Highlight on Maine: addressing seniors, aliens, diabetes, dental health care

Maine has experienced highs and lows in its delivery of health care in the first half of 2015. It has improved its ranking in the nation in terms of care provided to seniors and on seven measures of a health care index report, but it ranks low in dental health care. To help with those dental statistics, Maine received a grant from HHS targeting children’s dental health. Maine also embarked on a diabetes prevention program. Finally, the Maine Superior Court ruled in favor of the Maine Department of Health and Human Services (DHHS) denying General Assistance welfare reimbursement for claims municipalities paid to nonqualified aliens.

Senior health care ranking

Maine is ranked the 11th healthiest state overall for adults aged 65 and older, up from 14th in 2014. It ranked first in the nation for clinical care, according to the third annual Senior Report released by America’s Health Rankings®. The Senior Report provides a comprehensive analysis of senior population health on a national and state by state basis. According to a news release from MaineHealth, an accountable care organization and integrated not-for-profit health care system of providers and other health care organizations working together in their communities, clinical care includes seniors receiving care for heart attack, heart failure, pneumonia, and surgical procedures.

The Senior Report identified Maine’s strengths as follows: (1) high percentage of quality nursing home beds, (2) low percentage of low-care nursing home residents, and (3) low intensive care unit use. Challenges include: (1) low percentage of dental visit, (2) low prescription drug coverage, and (3) high prevalence of full-mouth tooth extraction. Highlights of senior health care in the past year include that: (1) obesity increased from 25.9 percent to 27.2 percent of adults aged 65 and older; (2) pain management decreased from 50.7 percent to 42.9 percent of adults aged 65 and older with joint pain; (3) community support increased from $525 to $639 per adult aged 65 and older in poverty; (4) home health care increased from 106.3 to 137.4 home health care workers per 1000 adults aged 75 and older; and (5) premature death decreased from 1902 to 1692 deaths per 100,000 adults aged 65 to 74.

Diabetes prevention

The Maine Center for Disease Control (CDC) is targeting diabetes prevention at 16 sites across the state that are delivering the National Diabetes Prevention Program, a year-long lifestyle change program designed to help participants decrease their risk of developing Type 2 diabetes, the Maine DHHS reported on June 11, 2015. The Maine CDC noted that less than 7 percent of Maine adults have ever been told they have pre-diabetes (higher than normal blood sugar) even though the United States Center for Disease Control estimates that one of every three adults has this condition. In 2014, 800 Mainers completed the prevention program in which a lifestyle coach works with small groups of individuals to support life style changes such as changing eating habits, managing stress, staying motivated, and increasing physical activity. Data shows that those who have completed the program reduced the likelihood of developing Type 2 diabetes by 58 percent, and many experienced weight loss and a drop in blood pressure.

Children’s oral health

On July 24, 2015, MaineHealth announced that HHS had awarded the health care organization a grant to improve children’s oral health across the state in the amount of $250,000 per year for a total of $1 million over four years. Maine is one of eight states to receive this funding. The grant expands access to oral health care through the From the First Tooth initiative to include pregnant women and enhance the focus on establishing early dental care for babies. From the First Tooth, which is led and administered by MaineHealth in partnership with MaineGeneral Health and Eastern Maine Healthcare Systems (EMHS), is a statewide effort to integrate oral health into primary care delivery systems through early interventions by pediatricians and family physicians. Kneka Smith, MPH, Director of From the First Tooth at MaineHealth, noted that, “tooth decay is one of the largest health problems impacting Maine children.”

Health Index Report

MaineHealth, released its fifth annual Health Index Report on March 25, 2015. The report, which is released in conjunction with the Robert Wood Johnson Foundation’s County Health Rankings, an annual report that compares the overall health of almost every county in the United States, provides community health data specific to Maine. According to MaineHealth, the rankings compare counties on 30 factors that influence health including education, housing, violent crime, jobs, diet, and exercise. The rankings indicated that Sagadahoc is the healthiest county in Maine and Somerset is the least healthy county. The rankings also showed that Oxford County had the most improved health outcomes in the state. The Health Index Report tracks progress on seven high priority issues that have a major impact on Maine’s overall health status, including: childhood immunizations, tobacco use, obesity, preventable hospitalizations, cardiovascular deaths, cancer deaths, and prescription drug abuse and addiction. Key findings in the 2014 report specific to Maine include:

  • up-to-date immunization rates at MaineHealth practices increased from 77 percent in 2012 to 80 percent in 2014;
  • Maine’s youth smoking rate was 13 percent in 2013 versus the 2011 rate of 15.5 percent;
  • 58 percent of Maine’s adult smokers have made a serious attempt to quit in the past 12 months;
  • 78 percent of Maine fifth graders drank zero sugary beverages per day in 2013–an increase of 9 percent since 2009; and
  • In 2010-2012, Maine’s rates for overall cardiovascular death, as well as rates for heart disease, coronary heart disease and heart attack, were significantly lower than the U.S. rates.

The report identifies opportunities for community health improvement and describes how the MaineHealth system and its partners are addressing the high priority issues through clinical, community, and policy strategies.

Welfare to illegal aliens

On June 9, 2015, the Maine Superior Court, issued a ruling that the Maine DHHS cannot withhold all General Assistance funds from municipalities that give the funds to immigrants seeking asylum until the agency follows state law that outlines how rules may be changed; however, the state does not have to reimburse cities and towns for the aid that they give to asylum seekers, Judy Harris reported in the Bangor Daily News. “DHHS has no statutory or regulatory authority to penalize municipalities for noncompliance with DHHS instruction or directive relating to persons who DHHS deems ineligible for general assistance,” according to the opinion. Finally, the court concluded that until the state legislature enacts laws that allow asylum seekers to receive General Assistance funds, they are ineligible under federal law.

The Portland Press Herald reported on July 13, 2015, that a preliminary analysis by city staff found that “as many as one-third of the 900 or so immigrants who live in Portland and have been at the center of a debate about public assistance may be ineligible for city aid because they have expired visas and have not applied for asylum.” An immigration attorney quoted in the article explained that under federal law, only immigrants who have formally applied for asylum are protected from deportation until their final legal status is determined; asylum applicants are considered to be lawfully present while they wait for a decision. The question is whether someone can be described as an asylum seeker without having formally applied, according to the article.

No fun before 21: smoking age may be raised in Hawaii

Hawaii state Senate bill SB1030 HD2 has been passed by both chambers and sent on to Governor David Ige (D) for consideration. The bill includes electronic cigarette devices in its definition of tobacco products. If signed into law, the age for purchasing, selling, possessing, or consuming tobacco would be raised to 21 from the current age of 18. Although many local governments have similar bans, Hawaii would be the first to enact statewide legislation on the matter.

Motivation

The Coalition for a Tobacco-Free Hawaii threw its support behind the legislation, with its executive director calling it “groundbreaking.” The Department of Health estimates that 5600 children try smoking each year. The overwhelming majority of daily smokers start before age 19. Senator Rosalyn Baker (D) introduced the bill, which would impose a $10 fine for first violations and $50 fines or mandatory community services for subsequent offenses, as an attempt to “change the paradigm.” The Institute of Medicine reported that raising the smoking age to 21 may result in an estimated 12 percent decrease in smoking prevalence.

Marketing to teens

Health concerns about tobacco products have grown due to the increasing popularity of electronic cigarettes (e-cigs), the use of which is known as “vaping” due to the inhalation of vapor from heated liquid. This liquid is often flavored, with many sweet flavors such as bubble gum or candy directed toward younger customers. Although marketing to children and teens is not technically allowed, packaging and advertising is still being created to attract children. According to a report released by the Centers for Disease Control and Prevention (CDC), e-cigarette use tripled from 2013 to 2014 among middle and high school students. The National Youth Tobacco Survey asked high school students if they had used e-cigarettes at least one day out of the last 30 days, and found that reported use rose from 660,000 to 2 million. The use of traditional tobacco products, such as cigarettes and cigars, declined somewhat between 2011 and 2014, but e-cigarette use offset these declines.

Opposition

Some argue that the bill violates common sense. Children become legal adults at 18, and are able to serve in the military, sign contracts, and get married. Senator Gil Riviere (D), voted against the bill, saying that the state should ban smoking for everyone if it is concerned about elimination. Governor Ige is being cautious about signing the bill, stating that various teams are researching the legalities of raising the smoking age and that he will make a decision based upon available information.

Other legislation

Governor Ige did recently sign House Bill 940, which puts e-cigarettes under the same restrictions as traditional cigarettes in public places. Three other states (North Dakota, New Jersey, and Utah) already have such legislation in place. E-cigarettes are still new enough that little regulation of them exists, although states are beginning to catch up.

In California, proposed legislation include an increase of cigarette taxes by $2 per pack, as well as a similar smoking age increase. Activists state that although California once led the push against tobacco, a strong lobby presence has turned the tide. California has failed to raise the tobacco tax on its last 17 attempts. Numbers indicate that between 2007 and 2014, the industry spent $64 million on lobbying activities. Yet the state is beginning to respond, having just launched a $7 million advertising campaign decrying e-cigarette usage.

In Washington state, Attorney General Bob Ferguson has been hoping to see the smoking age raised to 21 there as well. However, the House Finance Committee gutted House Bill 1458, which originally passed the House Health Care and Wellness Committee with no problems and strong support. The April 3 committee meeting changed the age to 19 and and delayed the effective date by four years. The bill was sponsored by Senator Mark Miloscia (R) and Representative Tina Orwall (D).

Quitting smoking with Chantix®? Watch your alcohol intake

Chantix® (varenicline), a prescription smoking cessation medicine manufactured by Pfizer, can change the way people react to alcohol, including decreased tolerance to alcohol, increased drunkenness, unusual or aggressive behavior, or blackout memory loss. There have also been rare accounts of individuals with no history of seizures experiencing seizures while taking Chantix. In a safety announcement, the FDA updated the Warnings and Precautions section of the drug label and the patient Medication Guide for Chantix to tell patients to decrease their alcohol intake until they know how the drug affects their ability to tolerate alcohol, and patients who have a seizure while taking Chantix should stop taking the medication immediately.

Chantix

According to the Centers for Disease Control and Prevention (CDC), tobacco use is the leading preventable cause of death, disease, and disability in the United States. Around 443,000 Americans die from smoking or exposure to secondhand smoke each year. Approximately 46.6 million American adults smoke, exposing 88 million nonsmokers to secondhand smoke. In May 2006, the FDA approved Chantix as a smoking cessation drug. The medication acts at sites in the brain affected by nicotine, and may help those who wish to stop smoking by providing some nicotine effects to ease withdrawal symptoms. It can also block the effects of nicotine from cigarettes if users resume smoking. Clinical trials show that Chantix increases the likelihood of abstinence from smoking for as long as one year compared to placebo treatment.

Safety announcement

The FDA reviewed information about adverse reactions to alcohol experienced by patients taking Chantix from a case series submitted by Pfizer and cases in the FDA Adverse Event Reporting System (FAERS) database. The FDA also reviewed FAERS and medical literature for cases of seizures in Chantix users, particularly those who had no history of seizures or who had a well-controlled seizure disorder prior to taking the drug. In most cases, seizures occurred within the first month of starting Chantix. Information about these risks was added to the drug labeling and patient Medication Guide.

The FDA also updated the Warnings and Precautions section of the label to include information about several studies that investigated the risk of neuropsychiatric side effects on mood, behavior, or thinking occurring with Chantix. Available observational studies and analyses conducted by Pfizer of randomized controlled clinical trial data did not show an increased risk of neuropsychiatric side effects with Chantix; however, the studies did not examine all types of neuropsychiatric side effects, and had limitations that prevented the FDA from drawing reliable conclusions. The FDA previously noted that possible serious neuropsychiatric side effects may occur from Chantix use; Pfizer is conducting a large clinical safety trial to investigate the risk, and expects results from that study in late 2015.

Report side effects

The FDA urges health care professionals and patients to report side effects involving Chantix to the FDA MedWatch program, using the information in the “Contact FDA” box at the bottom of the page.

FDA Commissioner Stepping Down After 6 Controversial Years

Dr. Margaret Hamburg, the FDA’s leader for the last six years, announced that she will be stepping down in March 2015. The FDA’s chief scientist, Stephen Ostroff, will become acting commissioner while Commissioner Hamburg’s permanent successor is appointed by the President and confirmed by the Senate. Commissioner Hamburg’s stint in the top role was one of the longest in decades. She was well-prepared for the job as a Harvard Medical School graduate and the former New York City health commissioner. While Commissioner Hamburg states that she is unsure of her next move, she says that she’s pondered leaving for some time and never planned to stay in the position for this long but found the agency “extraordinary.”

Legacy

Commissioner Hamburg’s reviews are mixed after years of FDA-centered controversy, some of which her defenders point out were not her fault or within her control. For example, in 2012, a compounding pharmacy in Massachusetts released tainted steroids that caused 64 deaths and hundreds of other illnesses from fungal meningitis. Lawmakers argued that Commissioner  Hamburg and the FDA had failed in their regulatory duties, but others pointed out that compounding pharmacies are regulated by states and not under federal purview.

Key Moments

Commissioner Hamburg led the agency through the implementation of the Food Safety Modernization Act (FSMA) (P.L. 111-353) and the Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) (P.L. 111-31). She was at the center of a controversy between the courts, the White House, HHS, and the FDA, regarding age restrictions on emergency contraception with the Secretary of HHS overruling her decision to make emergency contraception available to all women of child-bearing potential.

Industry Responses

Commissioner Hamburg was named to the job in 2009 by President Obama after problems at the agency grew increasingly alarming, and she describes the agency morale as “low” when she started. In years prior to her appointment, the FDA failed to publish warnings regarding the anti-inflammatory drug Vioxx®, which was believed to have caused thousands of deaths before it was pulled from the market, and a previous commissioner had hidden his investments in pharmaceutical companies regulated by the agency. Although many find that her presence stabilized the agency and allowed it to flourish, others were concerned about overreaching. The FDA approved 51 new drugs and biologics last year, the most in 20 years. Some think the agency has gotten too close with pharmaceutical companies and is approving drugs too quickly without clearly studying the effects. Others praise the expedited development and streamlined process of drug testing and approval. Many are concerned about the FDA’s lack of involvement in opioid dependency. Regardless of opinion, most agree that the FDA has many important steps to take in the future regarding obesity, electronic cigarettes, opioids, cancer treatments, and food safety.