Legislative Session Session PowerPoint

Here’s a Summary of the 2019 Legislative Session (PPT) and the Summary of the Legislative Session as a (PDF). It's been updated a bit since last week as the Governor signed the medical marijuana bill this week (which will require testing of medical marijuana, gives the ADHS additional dispensary enforcement authority, allows MM data to be used for research purposes, and makes the MM cards good for 2 years (effectively reducing the card fees by half).

Many States Using State Earned Income Tax Credits as a Prevention Strategy for ACEs

Is it Arizona’s Turn?

It’s no secret that exposure during childhood to negative events called adverse childhood experiences increase a person’s likelihood of having long-term chronic or behavioral health issues like heart disease, violence, suicide, and substance use.  ACEs like child abuse, neglect, parent incarceration, substance use, or separation are often clustered.

Policymakers in many states are looking for ways to prevent ACEs… which includes strategies to strengthen protective factors like social connectedness, access to healthcare and community resources, enhancing parental skills to promote healthy child development, and providing quality care and early education, and reduce risk factors before they occur. Arizona took a step forward this year by passing a budget bill that will draw down more than $60M in additional funds to support affordable childcare in Arizona.

Leading evidence-based policies to prevent ACEs before they occur are usually linked in some way to strengthening economic supports to help working families out of poverty and reduce parental stress. One well known economic support is the federal Earned Income Tax Credit

Many states are recognizing that they can also play a role through their state-based tax codes – and implementing Earned Income Tax Credits at the state level. Arizona hasn't done so yet.

Here’s how they work. The Earned Income Tax Credit is a refundable income tax credit that can be used to reduce the tax burden for low- to moderate-income working people.  The federal government along with 29 states have established them at the local level. Arizona doesn’t.

Economic support from Earned Income Tax Credits is associated with improved infant and maternal health, better school performance for children, and increased college enrollment. Research suggests they reduce risk factors for child abuse and neglect ACEs by offsetting the costs of raising a child among working families.

This webpage from the National Conference of State Legislatures has a host of information about which states have state based Earned Income Tax Credits and how they work. They’re usually based on a reference to the federal EITC.

State Earned Income Tax Credits are a promising economic support for working families that help to raise more than six million people—half of them children—above the poverty line each year.

Arizona lawmakers have long had a zeal for reducing taxes.  Perhaps next year they should look at taxes from a new angle- using tax policy to support an evidence-based policy a state based earned income tax credit- that will that prevent negative childhood events and bad public health outcomes.

Report Suggests Paternal Parental Work Flexibility Improves Maternal Outcomes

A new report published this week from the National Bureau of Economic Research found increasing a father's work flexibility after a baby is born reduces the risk of the mother having physical postpartum health complications and also improves her mental health.

Workplace flexibility has long been key factor in improving postpartum outcomes but less has been known about how a father's work hours flexibility influences outcomes.  The paper this week examined father's work flexibility and the affect that it has on intra-household responsibilities and the effect that that flexibility has on maternal outcomes. 

The paper examined the effect that work flexibility has in the months immediately following childbirth. The authors found that a dad's access to workplace flexibility improves maternal health. They modeled household demand for paternal presence at home in the context of a Swedish reform that granted new fathers more flexibility to take intermittent parental leave during the postpartum period.  

Increasing the father's work hours flexibility reduces the risk of the mother experiencing physical postpartum health complications and improved her mental health. The abstract concludes that "Our results suggest that mothers bear the burden from a lack of workplace flexibility–not only directly through greater career costs of family formation, as previously documented–but also indirectly, as fathers' inability to respond to domestic shocks exacerbates the maternal health costs of childbearing."

Interesting research in the context of what kinds of public health policy interventions are effective at improving maternal postpartum health, don't you think?

Title X Family Planning Article

Andrew Howard from the Arizona Capitol Times wrote this informative story about the outcome of a 2017 state budget provision requiring the ADHS to apply for Title X family planning grant.  Many people believe that the requirement was included in the budget in hopes that the ADHS would get Title X funds (as they're prohibited from contracting with Planned Parenthood).

I won't say anymore about the story...  except that it's a quick informative read about the outcome of a key public health policy decision here in AZ.  

What Can You Do this Summer RE Public Health Advocacy?

Send your elected officials a short note thanking them for their service.  The last few days were long and stressful for all.  

  • Invite them to tour your facilities over the interim.  

  • "Like" your elected officials on social media and follow them.  

  • Attend any events they are holding over the summer.  

  • Monthly send them a short note with interesting information about their district and those they serve (who you also serve!)

  • Use this time during the interim to build relationships with your home and work district elected officials so they know who are when session starts January 13, 2020.

This spreadsheet has legislator contact information and committee assignments.  Targeting legislators who serve on committees of interest to us is a good strategy to start with.  This spreadsheet has our member facilities by legislative and congressional district.  

Yuma County Captures 2019 Spotlight Award

Blue Cross Blue Shield of Arizona and fitness icon Jake “Body by Jake” Steinfeld have teamed up to shine a light on people and programs that are making Arizona healthier. The 2019 Spotlight Awards honor leaders across our state who are inspiring health and wellness in their communities, where it matters most.

WINNERS:

Business of the Year: Chicanos Por La Causa
City of the Year: City of Phoenix
County of the Year: Yuma County
Tribal Nation of the Year: Tohono O’odham
School District of the Year: Tempe Elementary School District #3
School of the Year:  Brunson-Lee Elementary

Terrific Op-Ed Regarding Vaccine Safety and Herd Immunity

Dr. Bob wrote a really good op-ed in the Daily News Sun this week.  I thought I’d include it in this week’s Policy Update because it’s so well written.

I’d like to try to offer some perspective in response to Diane Douglas’ May 24 commentary on vaccine safety.

“Herd immunity” is a medical miracle, preventing millions of cases of disease and many deaths every single year.  Yet it’s a pretty simple concept. 

No vaccine works perfectly.  But the more people are immunized, the less likely one person’s germs are to spread to the next person.  Depending on the disease, one sick person might infect several others, each of whom infect several more.  That’s an outbreak.  But if you keep the level of immunizations high enough that there is less than one new case of disease for each original sick person, then outbreaks simply don’t happen.  Your personal immunity from your own vaccine never gets put to the test, because you are never exposed in the first place.  This makes vaccines unlike any other health decision – because your action affects others.

Herd immunity results in remarkable protection.  Diseases that were once nearly universal can be practically wiped out.  In the example of smallpox, a disease that killed perhaps half a billion people in the 20th century alone, we were able to eliminate the disease entirely.  There’s no biological reason that we couldn’t do the same with some other diseases – we’ve come close to eliminating polio, for example.

You are, right now, being protected not just from the vaccines you got, but from all the vaccines that everyone around you got.  And what you do by immunizing yourself or your kids doesn’t just benefit your own family – it helps to protect everyone else, notably all those who, for medical reasons, can’t be vaccinated themselves.  Similarly, choosing not to be vaccinated, yet living among others, lowers that level of herd immunity and puts others at risk.  Exactly what that threshold of herd immunity is varies by disease (how infectious it is), by the vaccine (how effective it is), and by the setting (how congested and interactive people are).  Among the worst settings for spreading disease are schools and childcare centers. 

That concept of pitching in to benefit each other is a thoroughly American idea, from the early colonists creating a commons in nearly every town, to compulsory quarantine in the 1600s, to requiring vaccination for school attendance beginning in 1855, to early and repeated court decisions that have upheld various vaccination laws and regulations since at least 1905.  This is not new, and since it has been in place for all our entire lives, it is obviously not a “slippery slope” that has led to any sort of draconian consequences.

Vaccines must meet the same safety and efficacy standards that other pharmaceutical products must reach before being licensed for use in the U.S.  The benefits to an individual and to society of vaccines far outweighs the small risk, for example, of an allergic reaction.  Yet recognizing the societal value of immunizations, the nation established the National Vaccine Injury Compensation Program, which requires a far lower burden of proof and a simpler process than a lawsuit, to assure that anyone who legitimately might have been harmed by vaccines is compensated.  Even with these looser standards, which mean that some people are compensated even though it may be unlikely that the vaccine caused the injury, approximately one person is compensated for every 1 million doses of vaccine given in this country.

In her commentary, Ms. Douglas invoked appeals to individual liberty.  All of us can relate to that.  America guarantees many liberties, but we establish limits when others might be harmed.  Any one of us is free to use public streets, but we don’t get to drive however fast we want, because that would put others at risk.  Similarly, any one of us is free to send our kids to public schools, but we should not be allowed to deliberately put other people’s children at risk by ignoring vaccine requirements. 

Bob England, MD, MPH

Former Director (2006-2018) of the Maricopa County Department of Public Health

Legislative Session Wrap Up

Another legislative session is in the books.  All in all - a solid legislative session with some pretty significant public health policy gains.  The main areas where progress was made were in access to care, maternal and child health, assurance and licensure and injury prevention. 

There were several bills that didn't progress which would have been a public health benefit and several really good ideas which never even got a hearing- so there were missed opportunities- but overall a solid B+ session I'd say.

We had lots of help with our advocacy efforts this year. Annissa Biggane and Timothy Giblin worked hard each and every week tracking bills, doing triage, ferreting out schedules, and writing risk/benefit analyses.

Eddie Sissions carried a lot of water as usual. She has great insight and a keen ability to figure out the nuances of session and figuring out "how the water flows". Also a big help were our cadre of folks that called in to our bi weekly calls and strategy sessions.

The real key to our advocacy success is you - our membership.  The relationships you make with our elected officials and your focused advocacy efforts are super important to our success at influencing public policy.   Thank you all and well done this year!

I put together a Powerpoint summary of the 2019 legislative session to help y'all digest what happened this year.  I've got links on the pages that'll drive you to the actual bills. Take a look.  BTW- if you open the link with an Apple product like an iPad- the PowerPoint will look weird and unprofessional- so open it on a laptop and in PowerPoint.

State Supreme Court Says Edibles are Protected by the AZ Medical Marijuana Act

The Arizona Supreme Court put to rest the question whether edibles, extracts and resins are covered in the Arizona Medical Marijuana Act and whether patients are protected from criminal charges for possessing them.  The court was unambiguously clear this week that edibles are indeed covered in the Act.

The Ruling came in the form of the final decision in the State v. Jones case which was released on Tuesday.

Here's the case in a nutshell. Back in 2013 a medical marijuana patient (who had a valid ADHS Medical Marijuana Card) was arrested for possession of a small amount of hashing (a preparation of marijuana) in Yavapai County.  Even though he was a Qualified MM Patient, he was convicted by a jury of a class 6 felony and spent 2.5 years in jail. 

Mr. Jones appealed his conviction in Superior Court to the Court of Appeals which upheld his conviction. He appealed to the state supreme court who heard the case about 6 weeks ago. 

The Arizona Medical Marijuana Act provides qualified patients and dispensaries a number of legal protections under the voter approved  Act.  The Act's definition of “Marijuana” in A.R.S. § 36-2801(8) differs from the Arizona Criminal Code’s definition of “Marijuana” in A.R.S. § 13-3401(19). In addition, the Arizona Medical Marijuana Act makes a distinction between “Marijuana” and “Usable Marijuana” A.R.S. § 36-2801(8) and (15).  The basics of the case consists of a profound difference of opinion between the prosecutor, who believes that edibles are not included in the definition of Marijuana in AMMA, and the defense, who makes the common sense argument that edibles are included.

Mr. Jones’ appeal was successful and Qualified Patients can now be assured that as long as they have the allowable amount of marijuana in their possession they are protected from prosecution. That means they can have up to 2.5 ounces of dried marijuana flower or, as the court said this week, "... mixtures or preparations made from two-and-one-half ounces of dried flowers".

Dispensaries can now be assured that their business models that rely on the production and sale of edibles and extracts are protected as well.

Case closed.

Measles-response Toolkit Offered to Health Departments

State and local health department are tasked with the difficult job of leading the response to measles outbreaks when they occur in their communities. To assist in the effort, CDC has developed this one-stop-shop digital toolkit with products that can be used to reach a variety of audiences during measles outbreaks.

The products include accurate, science-based evidence that can help to counter misinformation in communities about measles and MMR vaccine. The kit includes answers to frequently asked questions; a place to direct additional public inquiries to CDC; a measles microsite that you can syndicate on your own website; graphics to post on your websites; and modifiable letter templates (to school principals, parents, etc.) to quickly reach key stakeholders during measles outbreaks.

Final 2019 Legislative Summary

The 2019 Legislative Session is in the books.  There were several good things that came out of Session this year.  Of course, there were also some missed opportunities that would have improved public health.  There were also a few close calls on bills that would have done some damage to public health.

The session ended Monday night when the House and Senate agreed on a series of budget bills.  Once those were passed and sent to the Governor, Legislators voted to adjourn for the year.

The budget highlights included funding to protect Arizona’s Kids Care program, some additional investment in the state loan repayment program and graduate medical education, some funding for prenatal care equipment in rural Arizona, needed funding for providers that serve folks with disabilities, and an appropriation of federal funds to draw down federal funds from the Child Care Block Grant. Disappointments in the budget included a failure to fund preventative oral health coverage for pregnant women and investing in the state’s 211 information hotline.

Here’s the subset of the budget that was passed related to public health and human services and a link to the health budget reconciliation bill and the Budget Bill Summary: https://apps.azleg.gov/BillStatus/GetDocumentPdf/471479

Medicaid

  • Fully funds KidsCare and eliminates the risk of an enrollment freeze by paying the increased state match requirements that are coming up.  The language also eliminates the former trigger language that would have frozen KidsCare when the federal match requirement changes again.

  • Makes last year’s one-time $13M increase for providers that serve persons with developmental disabilities ongoing (because of the Prop 206 minimum wage increase) and an additional $13M in provider funding (rate increases) for the upcoming fiscal year.  There’s an additional $4M in provider rate increases for Prop. 206 impacted services for January 1, 2020 (this funding is for half a fiscal year to address the January 1, 2020 minimum wage increase). 

  • Provides new Prop 206 (minimum wage increase) funding for Elderly Long-Term Care (for persons with developmental disabilities) of $4.8M.

 

Child Care Subsidies

  • Appropriates $56M Childcare Block Grant funding (this is entirely federal funding- but the feds still require a state appropriation to draw down the funds). Will go a long way toward reducing the wait list for child care subsidies and will help improve reimbursement rates.

Miscellaneous Health Items

  • Appropriates an additional $750,000 for the State Loan Repayment Program (in addition to the current $1M/year).

  • Appropriates $1.6M for rural Graduate Medical Education ($5.5M w fed match) and $1.3M for urban GME ($4.4M w fed match)

  • $750,000 for North Country Graduate Medical Education

  • $1M for rural prenatal equipment

  • Provides $10M to the Housing Trust Fund for programs related to homelessness

  • $700K for Colorado City primary care clinic

  • $1.5M for Benson and Northern Cochise critical access hospitals

  • Continues $3M annual appropriation for TGEN for 3 years

  • Increases Alzheimer's funding by $2M ($1M base)

  • Provides an additional $15M for an Arizona Department of Education school safety grant program for School Resource Officers, behavioral health counselors and social workers

  • Provides $1.6M for Veteran's Suicide Prevention (includes $450K for trauma training)  

  • $8.0 million for the UofA Health Sciences Center

 

Arizona State Hospital

  • Provides $2.8M in pay raises for AZ State Hospital staff

  • Provides $300K for AZ State Hospital for a temporary staffing contract increase

I’m still in the process of putting together a PowerPoint that will summarize the legislative session.  Below is a summary of the various bills related to public health that passed followed by some of the missed opportunities and the close calls.

 

Bills Passed and Signed

Injury Prevention

SB 1468 Suicide Prevention Training

This new law will require school districts, charter schools, and Arizona teacher training programs to include suicide awareness and prevention training in their continuing education curricula.  It’ll require AHCCCS to make suicide awareness and prevention training available (fortunately some evidence- based tools curricula already exist).

Starting in the 2020 school year, school districts and charter schools would need to provide training in suicide awareness and prevention to school personnel in grades 6 to 12.  The bill also establishes requirements for suicide awareness and prevention training and specifically says that the training use evidenced-based training materials and instruct participants on how to identify the warning signs of suicidal behavior in adolescents and teens.

HB 2488 Veteran Suicide Annual Report

Requires ADHS (starting this year) to complete an annual report on veteran suicides in Arizona that includes the number and rate of veterans who died by suicide, trends, an analysis of the years of potential life lost, a comparison of Arizona's resident veteran suicide rate to those of the nation, and the relative risk of suicide by race or ethnicity, age group, gender and region. 

The report is also supposed to analyze patterns of drugs, or combinations of drugs, that were used by Arizona's resident veterans when drug poisoning was the mechanism of suicide. The idea is to create the surveillance and data linkages needed to inform suicide prevention strategies based upon medical risk factors that significantly correlate to suicide.

HB 2318 Hands Free Cell Requirement 

This bill was a long time coming- but were on the precipice of having this good public policy finally happen. It will prohibit using a hand-held cell phone while driving.  There are some common-sense exemptions for example if the person is using it hands free etc.  It'll change driving behaviors and save lives.

Violations are a civil money penalty (no driving points) with the first offense being between $75- $150 and the 2nd offense between $150 and $250.  The bill would provide a state overlay so the cell phone use laws would no longer be different from jurisdiction to jurisdiction. Warnings for a year and a half - and then the penalties kick in.

Licensing Requirements

SB 1247 Residential Care Institutions

This good bill will require more robust staffing background checks for facilities that provide services for children and will remove the “deemed status” designation for child residential behavioral health facilities.   

Under the old law, facilities in this category (e.g. Southwest Key) can be accredited by a third party (e.g. Council on Accreditation) and avoid annual surprise inspections by the ADHS.  This intervention will provide more oversight to ensure background checks are done and that the facilities are compliant with state regulations. 

SB 1211 Intermediate Care Facilities

Like SB 1247, this bill closes a licensing loophole. This good bill will require more robust staffing background checks for facilities that provide services to people with disabilities at intermediate care facilities.  These facilities would also require a license to operate from the Arizona Department of Health Services beginning on January 1, 2020.  Under current law these facilities (Hacienda de los Angeles and similar facilities run by the ADES are exempt from state licensing requirements).

HB 1494 Medical Marijuana Testing

This bill will require medical marijuana dispensaries to test their product for potency and contaminants.  It will also require the ADHS to develop testing standards and laboratory certification criteria to implement the requirements. Still needs to be signed by the Governor.

Maternal & Child Health

SB 1040 Maternal Mortality Report

The new law 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.

SB 1456 Vision Screening

This bill would require schools to provide vision screening services to students in grades prescribed by future ADHS rules, kids being considered for special education services, and students who are not reading at grade level by the third grade. Appropriates $100,000 from the state General Fund to the ADHS for the tracking and follow up.  

Access to Care

SB 1089 Telemedicine

Any healthcare service covered in-person by a commercial insurer will also be covered when provided through telemedicine. Currently, Arizona law limits telemedicine coverage to a handful of medical services.

SB 1109 Short Term Limited Health Plans

This authorizes the sale of short- term limited health plans in Arizona for terms up to 3 years.  The previous limit was 1 year.  These plans don’t cover pre-existing conditions and have limited consumer protection because they aren’t required to cover the essential health services under the ACA and can drop enrollees.  We urged a not vote because of the poor consumer protections.

SB 1085 Association Health Plans

This new law basically provides a regulatory structure at the state level for Association Health Plans - serving to make them more available in Arizona. A primary concern for folks interested in public health and consumer protection is that this category of health plan won’t need to cover the essential health benefits and can charge differently depending on gender and age. 

Missed Opportunities:

SB 1354 Graduate Medical Information & Student Loan Repayment

The final budget did make some investments that were included in this bill, but not all.  This bill would have done a great deal both in the short-term by boosting the primary care loan repayment program and really enhancing graduate medical education residencies over the coming years (important because where a practitioner does her or his residency greatly influences where they ultimately practice).

HB 2718 Syringe Services Programs

This bill would have decriminalized syringe access programs, currently a class 6 felony. To qualify, programs need to list their services including disposal of used needles and hypodermic syringes, injection supplies at no cost, and access to kits that contain an opioid antagonist or referrals to programs that provide access to an opioid antagonist.

SB 1088 Dental Care During Pregnancy

This bill would have expanded AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding. Good oral health is well established to improve birth outcomes including reducing pre-term birth while also preventing the transmission of caries from mom to infant after birth. 

SB 1174 Tribal Area Health Education Center

Health Education System consists of five area health education centers each representing a geographic area with specified populations that currently lack services by the health care professions.  

SB 1355 Native American Dental Care

This bill would have required AHCCCS to seek federal authorization to reimburse the Indian health services and tribal facilities to cover the cost of adult dental services.

SB 1245 Vital Records- Death Certificates

This bill would have made it clear that both state and county Registrars can provide certified copies of death certificates to licensed funeral home directors upon request.  There’s been some confusion about this authority and this bill would clear it up.

SB1399  School Health Pilot Program

This bill would have charged the AZ Department of Education with conducting a 3-year physical and health education professional development pilot program to improve the ability of physical and health educators in this state to provide high quality physical and health education to students in this state, improving student health and reducing Arizona health care cost containment 10 system and other health-related costs.

Others:

SB 1363  Tobacco Product Sales (Tobacco 21) (Carter)

HB 2162  Vaccine Personal Exemptions (Hernandez)

HB 2352 School Nurse and Immunization Postings (Butler)

HB 2172  Rear Facing Car Seats (Bolding)

HB 2246  Motorcycle Helmets (Friese)

SB 1219  Domestic Violence Offenses & Firearm Transfer

HB 2247  Bump Stocks (Friese)

HB 2248  Firearm Sales (Friese)

HB 2161  Order of Protection (Hernandez)

SB 1119 Tanning Studios (Mendez)

HB 2347  Medicaid Buy-in (Butler)

HB 2351  Medical Services Study Committee (Butler)

Bills that Didn’t Pass that We Opposed:

HB 2471 Informed Consent

This bill would add a requirement that physicians provide to parents and guardians the full vaccine package insert and excipient summary for each vaccine that will be administered.  Physicians already provide a Vaccine Information Summary to parents and guardians for each vaccine administered, which is noted in the medical record.  This new requirement would mandate provision of the 12-15 page insert, which is not presented in a format that incorporates health literacy principles.

HB  2472 Vaccinations- Antibody Titer

These bills would mandate that doctors inform parents and guardians that antibody titer tests (which involve a venous draw) are an option in lieu of receiving a vaccination and that there are exemptions available for the state requirements for attending school.

HB 2470 Vaccination Religious Exemptions

This bill would add an additional exemption to the school vaccine requirements into state law.  Currently there are medical and personal exemptions.  The bill doesn't include any verification of the religious exemption from a religious leader, just a declaration from the parent that they are opposed to vaccines on religious grounds. 

Legislative Budget Negotiations Underway & Several Public Health Initiatives in the Mix

All signs are that the Legislature is focusing on building a budget for next fiscal year.  The Republican leadership in the House and Senate met with representatives from the Governor’s Office over the weekend to come up with a budget proposal.  Here’s a link to the proposed budget worksheet.

It’s still unclear whether they have a plan that'll pass. Several issues stand in the way - including a dispute about the statute of limitations for sexual assault victims and other specific priorities that some lawmakers are linking to their support of a budget.  Committee hearings on the spending plan won’t occur until Wednesday at the earliest (if they happen this week at all).

Some of our priorities are included in the weekend proposal (e.g. KidsCare funding & an appropriation for federal funds for child care subsidies), but several other priorities aren’t included (increases in the AZ primary care and loan repayment program and for additional primary care residencies).  Also not included is preventative dental services for pregnant Medicaid members.

Now would be a really good time for you to use any relationships you have with legislators to let them know that you support the encouraging portions of the initial proposal (e.g. KidsCare) but you believe more needs to be done to support access to care in rural and underserved areas by investing in the state’s loan repayment program and through increased residency opportunities (GME), as well as preventative dental care for pregnant Medicaid members.

Here’s the subset of the budget proposal related to public health and human services:

Medicaid

  • Fully funds KidsCare and eliminates the risk of an enrollment freeze by paying the increased state match requirements that are coming up (FY20 = $1.6M, FY21 = $9.4M, FY22 = $9.4M) 

  • Makes last year’s one-time $13M increase for providers that serve persons with developmental disabilities (because of the Prop 206 minimum wage increase) ongoing.  The proposal also includes a $6.7M cap rate increase for the current year for those providers.  Proposes an additional $13M in provider funding for the upcoming fiscal year.

  • Provides new Prop 206 (minimum wage increase) funding for Elderly Long-Term Care (for persons with developmental disabilities) of $4.8M

Child Care Subsidies

  • Appropriates $56M Childcare Block Grant funding (this is entirely federal funding- but the feds still require a state appropriation to draw down the funds)

Arizona State Hospital

  • Provides $2.8M in pay raises for AZ State Hospital staff 

  • Provides $300K for AZ State Hospital for a temporary staffing contract increase

Miscellaneous Health Items

  • Increases Alzheimer's funding by $2M ($1M base)

  • Proposes $1M for rural prenatal equipment

  • Proposes $700K for Colorado City primary care clinic

  • Proposes $1.5M for Benson and Northern Cochise critical access hospitals

  • Continues $3M annual appropriation for TGEN for 3 years

  • Provides $10M to the Housing Trust Fund for programs related to homelessness

  • Provides an additional $15M for an Arizona Department of Education school safety grant program for School Resource Officers, behavioral health counselors and social workers

  • Provides $1.6M for Veteran's Suicide Prevention (includes $450K for trauma training)  

This part of the legislative session is very fluid and things can move quickly or completely stall out at any time.  

Now would be a really good time for you to use any relationships you have with legislators to let them know that you support the encouraging portions of the initial proposal (e.g. KidsCare) but you believe more needs to be done to support access to care in rural and underserved areas by investing in the state’s loan repayment program and through increased residency opportunities (GME), as well as preventative dental care for pregnant Medicaid members.

To find your Senator and Representative go to: https://www.azleg.gov/findmylegislator/

Arizona Research will Change EMS Brain Injury Care

Traumatic brain injury is involved in about 1/3 of all injury-related deaths... it’s clearly a public health issue.  That’s why back in 2013 Arizona created the Excellence in Pre-hospital Injury Care (EPIC) project- which has been aimed at improving brain injury outcomes in AZ. 

Back in 2013 the National Institutes of Health chose AZ as the only state to evaluate the national standards for pre-hospital emergency care of brain injury (under a grant application led by AZPHA member Ben Bobrow, MD). 

EPIC has been a unique partnership between state government, the U of A and more than 130 fire departments and ground/air ambulance companies.  Together they implemented a series of pre-hospital traumatic brain injury treatment interventions and measured the effectiveness of the results.

The interventions included: 1) prevention of hypoxia by early oxygen administration; 2) airway interventions to optimize oxygenation; 3) prevention of hyperventilation; and 4) quickly treating low blood pressure by infusing fluids.

Participating EMS agencies sent treatment information to the ADHS and the UA College of Medicine for tracking and evaluation. An early donation from the Ramsey Justice Foundation made it possible for the agencies to receive special breathing devices to implement the new protocol and assist in the treatment patients at no cost.

More than 5 years of work by literally hundreds of Arizonans resulted in the publication of the results this week in JAMA Surgery entitled Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines with Patient Survival Following Traumatic Brain Injury.

Remarkably, the team found that implementation of the protocol doubled the chances of survival among persons with a critical traumatic brain injury and improved neurological outcomes. Doubling the chances of survival is no small thing for a public health intervention, so this is really a landmark study.

This Arizona study will change the way EMS providers treat traumatic brain injury in the field around the globe. That shows the importance of publishing. When hard work like this with dramatic results is published in reputable journals- people take note. It won’t be long before the Arizona protocol becomes a global EMS standard for traumatic brain injury care. For more info go to www.epic.arizona.edu.

A huge public health thank you to the entire research team including Dan Spaite, MD; Ben Bobrow, MD; Sam Keim, MD, MS; Bruce Barnhart, RN, CEP; Vatsal Chikani, MPH; Joshua Gaither, MD; Duane Sherrill, PhD; Kurt Denninghoff, MD; Terry Mullins, MPH, MBA; P. David Adelson, MD; Amber Rice, MD, MS; Chad Viscusi, MD; and Chengcheng Hu, PhD.

Washington Passes Medicaid Buy-In Law

This week Washington Governor passed the nation’s first Medicaid buy-in law.  The new law will offer a new health insurance option to people who make too much money to qualify for Medicaid but not enough to afford private health coverage. 

Washington's new law directs their state Medicaid agency to contract directly with at least one private health insurer to offer a "qualified health coverage" plan that meets Affordable Care Act standards on the state’s marketplace. It will expand subsidies to people making up to 500% of the federal poverty line, or $62,450 a year, for a single person.

The tiered public plans are expected to be up to 10% cheaper than comparable private insurance, in part because of savings from a cap on rates paid to providers. The WA public plans are set to be available to all residents regardless of income by 2021.  Here’s more info in a Time Magazine article from this week.

In addition to Washington, legislation to study or start a public option or Medicaid buy-in program is currently pending in Colorado, Connecticut, Maine, Massachusetts, Minnesota, Missouri, New Hampshire, New Jersey and Oregon.

The basic idea is to leverage the buying power of state Medicaid programs to negotiate better premium rates that offer a lower-cost alternative to the health-care marketplace and spur competition which would lower premiums overall.

Washington State Eliminates the Personal Exemption for MMR

Washington’s Governor also signed a new law this week that will eliminate the “personal exemption” that parents can sign to exempt their kids from school and pre-school vaccination attendance requirements. 

Interestingly, the new law just eliminates the personal exemption for the MMR (measles, mumps, rubella) vaccine.  The personal exemption option will still be available for the other school-required vaccines.  The new law will be effective before the start of this year’s school season.

Washington lawmakers overcame strong lobbying by anti-vaccine groups who mobilized hundreds of supporters, who telephoned and sent emails to lawmakers, and turned out in large numbers for the hearings.

As is often the case, a protracted outbreak created the political will to pass the measure.  Earlier this year Washington declared a  state of emergency after officials reported 25 measles cases. The cases continued to climb – and so far 78 measles cases have been confirmed in Washington and neighboring Oregon.

As is the case in AZ, Washington has seen a consistent increase in the number of kids whose parents have exempted them from vaccination school enrollment requirements.  In fact, Washington’s exemption rate for Kindergarteners is 4.7%.  Arizona’s exemption rate is even worse than Washington’s- as the exemption rates for Kindergarten went up this year to 5.9%.

It’s only a matter of time before Arizona has a Washington/Oregon style outbreak.  Most likely it’ll be in a place like Yavapai County- which has the state’s lowest immunization rates.  There’s a good chance it’ll start when an unvaccinated Arizonan returns from Europe with measles and spreads it within their community.

AzPHA Letter to AHCCCS Urging them to Consider Adding Additional Opioid Use Disorder Medications

AzPHA sent the following letter to AHCCCS’ Pharmacy & Therapeutics Committee (which meets next Thursday), urging them to consider expanding the MAT Preferred Drug List for treating AHCCCS members with an opioid use disorder.  This work fits under the Administrative Advocacy portion of our mission.

I write on behalf of the Arizona Public Health Association – one of Arizona’s oldest and largest membership organizations dedicated to improving the health of Arizona citizens and communities. An affiliate of the American Public Health Association, our members include health care professionals, state and county health employees, health educators, community advocates, doctors, nurses and students.

Thank you for the opportunity to comment on the Pharmacy & Therapeutics Committee’s recommendation regarding the Preferred Drug List for Medication-Assisted Treatment (MAT) for opioid use disorder.

As Governor Ducey correctly declared, opioid addiction and abuse constitutes a public health emergency in Arizona.  While the Arizona Opioid Epidemic Act passed last year included several evidence-based interventions that will have an impact on the public health crisis over time, we believe that additional measures are necessary to improve MAT options for clinicians and patients.  In the area of medication options, we believe that more should be done to improve the therapeutic options available to clinicians as they treat patients for opioid use disorder. 

Buprenorphine products have demonstrated clinical efficacy in treating individuals with opioid addiction. There are now several FDA approved medications which each work differently and exist in several forms, strengths, and routes of administration.  Physicians treating AHCCCS members with opioid use disorder should be able to take advantage of the growing number of therapeutic options and be able to select the optimal medication in consultation with their patient.

The current PDL for AHCCCS members provides one buprenorphine treatment option: Suboxone film. While this medication may be the best currently available FDA approved option for many patients, evidence suggests that other patients may respond more positively to some of the other alternatives that are now FDA approved.

While “non-preferred” MAT options can be obtained by physicians via pre-authorization for Medicaid members, the process represents an unnecessary barrier to treatment. Time is of the essence when treating patients with opioid use disorder, and delays between when an individual decides to seek treatment and begins his/her regimen can reduce the likelihood of treatment success.

In summary, we ask that the Pharmacy & Therapeutics Committee recommend that AHCCCS open the Preferred Drug List to additional FDA-approved MAT medications.  When evaluating the list of FDA approved medications for the Preferred Drug List, we urge the Committee and AHCCCS to take into consideration the various FDA approved forms, strengths, and routes of administration as well as individual medication risks for diversion and accidental poisoning. 

Using those criteria, we believe the Committee can responsibly recommend an expansion of the MAT Preferred Drug List for treating AHCCCS members with an opioid use disorder that would improve outcomes for Medicaid members with an opioid use disorder.

We commend the Governor, our state legislators, and the staff at the ADHS and AHCCCS for recognizing the public-health threat posed by opioid abuse and taking concrete steps to implement evidence-based interventions to save lives.  Expanding options for MAT would be an additional concrete step toward that end.

Legislative Update

Not a ton news since last week. I'm beginning to sound like a broken record.

On the e-cigarette and smoking front, the good bill (HB 2357) remains in limbo- as it's passed the full Senate and got through it's Conference Committee- but wasn't called to the floor of the House for a vote again this week.

The competing- not so good bill- SB 1147 passed on a voice vote through the Committee of the Whole in the House- but didn't make it to a floor vote this week. 

Other than that, legislators are mostly focused on the budget negotiations.  There are a few items we'll need to ask you to press for in the next couple of weeks with the legislators in your district including:

1) preventative and comprehensive oral health services for pregnant Medicaid members;

2) increased investment in funding for the state loan repayment program and health profession residencies (especially for primary care); and

3) funding Kids Care.

In addition, there's an important $65M appropriation of federal funds that needs to be made to provide additional subsidies for child care services for folks that qualify- along with a needed increase in reimbursement rates. No state dollars are needed- simply an appropriation of the federal funds that have been allocated to AZ.

A Tale of 2 Vape Bills

This week featured a dual between bills that say their goals are to address the vaping epidemic.  One does and one doesn’t.

The Good Bill

This week the Senate approved (29-0) a bill from Senator Carter (a strike amendment HB 2357) that would classify vaping products in the same category as tobacco.

That means vape pens and the like would be subject to the same laws and rules that govern sales and where you can use them (e.g. vaping would be covered under the Smoke Free Arizona Act). It would also continue to allow cities and towns to impose their own stricter regulations.   HB 2357 would continue to keep the sale age at 18 (rather than 21 which would be ideal) but it would still allow communities to adopt and keep their own ordinances which have raised the age for the purchase of tobacco and vaping products to 21.

After passing the Senate unanimously (as the e-cig version) it went to a Conference Committee a couple of days ago and passed through unanimously. Looks like it’ll be up for a floor vote on Monday in the House.

Now would be a great time to get with your 2 Representatives and let them know you support 2357 because it’s a common-sense bill that defines e-cigarettes as a tobacco product and would remove vaping from public spaces, workplaces and schools.

The Not Good Bill

The tobacco bill dualing for attention is SB 1147 (a different striker bill) which I blogged about last week.  It would set the minimum age statewide for tobacco possession at 21 but it would override lots of other local ordinances about how tobacco and vaping products could be sold and would allow only “reasonable” zoning regulations about where sales can take place.

Another bad thing about SB 1147 is that e-cigs would be in a separate legal category from tobacco meaning it would specifically exempt vaping products from the Smoke Free Arizona Act (vaping didn’t exist when the Smoke Free AZ Act passed in 2006).

This one will likely see a House floor vote next week too.  If it passes it would also need a conference committee because the original Senate version was completely different (about city development). If it gets through the conference committee- it would need another Senate floor vote.

Legislative Update

Not a ton news since last week. The main thing that happened this week is that the Governor signed a good bill on suicide prevention (more info below). He also signed a bill that will make Association Health Plans more available in AZ. Info on that below too.  Last week’s  Legislative Update covers things pretty well so far.

Other than that, we're moving full force into the budget negotiations process now. By all accounts it looks to be a more deliberative process than in years past because of the tight party affiliation margins and the disconnect between the executive budget priorities and those of the legislature. It's likely that we'll have at least a few more weeks before a final budget is complete- and it might even go into June this year. 

SB 1468 Suicide Prevention Training

It will require school districts, charter schools, and Arizona teacher training programs to include suicide awareness and prevention training in their continuing education curricula.  It’ll require AHCCCS to make suicide awareness and prevention training available (fortunately some evidence- based tools curricula already exist).

Starting in the 2020 school year, school districts and charter schools would need to provide training in suicide awareness and prevention to school personnel in grades 6 to 12.  The bill also establishes requirements for suicide awareness and prevention training and specifically says that the training use evidenced-based training materials and instruct participants on how to identify the warning signs of suicidal behavior in adolescents and teens.

SB 1085 Association Health Plans (AzPHA Opposed)

This bill was passed by the House this week and is awaiting the Governor’s signature.  He’s sure to sign it. It basically provides a regulatory structure at the state level to regulate AHPs in AZ - serving to make them more available in Arizona. A primary concern for folks interested in public health and consumer protection is that AHPs don’t need to cover the essential health benefits, they can charge differently depending on gender and age. 

Additionally, we’re concerned that if an employer offers a “skinny” benefit plan that barely meets the definition of minimum value (and doesn’t include important essential health benefits) families could be prevented from benefitting from the subsidies that would otherwise be available to them on the Marketplace.

Back in August (at the direction of the President) the US Department of Labor issued a final rule that established criteria for determining when employers can join in an association and be treated as an employer sponsor of a group health plan.  The federal regulation loosens the rules for additional plans to come onto the market, allowing more small businesses including individuals who work for themselves to join these plans.  This bill will make these plans more available in AZ.

Leveraging Managed Care Contracts to Address Social Determinants

Medicaid programs across the country and our own Medicaid agency (AHCCCS) are increasingly considering how best to address the social factors, such as housing, healthy food, and economic security, that can affect health and medical expenditures (social determinants).

That’s because social determinants of health drive as much as 80% of population health outcomes.  It’s easy to see why there’s such an interest in addressing social determinants as Medicaid program administrators look for ways to contain costs.

Many Medicaid programs including ours have focused much attention on the social determinants that drive costs in expensive or high needs populations (e.g., people with disabilities or a mental illness or HIV/AIDs)… but as the knowledge about how profound social determinants are in terms of costs overall, many are now thinking about how they can address social determinants across the general Medicaid population.

An organization called State Health and Value Strategies has developed an Issue Brief that explores practices states are using to address social factors using Medicaid 1115 waivers and in their managed care contracts The issue Brief also includes steps states can take to implement these practices.

The issue brief includes a review of Medicaid managed care contracts in 17 states and Medicaid 1115 provisions in 6 states.  There are quite a few examples in the report- so I’ve just picked a couple to give examples:

Aligning financial incentives to support SDOH interventions.  States are deploying a range of tools to strengthen the financial incentive for plans to address SDOH. These include the use of withhold payments linked to SDOH-sensitive outcomes and allowing plans to count investments in high-impact social services toward the numerator of their medical loss ratio (MLR).

Creating opportunities for affordable housing. Medicaid does not directly pay for housing, but states are increasingly identifying new ways to connect people to housing resources; providing housing-related services that can be covered via Medicaid; and encouraging their Medicaid managed care plans to participate in broader, cross-sector initiatives to address the affordability and safety of housing.

Building a stronger network of community-based organizations and collaboration with providers. Recognizing that many community-based organizations operate on tight budgets and lack experience contracting with health care plans and providers, states are investing in community-based resources and fostering stronger working relationships between such organizations and health care plans/providers.