Quarterly News from the WI Cancer Council Policy Committee | August 2018
Biden Cancer 
Community Summit

Sept. 21 | Noon - 2:30 | Lunch Provided
A special celebration of cancer treatment innovation in Wisconsin.

What We Know About E-Cigarettes
This month the Policy Committee welcomed Dr. Douglas Jorenby, a Professor of Medicine at UW's School of Medicine and Public Health and Director of Clinical Services at the UW Center for Tobacco Research & Intervention, to discuss the latest science surrounding e-cigarettes and other electronic nicotine delivery systems. 

(Note: We will use the term "e-cigarettes" to encompass all such products in this article.)
The Policy Committee has been following the emerging issue of youth e-cigarette use for some time, and recently added this issue to the 2018-2020 Policy Agenda. Dr. Jorenby's presentation, and the conversation that followed, added depth and nuance that will contribute to our efforts to track policy and regulation in this arena.
Dr. Jorenby began by highlighting the substantial diversity and rapidly changing technology of e-cigarette devices. "Any conclusions we draw come with an asterisk," he said. "This field is moving so quickly-both the technology, and the research into what's going on."
This product diversity comes with significant policy implications. For example, because levels of nicotine and other chemicals in secondhand smoke from e-cigarettes vary between products, smoke-free air policies that include e-cigarettes must comprehensively include all device types in order to be effective and enforceable.
Dr. Jorenby also discussed the data on usage and the implications for policy and practice. E-cigarette use among youth is substantially higher than use among adults (a trend we have been tracking in Wisconsin). This is significant, as evidence presented by Dr. Jorenby shows that youth and young adults who begin using e-cigarettes are not only exposing themselves to harmful amounts of nicotine, but also are more likely to begin smoking traditional cigarettes, and potentially at an even higher frequency and intensity. This is supported by a recent National Academies of Sciences, Engineering, and Medicine (National Academies) report.
In addition, e-cigarettes are attracting new users who previously have never used tobacco products-more than 11% of adult e-cigarette users were previously never smokers. And almost 60% of adult users are "dual-users" who are using both traditional and e-cigarettes.
However, evidence suggests that completely substituting e-cigarettes for traditional cigarettes does reduce a user's exposure to dangerous chemicals associated with cancer risk (the National Academies calls this conclusive evidence). Harm reduction potential could be tempered by the exponential increase in youth initiation and the fact that most users appear to be dual-users and not exclusive e-cigarette users, but more research is needed to determine the overall public health impact. Currently, UW CTRI is conducting research specifically into these dual-users.

As this evidence continues to develop, it may be important to  strike a balance between policies and regulation that prevent youth access to e-cigarettes with those that support investigating the potential e-cigarettes have for reducing the cancer risk of current adult smokers.
For the time being, the Policy Committee's focus will remain on  youth access and  local progress on expanding smoke-free air policies to include e-cigarettes, while we continue to track the evidence surrounding harm reduction and adult cessation potential.


E-Cigs, JUUL, and Vaping Resources  - UW Center for Tobacco Research and Intervention

Learn about the evolution of e-cigarette technology--check out our sidebar online
How Does Wisconsin Measure Up?
The report grades each state in nine areas of public policy affecting cancer prevention and access to care, including cancer screening, indoor tanning restrictions, and access to palliative care.
In six of the nine categories, the report graded Wisconsin as "doing well" or making "some progress."
"We use the report in a number of ways- the most important way is with state lawmakers," said Sara Sahli,  WI Government Relations Director for the American Cancer Society Cancer Action Network . " The report gives them a comprehensive look at all of the policies a state could choose to pass that would have an impact on cancer."
Each state chooses one area of their report card to highlight in the media. ACS CAN Wisconsin has chosen palliative care as its priority issue for 2018, due to the significant impact early access to palliative care services has on the quality of life of cancer survivor and their families. Our state made progress in this area last legislative session , by introducing and beginning to advance a bill to create a state palliative care advisory council that would evaluate access and identify barriers to palliative care services in our state, educate the public on this essential service, and recommend solutions to policymakers. ACS CAN will be looking to build on last year's progress as the next session begins.
ACS CAN Wisconsin will be sharing the report with Gov. Scott Walker and gubernatorial candidate Tony Evers (D). In addition, this is the first year the group will share the report with every member of the state legislature.
>> Check out Wisconsin's report card - and read the full report for emerging issues and state-specific examples and best practices.
Preview: 2019 Open Enrollment
The 2019 Open Enrollment period in the Affordable Care Act marketplaces will run Nov. 1-Dec. 15, 2018. Sam Austin, health policy analyst at UW's Population Health Institute, shared a preview of what to expect in Wisconsin as we look toward the open enrollment period.
So far, Wisconsin's marketplace looks to be quite stable, with limited premium increases and insurers continuing to participate (and even returning, in the case of Molina Healthcare). This is good news for Wisconsin residents, and especially for cancer survivors, as it should mean continued access to affordable and comprehensive health insurance options across the state this year.
The Committee discussed why premiums appear to be more stable - last year, in contrast, they rose an average of 36%. Potential reasons include the state's recently approved reinsurance program and the fact that marketplace enrollment remained relatively stable last year despite anticipated fall-out from certain federal changes- such as reduced support for outreach and enrollment, a shortened enrollment period, and the halting of the reimbursements insurers received for discounts they provide to consumers. In essence, insurers may have overcompensated last year and raised premiums more than warranted.
Unfortunately, Covering Wisconsin and other marketplace Navigator groups across the country are once again tasked with doing the same level of outreach with less funding support. To supplement a significantly smaller federal grant amount-WI will receive 85% less this year than the state received in 2016-local groups in Dane County and Milwaukee are stepping up with funding, similar to last year, to support outreach and enrollment efforts in those areas of the state.
Continued health insurance outreach to consumers is crucial. Data show that a significant portion of Wisconsin's remaining uninsured residents are potentially eligible for BadgerCare or financial help paying for a Marketplace plan and may not know about open enrollment. Health insurance is complicated- especially for cancer survivors and those undergoing active treatment-and many people need help understanding how to choose and use their coverage. Surveys show that people who are uninsured, need language help, or have other barriers to accessing insurance are more likely to be served by navigators than other assisters like health insurance agents or brokers. Covering Wisconsin and the Northwest Wisconsin Concentrated Employment Program are partnering to apply for this year's federal grant and will find out their final award amount next month.
As we near November 1 , we will keep you informed of changes and ways you can help spread the word about this year's Open Enrollment period. Stay tuned!
Announcing a New Committee Chair
Paul Westrick
Big news! After almost eight years of service in WI Cancer Council leadership, including five as Policy Committee Chair, Paul Westrick is stepping down from his leadership role. Assuming the gavel as Policy Committee chairperson will be HJ Waukau, policy specialist with the Wisconsin Medical Society .
"Paul has been an outstanding leader of this committee," said Courtney Harris, WI CCC Program policy coordinator who staffs the Policy Committee. "I'm personally very grateful for everything he has taught me about health policy, advocacy, and cancer survivorship. Paul has helped me understand what cancer prevention and control really mean for the people we're serving-the people experiencing cancer across the state of Wisconsin."
HJ Waukau
After retiring five years ago from administration at Columbia St. Mary's in Milwaukee, Westrick said he "dove from paid work into volunteer work around cancer advocacy." Fortunately, he will remain on the Committee as a member-at-large.
The Policy Committee is excited to welcome HJ Waukau as the new chairperson. "He's someone who can pay attention to the details, decipher what those details mean, and help the rest of us understand," Westrick said. "He will be a great voice for the work we do."
Added Waukau: "When Courtney [Harris] approached me to see if I was interested in the position, I said one, absolutely! And two, I don't know if can fill the shoes Paul is leaving. Cancer strikes a personal cord for me, and I'm really looking forward to this work."
Preparing for the 2019 Legislative Info Drop
At the beginning of each new legislative session, members of the Policy Committee visit the state capitol and deliver materials to the office of every member of the senate and assembly, introducing legislators to the WI Cancer Council and our work.
In early 2019, the Committee will be at it again-but this time, they will be taking a more targeted approach in the hopes of making an even greater impact.
In addition to the usual introduction letter and data sharing, the 2019 info drop will include issue-specific education aligned with our WCC Action Plans, and may also include more targeted meetings with legislators and personal stories from Council members working on the frontlines of cancer prevention and control.
"We don't make any asks," explained Courtney Harris, WI CCC Program policy coordinator. "We just introduce ourselves, talk to lawmakers about the cancer burden in their districts, and let them know that we're a resource for information."
>> Interested in learning more about the legislative info drop? E-mail Courtney Harris at charris2@wisc.edu.

>>  As part of the Trump Administration's Blueprint to Lower Drug Prices , the Centers for Medicare & Medicaid Services announced this month that it would allow Medicare Advantage plans to require prior authorization or step therapy for prescription drugs covered under Medicare Part B. These are mainly physician-administered drugs, including many chemotherapies . The goal of this change is to give Medicare Advantage plans-which cover about 30% of Medicare beneficiaries- leverage to negotiate lower prices from drug companies, which could lower costs for Medicare and consumers. However, prior authorization and step therapy-where patients are required to "fail first" on a less expensive drug before moving on to the one preferred by their physician-also create hurdles for both patients and physicians that can negatively affect timely access to treatment and physician workload. Given the potential impacts on cancer patients, it will be important to watch how these tools are used and what safeguards are put in place to protect patients.

>> Wisconsin's request to create a state-based reinsurance program was approved by CMS in July. The Wisconsin Healthcare Stability Plan (WIHSP) will reimburse insurers for a portion of the costs they incur covering patients in need of expensive care, such as individuals undergoing cancer treatment, which should lower premiums in Wisconsin's marketplace. Programs like WIHSP that help hold down premiums are especially essential given other recent federal changes, such as the zeroing out of the individual mandate penalty and expanding access to short-term and association health plans . These changes threaten to increase premiums as healthy individuals choose to leave the marketplaces, leaving behind a pool of patients with more expensive coverage needs.

>>  The Policy Committee has been following the progress of the  Legislative Study Committee on Alcohol Beverages Enforcement  happening at the State Capitol this summer. So far, it appears this group is pursuing a very narrow agenda. It includes potential changes to certain unlicensed venues, so called "wedding barns," that may modestly impact alcohol availability, and enforcement concerns within the Department of Revenue. This relieves some  public health advocate concerns  that the Legislative Study Committee could pursue preemption of local control of the alcohol environment or specific policies that could exacerbate Wisconsin's  excessive drinking problem  by  increasing alcohol availability or affordability

>> The Palliative Care Hospice Education & Training Act (PCHETA), the federal bill to support and expand access to palliative care, unanimously passed the House in July and is now progressing in the Senate. PCHETA, co-sponsored by WI Sen. Tammy Baldwin in the Senate, is a bipartisan effort to support this key component of quality cancer care. The American Cancer Society Cancer Action Network  supports the bill and is working to mobilize grassroots support in preparation for its federal lobby day in Washington, DC, in September.

>> A new bipartisan federal bill, the SAFE Kids Act (S. 3319), introduced by Sens. Dick Durbin (D-IL) and Lisa Murkowski (R-AK), would ban flavors in most tobacco products, including e-cigarettes. Although flavors except menthol have been banned from traditional cigarettes since 2009, this bill would expand that prohibition to other tobacco products with significant youth appeal. The bill aligns with other efforts at the FDA and at state and local levels to target kid-friendly flavors and marketing practices thought to be contributing to exponential increases in youth use of these products in recent years.
The ACA Goes to Court 
Next week, the lawsuit being brought by Wisconsin and several other states that threatens to overturn the Affordable Care Act's health insurance protections for individuals with pre-existing conditions, will be in court.  Recently, several Republic Senators introduced a bill with the stated purpose of saving those protections if the lawsuit is successful. 

However, experts say that the bill still leaves a huge gap in protections -- namely, it would prohibit insurance denials or higher premiums based on health conditions, but would allow insurers to deny coverage of the health condition itself. For example, a cancer survivor could still purchase insurance, but that insurance may not cover any treatment related to their cancer. 

Again, this lawsuit is far from decided , and this bill may not be necessary, but we will continue to track its progress.
Including a session on communicating the cancer risk of excessive drinking.
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