November 2015—Public Health Law News

The past year, and the last six months in particular, have been incredibly busy for CDC’s Public Health Law Program (PHLP). We hit the ground running in autumn 2014, responding to requests for assistance related to CDC’s Ebola response. Two attorneys in our office, Gregory Sunshine and Dawn Pepin, collected and analyzed state Ebola protocols. We published State Ebola Screening and Monitoring Policies for Asymptomatic Individuals in December 2014 and have continued to update the document as states continue to update their policies.

As the year continued, we published research, including Coroner/Medical Examiner Laws, by State, State School and Childcare Vaccination Laws, and a Menu of State Turtle-Associated Salmonellosis Laws.

Beginning in June 2015, PHLP attorneys Tara Ramanathan and Aila Hoss were deployed to assist in the Ebola response. They responded to legal and policy issues in CDC’s Emergency Operations Center (EOC), which heads up CDC’s Emergency responses across the globe. In September 2015, Ms. Ramanathan was also deployed to Guinea as part of the Ebola response, and Mr. Sunshine began a part-time deployment in the EOC.

At the same time, PHLP attorneys were traveling all over the country to deliver Public Health Emergency Law (PHEL) trainings to local and state health departments. PHLP trained more than 540 people in PHEL and more than 4,600 people overall since December 2014. 

These are just a few highlights of the past year, highlights that wouldn’t be possible without the other PHLP attorneys and staff, our external partners, and the exceptional support of our home office within CDC, the Office for State, Tribal, Local and Territorial Support.

This November, at the American Public Health Association Conference in Chicago, Illinois, our director, Matthew Penn, was awarded the Jennifer Robbins Award for the Practice of Public Health Law. It is both humbling and thrilling to have such attention focused on our program.

In 2016, PHLP will celebrate our 15th year. We are incredibly grateful to the community of public health and public health law practitioners who support us and are the driving force behind our work. Over the coming year, PHLP is committed to continuing to serve state, tribal, local, and territorial communities and increase their ability to use law as a tool to improve public health.

Stay tuned to the Public Health Law News for announcements about PHLP’s upcoming plans, trainings, meetings, and developments in public health law.

With gratitude,

F. Abigail Ferrell, JD, MPA,
Editor in Chief

Job Announcement: Public Health Attorney, Network for Public Health Law—Mid-states Region
The Network for Public Health Law is seeking a public health attorney for its Mid-States Regional Office, located at the University of Michigan School of Public Health. The public health attorney will help the Mid-States Region with its efforts to strengthen the ability of public health practitioners, counsel, and other stakeholders to use law efficiently and effectively to protect and promote population health. The public health attorney will provide technical assistance on specific issues of public health law, conduct training, develop tools and educational materials, and facilitate opportunities for networking and peer-assistance. Applications must be submitted to through the University of Michigan website by November 30, 2015.

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Webinar Series on the Intersection of Public Health and Health Care—The Role of Law. The American Health Lawyers Association and CDC’s Public Health Law Program (PHLP) are co-hosting a six-part, free webinar series focused on legal issues at the intersection of public health and health care. The last webinar in the series, One Year of Ebola—Legal Issues and Considerations will take place Friday, November 20, 2015, 1:00–2:30 pm (EST). This webinar will examine the current state of Ebola in West Africa, the legal considerations implicated in the US response to the outbreak, state screening and monitoring policies and their evolution over the past year, and how healthcare settings are legally preparing for the next threat. 

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NACCHO Annual 2016. The National Association of City and County Health Officials will host its annual conference July 19–21, 2016 in Phoenix, Arizona. The theme is “Creating a Culture of Health Equity.” Proposals for sessions and posters must be submitted by Friday, December 18, 2015.

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2016 Public Health Law Conference. The Public Health Law Conference will take place September 15–17, 2016, at the Grand Hyatt, in Washington, DC. The conference, hosted by the Network for Public Health Law, is for public health lawyers, practitioners, officials, policymakers, researchers, and advocates. Conference attendees will learn about laws and policies affecting critical public health issues such as disease prevention, drug overdose, health data sharing, and access to care. Early bird registration is available now.

CDC Community Health Improvement Navigator (CHI Navigator). The CHI Navigator is a website for people who lead or participate in community health improvement work within hospitals and health systems, public health agencies, and other community organizations. It’s a one-stop-shop that offers community stakeholders expert-vetted tools and resources about the process of identifying and addressing communities’ health needs.

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Reducing Environmental Exposures in Child Care Facilities, A Review of State Policies. This report, prepared by the Environmental Law Institute and the Children’s Environmental Health Network, provides an overview of how state policy addresses indoor environmental exposures in childcare settings. While there has been considerable progress in establishing policies to address key indoor contaminants, there is ample room for strengthening state laws, regulations, and non-regulatory initiatives. The report describes the state of state policy today and highlights notable examples to assist policymakers, agency officials, non-governmental organizations and associations, and others who work to advance quality child care and promote children’s health.

Indian Country: US to share criminal records with Native American Police

New York Times   (11/05/2015)   Eric Lichtblau

The US Justice Department announced a new program aimed at filling gaps in current data sharing among tribal and US criminal justice entities. Namely, the new program, the Tribal Access Program for National Crime Information (TAP), will allow 10 Native American tribes around the country to share criminal and civil records with the federal government.

Certain offenses require that those who are convicted relinquish guns and makes these individuals ineligible to buy firearms. Tribes are sovereign nations within the United States and, as such, their criminal justice records are separate from those of US federal and state agencies. Though the conviction should preclude firearm sales, this separation means that people who were convicted in one court may be able to purchase or possess firearms without the non-convicting authority knowing.

This gap in the law was made painfully evident when a 14-year-old boy from a reservation used his father’s handgun to shoot four others and himself. During the investigation, authorities revealed that a prior restraining order against the father should have prohibited the father from buying the gun, but the order was never entered into the federal database.

In addition to obscuring prohibited gun sales, the lack of information sharing has also prevented officials from investigating crimes, apprehending fugitives, and to investigate and prevent domestic and sexual assault.  

“It’s been extremely frustrating. Sometimes the records get entered, sometimes they don’t. I believe this is something that should have happened years ago,” said Carlos Echevarria, the police chief for the Tulalip Tribe in Washington State, one of the tribes that will participate in TAP.

[Editor’s note: Learn more about the US Department of Justices’ Tribal Access Program for National Crime Information to provide tribes access to national crime information databases for both civil and criminal purposes.]

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Washington: Court orders TB patient to comply with treatment

Public Health Insider   (10/30/2015)  

In October, King County Superior Court, Washington, issued an order for electronic home detention of a non-compliant tuberculosis (TB) patient. It is estimated that this is only the eighth time in more than a decade that Seattle and King County Health Services Department has sought a court order to restrict a potentially contagious, non-compliant patient.

Dr. Masa Narita, Seattle King County’s TB control officer, said an action like this is always a last resort, but it was necessary in this case to protect the community’s health. “Tuberculosis can be infectious without treatment, so to prevent others from being exposed to TB in the community and to prevent development of drug resistant TB, a person with active TB needs to be treated with antibiotics consistently for several months. This person did not comply with treatment on numerous occasions, which puts the patient at risk for a prolonged illness or dying and puts others at risk as well,” said Dr. Narita.

The case has been ongoing since January 2015, when the patient was initially diagnosed with active TB in King County. At that time, the patient began treatment and agreed to stay away from other people, or isolate, until he or she was no longer infectious. The patient also had to complete directly observed therapy (DOT), which is when a healthcare worker watches the patient take each dose of the prescribed medicine. In March 2015 the patient was considered non-contagious and cleared from isolation. Subsequently, the patient began missing more and more DOT appointments, despite encouragement to continue the prescribed treatment and monitoring.

On Friday, October 23, 2015, King County Superior Court ordered the patient to be available at home each day for directly observed TB treatment. The patient will be detained and monitored at home through electronic home detention. Treatment will be completed in approximately four months, if the patient takes the medication consistently.

“Our goal is always to work with clients to help them successfully complete treatment which also protects the community from the spread of disease. We would always prefer to engage the patient and gain cooperation, and our program is typically very successful in these efforts,” said Dr. Narita.

[Editor’s note: Learn more about tuberculosis.]

California: Flytenow, the aviation version of Uber and Lyft, is locked in court battle with regulators
Los Angeles Times   (10/27/2015)   Dan Weikel

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Illinois: Illinois medical marijuana dispensaries begins sales
Chron.com   (11/09/2015)   Carla K. Johnson
[Learn more about medical cannabis in Illinois.]

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Massachusetts: Massachusetts medical schools aid war on opioid abuse
WPRI.com   (11/9/2015)  

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National: Claims for cryotherapy treatments get new scrutiny after a death
New York Times   (11/05/2015)   Julie Turkewitz

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National: FDA issues new guidance on new HIV antiretroviral drugs
Bloomberg   (11/02/2015)  
[Editor’s note: Read the FDA’s final guidance, Human Immunodeficiency Virus-1 Infection: Developing Antiretroviral Drugs for Treatment.]

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National: Lawmakers struggle to legalize Airbnb
Stateline 911/03/2015)   Sophie Quinton

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National: The complexities of defining a ‘farm’ under the Food Safety Modernization Act
Food Safety News   (10/26/2015)   Lydia Zuraw
[Editor’s note: Learn more about the Food Safety Modernization Act.]

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Indian Country: Adoptions of Native foster children by Native families becoming easier
KTUU   (10/30/2015)   Paula Dobbyn
[Editor’s note: Learn more about the Indian Child Welfare Act.]

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Indian Country: Marijuana legalization in South Dakota: Native American pot resort suspended until tribe gets legal guidance from US government, report says
International Business Times   (11.09/2015)   Aaron Morrison

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Indian Country: Meetings will address recovery after spill
Farmington Daily Times   (11/07/2015)  
[Editor’s note: Read the Navajo Nation’s Environmental Protection Agency’s notices regarding the spill and the US Environmental Protection Agency’s Emergency Response to August 2015 Release from Gold King Mine.]

Interview with Ashley Tuomi, Executive Director, American Indian Health and Family Services, Detroit, Michigan

Title:
Chief Executive Officer for American Indian Health and Family Services (AIHFS), Detroit, Michigan, President-elect for the National Council of Urban Indian Health

Education:
Doctorate in health sciences from AT Still University, master of health policy and administration from Washington State University

Tribe: The Confederated Tribes of Grand Ronde

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Public Health Law News (PHLN): Please describe your career path.

Tuomi: From a young age, I wanted to become a plastic surgeon and perform reconstructive skull surgeries. I ended up having what I call my mid-life crisis during my undergraduate studies as I was struggling with some of my coursework. I was pretty lost but found my master’s program and thought that I could run a plastic surgery clinic so I could at least watch some surgeries. Fast forward to today where I have nothing to do with plastic surgeries, but I have spent the last eight years working with tribal health clinics and urban Indian health programs.

PHLN: Moving from an interest in plastic surgery to urban Indian health seems like a dramatic leap. What motivated your change in course?

Tuomi: While I was completing my master’s program, I received a scholarship from the Indian Health Service (IHS) and knew that I would need to complete my payback at a clinic that provided services to American Indians/Alaska Natives (AI/AN). I decided that I needed to do everything that I could to learn about the IHS system. I took this as an opportunity to complete every project and paper on Native health. This included everything from health law classes to health technology.

PHLN: Please describe your day-to-day work responsibilities.

Tuomi: This is actually quite hard because I feel like I do so much, but if you were to look at my job description you would see that I am responsible for the day-to-day operations of the clinic, including management of finances, personnel, and provision of services, and representing the clinic in partnership with other clinics and entities. Some of the fun things that I also get to do include enrolling consumers in health insurance as a Navigator, doing community outreach, and working with the tribes in Michigan.

PHLN: What does “urban Indian” mean?

Tuomi: Urban Indians are Natives that currently reside off of the reservation and in an urban setting. They might have recently located to an urban location looking for better resources, including better access to employment. For some urban Indians, they were born and raised in an urban setting because their ancestors had moved to the area.

PHLN: What percentage of AI/AN people live in urban areas?

Tuomi: Approximately 70% of Natives live off of a reservation. This has risen dramatically from the 1960s and 1970s when almost half of the Native population lived on a reservation.

PHLN: Given the existing healthcare resources in urban areas, why are urban Indian health clinics necessary?

Tuomi: Urban Indian health clinics provide many more services than Natives can receive at another clinic down the street. We focus on providing a true integration of care focused on our culture and teachings. We integrate traditional medicine into the western medicine part of the services that we provide. Following the medicine wheel, we treat each patient as whole person. We pay attention to the physical, mental, emotional, and spiritual needs of our clients. In addition to medical and behavioral health services, we offer an array of complementary services and community programming.

PHLN: What’s the difference between a tribal health clinic and an urban Indian health clinic?

Tuomi: Besides the obvious difference in location, I think the biggest difference is the level of funding. Urban Indian health programs receive less than 1% of the total IHS budget, which means that we have fewer resources than many of the tribes. The tribal clinics also have funding that can be used for purchased and referred care to cover services outside of their clinics. As an urban clinic, we do not have access to that funding; therefore our clients receive fewer services than they would on a reservation.

PHLN: What health issues are most relevant to AI/AN populations? Are there health concerns that are unique or more pressing for urban Indians than those who live on reservations?

Tuomi: The health issues faced by urban Indians are similar to those who live on reservations. Overall AI/AN face many health disparities, including shorter life expectancy. They also face higher prevalence and morbidity rates of diabetes, depression, and cardiovascular disease.

PHLN: Can you please describe your clinic and the services it offers?

Tuomi: American Indian Health and Family Services (AIHFS) is a multi-service agency that provides medical services, behavioral health, substance abuse counseling and prevention, nutrition and exercise, cooking classes, youth programs, traditional healers and ceremonies, sweat lodges, suicide prevention, gardening, insurance enrollment, food assistance, and energy assistance.

PHLN: Who are your clients? Do you only see AI/AN patients?

Tuomi: Our mission is to serve the AI/AN community, their families, and other underserved people in the community. We accept anyone who seeks our services. We rely on cash payments and third-party billing for people who do not meet our funding requirements. We have a unique situation in Detroit, where we have a significant First Nations and Canadian Native population. While these populations do not fit into our IHS funding guidelines, we are still able to provide services through other funding that is not as restrictive and through our billing efforts.

PHLN: As a Patient Protection and Affordable Care Act health exchange insurance navigator can you describe why health insurance is particularly important to urban Indians?

Tuomi: As I mentioned previously, urban Indian health programs are not funded at the same level as tribal or IHS facilities. Therefore, patients often do not have access to important services, such as pharmaceuticals, x-rays, emergency room visits, specialty care, colonoscopies, mammograms, surgeries, or hospital stays. Without insurance, it is difficult to refer clients for services and the creativity that is needed to gain access requires a lot of time and is not always successful. With the changes that came with the Affordable Care Act, our clients have greater access to affordable health insurance.

PHLN: Why is insurance navigation particularly important to your clinic?

Tuomi: As a navigator organization, we are able to enroll our clients in affordable health insurance plans. In addition to our clients, we are also able to help others in the community. This last year we signed up more than 1,800 individuals in insurance plans that they can afford. We are very fortunate that Michigan also expanded its Medicaid program, which has decreased the rate of uninsured people in Detroit and the surrounding area.

PHLN: Can you describe your suicide prevention program?

Tuomi: AIHFS just received a second award as a Garrett Lee Smith grantee for our Sacred Bundle Program. The goal of this program is to promote mental and spiritual wellbeing and includes reaching out to at-risk groups. AIHFS provides the training and tools for our community members to actively participate in suicide prevention efforts.

PHLN: What is a gatekeeper and what kind of training do they receive?

Tuomi: Gatekeepers in our community are trained and able to assist in interventions with youth in the community. We know that not all youth who are need of services will seek out professional care or might not know where to get these services, so it is important to train our community members to help. Our gatekeepers receive trainings, such as “Question Persuade Refer and Applied Suicide Intervention Skills.” Other trainings include “American Indian Lifeskills,” “Gathering of Native Americans,” and “Native H.O.P.E. (Helping Our People Endure).”

PHLN: Can you describe your clinic’s services related to traditional medicine? Does it matter that traditional medicine practices vary from tribe to tribe?

Tuomi: As an urban clinic, we serve tribal members from all across the country, which can make it difficult when trying to offer traditional and language services to such a diverse population. Because we can’t bring in every traditional healer, we rely on the culture and practices of the region that our clinic is located in. We bring in traditional healers from Michigan tribes and Canada to offer one-on-one visits with traditional healers, ceremonies, and sweat lodges. We also integrate the local language into our services as well.

PHLN: It sounds like you have a highly integrative practice model. Is that intentional and, if so, why?

Tuomi: This is very intentional because we recognize that we cannot treat just one part of a person. The care we provide follows the medicine wheel. Therefore, our services need to address the physical, mental, emotional, and spiritual needs of our clients. Before the trend of integrative medicine became popular, native clinics were already using this model

PHLN: How does law relate to your clinic’s practice and operations?

Tuomi: The biggest way that our clinic is impacted by law is that we would not exist as we are today without some very important laws. In 2010, the Indian Healthcare Improvement Act was permanently reauthorized as a part of the Affordable Care Act (ACA). This important act provides the basis for the provision of care to the AI/AN tribal members throughout the United States. While this was an important part of the ACA, there were also some complications that came from the language in the ACA. The definition of Indian was not the same as the definition used by IHS or the Bureau of Indian Affairs. It is also different from the definition used by Medicaid. This has made it difficult for many Natives to discern whether or not they qualify for an insurance enrollment exemption and whether they qualify for the special provisions related to cost-sharing and open enrollment. For one purpose, a person might be considered to be a Native, but for the cost-sharing provisions that person would be considered a non-Native. We are also currently working on issues related to 100% Federal Medicaid Assistance Percentages (FMAP) and payments for Medicaid services. Urban Indians currently do not qualify for 100% FMAP or receive the same Medicaid payments as they do through tribal clinics.

PHLN: Who are First Nations people and why are they not always eligible for US-funded services?

Tuomi: When the United States was created, there was an imaginary line drawn between the United States and Canada. This caused many tribes to be split between the United States and Canada. The US government has a unique government-to-government relationship with the 566 federally recognized tribes in the United States. Our government also has a treaty obligation to provide health care to tribal members. This relationship and obligation leads to funding for IHS; therefore there are defined eligibility requirements that restrict the availability of services for tribal members from Canadian tribes.

PHLN: Can someone be First Nations and AI/AN?

Tuomi: In terms of membership, a person generally cannot be a member of two different tribes. However, there are some tribes in the United States that have adopted their members across the border.

PHLN: Can someone be First Nations and an American citizen?

Tuomi: Many First Nations tribal members have relocated to the United States based on the Jay Treaty and their right to live and work in the United States. In fact, many First Nations tribal members were born and raised in the United States.

PHLN: You mentioned FMAPs—what do they have to do with urban Indians and public health law?

Tuomi: With 100% FMAP, states receive reimbursement for 100% of the services provided by the state’s Medicaid program if those services are received at an IHS or tribal health facility. Currently services provided by the urban Indian health programs are not reimbursed at 100% even though these programs are contracted by IHS to provide services to Natives. Currently, the states are only reimbursed at the state established FMAP for patients of an urban clinic. In Michigan, that rate is 65.60%; therefore, the state is missing out on a large amount of reimbursement from the federal government. Currently, tribes and IHS facilities also receive an IHS published rate for visits, while urban clinics have to apply for the federally qualified health centers ates that are much lower. As urban Indian health programs, we are working towards getting parity in level of reimbursement.

PHLN: How can reservation-based health entities and urban-based entities coordinate to protect and support AI/AN health?

Tuomi: As urban programs, we have done a lot to educate the tribes about the services that we provide for their tribal members. This effort to educate has allowed us to gain the support of most tribes, which can lead to support for increased funding allocations and resource sharing in some areas. It is also important for urban clinics to lend support to the tribal health centers in their areas. AIHFS has been focusing on giving back to the tribes by providing training and assistance with Navigator activities, electronic health record training, and suicide prevention training.

PHLN: What do you like about your job?

Tuomi: There is so much that I like about my job, but most importantly I get to work with other Natives to improve the health and well-being of our community. Besides that, I love that I get to work in the community and am not stuck behind a desk in some high-rise, for-profit health center. I get to see firsthand the impact that our clinic has. I also get an opportunity to work directly with clients as I assist them with enrolling in insurance.

PHLN: If you weren’t directing an urban Indian health clinic, what would you likely be doing?

Tuomi: I really don’t know what else I would be doing, but I know that I would still be working in Indian health in some capacity. This truly is my passion and I can’t imagine working in any other sector.

PHLN: Have you read any good books lately?

Tuomi: I rarely get the chance to read for fun anymore, but I do try and keep up with various healthcare and public health journals. If I do have time, I like to read cookbooks or cooking magazines. It seems the only time I get to read for pleasure is when I’m on a plane.

PHLN: What are your hobbies?

Tuomi: I love to bead. I was taught a little while ago by one of my cousins, and my beading has taken off from there. I currently just bead earrings or other jewelry for myself, family, and friends. I did just finish my first pair that I am actually going to sell, which is exciting. I have a couple of projects lined up, but I am most excited to make my breast cancer awareness earrings that will be used as an incentive to our Native women who get their mammograms.

PHLN: Is there anything you would like to add?

Tuomi: I feel like there is so much more that I could share, but I would take up this entire newsletter. Thank you for this opportunity to share part of our story with your readers.

The first reader to correctly answer the quiz question will be given a mini public health law profile in the December 2015 edition of the News. Email your entry to PHLawProgram@cdc.gov with “PHL Quiz” as the subject heading; entries without the heading will not be considered. Good luck!

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Public Health Law News Quiz Question: November 2015

Dr. Ashley Tuomi is the president-elect of what national organization?

Kimberly Noble Piper

October Question: What law school did Andy Baker-White attend?

Winning response: 
Andy Baker-White received his JD from the University of Kentucky College of Law

Employment organization and job title: Comfort Care Home Health, LLC; Agency Administrator

Employment organization and job title: Executive Officer, State Genetics Coordinator, Iowa Department of Public Health, Center for Congenital and Inherited Disorders. 

A brief explanation of your job: I am the administrator for Iowa’s public health genetics programs, including newborn screening, maternal prenatal screening, regional genetics consultation clinics, family health history, and Iowa’s birth defects registry.

Education: RN, Iowa Methodist School of Nursing; BS in health arts, University of Saint Frances in Joliet, Illinois; certification in public health, University of Iowa; certification in public health genomics, Sarah Lawrence College, Bronxville, New York

Favorite section of the News:  I like the Briefly Noted section for a broad perspective of public health issues important to other states and at the national level. I also like the Court Opinions section to see how challenges for public health law are addressed.

 Why are you interested in public health law? As most of you know, genetics and genomics is faced with many ethical and legal issues. Every day can bring a new challenge. I am fortunate to have the guidance of a wonderful state assistant attorney general, but the more I can understand about laws and policies concerning public health genomics, the better administrator I can be.

What is your favorite hobby?  I enjoy reading, mostly non-fiction with an occasional historical fiction thrown in. I especially like sitting outside and reading with a glass of wine!

Georgia: Failure to notify patient of HIV diagnosis is classic medical malpractice claim
Piedmont Hospital, Inc. v. DM
Court of Appeals of Georgia
Case No. A15A1572, A15A1573
Filed October 28, 2015
Opinion by Judge Carla Wong McMillian

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Federal: No federal privilege for peer or mortality reviews, defendant must produce these reviews
Avila v. Mohave County
United States District Court, District of Arizona
Case No. 3:14-cv-8124-HRH, Prescott Division
Filed 11/02/2015
Opinion by District Judge H. Russel Holland

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Federal: EPA granted access to contaminated site, planned remedial actions sufficiently justified
United States v. Gearing
United States District Court, Central District of Illinois, Peoria Division
Case No. 15-cv-1333
Filed 10/30/2015
Opinion by Senior District Judge Joe Billy McDade

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Federal: Patent attorney’s suit dismissed, no evidence patent filing quotas violated rules of attorney conduct
Trzaska v. L'Oréal USA, Inc.
United States District Court, District of New Jersey
Civil Action No 2:15-cv-02713-SDW-SCM
Filed 10/30/2015
Opinion by District Judge Susan D. Wigenton

Quotation of the Month: Navajo Nation Attorney General Ethel Branch

"We want the Navajo people to obtain full, fair, and prompt recovery for all damages suffered. Additionally, we want to ensure that the public is informed about the status of ongoing recovery efforts and efforts to clean up the environmental damage caused by the Gold King Mine spill," said Navajo Nation Attorney General Ethel Branch.