Homeland Security Establishes Final “Public Charge” Rules

Here’s my Best Shot at Explaining What the New Rules Will Do

I’m sure you've the flurry of reports about the Department of Homeland Security (DHS) “public charge” final rule. There will be lawsuit(s) challenging the new rules, but for now the new regulations are scheduled to kick in October 15, 2019.

The bottom line is that the new regulations will change the criteria the federal government uses to make decisions about legal permanent resident applications. The final rules will block legal immigrants from extending their temporary visas or gaining permanent residency if the government decides the applicant is likely to rely on public benefits in the future.

The Feds already consider whether applicants for legal permanent residency receive Temporary Assistance for Needy Families or Supplemental Security Income (SSI) when they evaluate applications for permanent resident status.

When the new Rules take effect on October 15 they’ll also consider whether applicants receive Medicaid (AHCCCS), the Supplemental Nutrition Assistance Program (food stamps), or Section 8 Housing assistance. 

The definition of a "public charge" in the final Rule is: "an individual who receives one or more designated public benefits for more than 12 months in the aggregate within any 36-month period”.

The draft rules released last year had included criteria that would have applied these standards to kids and adults. The final Rule won’t consider whether benefits were used by an applicant’s children. Likewise, if lawfully present kids receive benefits (e.g. Medicaid) that fact won’t be considered against them if the child later applies for legal permanent residency (a “green card”).

Here are some things to remember about this new Rule

  • This is an issue of legal immigration- unauthorized migrants are largely ineligible for public assistance;

  • This doesn't directly impact current legal permanent residents (current green card holders). The public charge test won't be applied to legal current residents (green card holders) applying for citizenship;

  • The new rule isn’t retroactive – meaning public benefits received before 10/15/19 won't be counted as a public charge; and

  • The new rules don't apply to refugees. Existing statute prevents DHS from using these criteria for refugees.

Even though the final Rule excludes benefits received by children, this policy will still have a significant impact on children’s health as well as the health of their families and our communities.

Public health note:  We know from both national reports and from assistors and community organizations working in Arizona, that families are afraid and withdrawing from or reluctant to participate in benefits for which they or their children are legally eligible. Nationally, nearly one in four children have an immigrant parent, and almost 90% of them are US citizens.  Missing out on safety net programs for which folks are entitled can result in bad health outcomes because of social determinants that won't be addressed and missed doctor's appointments which could result in missed developmental screenings and interventions.

The US government has made their decision - and the new policy will be implemented unless overturned by the courts. There's nothing short suing that will undo this decision for now (although a change in top leadership in the executive branch in January 2021 could result in a rollback).

What we can do is to get the word out to families in this category that signing up their kids for safety net benefits to which they're entitled won't count against them when they apply for legal permanent status- nor will it count against their kids if they eventually apply for a green card. We can minimize the public health impact of this decision if the public health system is effective in ensuring that families know this important information! 

Immigration Status, Public Benefits & Access to Care

Medicaid generally limits eligibility (for immigrants) to qualified legal immigrants with refugee status, veterans, and people lawfully present in the US for 5 years or more. State Medicaid programs can elect to provide coverage to legally present immigrants before the 5-year waiting period ends (Arizona does not).

States get matching funds from CMS when they choose to provide Medicaid coverage to legally present immigrants who are children or pregnant before the end of the 5-year waiting period.  33 states have elected to cover lawfully residing immigrant children and 25 states cover legally present pregnant women (Arizona does not).

The Affordable Care Act made it possible for the legally present immigrants who are ineligible for Medicaid (due to being in the five-year waiting period) to qualify for commercial coverage and subsidies on the Federal health insurance marketplace.

Immigrants eligible for Medicaid or employer-sponsored insurance face several coverage and service barriers.  As I mentioned above, immigration officials consider the likelihood of individuals and families becoming a “public charge,” which can result in denied admission to the US or status as a lawful permanent resident. 

The criteria that will be considered beginning 10/15/19 will include whether applicants receive Medicaid (AHCCCS), the Medicare Part D Low Income Subsidy, the Supplemental Nutrition Assistance Program (food stamps), and Section 8 Housing program. The existing Rule only considered participation in Temporary Assistance for Needy Families.

Fear that using safety net services will mean that they’ll be considered a public charge contributes to some families of mixed immigration status avoiding use of services like TANF, Medicaid, SNAP etc.  Some eligible immigrants avoid services because they think family members will become involved in immigration enforcement actions.

Research findings by the Kaiser Family Foundation found that changes in healthcare use and decreased participation in Medicaid and the Children’s Health Insurance Program because of this immigration policy.

Anyway, it’s a complicated system but I hope this makes it a little clearer.

History of Considering Public Benefits

The term “public charge” as it relates to admitting immigrants has a long history in immigration law, appearing at least as far back as the Immigration Act of 1882.  In the 1800s and early 1900s “public charge: was the most common ground for refusing admission at U.S. 

Those immigration laws have evolved over the history of the country, with the most recent overhaul being the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (often referred to as PRWORA or welfare reform).  That's the law that created Medicaid’s “qualified immigrant” standard.

In 1999, the Immigration and Naturalization Service (DHS didn’t exist yet) issued Rules to "address the public’s concerns about immigrant fears of accepting public benefits for which they remained eligible, specifically medical care, children's immunizations, basic nutrition and treatment of medical conditions that may jeopardize public health.”

Here's that final Rule from 1999, which didn't include Medicaid our housing benefits in the public charge definition. The new DHS Rules will consider whether adult applicants receive Medicaid (AHCCCS), the Medicare Part D Low Income Subsidy, the Supplemental Nutrition Assistance Program (food stamps), or Section 8 Housing assistance.  

The final Rule won’t consider whether benefits were used by an applicant’s children. Likewise, if lawfully present kids receive benefits (e.g. Medicaid) that fact won’t be considered against them if the child later applies for legal permanent residency (a “green card”).

FDA Finally Proposes Updated Cigarette Warning Labels

In 2009 the Congress directed the FDA to create more graphic warning labels and mandate them on packs of cigarettes. In 2012, the FDA proposed 9 new more graphic labels. The tobacco industry sued the FDA arguing that the proposed new warning labels violated their 1st Amendment rights to free speech. Astonishingly, a 3 judge panel agreed because the propoised labels were crafted to evoke a strong emotional response rather than to educate consumers.

So it was back to the drawing board. Over the next few years the FDA didn't propose new labels, so some health groups sued the FDA in 2016 because they still hadn't complied with the 2009 law (now 10 years old). The health groups won, and the court ordered the FDA to come out with new draft warning labels by August with final ones in March of 2020.

You can read more about the new labels and look at them on the FDA website. Perhaps the new labels will be finally on packs of cigarettes next spring- more than 10 years after the law was passed and signed.

National Family Planning Program in for a Major Shake-Up

Title X is a super important public health program that provides folks with comprehensive family planning and related preventive health services. It's designed to prioritize the needs of low-income families or uninsured people. The overall purpose is to promote positive birth outcomes and healthy families by allowing individuals to decide the number and spacing of children.

The services provided by Title X grantees (the funding comes from the federal government) include family planning and contraception, education and counseling, breast and pelvic exams, breast and cervical cancer screening, screenings and treatment for sexually transmitted infections and HIV.  It also focuses on counseling, referrals to other health care resources, pregnancy diagnosis, and pregnancy counseling. Title X funding does not pay for abortions.

Back in March of this year, the US Department of Health & Human Services published in the Federal Register a final rule making changes to the federal regulations governing the Title X national family planning program. The final rules dramatically change the existing Title X family planning program nationally and in AZ.  The changes include:

  • Eliminating Title X’s long-standing legal and ethical requirement for non-directive pregnancy options counseling; and

  • Requiring a “bright line” of physical and financial separation between the provision of family planning and abortion services.

Numerous provider groups, state attorneys general and non-profit organizations sought an injunction after the new Rules were announced (seeking an injunction to stop the rule from taking effect while the courts decide the legality of the rule). 

Legal History of the Case

Multiple federal district court judges blocked the new restrictive rules from going into effect. On June 20, 2019, a three-judge panel of the 9th Circuit Court of Appeals granted the Administration’s request to lift the preliminary injunctions, allowing the new Title X rules to be enforced. In early July, the 9th Circuit court ordered the cases be reheard en banc (meaning by all the judges on the 9th circuit versus a three-judge panel).

On July 11, the en banc court refused to block the new Title X rules from taking effect.

So, what’s the bottom line then?  For now- the new April Title X Rules that eliminate Title X’s long-standing model of offering non-directive pregnancy options counseling, and requiring a “bright line” of physical and financial separation between the provision of family planning and abortion services stand. 

Title X grantees including the Arizona Family Health partnership received notice from HHS that they must certify that they comply with the new regulations by September 18.  The plans for how they intend to comply were due Friday August 18.

What remains to be seen is what happens to the family planning network after September 18.  If Planned Parenthood decides to no longer provide Title X because of the new Rules, there would be a big gap in the network and folks that usually get their family planning services via Title X would need to find other places to go for these services. Since other providers are likely booked up- that means there cojld be some pretty significant delays in getting appointments for family planning services.

A Primer: How Arizona’s Ambulance Licensing System Works

The Basics

Arizona uses a Certificate of Necessity (CON) system to regulate ground ambulance service.  The overall idea is to have a regulatory system that optimally allocates resources, makes sure every place in the State has adequate emergency medical services, and that reduces rates to the extent possible.  

Any entity that wants to run an ambulance service needs to get a CON from the ADHS. It’s basically a license to run an ambulance service. The CON describes the geographic service area, level of service (advanced life support or basic life support), hours of operation, response times, effective date, expiration date for emergency medical services in the specific geographic area.  

An ambulance service that gets a CON is supposed to stick with the criteria on their certificate and operate in accordance to the statutes and rules by which it's governed. 

A common misconception is that Arizona’s CON system is designed to limit the number of ambulance services in Arizona. That’s not the case.  Parts of the State (especially areas with high populations lots of transports) have multiple providers and overlapping service areas where more than one ambulance company can provide services. 

The Statutes and Rules require that people who want to start an ambulance service have to demonstrate that there's "a public necessity" for the proposed service. There are detailed statutes that define what the words “public necessity” mean for the purposes of providing direction to the ADHS Director when she or he decides whether to approve a CON application.  There’s also a guidance document that outlines what the words “other things as determined by the Director” means.

How it Works

When someone wants to get a CON they apply to the ADHS. There are usually competitors that don’t want the applicant to get it (because the new applicant will be taking some of their cheese).  When someone challenges an application (called an intervenor) a hearing is scheduled with the Office of Administrative Hearings (in the ADOA).

A new statute limits that hearing to 10 days of testimony (a big improvement because these hearings used to go on for weeks or even months). The Hearing Officer listens to the testimony and documents and issues an “Order” with their opinion whether the Director should issue the CON. 

The ADHS can take or not take the Hearing Officer’s opinion. She or he can approve the CON, deny it, or approve it with some modifications.  There's a lot of interest among the parties when these CON applications are being considered - mostly because there's a bunch of money at stake. CON applications are quite litigious.

Here's a couple of recent cases that illustrate recent urban and rural CON applications. 

The Case of Community Ambulance (Urban)

An outfit called Community Ambulance applied for a CON to be able to do inter-facility transports (no 911 service) in Maricopa County. The goal was to have a CON that would provide inter-facility service between the Dignity Health facilities in Central AZ.  Dignity Health was supportive of the application because they believe contracting with Community Ambulance would help them more efficiently transport their patients between facilities- improving patient care and reducing costs. 

While the current providers (AMR and a couple others) can and do provide inter-facility transports in Maricopa County, the applicant and their supporters believe that a specific service dedicated strictly to interfacility would improve efficiency (Dignity would have contracted with Community Ambulance for this specific service). 

After reviewing the application and documents, a Hearing Officer at the Office of Administrative Hearings recommended that the ADHS deny the application. Here’s that Opinion. Upon review of the Hearing Officer’s opinion, the ADHS Director agreed with the hearing officer opinion and denied the CON. 

There’s an opportunity to appeal, and Community Ambulance filed a Motion for Review with the Director. The ADHS Director can review the case and change her mind or stay with the initial decision. If the CON remains denied, Community Ambulance can appeal to Maricopa County Superior Court.

The Case of Timber Mesa (Rural)

Back in 2017, an outfit called the Timber Mesa Fire District applied to extend the boundaries of their CON to include the city of Show Low.  An existing CON was in place in Show Low (Show Low EMS- now called Arrowhead Mobile Healthcare).

After hearing the evidence- the Hearing Officer recommended that the ADHS deny the CON application because: 1) Timber Mesa didn’t show that more resources were needed in the service area; 2) the reduction in call volume for Show Low EMS would make Show Low EMS unable to meet their current obligations; and 3) Timber Mesa didn’t prove that Show Low EMS has engaged in substandard performance in either 911 or interfacility service.

The ADHS Director didn’t agree with the Hearing Officer’s recommendation and approved Timber Mesa's CON boundary expansion into Show Low. 

Show Low EMS (now Arrowhead Mobile Healthcare) appealed the ADHS Director’s decision in Superior Court.  Last week, the Superior Court judge in the case agreed with Arrowhead that “the Director exceeded her statutory authority when she "sua sponte" amended CON 111 to include the Expanded Service Area”.  It’s now the ADHS’ job to read the Judge’s decision and figure out what to do next.

Editorial Note: When I was in the Director position, I was reluctant to issue additional CONs in rural areas because adding too many providers in rural areas can jeopardize overall service and increase costs. That’s because when transports are spread “too thin”, one or both ambulance service providers may not be able cover their expenses - which can cause them to ask for rate increases or neglect underpopulated areas which jeopardizes response times.  

In urban and suburban urban areas, I was more inclined to approve CONs that met the basic statutory requirements because there are usually plenty of transports around to ensure that ambulance providers can meet their expenses...  and increasing the number of providers can safely increase competition. In urban and suburban areas there’s a lot less risk that adding additional resources will cause rate increases or result in providers neglecting the less populated parts of the service area.

This primer is just a short summary of the CON system and how it works in Arizona. One can spend an entire career on this subject and still learn something every day- so take this for what it’s intended- a small window into the complicated world of Ambulance service Certificates of Necessity in Arizona.

Recent Oral Health Research

Ending the neglect of global oral health: time for radical action

Richard G Watt, Blánaid Daly, Paul Allison, Lorna M D Macpherson, Renato Venturelli, Stefan Listl, and others

The Lancet, Vol. 394, No. 10194, p261–272

Published: July 20, 2019

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Oral diseases: a global public health challenge

Marco A Peres, Lorna M D Macpherson, Robert J Weyant, Blánaid Daly, Renato Venturelli, Manu R Mathur, and others

The Lancet, Vol. 394, No. 10194, p249–260

Published: July 20, 2019

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Conflicts of interest between the sugary food and beverage industry and dental research organisations: time for reform

Cristin E Kearns, Lisa A Bero

The Lancet, Vol. 394, No. 10194, p194–196

Published: July 20, 2019

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Richard Watt: time to tackle oral diseases

Rachael Davies

The Lancet, Vol. 394, No. 10194, p209

Published: July 20, 2019

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Promoting radical action for global oral health: integration or independence?

Rob H Beaglehole, Robert Beaglehole

The Lancet, Vol. 394, No. 10194, p196–198

Published: July 20, 2019

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Oral health at a tipping point

The Lancet

The Lancet, Vol. 394, No. 10194, p188

Published: July 20, 2019

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Arizona Scores $10.5M to Boost Medication Assisted Treatment for Opioid Use Disorder 

On Friday the US Substance Abuse and Mental Health Services Administration announced the release of an additional $10.5M in State Opioid Response funds for Arizona (AHCCCS) to supplement 1st year funding.

SAMHSA expects to also release additional 2nd year continuation awards later this year. The objective of the grant is to expand access to evidence based treatment...  especially to medication-assisted treatment (MAT) with social supports.  There are three medications commonly used to treat opioid addiction:

  • Methadone – clinic-based opioid agonist that does not block other narcotics while preventing withdrawal while taking it; daily liquid dispensed only in specialty regulated clinics

  • Naltrexone – office-based non-addictive opioid antagonist that blocks the effects of other narcotics; daily pill or monthly injection

  • Buprenorphine – office-based opioid agonist/ antagonist that blocks other narcotics while reducing withdrawal risk; daily dissolving tablet, cheek film, or 6-month implant under the skin

Reducing the public health impact from the opioid epidemic will take a combination of evidence based interventions including continued reforming of prescribing practices, increasing treatment options and access, additional community based interventions including syringe access services, increasing access to rescue medications and interventions by law enforcement and the criminal justice system.

This new supplemental award as well as the upcoming 2nd year funding will provide important new opportunities to make additional progress.

Retail Marijuana Voter Initiative In the Works

A group of Medical Marijuana Dispensary operators have completed statutory language for a retail marijuana and marijuana law criminal justice reform voter initiative. The Initiative isn't posted on the Secretary of State's website yet but I was able to get the text of the Initiative. The statutory language is 16 pages long- and there are a lot of provisions...  but here's a review of some of the highlights:

The existing medical-marijuana dispensaries would be allowed to apply to the ADHS for a license to run a retail marijuana storein early 2021. It's possible that there could be a few more stores that open eventually, but not many, because the total number is limited to about 130 total (10% of the number of pharmacies in AZ). Existing medical marijuana dispensaries, with a handful of exceptions, would essentially be the only stores that exist. ADHS would regulate the program.

There would be no criminal penalty for people 21 or over to have 28 grams (one ounce) or less of marijuana or 5 grams of extract. Minor penalties and low grade misdemeanors are outlined for people 21 and over that give or sell marijuana to people under 21.

People under 21 that possess marijuana would be subject to a $100 fine for the 1st offense, a petty offense the 2nd time, and a Class 1 Misdemeanor for the 3rd offense.

People previously convicted of possessing less than 28 grams of marijuana can petition to have their record expunged. The petitions must be granted unless law enforcement provides clear and convincing evidence the person isn't eligible.

Adults 21 and over could grow 6 plants at home with a maximum of 12 per house.

A 16% excise tax would be placed on marijuana products. Money from the excise tax would fund the various state agencies such as ADHS and Department of Public Safety for expenses related to the act. Other entities that will get excise tax funds are the community colleges (31%); police, fire and sheriff's departments (31%) and a highway fund (30%). There's also a one-time distribution ($10M) the ADHS from the existing medical marijuana fund for public health stuff.

Employers can have drug-free workplace policies and can restrict marijuana use by staff.

Driving while impaired (to the slightest degree) by marijuana would still be illegal.

The folks running the campaign still need almost 238,000 valid signatures by July 2, 2020 to get on the ballot- no easy feat given the recent new requirements passed by the Legislature and signed by the Governor which make getting things on the ballot harder.

We'll continue to review the language and evaluate whether basic public health principles related to our Retail Marijuana Resolution before taking any position.

Cannabis Communications Toolkit for State and Local Health Departments

The CDC & the CDC Foundation Foundation have developed have developed a Communications Toolkit to help communications staff and program managers in states and local health departments communicate effectively about cannabis to providers and the public. The toolkit also summarizes the health of effects of marijuana for youth and pregnant women and has summary findings around mental health effects of cannabis. Access the toolkit here and hover over "toolkits."

APHA Opens Access to American Journal of Public Health Firearm Research 

The American Public Health Association has opened up public access to all of their research papers and analytic essays on public health and firearms.  

Research is available now available to everybody (including non-members) regarding the effect of state legislation on firearm homicide, interventions to improve safe firearm storage, employer firearm policies and workplace homicide, public opinion on carry laws.

Also included is research on role firearms play in establishing homicide as a leading cause of death for pregnant and postpartum women, the urban-rural differences in firearm suicides, how law enforcement and firearm retailers can serve as partners in suicide prevention, loaded handgun carrying, the financial cost of firearm injury, among other subjects.

Perhaps our elected officials will examine the public health evidence and consider some evidence-based interventions in state law to curb the increasingly devastating impact of firearm violence.

Several Bills to Address Firearm Violence Failed Last Legislative Session 

Actually, They Weren't Even Heard

Several bills that addressed various aspects of firearm violence were proposed last legislative session. None were successful. In fact, a quick perusal of the bills will reveal to you that none were even given a hearing. Sad state of affairs, don't you think?

SB 1219 Domestic Violence Offenses & Firearm Transfer (Carter)

Persons that have been adjudicated and the court rules that they may not possess a firearm must surrender their firearms to a law enforcement agency.  The law enforcement agency may then dispose of the firearm(s) in accordance with law.  People that have an Order of Protection against them must also surrender their firearms, although the law enforcement agency must return the firearm when the Order expires (after a background check).

HB 2247 Bump Stocks (Friese)

This bill would outlaw the sale of bump stocks on firearms.

HB 2248 Firearm Sales (Friese)

This bill would require a background check for all sales at gun shows.

HB 2161 Order of Protection (Hernandez)

A person who is at least 18 years of age and who is either a law enforcement officer, a “family or household member” (defined), a school administrator or teacher or a licensed behavioral health professional who has personal knowledge that the respondent is a danger to self or others is permitted to file a verified petition in the superior court for a one-year Severe Threat Order of Protection (STOP order), which prohibits the respondent from owning, purchasing, possessing or receiving or having in the respondent’s custody or control a firearm or ammunition for up to one year.

HB 2249  Mental Health and Firearm Possession (Friese)

An immediate family member or a peace officer is authorized to file a verified petition with a magistrate, justice of the peace or superior court judge for an injunction that prohibits a person from possessing, controlling, owning or receiving a firearm. Any court may issue or enforce a mental health injunction against firearm possession, regardless of the location of the person. Information that must be included in the petition is specified. If the court finds that there is clear and convincing evidence to issue a mental health injunction against firearm possession, the court must issue the injunction. Information that must be included in the injunction is specified.

Arizona Area Health Education Center System in Transition

Arizona and 47 other states have programs called Area Health Education Centers that focus on enhancing access to quality healthcare (especially particularly primary and preventive care) by improving the supply and distribution of healthcare professionals through academic-community educational partnerships in rural and urban medically underserved areas.

Arizona’s state Area Health Education Center (AzAHEC) is housed at the University of Arizona.  Like the AHECs in most other states, Arizona’s statewide AzAHEC focuses on developing health professions workforce education programs that emphasize primary care and increasing access to care in rural and underserved communities.  Many of the strategies to accomplish this include improving the supply, quality, diversity and distribution of the health professions workforce.

The state AHEC program at the UA works in collaboration with the 5 statewide Arizona AHEC regional centers which are independent non-profit organizations that work in coordination with the state program:

The 5 regional centers each have their own unique strategies to improving the supply, quality, diversity and distribution of the health professions workforce.  Many of the regional strategies include strategies to develop health professions students and health professions workforce, recruiting and retaining a health professions workforce, and inter-professional training.  The regional centers also support many health careers programs including students in medicine, nursing, pharmacy, public health, dentistry, and allied health.

As of July 1, 2019 the Central Arizona Health Education Center took over as the Area Health Education Center for Central AZ.  For many years, Empowerment Systems dba the Greater Valley Area Health Education Center had been the Central Regional AHEC.  Sean Clendaniel is busy getting the business model and systems up and running as you read this. I’ll be updating the happenings in the Central AHEC in the coming months.

The combined work of the 5 regional centers and the state program are far too wide-ranging to capture here- but you can get an idea of the particulars by reading the state program Annual Report which includes summaries of the priority programs at the state program (UA) as well as the regional AHECs.

How it’s Funded

Funding for Arizona’s AzAHEC system is voter protected. The statute authorizing and funding the state system was approved by Arizona voters as Proposition 203 (in 1996) (aka Healthy Arizona 1) which required the Arizona State Lottery to allocate funds including the state AzAHEC programs [A.R.S. §5-522(E)] when annual Lottery revenues reach a specified threshold.

The system really matured in 2000 when voters passed Proposition 204 (aka Healthy Arizona 2) which expanded eligibility for the AHCCCS to 100% of the federal poverty level guidelines…  but also included a directive to distribute $4M annually to the AzAHEC system. 

It’s rare to have a state program that has a guaranteed source of income that doesn’t require an appropriation authorization from the state legislature, which is a real source of strength and stability. Also, because the funds are voter protected, if money is still available at the end of the fiscal year the reserves aren’t swept (like they are in most other state government programs).  As a result, the system has accumulated some carry-forward funds that are available for use in future years.  FY 2016 began with an effective carry-forward balance of approximately $7.5M.  Annual reports after 2016 didn’t disclose carry forward balances- so I’m not sure what the current carry forward is.

Leadership Change at the State Level & Moving Forward

Earlier this month, Dr. Sally Reel decided to step down from her role as the head of the AzAHEC system. Dan Derksen, MD, has agreed to serve as acting director as the U of A conducts a search for a successor.  As is the case with any leadership change- this will provide an opportunity to take a fresh look at the direction and priorities of the AzAHEC system including mission priorities and allocation of the funds.

With this leadership change, the state program moved out of the administrative control of the College of Nursing where it has been for many years to the office of the Senior Vice President for Health Sciences at the UA.  This administrative change will also provide some additional opportunities to better develop cross program inter-professional training opportunities.

Another opportunity for the state AzAHEC system is the implementation of new budget items that were in this year’s state budget- especially the addition of $12.5M more for Graduate Medical Education ($7M rural and $4.5M urban) in the coming year.  Graduate Medical Education is important because Residency programs have a huge impact on retaining primary care physicians and other allied health professionals- a big leverage point for driving healthcare professionals toward rural and underserved areas of AZ.

While Arizona has some pretty robust Medicaid GME spending already, those residencies are generally distributed in urban areas.  That’s because the money used to draw down the federal matching funds comes mostly from urban area hospitals - and the residencies go to those areas.  Also, those residency slots are generally for subspecialists – not primary care (which has the greatest need).

The new state AzAHEC program will now be in a position to influence the decisions to allocate the new $12.5M in Graduate Medical Education funding- that’s great because of the expertise within the program and at the AZ Center for Rural Health at the UA.

Other opportunities for program include soliciting input from regional AzAHEC office which could result in new innovative strategies that could be implemented either by the regional AHEC offices of the statewide AzAHEC.  Perhaps this could best be accomplished by convening a statewide primary care workforce forum to get input from a cross section of Arizona Stakeholders regarding strategic planning options and use of state AzAHEC funds.  An independent entity such as AzPHA could convene the forum, which would solicit ideas presented by participants including local AzAHEC programs.

More to come.

Voter Initiatives for 2020 Beginning to be Filed

108 years ago, Arizona's founders protected ordinary voters with a state constitution that guaranteed AZ residents the power of referendum, recall and initiatives.  Many of the bold moves to improve public health policy have come via citizens initiatives. A few examples are:

  • The Smoke Free Arizona Act;

  • The TRUST Commission for tobacco education and prevention;

  • First Things First;

  • Proposition 204 (from 2000) which extended Medicaid eligibility to 100% of federal poverty

The next set of Voter Initiatives (if any qualify for the ballot given the new restrictions and requirements) will be on the ballot in November of 2020- and the deadline for filing the required signatures is July 2, 2020.  Because it takes a long time to get the required signatures (and because of the new restrictions) folks that want to run voter initiatives need to start collecting signatures pretty soon.

Several entities have filed to notice their intent to get on the ballot so far (here’s that list on the Secretary of State’s website) but the only one that looks legit so far is one called the “Voters' Right to Know Amendment”.  Terry Goddard is the Applicant and Chair for that one.  Here’s a link to the voter initiative language and here’s the summary from the site:

Under this Amendment, it will no longer be possible to hide from public view the true sources of campaign spending. Anyone spending more than $20,000 on a statewide campaign or $10,000 on a local campaign must disclose contributions of $5,000 or more used to fund campaign expenditures. Major contributions must be tracked to their original sources. Violators are subject to fines. 

Because elections can have a profound impact on public health policies- we’ll be diving into the details of this Initiative to determine whether and how to support this effort.  More on that in a future update.

No doubt additional Initiatives that will have an impact on public health policy will be filed soon (including one that will legalize the retail sale of Cannabis).  We’ll continue to watch for those and will dive into the details after they’re released – probably in next week’s Policy Update.

Federal Budget Deal Reached

Here’s the Public Health Impact

The US House and Senate passed the “Bipartisan Budget Act of 2019” this week.  The president is expected to sign this bill into law soon.  Here’s what the budget bill will do:

  • Discretionary Spending: Increases the allocation for non-defense discretionary spending to $621.5 billion for FY20, which is an increase of $24.5 billion from FY19 non-defense discretionary caps. It also provides $626.5 billion for FY21, which is a $5 billion increase from FY20.

  • Census: Provides $2.5 billion for the 2020 Census.

  • Offsets: This legislation includes $77 billion in offsets achieved through increased fees and extending the sequestration cuts for non-exempt mandatory programs such as the Prevention and Public Health Fund through FY29. In other words- the Prevention and Public Health Fund won’t be cut this fiscal year – but the budget agreement contemplates cutting the fund in future years.

In Arizona the Prevention and Public Health Fund investments include immunizations, smoking cessation, diabetes prevention, opioid treatment, and more.  Here’s a report we wrote that summarizes what the Fund does here in Arizona.

Upcoming Events Calendar

It’s been awhile since I mentioned out Upcoming Events public health calendar.  Our website at http://www.azpha.org/upcoming-events contains a listing of upcoming webinars and meetings that might be of interest to our members- so make sure to bookmark it and visit the site from time to time. 

Also, let me know when you see something interesting that’s coming up at willhumble@azpha.org and I’ll add it to the calendar.

AzPHA Urges No Vote On Phoenix Proposition 105

A light rail extension on Central Avenue in South Phoenix will have a long-lasting, positive impact on community health in South Phoenix.  That’s not just an opinion, that comes from a scientific and detailed 2015 Health Impact Assessment by the Maricopa County Department of Public Health and the Arizona Alliance for Livable Communities.

The South Central Neighborhoods Transit Health Impact Assessment concludes that a thoughtfully planned transportation plan that includes a light rail extension in South Phoenix will result in positive long-term health outcomes for residents, including lowering rates of chronic disease, improving pregnancy outcomes, and reducing violent deaths.

The City of Phoenix’s current transportation plan has been developed over a decade and approved by voters 3 times.  The public has been heavily engaged in this planning effort which has included more than 500 public meetings held to gather input.

Proposition 105 will dismiss this planning and prohibit Phoenix from investing in any kind of rail project – including light rail, commuter rail, or other potential train connections despite the fact that light rail extension have a long-lasting positive public health impact and reinforce the positive aspects of the community.

The Existing Transportation Plan is Good

Four years ago, Phoenix voters passed Proposition 104, a comprehensive transportation plan that included input from public health stakeholders.  The plan incorporated evidence-based provisions to improve many facets of transportation – including things to make transportation easier for folks with disabilities and improving opportunities for physical activity with more walkable and bike-able transportation options.

The voter approved plan extended Phoenix’s existing 4/10ths of a cent transportation sales tax (originally passed in 2000) and increased it by 3/10ths of a cent to:

  • Greatly enhancing Dial-a-Ride for persons with disabilities;

  • Add 1,150 new bike lanes;

  • Add 170 miles of new sidewalks;

  • Increase bus frequency by 70%;

  • Increase transit hours of operation by 20%;

  • Invest $280 million for new roads and bridges;

  • Repair 750 miles of asphalt streets; and

  • Increase investments in light rail.

Phoenix’s existing Plan is well-balanced to provide various services based on differing community needs, contributing to improved transportation flexibility options and improving social determinants of health related to transportation.

For example, the existing transportation plan includes substantial investment in new transportation options in South Phoenix including a light rail extension.  That’s important because South Phoenix households are four times more likely to not have a car compared to other households throughout the Valley. 

The existing plan also enhances public transit services to South Phoenix and provides families with convenient access to key destinations such as work and school. In fact, over 70% of South Phoenix residents voted in favor of the current transportation plan. 

For all these reasons the Arizona Public Health Association urges Phoenicians to VOTE NO on Proposition 105.  Our health depends on it.

Thank you for a Successful FY 18-19!

We've had a terrific FY-19 as an organization.  Our membership has grown more than 30% in the last two years and we've been increasingly becoming a force for positive public health policy development.  We also have a growing list of Organizational Membership supporters- which you can view on our Supporters Page: http://www.azpha.org/oursupporters 

Here's a link to our end of FY-19 MEMBERSHIP REPORT and some current membership SUMMARY CHARTS.  As a refresher- here's a link to our PowerPoint Summary of the 2019 Legislative Session (PDF)

Maternal Morbidity & Mortality in AZ to be Examined

The US has the highest maternal mortality rate of any developed country.  Sadly, it’s getting worse each year.  About 800 American women die and 65,000 almost die during pregnancy or childbirth. The number of deaths in AZ jumped from around 10 in 2015 to about 30 in 2016 (the last year for which ADHS has data posted- the numbers are cell-suppressed to protect confidentiality). 

Nationally, back women die from pregnancy-related causes at three to four times the rate of white women, even after controlling for social determinants. Women in rural areas also have higher maternal mortality rates than urban women.  Here’s a story that highlights some of the issues in an easy to read way.

Evidence-based policy making is a key.  Twenty-nine states (including Arizona) have committees that review maternal deaths and make public policy recommendations.  Arizona took a big step forward this last legislative session with the passage of SB 1040 Maternal Mortality Report which will establish an Advisory Committee on Maternal Fatalities and Morbidity.

It requires ADHS and the Committee to hold a public hearing to receive public input regarding the recommended improvements to information collection concerning the incidence and causes of maternal fatalities and severe maternal morbidity and complete a report (including recommendations) by the end of this year.

Syringe Services: A Proven Public Health Intervention that Saves Lives

Arizona Law is Having Chilling Effect

The opioid epidemic is one of the greatest public health crises of our time.  The roots that caused the epidemic are deep and the public health interventions that will be needed to ease the crisis are many.  Those interventions include dramatic changes to prescribing practices, things like the distribution of naloxone, more robust treatment options including Medically Assisted Treatment, and harm reduction and engagement strategies like Syringe Services.

We need all those tools working together in order to mount an effective response.  Last year’s Arizona Opioid Epidemic Act was an important new law that is addressing many of those factors- but not all.  A real outlier is that the Act didn’t make an important change that is needed in Arizona – decriminalizing syringe service programs. As this excellent report by Stephanie Innes in the Republic this week shows, needle exchange efforts in Arizona have been impaired because some of the things that syringe service programs do are considered felonies under state law.

Syringe services programs are community-based prevention efforts that offer a range of interventions. They provide access to and disposal of sterile syringes and injection equipment, linkage to substance use disorder treatment, and naloxone distribution.  People who use syringe service programs gain access to other vital services including vaccination, testing, and linkage to care and treatment for infectious diseases including viral hepatitis and HIV. 

Nearly 30 years of research shows that comprehensive syringe service programs are safe, effective, and reduce overall health costs. They play an important role in reducing the transmission of viral hepatitis, HIV, and other infections and are a major component of the Ending the HIV Epidemic: A Plan for America initiative. The U.S. Surgeon General determined that syringe service programs don’t increase the illegal use of drugs by injection. Studies also show that they protect the public and first responders by providing safe needle disposal.

Sadly, syringe service programs in Arizona are illegal because syringes are considered drug paraphernalia under Arizona law (a class 6 felony). While arrests, indictments and convictions of workers that operate syringe service programs are rare- the fact that syringe service programs are illegal has a marked chilling effect on the ability of organizations and individuals to operate and fund these important programs. 

After all- it’s pretty hard to get a grant award if you need to disclose to the funder that you intend to commit felonies with the money!

A cohort of public health organizations led by Sonoran Prevention Works have been trying for the last few years to simply decriminalize syringe service programs.  Pretty simple, right?

Sadly, the effort has been unsuccessful. 

In 2018 HB 2389 Syringe access programs; authorization passed the full House of Representatives, was dramatically weakened by a poor amendment in the Senate but ultimately failed to come out of a Conference Committee.  This year, HB 2148 Syringe Services Programs failed to even make it to the House Floor for a vote.

Public health stakeholders will continue to try to get our Legislature to pass a bill that will decriminalize this important evidence-based public health practice.

By the way, the CDC has released materials that health departments can use to provide information on the critical role of SSPs in prevention and treatment, including:

  • A summary of information on the safety and effectiveness of SSPs in reducing viral hepatitis and HIV;

  • A fact sheet outlining the various ways syringe service programs can prevent transmission of blood-borne infections and link people to care, reduce and treat substance use, and enhance public safety;

  • A fact sheet for health departments and community partners that defines syringe service programs and their public health impacts; and

  • Frequently asked questions and answers about syringe service programs.

All of these materials are available to you online on the CDC’s Syringe Services Programs website.

Here’s a statement from the CDC on the subject: “It is our hope that by sharing these materials with you, we will engage the full strength of the nation’s public health and community infrastructure to reduce the toll of opioids and infectious diseases in our communities. We have the tools. We have the science. We can work together to improve the health and security of current and future generations.”