, and Kimberly Allar whose children were born prematurely.

All participants discussed their experiences dealing with a pre-existing condition and how the struggle to obtain and maintain insurance coverage has shaped their lives. They highlighted their concerns about proposed alterations to the current health law and also identified facets of the current health care system they believe could be improved, such as costs and access to specialists for their children’s conditions.

We are hopeful that Congressional leaders will listen to the messages these panelists shared and choose to make the health care system less complex and costly for those already dealing with the burden of a pre-existing condition.

Contact: Alison Council

FAST Act Makes Headway in House and Senate

The Furthering Access to Stroke Telemedicine (FAST) Act continues to make strong bipartisan progress in the House after its introduction in February by Reps. Morgan Griffith (R-VA) and Joyce Beatty (D-OH). The bill would expand access and treatment to telemedicine to treat stroke in non-rural areas by allowing Medicare to reimburse for services.

The Senate version, introduced by Sens. John Thune (R-SD), Brian Schatz (D-HI) and Roger Wicker (R-MS) is also picking up momentum and is included in several legislative packages including the Senate Finance Committee’s Chronic Care bundle, a standalone bill and a bill focused on telemedicine applications.

The American Heart Association has been working with the American Academy of Neurologists to make sure members of Congress understand that time is brain – and that quick diagnosis and treatment are key to improving patient outcomes. Increasing and expanding access to this program could have a measurable benefit for the more than 800,000 Americans who experience stroke every year.

At the time of press, the bill had 77 co-sponsors in the House.

Meanwhile, on May 16, AHA volunteer neurologist Lee Schwamm, M.D., testified at a Senate Finance Committee hearing about how telemedicine in the acute treatment of stroke can greatly improve health outcomes. During his testimony, Schwamm urged the committee to pass the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017.

The bill includes provisions that would strengthen and improve care coordination for Medicare beneficiaries living with chronic conditions such as heart disease and stroke. Expanding reimbursement for telestroke is a key provision in the bill.

The current Medicare policy, which limits coverage for telestroke services to rural hospitals, has hampered sufficient telestroke coverage, Schwamm said. He noted that removing the rural restriction would be a “game-changing” step toward “easing the burden” of stroke.

The bill also calls for expanding the use of telemedicine in Medicare Advantage plans and accountable care organizations. Medicare Advantage plans would have more flexibility to vary benefit structures based on chronic conditions. In addition, it includes funding for studies on synchronizing medications and obesity drugs.

Schwamm concluded his testimony by saying telestroke is a common-sense, cost-effective step to increase the use of effective acute stroke treatments, reduce stroke-related disability and save health care dollars.

After the Finance Committee marks up the CHRONIC Care Act on May 18, the bill will head to the Senate floor.

Contact: Katie Berge

AHA Volunteers Speak at MEDCAC, FDA Events

On March 22, American Heart Association volunteer Dr. Nancy K. Sweitzer, director of the University of Arizona Sarver Heart Center and a professor of medicine and chief of the Division of Cardiology in the University of Arizona College of Medicine, spoke on behalf of the AHA on a panel hosted by the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC).

The panel explored the extent to which different outcomes should be considered meaningful primary health outcomes in heart failure research studies. Dr. Sweitzer, discussed the value of disease-specific quality of life measures in reflecting the patient experience.

Dr. Sweitzer was joined on the panel by volunteers from the Society for Cardiovascular Angiography and Interventions, the American College of Cardiology and the Heart Failure Society of America.

Likewise, on May 3, Robert Page, a clinical pharmacist who specializes in inpatient cardiology and heart failure, presented on behalf of the association at a Food and Drug Administration-sponsored (FDA) public workshop on the rising cost of prescription drugs.

Page gave an impassioned and informative speech about the rising cost of generic drugs. He urged the FDA to consider the vulnerable populations that have been subjected to the burden of rising generic drug prices. Furthermore, he expressed the AHA’s desire to work collaboratively with the FDA to identify specific solutions to address generic drug price increases, particularly for evidenced-based, lifesaving medications.

The agency hosted the Generic Drug User Fee Act (GDUFA) workshop to receive stakeholder feedback on regulatory science initiatives specific to generic drugs. The FDA was particularly interested in receiving input on a variety of topics, including identifying high-impact public health issues involving generic drugs that can be addressed by the prioritized allocation of FY 2018 funding for regulatory science research.

STATE UPDATES

More Wins for Tobacco Prevention

Genesee County, MI and Orange County, NY councils have raised the tobacco sales age to 21. Washington, D.C. also took this important action to protect youth from the dangers of tobacco use.

This year, Kentucky lawmakers supported Senate Bill 89 to improve smoking cessation coverage. This policy ensures that Kentuckians have access to all necessary treatments to quit smoking. It’s estimated that this policy will positively impact 650,000 Kentucky smokers and improve the health of 4.3 million Kentucky residents.

Also, on May 9, the City of Arlington, TX passed a comprehensive smoke-free ordinance with a final vote of 7-2. After the successful first reading and vote on April 11, the smoke-free ordinance faced significant opposition from bars, pool halls, vape shops and others who quickly mobilized to try to defeat the smoke-free ordinance. The Smoke-Free Arlington coalition stayed focused and doubled their efforts to keep members of the Arlington City Council supportive of becoming a comprehensive smoke-free city.

Contact: Lucy Culp

Bike and Pedestrian Appropriations See Big Wins Nationwide

Four California counties – Santa Clara, Los Angeles, Monterey and Stanislaus – all approved funding for active transportation and infrastructure improvements. Los Angeles County received the biggest boost, with $120 billion over a 40-year period. Santa Clara County received $6.3 billion over a 30-year period, while Monterey and Stanislaus counties received about $500 million each over 30-year and 25-year spans, respectively.

Funding in all counties will be used for a multi-pronged, geographically balanced approach to widening and improving highways, expressways and interchanges; repairing potholes and repaving city streets; expanding public transportation systems, improving bicycle and pedestrian paths; and providing additional transit options for seniors, students and individuals with special needs.

In addition, significant dollars will be invested toward Safe Routes to School projects and education efforts.

T-SPLOST, a special purpose local option sales tax for transportation approved by voters in Atlanta, Georgia, went into effect April 1. It allocates more than $166 million for future walking and biking projects. The projects approved include high priority sidewalk and bikeway projects connecting neighborhoods to 80 Atlanta public schools and all of Atlanta’s rail stations. Ninety-four percent of the city’s residents and 98 percent of the city’s jobs will be within a half mile of a proposed T-SPLOST, MARTA or Renew Atlanta transportation or infrastructure project once all projects are complete.

The Empire State Trail, a proposed trail that would stretch 750 miles and connect New York City to Albany and across the state to Buffalo, secured $200 million in the state budget, which was approved in April. By 2020, millions of New Yorkers will have additional options for safe and healthy active transportation.

Out in Nevada, Clark County Question 5 allocated approximately $43 million to Safe Routes to Schools projects and $119 million to biking and walking projects over the next 10 years. Southern Nevada has the lowest funding in the nation, and the money for these projects will increase physical activity throughout the region, making it safer to work, live and play.

Residents in Salt Lake County Utah have voted on Proposition A, which proposed to pay all or a portion of the costs of acquisition, construction, renovation and equipping of parks and recreation facilities. More than one million Utah residents will now have safe, local access to walking and biking trails in their communities. Portions of the funds will also be set aside for the creation of ADA-compliant swings, slides and other amenities to ensure that children and citizens of all ages and abilities are able to engage in healthy, wholesome recreational activities.

Contact: Tim Vaske

Stroke Registry/Facility Designation in Tennessee, Iowa and Indiana

A policy campaign in Tennessee established a mandatory statewide, centralized registry requiring all certified comprehensive and primary stroke centers to report data to the registry. The state has had a voluntary registry in place from legislation that was passed in 2008. A state bill amended the previous legislation and requires stroke facilities at the primary stroke center and comprehensive stroke center levels to report data. Over 20,000 stroke victims will now have access annually to more comprehensive stroke systems of care.

Through the passage of House File 548, Iowa now has a mandatory statewide, centralized stroke registry requiring all nationally certified comprehensive and primary stroke centers to report data to the registry. The registry will benefit close to 8,000 stroke victims every year.

Finally in Indiana, the passage of House Bill 145, will ensure that three tiers of stroke facilities certified by nationally recognized certifying bodies are recognized by the Department of Health. Additionally, the legislation requires the Indiana State EMS Commission to adopt rules for protocols for the transport of acute stroke patients and requires local and regional EMS authorities to implement these protocols. Close to 19,000 stroke victims every year will be served by these comprehensive stroke systems of care.

Contact: Douglas Dunsavage

Washington State Passes PE Quality Bill

Washington Gov. Jay Inslee (D) recently signed HB 1235 which requires the reporting of physical education quality at school, district and state levels.

This bill requires entities to report the number of students completing a physical education class during the school year, the average number of minutes per week of physical education received by students in first grade through eighth grade and the number of students granted waivers from physical education.

In addition, the bill mandates reporting of the frequency with which physical education is provided to students, an indication of whether, as a matter of policy or procedure, the district routinely modifies and adapts its physical education curriculum for students with disabilities, and other key information to assess the quality and quantity of physical education throughout the state.

More than one million students enrolled in Washington’s public school system will be impacted by this bill. Physical education assessment is an incremental approach that will lead to deeper work regarding credentialing and required minutes of PE.

Contact: Tracy Weldon