Three ways Shapiro’s budget would change public health in Pennsylvania

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HARRISBURG — When Josh Shapiro pitched his first budget as Pennsylvania’s governor during a nearly hour-and-a-half speech in March, the Democrat didn’t say “COVID” or “coronavirus.”

But Shapiro’s budget responds to the pandemic, which has exposed weaknesses in the state’s public health system, by proposing more funding for local health departments. Those agencies were on the front lines of responding to the coronavirus, and advocates say they have been underfunded for years.

His pitch for the Department of Health also revealed other priorities, including addressing the deaths of Black mothers through a small new and targeted investment.

The proposal also looks to the future by proposing a 20% tax on adult-use cannabis — which advocates see as a powerful symbol that the issue is important to the new administration. But they also know it comes with no guarantee that the legislature will actually approve legalization.

That particular change could impact a wide range of public health issues, including emergency room visits and poison control center calls. It would also give an alternative option to hundreds of thousands of patients who now need a doctor’s permission at least once a year to participate in the state’s medical program.

As lawmakers face a June 30 deadline to pass a final budget, here’s a closer look at those three measures, what Shapiro’s proposing, and how they would affect health care in the state.

The coronavirus, in many ways, dominated state politics for much of former Gov. Tom Wolf’s final years in office. Shapiro’s Democratic predecessor issued more than a dozen vetoes related to the pandemic, a Spotlight PA analysis found. And in 2021, voter referendums pushed by GOP lawmakers put new limits on a governor’s emergency powers.

The coronavirus hasn’t received as much attention as newly reported cases and deaths have dropped nationwide. But the state’s acting health secretary, Debra Bogen, and some public health advocates said the pandemic highlighted long-standing gaps in the state’s public health infrastructure.

“Making sure health departments are fully funded prepares us for things we can’t predict and helps just overall create a healthier Pennsylvania,” Antoinette Kraus, executive director of the Pennsylvania Health Access Network, a consumer advocacy organization, told Spotlight PA.

Shapiro’s budget proposes an increase for county and municipal health departments that would give $1.2 million more to their operating budgets and an additional $6.6 million for initiatives that address water pollution, food safety, and other health concerns.

Seven counties in Pennsylvania have their own health departments: Allegheny, Bucks, Chester, Delaware, Erie, Montgomery, and Philadelphia. Four cities — Allentown, Bethlehem, Wilkes-Barre, and York — operate their own, as well. In its budget materials, the Shapiro administration said more than 40% of Pennsylvania residents live in a county or municipality served by a local health department. The budget also includes funding for a planned new health agency in Lackawanna County, a Shapiro spokesperson told Spotlight PA.

During a budget hearing, State Rep. Eric Nelson (R., Westmoreland) noted that his county does not have its own health department and said he’s concerned about giving a “massive increase” to a relatively small number of counties and cities.

“It appears we’re building silos versus breaking them down,” Nelson said.

Local health agencies do work that otherwise would fall to the state government, Bogen replied during the hearing, arguing that dividing responsibilities among local and state officials “seems to work.”

Budget materials from the governor’s office say other proposals — such as increased mental health funding and initiatives to recruit and retain workers — respond to problems exacerbated or highlighted by the pandemic.

Local health leaders told Spotlight PA that their offices are able to quickly address problems that arise in their communities, and the proposed increases in funding would offer stability to their offices, since support from various grants, and other sources varies year to year.

“COVID showed that we need to have a strong infrastructure if we’re going to handle the next thing that comes down the pike,” David Damsker, director of Bucks County’s Health Department, told Spotlight PA.

During Shapiro’s budget address, he described a rising maternal mortality rate in Pennsylvania and nationally, and noted that Black women are at greater risk for pregnancy-related deaths, an inequity he called unacceptable.

“The first step is understanding why that is happening,” Shapiro said. “So for the first time ever, we are going to put real resources into studying exactly that — so we can make concrete investments to address this disparity.”

His budget proposes a modest amount of new funding aimed at building off of the work of the Pennsylvania Maternal Mortality Review Committee. Lawmakers created that group in 2018, and tasked it with reviewing pregnancy-related deaths and developing prevention strategies.

Shapiro’s budget calls for $2.3 million to implement strategies and recommendations from the committee, and his administration says it could leverage that additional state funding to receive $1.25 million more in federal funds. The proposed state money would be used to establish a Division of Maternal Health in the Health Department.

During one budget hearing, acting Health Secretary Bogen referred to the proposed $2.3 million as “a great start.” State Rep. Gina Curry (D., Delaware) told Spotlight PA the proposal is an “initial investment” and “an acknowledgment that we haven’t seen in the past.”

While pregnancy-related deaths are rare, research shows they are often preventable, and maternal health advocates say they have a large impact.

“When moms die, it has a ripple effect — and lasting effect on children … on support people, on families, communities, and, quite frankly, the entire human race,” said Sharee Livingston, an obstetrician and gynecologist in Lancaster County, during recent testimony in Harrisburg.

The number of pregnancy-associated deaths rose in Pennsylvania from 84 in 2013 to 102 in 2018, according to a state Health Department report from 2020. Pregnancy-associated deaths are defined as ones that occur while a person is pregnant or up to one year from the end of the pregnancy, regardless of the cause.

Non-Hispanic Black people accounted for a disproportionate share of pregnancy-associated deaths, the 2020 report found. They accounted for 14% of births in Pennsylvania during the six-year time period reviewed, but they represented 23% of the pregnancy-associated deaths.

“Every year we experience an overwhelming loss in Black maternal mortality,” Curry said during a recent Capitol rally. “And the research shows that we are losing the fight ultimately because of the racial disparities that continue to haunt the very experience that is supposed to bring joy and autonomy.”

In interviews and public comments, some lawmakers and maternal health advocates have called for broader changes to address systemic issues, including diversifying the medical ranks and expanding Medicaid to cover doulas who provide physical and emotional support to pregnant people.

Under Wolf, Pennsylvania opted into a change that advocates say can help improve maternal health and address racial disparities: extending pregnancy-related coverage through Medicaid from 60 days after a child’s birth to 12 months. A Shapiro spokesperson said the governor’s budget continues that extension.

Doulas cannot currently be directly paid by Pennsylvania’s Medicaid program, according to Department of Human Services spokesperson Natalie Scott. But she said the agency is working to expand their availability.

Advocates say change is needed — and possible.

“There are solutions. This isn’t a problem that we can’t fix,” Livingston, a founding board member of health advocacy group Patients R Waiting, told Spotlight PA. “We just have to remain steadfast on the solutions and commit to them.”

Cannabis for adults 21 and older is already legal in New York and New Jersey. Maryland plans to launch its adult-use program in July, and Delaware’s governor in April allowed adult-use legislation to become law without his signature.

But the future of legalization in Pennsylvania is unclear.

Many state House Democrats are pushing legislation that would legalize adult use, but the caucus has a narrow majority. A caucus spokesperson told Spotlight PA “proposals for adult use cannabis and proposals for taxation will be discussed over the course of budget negotiations” but didn’t make any commitments.

Republicans control the state Senate, and only two GOP legislators in that chamber have publicly come out in support of adult-use legalization.

State Senate Majority Leader Joe Pittman (R., Indiana) recently declined to say whether the legislature was likely to modify the medical program or legalize adult use. But he emphasized that marijuana remains illegal at the federal level.

“This is something, at the end of the day, the federal government is going to have to address head-on,” Pittman said in April. “I think the state-by-state policies make it very difficult from a law enforcement perspective to maintain consistency in how we handle drug enforcement policy.”

Despite those headwinds, Shapiro’s budget proposes a 20% tax on the wholesale price of adult-use cannabis products, and it assumes sales will begin at the start of 2025. Such a tax would eventually bring more than $188 million to the state annually, according to his administration’s revenue estimates.

Shapiro’s predecessor, Wolf, advocated for adult-use legalization in his final budgets but did not include specific rates or revenue projections.

Meredith Buettner, executive director of the Pennsylvania Cannabis Coalition, an industry group, sees the tax’s inclusion in Shapiro’s budget as a powerful symbol of support and an “impetus to get the ball rolling, to get it done.” She thinks an adult-use bill would need to pass by the end of 2023 to meet the 2025 sales goal in Shapiro’s budget.

Shapiro’s adult-use legalization proposal wouldn’t affect revenue for the budget lawmakers must pass by the end of June, and his budget package did not go into details about what an adult-use program would look like in Pennsylvania. It doesn’t address employment rights for cannabis users, protections against improper DUI arrests, expungements of prior convictions, and a host of other issues.

Bogen told lawmakers she had not seen a specific proposal for adult-use cannabis. But the health secretary said she wants to ensure the medical marijuana program — which she described as “very successful” — continues to serve people who wouldn’t access cannabis through an adult-use program.

“It’s going to take a lot of stakeholders at the table really talking about how we make those programs work together,” Bogen said during a state Senate budget hearing in April.

The impact of adult-use legalization is broad: The change could affect workplace policies, traffic safety, and other issues, according to a 2021 analysis from Pennsylvania’s Independent Fiscal Office. But the office’s director, Matthew Knittel, also noted that there are potential cost-savings associated with legalizing adult-use cannabis, including fewer public safety resources being dedicated to marijuana arrests.

Pennsylvania lawmakers in 2016 approved legalizing medical marijuana. Dispensaries have since reported $4.4 billion in sales, and there were more than 425,000 active certifications for patients as of late March. For next year’s budget, Shapiro’s administration estimates the medical marijuana program will bring in $37.5 million from a tax on sales to dispensaries, plus nearly $17 million from patient identification card fees.

In Pennsylvania, the state charges patients an annual fee of $50 for a medical marijuana card, although it waives the fee for some patients with financial hardships. At least once a year patients need a physician to approve them for the program, and those renewals sometimes cost $100 or more. Still, a medical program could have cost benefits for consumers, as states typically impose a lower tax rate on medical cannabis sales than recreational ones.

Across the country, legalizing recreational cannabis use is associated with declining enrollment in medical cannabis programs, according to findings published in the International Journal of Drug Policy last year.

The authors said their findings may be of public concern for a few reasons: People could be exaggerating symptoms in states where medical cannabis programs are the only legal option. Or, the authors wrote, people might be using cannabis for medical reasons in adult-use states, but opt out of doing so with any medical oversight.

While some cannabis advocates are pleased adult-use legalization made it into Shapiro’s budget proposal, they also worry lawmakers won’t make the issue a priority.

“People have to realize the urgency of the situation and the necessity for change,” said Les Stark, executive director of the advocacy group Keystone Cannabis Coalition.

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