2008-09 AMSA Legislative Agenda

8. Congress must pass legislation to control and eventually eliminate negative environmental determinants of health, and invest in a primary care workforce for underserved communities.

National Health Service Corps (NHSC) Background

On January 11, 2007, Rep. Conyers introduced the "United Sates Physician Shortage Elimination Act of 2007" (H.R. 410), which provides for an additional 1,500 NHSC annual awards to physicians.

On June 28, 2007, Rep. Braley introduced the `National Health Service Corps Scholarship and Loan Repayment Programs Reauthorization Act of 2007'. This bill passed in summer 2008.

We must not spread the limited resources of the NHSC too thinly in a way that would shift the focus of the program away from primary care: there are over 5000 HPSAs currently; 50% loan repayment program requests are denied; only 1 in 7-11 scholarships are granted.

The National Health Services Corps (NHSC) is a program of the Public Health Service Act. The definition of a health professional shortage area is set and updated by the Health Resources and Services Administration, whose experts estimate that about 20 percent of the U.S. population resides in primary medical care Health Professional Shortage Areas.

Recent trends in students and new physicians choosing to enter primary health care fields show a looming deficit in the number of these vital health care professionals.

AMSA NHSC Position

Congress must invest in incentives to address shortages in the primary care physician and health care work force in underserved communities. An increase in funding levels in future reauthorization legislation and during 2009 appropriations for the National Health Service Corps will increase incentives for health professions students to choose primary care fields, to address shortages in the primary care physician and health care work force in underserved communities. Investment in a health care workforce to create incentives for health care professions students increases the number of health care providers who choose to practice in underserved communities, and who select primary care over specialty fields.

Environmental Health Background

According to the American Lung Association, more than 40% of Americans live in areas where they are exposed to unhealthful levels of ozone or particulate materials, two major air pollutants with serious adverse effects on health 38.  Among these Americans whose health is jeopardized as a result of their zip code, roughly 50 million are living with chronic diseases that make them particularly vulnerable to the harmful effects of pollutants, including adult and pediatric asthma, chronic bronchitis and emphysema, cardiovascular disease, and diabetes.  Infants and children are also disproportionately harmed by toxic substances in the air 39. 

The evidence connecting pollutants such as particulates, ozone, mercury, and NOx, SOx, and CO2, with their negative health impacts is staggering:  Beyond the predictable but significant effects of irritating the airways, robust, statistically significant linkages have been identified between pollution and non-pulmonary diseases, including cancer, heart attack, stroke, low birth weight, cleft palate, and Sudden Infant Death Syndrome (SIDS) 40, 41, 42, 43.  Observational studies have shown how higher rates of blood clots 44, potentially-fatal arrhythmias 45, 46, and indeed, all-cause mortality 47, 48, closely track with short-term variations in pollution levels.  Further, it is now clear that poor air quality doesn’t just exacerbate respiratory illnesses such as allergies, asthma, and chronic obstructive pulmonary disease (COPD), but is actually causing these highly-morbid diseases 49.  For residents of cities like Boston, New York, Chicago, and Philadelphia, outdoor breathing of airborne carbon black particles can be as risky as taking up smoking.  Ironically, in study of Boston women, the only participants that did not experience damage to their lung function related to pollution were those whose lungs were already maximally stressed by airborne contaminants – current smokers 50. 

With the imminent changes in the White House and Congress, legislation from 2008 is rendered almost moot, and precise predictions on legislative action cannot be made at this stage.  However, President-elect Obama has stated that sustainable energy policy will be second only to the economy as an executive priority, and many leaders in the Senate and House are eager to reverse crucial losses in environmental protection incurred under the current administration.  Further, with rising fuel costs, press coverage of the health effects of air pollution at the Beijing Olympics, and public outcry over the politicizing of the environment, a groundswell for sizeable reform is taking shape. 

AMSA Environmental Health Position

AMSA supports the equitable treatment of all people with respect to the enactment and enforcement of environmental and air quality policies.  Everyone is entitled to clean, safe air, and to be free from the negative health impacts of unnatural airborne pollutants.  AMSA aims to eliminate disparities in environmental health and reduce the disproportionate exposure to toxic pollutants experienced by the socioeconomically disadvantaged.  In this way, AMSA will promote environmental justice, and urges our leaders in Washington to support the following measures:

1.  A public health approach to air quality standards. 

The EPA, utilizing an approach that is based on public health, rather than fiscal/economic considerations, should be empowered to set the Primary National Ambient Air Quality Standards (NQAAS), under the Clean Air Act.

1. Limiting America’s production of the six pollutants linked to the largest health impacts on Americans:  sulfur dioxide, nitrogen oxides, mercury, and carbon dioxide, ozone, and particulate materials. 

The Administrator of the EPA should be charged with setting tonnage limits on the six most harmful pollutants, through legislation such as S.1177 or S.1201 (2007-2008), beginning in 2011, and which would decline on a yearly basis.  Such limits could be designed to support a “cap-and-trade” system in the future. 

1. Promoting a path to decreasing emissions. 

The Secretary of Transportation should be empowered to enforce a graduated increased corporate efficiency standards, with elimination of any distinction between passenger automobiles and light trucks by model year 2013, as well as directing the Secretary of Energy to require a specified emissions reduction from the federal fleet of cars and trucks, as in S.1554 (2007-2008)

38 American Lung Association.  “State of the Air:  2008”  http://www.lungusa2.org/sota/SOTA2008.pdf, pp. 5-8.  2008.
39 Ibid., pp. 14-17.
40 Neher, J., and Koenig, J., “Health Effects of Outdoor Air Pollution.” American Family Physician.  1994; 49(6): 1397-1404.
41 Bobak, M.  “Outdoor air pollution, low birth weight, and prematurity.” Environ Health Perspect..  2000; 108(2): 173–176
42 Hwang B., and Jaakkola J., “Ozone and other air pollutants and the risk of oral clefts.”  Environ Health Perspect..  2008; 116(10):  1411-5
43 Woodruff, T., et. al., “Air Pollution and Postneonatal Infant Mortality in the United States, 1999–2002”  Environmental Health Perspectives.  2008; 116(1):  110-115. 
44 Baccarelli, A., et. al., “Exposure to Particulate Air Pollution and Risk of Deep Vein Thrombosis.”  Arch Intern Med. 2008;168(9):920-927.
45 Liao, D., et. al., “Ambient Particulate Air Pollution and Ectopy—The Environmental Epidemiology of Arrhythmogenesis in Women's Health Initiative Study, 1999-2004.” Journal of Toxicology and Environmental Health, Part A.  2009; 72: 30–38.
46 Rich, D., et. al. “Association of Short-term Ambient Air Pollution Concentrations and Ventricular Arrhythmias.”  Am J Epidemiol 2005;161:1123–1132.
47 Samet, J., et. al. “Fine Particulate Air Pollution and Mortality in 20 U.S. Cities, 1987–1994.”  N Engl J Med. 2000 Dec 14;343(24):1742-9.
48 Laden, F., et. al. “Association of fine particulate matter from different sources with daily mortality in six U.S. cities.” Environ Health Perspect. 2000; 108(10): 941–947.
49 Detels, R., et. al. “The UCLA Population Studies of CORD: X. A Cohort Study of Changes in Respiratory Function Associated with Chronic Exposure to SOX, NOX, and Hydrocarbons.”  Am. J. of Public Health.  1991; 81(3):  350-9.
50 Suglia, S., et. al.  “Association between Traffic-Related Black Carbon Exposure and Lung Function among Urban Women.”  Environ Health Perspect.  2008;116:1333–1337