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Legislative Update - Report from the Front Lines

North Dakota lawmakers gave their initial stamp of approval to nearly 600 bills before breaking for a three-day recess last Thursday, and a new state revenue forecast in mid-March will set the stage for the second half of the session.

For the last 37 days, lawmakers have been busy working on bills in their respective chambers. House and Senate lawmakers advanced a combined 599 bills – 70 percent of the 852 bills introduced – during the session’s first 38 days, while 249 bills failed and four were withdrawn. The vast majority of the bills will now be taken up in the opposite chamber which means it's time for cross-over.  That's when they start working on bills passed by the other chamber.

Most refer to the past two months as the “first half”.  AHA has always looked at session in thirds – first third sorting through the bills that survive to cross-over, second third giving the other chamber an opportunity to work, and then the important part of the legislative session - conference committee work.  This is when six legislators, 3 from each chamber, can meet to work through differences in each chamber’s work.  Last session, when our CPR in Schools funding bill had an opportunity to go to conference committee, we opted to encourage going with one chamber’s version, feeling we didn’t want to risk what we secured by that point.  This session, with several important areas of AHA interest in agency budget bills, we will be actively engaged in that 3rd part of session committee work during April.

Here is how we have fared so far:

  • Stroke System of Care (HB 1323):  This bill passed unanimously in House Human Services and the full House.  It was heard Wednesday, March 4 in Senate Human Services.  The bill is doing well due to: 1) stakeholder support of updating the century code to reflect important elements of system work; 2) survivor stories showing the impact of coordinated response and rehabilitation care; and 3) successful outcomes of our ND stroke work.  For example, the percent of acute ischemic stroke patients who arrived at the hospital within 2 hours of time last known well and for whom IV t-PA was initiated within 3 hours increased from 30.9% in 2010 to 80.9% in 2013.  This treatment improvement helps to reduce brain loss due to stroke by clearing out clots preventing blood flow to areas of the brain. That is significant!
  • Funding Bills:  Our priority issues have been challenged by the revenue forecasts at the beginning of session.  Given oil production is up in North Dakota, we hope the new projections in March will help move these funding areas forward:
    • Senate Action:  The Senate continues with strong support for CPR being taught in schools, and has added language into the Department of Public Instruction agency budget to continue funding, and to extend the resources to the junior high level.  We appreciate DPI’s support of this continued invest also.
    • House Action:  The House opted to not add in new funding opportunities into the Department of Health budget, and made cuts into the Governor’s proposed budget.  However, we know our advocates have been impactful on the needs for the key heart and stroke funding priorities, and during conference committee work we may gain some traction.  So as HB 1004 makes it way to the Senate, we are focused on:
      • Cardiac System of Care funding:  With available grant funding coming to an end, the cardiac system needs a small base of funding to continue its work of public, EMS and hospital collaborative work to ensure timely, appropriate care for acute cardiovascular events.
      • EMS Database system:  Our EMS responders are working with outdated programs for capturing response runs, which no longer receive vendor support.  This is a request for mostly one time funding, and if successful, will provide our acute care field providers with improved health information and also our state with invaluable information related to field care.
      • Million Hearts Funding:  We know high blood pressure and tobacco use are driving cardiac and stroke events.  Yet no prevention funding is available to start addressing the leading risk factor – high blood pressure, and that funding support for smoking cessation access falls short of CDC guidance.

And of course there are a number of other bills we are watching and engaging on as appropriate.  It’s been a busy first half!

Our advocates have been instrumental in our progress to date.  I love hearing from legislators on committees and in the halls saying they are hearing from you.  Your voice does make a difference as we work the halls.  Keep up the great work as we navigate the next two core decision-making opportunities!

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What's Up with School Nutrition?

There is a lot of discussion out there about school nutrition – and we couldn’t be happier about that!  Students consume 35% - 50% of their daily caloric intake at school where they are often exposed to junk foods and sugar-sweetened beverages that have little to no nutritional value.  Parents – and students – have concerns about the nutritional value of the foods their kids are consuming at school. Schools are in a unique position to provide a healthy environment by promoting and providing nutritious meals. 

CLICK HERE for an informational video about school nutrition. 

Here is what we know:  In December 2010, the President signed the Healthy Hunger-Free Kids Act, which gave the U.S. Department of Agriculture (USDA) the authority to update national nutrition standards for school meals and establish nutrition standards for other foods sold in schools throughout the school day.  As a result, in school year 2013-2014, nearly 90% of schools in the National School Lunch Program (NSLP) met nutritional standards, up from 14% in 2009-2010.  That means an overwhelming majority of children are receiving heart-healthy lunches while at school. 

We also know that a healthy school environment, including healthy nutrition, helps improve children’s physical well-being, enhances learning, minimizes behavior problems and increases attendance. 

The evidence is overwhelming that the new school meal standards are working.  Going into child nutrition reauthorization for 2015, the American Heart Association advocates for:

  • Continued support to schools for effective implementation of the federal nutrition standards for school meals.
  • Continued strong implementation of Smart Snacks in School standards. These standards include reducing sodium; eliminating trans fat; decreasing saturated far; minimizing fried foods; offering healthy beverage options; and increasing the offering of fruits and vegetables, whole grains, seafood, and low-fat dairy. 
  • Continued robust technical assistance by the USDA to support schools in implementing nutrition standards, effective nutrition education, and nutrition promotion and model local wellness policies with effective implementation and evaluation. 
  • Investments in kitchen equipment and infrastructure that can help schools serve healthier meals. 


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Advocate Spotlight: Sharon Buhr, Susan Milender, and Andrea Winter

Valley City, North Dakota

School Wellness is all about partnerships in Valley City. In 2012 when schools were asked to revise and strengthen their school wellness policies, the local nutrition and exercise partnership, Barnes ON THE MOVE Partnership (OTM-17 members strong), stepped forth and volunteered to work with Valley City Public Schools (VCPS).  Sharon Buhr, MPH, LRD was the chair of OTM and also chair-person of the local school board.  She teamed up with Susan Milender, LRD, who was then the Nutrition Services Director of VCPS to take the lead.

Together they established the process for the revision, setting a timeline using the WELSAT tool for evaluation of the present policy, included administration, teachers, parents and students and then ended up back at the school board in the summer of 2012 with the final product.

The VCPS Wellness Policy recognizes that the school can have a positive effect on the community.  The policy identifies that anyone who uses the school and chooses to serve a food, must also serve a fruit or vegetable so that there will always be a healthy choice available.

To help the various school booster clubs meet the nutrition guidelines of the wellness policy (as well as other community booster clubs) Sharon and Susan, along with Andrea Winter, LRD chose to hold a “Healthy Concession Food Expo” in both 2013 and in 2014.  They again looked to partner with other groups, such as the students in Fuel Up to Play 60 and the Girl Scouts.    An array of fast, healthy and easy to prepare foods were served for attendees to sample.  Follow up after the event proved the success of the event as more clubs added healthier items (that were featured at the expo) to their menu. 

For more information on the “Healthy Concession Food Expo” or other VCPS Wellness Policy ideas, contact Sharon Buhr at 845-6456 or  For a copy of the VCPS Wellness Policy go to and click on policies.

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Governor Dalrymple Proclaims Heart and Stroke Day in North Dakota

Governor Dalrymple met with AHA volunteers, survivors and staff on Monday, February 9th and proclaimed it Heart and Stroke Day in North Dakota.  Heart and Stroke Day is an opportunity to raise awareness about cardiovascular disease and stroke, and to bring attention to opportunities to improve health and well-being through legislative policy.  During his remarks, Governor Dalrymple reminder legislators and other visitors to the Capitol that while we have made significant strides in improving outcomes for heart disease, it is still our state's number one killer of adults. The Governor also noted that stroke is the leading preventable cause of disability and eighty percent of cardiac events can be prevented with a healthy lifestyle. 

We are proud of the work that has already been done to improve cardiac and stroke care in North Dakota. The Governor noted that North Dakota has championed improved emergency response and newborn screenings for congenital heart defects and has set a standard for other states to follow on strong stroke and cardiac systems of care. 

The Governor concluded his remarks urging all citizens to recognize that living healthier leads to longer, fuller and more active lives with less disease care in the later years and to call 9-1-1 at the first signs of heart attack or stroke symptoms. 


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Advocates Raise Their Voices on Heart and Stroke Issues

The legislative session is well underway in Bismarck.  AHA advocates from across North Dakota recently traveled from all corners of the state to participate in Heart and Stroke Day at the Capitol to raise awareness for heart disease and stroke.  More than 50 volunteer advocates, survivors, spouses, caregivers, emergency responders, and hospital partners participate in the 2-day event in Bismarck. 

We are pleased that our Stroke Bill, HB 1323, passed unanimously out of House committee and on the House floor.  This bill is important to clarify language related to stroke care already being done, and to serve as a model for other states to follow when it comes to stroke response and outcomes. We know our advocates will continue to raise their voices with their Senators when the bill comes before the Senate. 

We are working on several Appropriations requests that are also critical to improving heart and stroke care in our state.  Our Cardiac Systems of Care request will continue to build upon progress that has already been made in cardiac response, and will provide sustainability for statewide training and public education. 

Our work on CPR in Schools last session provided funding support for schools who want to provide CPR training to their students.  Only a small portion of this appropriation was used so we are working to protect those funds to enable more schools to provide this life-saving training.  Knowing CPR is the first response in the system of care for sudden cardiac arrest.

We are encouraging legislative support for Million Hearts funding to address the serious health concern of hypertension.  This funding will provide awareness and education to help to know the risk factors for hypertension and provide prevention strategies. 

We are also supporting HB 1421 which would raise the tobacco tax in North Dakota and reduce tobacco use and the impact tobacco has on chronic disease in our state.  With rising health care costs continuing to dominate the North Dakota health policy agenda, raising the tobacco tax will provide much needed funding to address healthcare needs in our state.

Much work is yet to be done throughout the session, and we need our advocates to continue to engage lawmakers on all these issues.  Together, we can make North Dakota a heart-healthier place to live! 

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Advocate Spotlight: Shelly Arnold

Shelly Arnold North Dakota

As the Chair of the American Heart Association’s Advocacy Committee, I understand the importance of statewide programs and the need to integrate work among all types of healthcare professionals. Heart attack and stroke are two life changing events that can sometimes be prevented by living a healthy lifestyle and visiting with a healthcare provider about your overall health and risk of heart attack or stroke.

The first step towards living a healthy lifestyle starts with you. Living a healthy lifestyle is key to preventing strokes and heart attacks. Make sure you are paying attention to the food you eat and the amount of exercise you get. Just a brief walk every day along with a healthy diet can decrease your risks for a heart attack or stroke. 

If you or a family member experiences any signs or symptoms of a heart attack or stroke, Tertiary hospitals such as Sanford Health along with rural hospitals, local emergency medical services and air medical services all serve a unique role in providing you the best care possible. Don’t hesitate to call 911, these emergency providers are ready and willing to help you, by providing the best possible care and will transport you to the most appropriate healthcare facility in the shortest amount of time.

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More Concerns about E-Cigs

As more research comes available and more studies are being done on the effects of e-cigarettes, today the New England Journal of Medicine raises a new worry about electronic cigarettes – exposure to formaldehyde.  You remember formaldehyde, right?  Who could forget that awful-smelling chemical used in your high school biology class to dissect frogs?  Turns out, formaldehyde is formed when the propylene glycol and glycerol in e-cigarette liquids and oxygen are heated together.   

According to an article in today's Los Angeles Times Science Now, The World Health Organization’s International Agency for Research on Cancer says formaldehyde can cause leukemia and nasopharyngeal cancer. The U.S. Environmental Protection Agency considers the chemical a probably human carcinogen. 

Let's not kid ourselves.  The study coauthor James Pankow, a chemistry professor and expert on cigarette smoke dangers at Portland State University, said the line between e-cigarettes and tobacco cigarettes was growing fuzzier by the day.

“No one should assume e-cigarettes are safe,” he said in a statement. “For conventional cigarettes, once people become addicted, it takes numerous years of smoking to result in a high risk of lung cancer and other severe disease; it will probably take five to 10 years to start to see whether e-cigarettes are truly as safe as some people believe them to be.” 

For more on this story, CLICK HERE.  

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High Blood Pressure causing more Deaths despite Drop in Heart Disease, Stroke Deaths

Fewer Americans are dying from heart disease and stroke, but deaths caused by high blood pressure are on the rise, according to new statistics from the American Heart Association.

Although cardiovascular disease is still the biggest killer in the U.S., deaths fell by nearly a third from 2001 to 2011—a drop scientists say reflects improvements in preventing and treating heart disease and stroke. Doctors are encouraged that the trend will continue as healthcare systems around the country better implement evidence-based prevention and treatment guidelines from the AHA and the American College of Cardiology.

Concerns are growing, however, over a 13 percent uptick in hypertension-related deaths over that same span according to the statistical report, “Heart Disease and Stroke Statistics — 2015 Update: A Report From the American Heart Association,”

“Deaths attributable to cardiovascular diseases have been on the decline in recent decades. Yet in the face of this good news, we have several disturbing observations that we need to pay attention to because we’re at risk of eroding the gains we have made,” said AHA President Elliott Antman, M.D., professor of medicine and associate dean at Harvard Medical School.

High blood pressure is a major risk factor for heart disease and stroke. Although the death rate going up for one while the other is going down may seem contradictory, one reason is that hypertension can directly lead to other deadly conditions such as heart failure or kidney failure if it is not controlled.

The report found that most cases have been detected—nearly 83 percent. But of the 80 million Americans with high blood pressure, only about half have it under control.  The rising hypertension death rate also is probably related to factors plaguing many Americans — lack of physical activity, obesity and too much sodium.

To learn more about understanding and managing blood pressure, CLICK HERE.

To assist worksites in addressing high blood pressure a worksite wellness program targeting blood pressure will launch on Giving Hearts Day, February 12, 2015.    For more information contact Joan Enderle.  or call 701-658-3046.  

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2015 Legislative Priorities

The 64th North Dakota Legislative session has begun, and elected officials are setting policy and funding priorities for the next two years – 2015 – 17.  As you can imagine, with heart and stroke being our leading cause of death in North Dakota, there are a significant number of touch points where AHA volunteers and staff can impact legislation.  While we will monitor and engage on many of these items, we also identify a select number of issues for our leadership focus.  These are highlighted below.  I’m also including some key talking points, in hope that you will find opportunities to connect with your local elected officials.

Why is our work so important?

Life is why.  Heart disease and stroke is our state’s leading cause of death and disability.  That’s impacting our families, our communities and our state. 

As a nation 75% of our healthcare dollars goes to treatment of chronic diseases.

Are we making an impact?

You betcha!  From 2011 to 2012, nationwide, age adjusted death rates decreased significantly for heart disease – 1.8% and 2.6% stroke nationwide.   During the same time period, in North Dakota, age adjusted death rates for heart disease decreased 22.3% and stroke declined 38%.  

So what’s our problem?

While we are showing improvement overall, we are seeing cardiac disease and stroke events increasing within our active workforce – hitting people at the prime of their life for key work and business production.

The state cost to treat cardiovascular diseases cost North Dakota more than $1 billion each year.

How can I help?

Watch for You’re the Cure action requests, and take action right away!  Build the relationship trust with your area legislators, let them know these issues matter to you.  Keep in mind this insight:  Budget leaders find it is easier to take the eggs from the nest of those who don’t squawk, than from the nests of those that do. 

 Core AHA priorities:

SB 2013 – Dept of Public Instruction Budget:  This bill is currently in Senate Appropriations.  We are seeking to insert language that carries over any unspent CPR training funds from the 2013-15 budget to the 2015-17 budget for continued support of teaching students CPR.  We anticipate there will be about $400,000 to carry over.  Why? Fewer than 1 in 3 victims of sudden cardiac arrest outside the hospital receive CPR from a bystander.  CPR can double or triple survival rates.  CPR is a lifelong skill, one that saves lives.

HB 1004 – Dept of Health Budget:  Currently in House Appropriations, Human Services.

  • Optional Request #6:  Cardiac Systems of Care.  $601,400 for expanded stakeholder work on  identifying emergency cardiac care system impact points, target educational efforts to improve the quality of care of patients, data tracking and public awareness. Why? This appropriation further develops ND cardiac capacity to enhance other time sensitive cardiac system of care initiatives which will save lives and improve outcomes.  
  • Optional Request #12: EMS Database.  $480,000 Funding recommendation which includes $448.000 for one-time cost and $32,000 for ongoing maintenance costs.  Why? The current system is outdated and lacks company support.  Inter-connectivity of technology components is essential, as are EMS patient care records to assist with system improvements.  
  • Optional Request #9: Million Heart Initiative. $2,039,573.  Public/Private/Healthcare Initiatives to address two of the state's leading chronic disease risk factors - high blood pressure and smoking.  The initiative will support HBP interventions and standard treatment guidelines through community and health system initiatives; increase health system capacity to provide private and group cessation counseling (Medicaid is adding reimbursement for such).  Why? In North Dakota, 32% of strokes are under age 65, and over 73% have high blood pressure, yet only .1% are being treated for high blood pressure.  A 5mm hG decrease in systolic blood pressure would result in 14% fewer deaths from stroke, and 9% fewer deaths from heart disease. 

Stroke System of Care Legislation.  This will be a policy bill and will be appearing in the coming days.  Why?  Current Century Code language (state law) has old dates.  It was also enacted at a time other standards for stroke system care were not yet available.  This bill updates state law and also reflects the status of system work in North Dakota.  

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Advocate Spotlight: Bonnie Staiger

Bonnie and Stacy, Staiger Consulting Group North Dakota

Question:  You've represented the American Heart Association in the halls of the state Capitol in Bismarck since 1999.  How has your firm grown since that time? 

Bonnie: We actually doubled in size in 2007!  I was pleased when my daughter, Stacy, decided to join the firm and work together with me to represent clients in Bismarck.  Stacy completed her MBA at Florida Gulf Coast University and made the decision to move back to North Dakota.  It's a pleasure working with her on a daily basis.  

Question: With your long history of representing the AHA in the halls of the Capitol, can you reflect upon the AHA's reputation as an organization advocating for health policy in our state?

Bonnie:  AHA's reputation has been built on the values of respect and trust.  No matter how difficult at times, we always respect legislators and agency personnel in their role of policy making and administering those policies. The diversity of Republicans, Democrats, majorities and minorities all bring dissimilar dynamics into the nuances of an issue.  Only from respect can trust be built and it is a fragile commodity.  We avoid polarizing factions and situations knowing the only currency we have is trust.  Our biggest gains have often come from volunteers touching base with their own legislators.  Then, when we chat with legislators at the Capitol, they often mention that a constituent has contacted them on a particular issue.  

Question:  You've observed many organizations and volunteers come to Bismarck to raise their voice on an issue.  Based on your experience, how can advocates be effective while being respectful, learn while educating at the same time? 

Bonnie: Step One, Advocates must first know their legislators.  Meet them and talk with them back in their home district.  Introduce yourself. Never barrage a legislator with your issues.  Keep it simple.  Legislative advocacy is built on relationships.  Step Two, We urge advocates to know the issues and be prepared to craft different talking points that will resonate with dissimilar groups.  Experience develops instincts and instincts often dictate when to press forward or back of on an issue.  The most noble issue is unlikely to move forward if outside factors are off - including timing.  A unified team effort is critical and lone rangers almost always cause problems.  

That's really good advice, Bonnie.  Finally, can you share with our advocates any final words of wisdom as they prepare to be effective advocates during the session this year?

Bonnie:  Every legislative session has 2 tracks going on simultaneously.  One is the legal track or How a Bill Becomes a Law.  That information is available on our state's website.  The other track is the political track which runs concurrently with the first.  The second track can speed up or slow down the first track.  Often advocacy is a chess game played in 3-D.  While it may seem glamorous from the outside, it's simply hard work and not for the faint of heart. But it can be very rewarding if gains are assessed in the long term. 

We'd like to thank Bonnie for taking some time to share her perspective and thoughtful advice on how to be an effective AHA advocate.  

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