AzPHA Public Health Policy Update- November 16, 2017

AZ’s New Minimum Wage Law Expected to Improve Infant Mortality

We’ve known for a long time in public health that a primary driver of health status is family income.  More family resources generally result in better health outcomes. New data suggest (not surprisingly) that increases in the minimum wage result in lower infant mortality.

Could the passage of Proposition 206 in November of 2016 be an evidence-based public health intervention that will lower infant mortality in Arizona?  The answer is yes!

In 2014, Arizona’s infant mortality rate was 6.2 deaths per 1,000 live births- well above other comparable countries including Japan (2.1), France (3.5), and the UK (3.9).  The national rate in the US is 5.8/1,000.  Here are Arizona’s Infant Mortality Rates: PDF | Excel

A team of researchers recently published a study in the American Journal of Public Health examining the effects of state minimum wage laws on infant mortality and low birthweight rates.  They found that a $1 increase in the minimum wage is associated with a 4% decrease in infant mortality and a 1% to 2% decrease in low birthweight births.  They concluded that…  “if all states in 2014 had increased their minimum wages by $1 dollar there would likely have been 2,790 fewer low birthweight births and 518 fewer post-neonatal deaths for the year.”

This research adds to a growing scientific literature on the beneficial effects of various income supports on improved birth outcomes and reinforces the fact that social determinants of health related to income have a significant impact on population and public health outcomes.

Of course, there are many factors at play when it comes to infant mortality and low birth weight- but it looks like Proposition 206, which raised the minimum wage in AZ to $10 this year and to $12 by 2020 will help us on our quest to improve Arizona’s infant mortality and low birth weight rates. 

 

AzPHA’s Positions on the Sunrise Hearings

Whenever health related professions ask to be regulated or want to expand their scope of practice a state law says that the regulation needs to be done only to protect the public interest.  Applicants that want to go through the process need to submit a report to the state legislature explaining the factors demonstrating that their request meets these standards.

A “Committee of Reference” studies the sunrise applications and delivers its recommendations to House and Senate leadership. This year there are 3 applications in the hopper and they’ll be heard on Tuesday, November 28 starting at 9 am in the House of Representatives.

In a nutshell, the Community Health Workers Sunrise Application asks for a pathway to set up a process for voluntary registration of CHWs; the Arizona Naturopathic Medical Association would like permission for them to sign medical waivers from the state’s school vaccination requirements; and the Dental Care for AZ Sunrise Application asks for authorization from the legislature to license a new class of dental professionals.

Here are AzPHA’s statements to the House and Senate Committee of Reference for the upcoming November 28 Sunrise Hearings.  We’re taking positions on the CHW and Naturopath Sunrise Applications (but not the Dental Therapist application).

 

Arizona Community Health Workers Association

We urge the Committee to recommend approval of the application submitted by the Arizona Community Health Workers Association for Certification/Registration for Community Health Workers.

Community Health Workers (CHWs) are an established group of health professionals that build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy. 

A variety of agencies use CHWs to serve communities in ways including access to primary care, prenatal care, chronic disease self-management, long-term care, utilization of services, and behavioral health.  CHW services are effective at improving health outcomes and reducing costs and providing a unique opportunity for provider groups as they increasingly adopt value-based purchasing practices.

There is currently no simple way for health care providers and members of the community to verify that a CHW is proficient in core competencies. Certification and registration will assure that CHWs meet minimum standards including education, continuing education, training, experience, and other qualifications. With certification and registration, payors reimbursing CHWs for services would have clarity about CHWs core competencies and their scope of practice allowing this workforce to become integrated with a medical team and/or in the community.

CHWs work with vulnerable populations. Registration of CHWs meeting minimum standards is essential for patient safety by assuring that CHWs have a background check, follow HIPAA regulations, and safeguard against inappropriate actions and/or behaviors.

In short, we are supportive of this application because CHW services are effective at improving health outcomes and reducing costs. In the absence of certification/registration, the community cannot be assured of CHWs’ core competencies, scope of practice, and that procedures are in place to safeguard patients.

 

Arizona Naturopathic Medical Association

We urge the Committee to recommend denial of the application submitted by the Arizona Naturopathic Medical Association to expand their scope to include medical exemptions from Arizona’s school vaccination requirements.

The Arizona Public Health Association is concerned about several aspects of this application, most importantly, that it could further erode Arizona’s vaccination rates resulting in the loss of herd immunity. 

We believe that medical exemptions are an important component of Arizona’s school vaccine requirement system. However, medical exemptions should be signed by physicians that are current with the latest scientific literature regarding vaccines. New vaccinations and combinations of vaccinations are approved on an ongoing basis by the Food and Drug Administration and are evaluated consistently by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP).

Guidance and recommendations from the CDC and ACIP are critical for physicians to understand the nuances of the various vaccines, their complex schedules, and data regarding evidence-based reasons for medical exemptions.  Medical exemptions are best signed by physicians that are current with these resources.

Our review of data regarding vaccines suggest that Naturopathic Physicians provide very few vaccinations in Arizona (less than 0.01% of all vaccinations in Arizona are provided by Naturopaths).  Because so few Naturopathic Physicians (NDs) provide vaccines, our concern is that they will not be well informed about when a medical exemption is appropriate, and that some NDs will err on the side of signing medical exemptions rather than study the detail provided by the FDA, CDC and ACIP. There is also a risk that a relatively small number of NDs could sign large numbers of medical exemptions and jeopardize herd immunity.

We urge the Committee to recommend denial of the application submitted by the Arizona Naturopathic Medical Association to expand their scope to include medical exemptions from Arizona’s school vaccination requirements.

 

Restaurant Calorie Labeling Back on Track?

One of the things that was tucked into the Affordable Care Act was a provision that requires restaurants with 20 or more locations to post calorie content information for standard menu items directly on the menu and menu boards- a potentially powerful public health intervention in our effort to reduce obesity.

The FDA issued proposed draft regulations way back in 2011... but various delays have kept the rules from being implemented (by both the Obama and Trump Administrations).  Some places have been voluntarily posting nutrition information- but it’s still not officially required.

This kind of nutrition clarity is a real opportunity for public health change.  Not only will the new labels give the public key information to help them make better decisions about what they buy for themselves and their families- it’ll give pause to restaurants before they label their menus- giving them an opportunity to change ingredients to lower calorie counts.  It may even spur a trend away from “super-sizes” and toward more appropriate and reasonable serving sizes.  With 32% of the calories consumed in the US tied to eating outside the home- this is an important opportunity.  

Last week the FDA released draft implementation guidance addressing menu labeling issues like caloric disclosure, compliance and enforcement, and marketing materials.  The new guidance suggests that the compliance start day will now be May of 2018.

The new draft guidance includes expanded and new interpretations of policy, and identifies places where FDA intends to be more flexible in its approach. It also includes many graphical depictions conveying the FDA’s thinking on various topics and provides examples of options for implementation.

The new guidance addresses calorie disclosure signage for self-service foods like buffets, various methods for providing calorie disclosure information (including pizza which has been a big hang-up because its’ so often delivered), and compliance and enforcement.

 

President Nominates New HHS Secretary
The President selected Alex Azar, a former pharmaceutical executive and a top health official during the George W. Bush administration, to lead HHS. Azar also served as president of Lilly USA (an affiliate of Eli Lilly and Co.) and as a health-care consultant. During the Bush administration he was chief counsel a deputy director.

He has been highly critical of the ACA and supports converting Medicaid from an entitlement program into block grants. However, Dr. Georges Benjamin (Executive Director of the American Public Health Association, said “Azar is far less partisan than his predecessor. He’s smart, practical, listens to all sides…  We’ve got somebody whose heart is in the right place.” Time will tell.

 

Open Enrollment for Marketplace Health Insurance

The Affordable Care Act remains the law, and insurance enrollment for Arizonans runs through 12/15.  The University of Arizona Center for Rural Health (AzCRH) has certified staff (Navigators) to answer questions and help you enroll in health insurance coverage. Navigator services are free http://crh.arizona.edu/programs/navigator

AzPHA Public Health Policy Update: November 9

AzRHA & AzPHA Webinar Tomorrow RE 2018 Legislative Session

Tomorrow we’ll be participating in a joint webinar regarding next year’s legislative session entitled: "Anticipating 2018!!! Arizona’s Fifty-Fourth State Legislature".  It's organized by the Arizona Rural Health Association in cooperation with AzPHA and the UA’s Telemedicine Program. You can tune in from 1-2:30 pm Thursday by visiting https://streaming.biocom.arizona.edu/event/?id=27824.

More information is on AzRHA's website www.azrhassociation.org or by contacting Claudia Gonzalez at cgonzalez@rcbh.edu.

 

National Opioid Commission Recommendations

Last week the President’s Commission on Combating Drug Addiction and the Opioid Crisis released its final report setting out 56 recommendations for addressing the national opioid crisis. The recommendations address issues like federal funding and programs, opioid addiction prevention like prescribing guidelines, prescription drug monitoring programs, and supply reduction and overdose reversal.

You’ll remember that the Acting Secretary for HHS declared that the national opioid epidemic is a Public Health Emergency. Here’s the Secretary’s one sentence declaration.  Presumably some of the recommendations from last week’s final report will make their way into the various HHS agency policies (e.g. CMS). The report is quite long so I didn’t have time to read it all - but this did catch my eye:

"A key contributor to the opioid epidemic has been the excess prescribing of opioids for common pain complaints and for postsurgical pain. Although in some conditions, behavioral programs, acupuncture, surgery, as well as FDA-approved multimodal pain strategies have been proven to reduce the use of opioids, while providing effective pain management, current CMS reimbursement policies create barriers to the adoption of these strategies. In the third Commission meeting, the Commission heard about the need for proper reimbursement of non-opioid pain medications to increase uptake among healthcare providers and limit the use of opioids."

 

Free Online CME Credits for Arizona Prescribers

There’s increasing evidence that opioid medications are over-prescribed and poorly managed because prescribers aren’t aware of appropriate opioid risk management strategies and non-opioid approaches to treating chronic pain. A new and free Continuing Medical Education course is now available to familiarize prescribers with current guidelines for opioid use and prescribing & educate prescribers about non-opioid strategies for pain management.

Opioid Prescribing CME Courses: Responding to the Public Health Emergency Available Online at:  http://www.vlh.com/AZPrescribing/

Learning Objectives:

  • Manage acute and chronic back pain
  • Assess the functional effects of pain in patients.
  • Appropriately utilize a range of therapeutic options when managing patients with chronic pain.
  • Comply with current opioid risk-management practices, including the use of pain contracts and urine drug testing.
  • Educate patients on the proper use, storage, and disposal of opioid medications.

Cost: FREE for Arizona Prescribers   

Arizona Prescribers Registration:  http://www.vlh.com/AZPrescribing/

Supported by a grant through the Governor’s Office for Children, Youth and Families. Developed in Partnership with Arizona Prescription Drug Misuse & Abuse Initiative, University of Arizona College of Public Health, University of Arizona College of Medicine & ADHS.

 

Information about HHS’ Proposed Rules RE: Marketplace Insurance

HHS published an annual set of proposed rules for the Affordable Care Act marketplaces on October 27. Called the “Notice of Benefit and Payment Parameters,” the rules set out expectations for insurers and the states that regulate them.  

It's a really long proposed Rule and I haven’t been able to find the time to analyze it all (nor am I really capable of doing a detailed analysis) but I found a pretty good summary regarding the proposals.  The proposed Rule changes focus on: 1) Essential Health Benefits; 2) Qualifying Health Plan Certification Standards; 3) Rate Reviews; 4) Medical Loss Ratios; and 5) Risk Adjustment.

 

New Bulletins from CMS about Waiver Reviews & Approvals

Last week CMS released two information bulletins outlining activities they say they’ll undertake to improve the transparency and efficiency of the various processes for Medicaid Waivers and State Plan Amendment review and approvals. The 2 bulletins are procedural commitments to move waivers and SPAs more quickly through the review and approval process.

The “State Plan Amendment and 1915 Waiver Process Improvements to Improve Transparency and Efficiency and Reduce Burden” bulletin and the “Section 1115 Demonstration Process Improvements” bulletin are both online at https://www.medicaid.gov/federal-policy-guidance/federal-policy-guidance.html

 

First Things First Parent Kit

From the day a child is born, the care, attention, love and support they experience lays the foundation for their future. The First Things First Parent Kit is online to help you meet the challenges of being a parent and do your best in supporting the healthy development of your baby, toddler or preschooler.

You'll find information and resources on child development, health and safety, quality child care and school readiness:  Go to the Parent Kit.

AzPHA Public Health Policy Update- November 2, 2017

ASU’s Executive Fellowship in Health Policy Accepting Applications

ASU’s College of Nursing and Health Innovation has developed a new fellowship program for health professionals interested in policy and advocacy and is taking applications through November 30th. The Executive Fellowship in Health Policy is a one-year cohort-based program, providing health leaders in-depth insights into the public policy world. Fellows will build connections and skills enabling them to lead change within their organizations to advocate for the work that they do and the populations they serve.

Fellows will also learn about health policy directly from the people who shape it. Through in-person immersions, webinar presentations, and online modules, lawmakers and health advocates from around the country will provide an intimate look at the politics and policy changes actively shaping our health systems today. Faculty mentors will guide and support Fellows to further develop their skills as effective health advocates through the creation of a tangible project based on a real-world situation from their organization.

The program has been developed by Faculty Director and Assistant Dean Heather Carter, EdD. Her vision for this new program is to empower health professionals to be more involved in the health policy arena. In addition to her work at ASU, Dr. Carter serves as an Arizona State Representative & Chairwoman of the House Health Committee.

The program is currently accepting applicants through November 30, 2017. Program tuition is $16K for the year, plus travel expenses for two in-person immersions located in Phoenix, AZ and Washington, D.C.

More information about the Fellowship and the application process can be found at efhp.asu.edu, or by contacting the project manager at efhp@asu.edu or 602-496-0414.

 

North Country HealthCare Receives Accreditation for Residency Program

Congrats to North Country HealthCare for achieving final accreditation last week from the Accreditation Council for Graduate Medical Education for their Family Medicine Residency Program.  The new program will improve access to comprehensive, affordable, culturally competent primary care across northern Arizona by increasing the number of practicing primary care physicians for years to come.

The program will engage family medicine residents in rotations throughout North Country HealthCare’s service region of Coconino, Mohave, Navajo and Apache Counties with rural rotations in Tuba City, Polacca and Whiteriver.

This novel residency program will help prepare family medicine physicians for autonomous practice in rural and frontier northern Arizona and will be the only graduate medical education program in the country with a required rotation in Indian Country.

A huge shout out to AzPHA member and NAHEC Executive Director Sean Clendaniel, MPH who’s the brain-child and work-horse behind the effort. Next we need to replicate the model in other areas of rural AZ. 

We all know that we have an acute physician shortage in rural AZ- and rural residency programs are probably the single most effective long-term tool we have to intervene- because where a physician does their residency has a huge impact on where they decide to practice.

 

Open Enrollment for Marketplace is Here through December 15

Open enrollment for the Marketplace insurance plans under the Affordable Care Act started today and runs through December 15.  We're recommending that folks that are interested in getting their health insurance through the federal Marketplace by going to  coveraz.org/connector first (rather than healthcare.gov) because the assisters and navigators at coveraz.org/connector are more familiar with the AZ products as well as our state's Medicaid programs.

Make sure everyone who needs coverage knows this: a convenient assister appointment is just clicks away, at coveraz.org/connector or by calling the Coalition’s statewide assistance line at 800-577-3536.

 

CMS Proposes New Rule Letting States Define their Own “Essential Health Benefits”

Late last Friday the Centers for Medicare and Medicaid Services released a proposed rule that would allow states to define the minimum essential health benefits that health insurers selling plans on the Affordable Care Act exchanges are required to offer. 

The proposed rule would give states greater latitude in choosing which benefits insurers must cover.  Perhaps most significantly, it would allow states to choose a benchmark plan from wider pool of existing plans including health plans from other states. Each state’s “benchmark plan” defines what essential benefits other Marketplace plans must cover. Right now, Governors choose each state’s benchmark plan from a list of existing state plans in various categories.  Governors Brewer & Ducey each chose the State of Arizona EPO Employee Health Plan as Arizona’s benchmark.

CMS' stated goal is to give states more flexibility that could potentially lead to more affordable health plan options in 2019. They concede the changes some states will make will result in less comprehensive plans and dropped services.

The ACA requires health plans on the individual and small group markets to cover 10 minimum essential health benefits including emergency services, hospitalization, prescription drug coverage, maternity care and care for mental health and substance abuse disorders.  What this new proposal essentially does is allow states to weaken (but not eliminate) the 10 essential services. The proposal bars states from making their essential health benefits more generous than they are currently.

For example, if the new rule is implemented, states could choose an employer plan with 5,000 enrollees that excludes inpatient mental health services or coverage for HIV or AIDS as their benchmark- and that plan would be considered OK.

The proposed rule is almost 400 pages long.  AzPHA is planning to work with other stakeholders in Arizona and coordinate comments to CMS on their proposed rule.

 

House Vote this Week Would Cut the Prevention & Public Health Fund

This week the U.S. House will be voting on a bill that will cut critical funding from the Prevention and Public Health Fund to offset the cost of funding community health centers and other important health programs that have expired.

Established in 2010 as the nation’s first funding stream dedicated to improving public health, the Fund invests over $9 million per year to protect Arizona from disease outbreaks and to reduce downstream health care costs.  We wrote a report that examines the Fund’s investments in Arizona, which include immunizations, smoking cessation, diabetes prevention, opioid treatment, and more.

While AzPHA supports reauthorizing funding for community health centers and the National Health Service Corps, we don’t support doing it at the expense of the prevention fund and the important public health programs that already depend on this funding.

Take the time to contact your representative and tell them to oppose the CHAMPION Act and any future effort to undermine the integrity of the Prevention and Public Health Fund!

 

HHS Acting Secretary Declares Opioid Epidemic a Public Health Emergency

Last week the Acting Secretary for HHS declared that the national opioid epidemic is a Public Health Emergency under Section 319 of the Public Health Service Act. Here’s the Secretary’s one sentence declaration.

Section 319 authorizes the HHS Secretary to lead federal public health and medical response to public health emergencies, determine that a public health emergency exists, and assist states in their response activities.

The Secretary’s declaration was only one sentence long- so there’s not much detail about what they might do, but among the things that HHS could do are: 1) waive or modify certain requirements under Medicare, Medicaid and HIPAA; 2) waive certain prescription and dispensing requirements; and 3) adjust Medicare reimbursement for certain Part B drugs.

The most meaningful things that they could do include;

  • Removing the Medicaid Institutions for Mental Diseases (IMD) exclusion to allow facilities to receive reimbursement for substance abuse treatment (the IMD exclusion prohibits the use of Medicaid financing for care provided to most patients in residential treatment facilities larger than 16 beds);

  • Allowing Medicaid to pay for substance abuse treatment in correctional facilities; and

  • Allowing physicians to treat more patients with Suboxone.

Right now we don’t know which if any of these things HHS will choose to do because they haven't disclosed their plans and the one sentence emergency declaration provides no detail.

AzPHA Public Health Policy Update - October 24, 2017

Health Profession Sunrise Applications to be Heard November 28

Whenever health related professions ask to be regulated or want to expand their scope of practice a state law (A.R.S. § 32-3103) says that the regulation needs to be done only to protect the public interest.  Here are the standards that define “public interest”:

  • If the unregulated practice harms or endangers the public, health safety or welfare and the potential for harm is easily recognizable and not remote or dependent on tenuous agreement;
  • If the public needs and can reasonably be expected to benefit from an assurance of initial and continuing professional ability; and
  • If the public can’t be effectively protected by other means in a more cost beneficial manner.

Applicants that want to go through the process need to submit a report to the state legislature explaining the factors demonstrating that their request meets these standards. A “Committee of Reference” studies the sunrise applications and delivers its recommendations to House and Senate leadership. 

This year there are 3 applications in the hopper and they’ll be heard on Tuesday, November 28 starting at 9 am in one of the rooms over at the legislature (I don’t know where yet).  I’ve included links below to the 3 sunrise applications for this year.

In a nutshell the Community Health Worker application asks for a pathway to set up a process for voluntary registration of CHWs; the Naturopath application would like permission for them to sign medical waivers from the state’s school vaccination requirements; and the Dental Therapist application asks for authorization from the legislature to license a new class of dental professionals.

We’re for sure in favor of the CHW application.  We’re going to dig a little deeper before making a decision about the other two.  We’re in the process of setting up a Policy Committee call next week to discuss the Naturopath and Dental Therapist applications.

 

Huge Hearing this Week in State Supreme Court

There’s a super-important hearing this Thursday in the State Supreme Court.  The outcome of the Biggs v. Betlach case will decide whether thousands and thousands of current Arizona Medicaid members (childless adults) will lose their AHCCCS eligibility and possibly causing a cascade of events jeopardizing coverage for the Medicaid expansion population (FPL of between 100 – 138%).

Oral Arguments on the Biggs v. Betlach case are Thursday, October 26 starting at 9 am at the Arizona Supreme Court at 1501 West Washington in Phoenix (Case CV-17-0130-PR).  In a nutshell- the case is about whether the hospital assessment that’s used to fund the state match for “childless adults” enrolled in AHCCCS is a fee or a tax.

When Arizona expanded our Medicaid program (AHCCCS) to cover people up to 138% of poverty we used a provision in the ACA that allows states to expand coverage with the federal government absorbing all the cost at first.

To qualify, AZ had to first restore coverage for “childless adults” that have income below the federal poverty level (a group that lost AHCCCS coverage during the recession).  AZ paid for covering the childless adults with an assessment (fee) on hospitals set by AHCCCS (right now it’s about $264M).

The bill that authorized the hospital assessment barely passed with just over 50% of the House and Senate.  Many of the lawmakers that voted “no” (and the Goldwater Institute) believe that the assessment is not a fee, but a tax, and requires a supermajority of 2/3 of each chamber in order to pass (a voter initiative requires laws that raise taxes to have a supermajority).

If the Court agrees with the Plaintiffs that the assessment is a tax and not a fee, AHCCCS wouldn’t be able to collect the $264M hospital assessment and there won’t be enough money to fund the childless adults…  which could also jeopardize our coverage for the expansion population (people between 100 – 138% of the federal poverty level). 

Unless the legislature were to vote by a 2/3 majority to fund the program, the only path to keeping the coverage would be via a voter initiative- which just got a lot harder with the passage and signing of HB 2404 (preventing signature gatherers from getting paid by the signature) and HB2244 (changing the citizen's initiative compliance standard from "substantial compliance" to "strict compliance").

 

Leaders Across Borders Applications Due 11/10/17

The U.S.-Mexico Border Health Commission was is currently seeking candidates for the 2018 Leaders across Borders Program.   Leaders across Borders (LaB) is an advanced leadership development program funded by the U.S.-Mexico Border Health Commission aimed at building the binational leadership capacity of public health, health care, and other community professionals working to improve the health of communities in the U.S.-México border region. 

This program is intended for public health, health care, and other community-sector leaders who meet the following requirements:

  • Are proficient in English and Spanish with an understanding of both languages, translation will not be provided at in-person learning event;
  • Have at least five years’ experience working in the U.S.-México border region;
  • Committed to working with vulnerable populations and promoting health equity, eliminating health disparities, and increasing quality of life within the U.S.-México border region; and
  • Seeking to enhance their leadership and health diplomacy skills, professional networks, and understanding of binational public health assets, challenges, and systems as a means to identify solutions

U.S. candidates must me formally nominated by their employers or professional organizations.  The nomination process is quick and easy and can be found on the U.S.-Mexico Border Health Commission website.

Please note that November 10, 2017 is the application deadline.

 

Community Health Center and Nat’l Health Service Corps Funding Hanging

Representatives Stefanik (R-NY) and Tsongas (D-MA) are leading bi-partisan Health Center effort seeking action to extend Health Center and National Health Service Corps funding and fix the cliff by passing the “CHIME Act” ( S. 1899 in the Senate and HR 3770 in the House). The CHIME Act lays out a five-year extension to Health Center funding to fix the Health Center and National Health Service Corps funding cliff without cutting the Prevention and Public Health Fund (like the Champion Act does).

You can Send your Members of Congress a message through the Health Center Advocacy Network asking them to co-sponsor the CHIME Act – click here to send your message and call your Representative using the toll-free Advocacy Hotline 1-866-456-3949 and ask that they co-sign the Stefanik-Tsongas Health Center Cliff Letter addressed to House Leadership asking for immediate action to fix the cliff.

 

Kids Care Extension Update

The US House of Representatives is in a holding pattern and is delaying consideration of a bill to extend funding for the Children’s Health Insurance Program (called Kids Care in Arizona). The hope is to reach a bipartisan agreement on paying for KidsCare- probably in November. 

The main drama isn’t whether to extend CHIP (KidsCare), it’s how to pay for it.  There are some that want to reduce the Prevention and Public Health Fund as an offset (which we oppose).

Word on the street is that AHCCCS still has funding for a few more weeks to keep KidsCare going, so it’s not an emergency to get the federal funding on board again- but we’re running out of time for sure.  We’ll keep tracking this.

 

AzPHA Public Health Policy Update - October 19, 2017

President Scraps Marketplace CSRs- but the Sky Isn’t Falling

Late last week the President announced that HHS won’t make any more subsidy payments to insurance companies that offer plans on the Marketplace.

The subsidy payments (cost-sharing reductions or CSRs) are payments to insurers to reimburse them for discounts they give policyholders with incomes under 250% of the federal poverty line (about $30,000 in income a year) for an individual. The discounts shield lower-income customers (that buy insurance in the Marketplace) from out-of-pocket expenses, like deductibles or copays.

Cutting off these payments to insurers doesn’t mean the policyholders won’t get help. The ACA and insurance company contracts require those discounts be granted by Marketplace insurers.

The decision does mean that insurance companies on the Marketplace will have to figure out how to recover the money they were promised under the ACA.  The two Marketplace insurers in AZ (Blue Cross Blue Shield and Centene Corp’s Ambetter by HealthNet) announced that they’ll have stable premiums next year. They apparently had already assumed that the CSRs wouldn’t be paid because they don’t expect this decision to impact their 2018 rates.

Remember, the cost-sharing reductions are separate from the tax credit subsidies (called advance premium tax credits) that help millions of people pay their premiums.  The premium tax credit is a refundable credit that helps eligible individuals and families cover the premiums for their health insurance purchased through the Health Insurance Marketplace.

People with income between 100-400% of the Federal Poverty Level still qualify for the tax credits, which are calculated depending on income, and help (and will continue to help) families pay their Marketplace health insurance premiums.

 

Integrated Health Plan for Children in AZ Foster Care?

AHCCCS & Mercer are conducting an analysis of an integrated health plan for children/youth involved in Arizona’s foster care system (e.g. a plan that would cover both acute care and behavioral health services).

Mercer is holding a series of stakeholder sessions - two with providers and two with family members (foster, adoptive, kinship and biological) and youth/young adults currently or previously involved with Arizona’s foster care system to solicit input about the concept. The goal is to gather feedback about the future of AZs health care system for kids in the foster care system

Tuesday, October 24

1 N. MacDonald, 3rd floor Mesa, AZ

Providers:                              10:00 a.m. – 11:30 a.m.

Family/Youth/ Young Adults:   3:30 p.m. – 5:00 p.m.

Wednesday, October 25

400 W. Congress Room 444, 4th floor Tucson, AZ

Providers:                              10:00 a.m. – 11:30 a.m.

Family/Youth/ Young Adults:   3:30 p.m. – 5:00 p.m.

To attend any session by phone, call 1-877-820-7831 and use guest code 679145.

 

200 Stories: Tucson Healthcare Forum Sunday, October 29

·        Are you concerned about the future of healthcare and health insurance?

·        What will the Affordable Care Act, Medicare and Medicaid look like in the future?

·        Have you had problems accessing affordable medical care, insurance, or medication?

Legislators from Legislative Districts 9 and 10 are hosting healthcare a forum in Tucson on Sunday, October 29.  Senators David Bradley & Steve Farley & Reps. Kirsten Engel, Randy Friese & Pamela Powers Hannley will be there to listen to your concerns and hear your stories about Medicare, Medicaid, the Affordable Care Act, insurance, medical care, drugs, cost and related topics.

Sunday, October 29, 2017 1:30 - 3:30 p.m. Unitarian Universalist Church of Tucson 4831 E. 22nd St.  Here’s the Eventbrite Link to sign up.

 

WV Medicaid Waiver Could Bode Well for AZ Opioid Treatment

CMS recently approved West Virginia’s proposal to expand Medicaid coverage for substance abuse treatment by lifting a restriction on Medicaid payments for inpatient treatment at large residential facilities. This waiver also allows the state Medicaid program to cover naloxone, peer support services, and methadone.

This approval could be important for Arizona because it signals that CMS is receptive to these kinds of waiver requests- and a similar recommendation was made in ADHS’ September 5 Opioid Action Plan.

 

2018 Public Health Law Conference

The Network for Public Health Law will be holding next year's national Public Health Law Conference in Phoenix on October 4 – 6, 2018. They’re already accepting abstracts for panels and individual presentations.

They’re soliciting abstracts related to this year's Conference theme,Health Justice: Empowering Public Health and Advancing Health Equity, as well as abstracts on other timely public health law topics. Deadline for abstract submission is December 15, 2017.  Here’s theSave-the-Date and Call for Abstracts.

 

Retail Marijuana & Opioid-Related Deaths in Colorado, 2000–2015

Researchers in Colorado did an interesting study recently that was published in the November American Journal of Public Health. They looked to see whether Colorado’s legalization of recreational cannabis had an impact on deaths from opioids in CO.

They used what’s called an interrupted time-series design (2000–2015) to compare monthly opioid-related deaths before and after Colorado stores began selling retail marijuana.  creational cannabis.

Interestingly, they found that opioid related deaths were reduced by 0.7 per month after retail sales of marijuana became legal. This is not a huge reduction by any means, but it was statistically significant.  Here’s what the authors described in the section labeled Public Health Implications:

"Although we found an apparent public health benefit in a reduction in opioid-related deaths following recreational cannabis legalization in Colorado, we note that expanded legalized cannabis use is also associated with significant potential harms. For policymakers to balance the potential beneficial and deleterious effects of these laws, researchers must continue to examine the full range of health effects in both clinic- and population-level research."

Community Health Center Funding Breakthrough?

There’s growing bipartisan support for a Health Center Funding Cliff Fix called the “CHIME Act” ( S. 1899 in the Senate and H.R. 3770 in the House). The Bill also addresses reauthorization of funding for the National Health Service Corps and Teaching Health Center Graduate Medical Education.

Community health centers rely on a combination of Medicaid payments and “330” grant revenues to keep their doors open. Because they also serve persons without any health insurance (on a sliding fee scale), they can't rely solely on insurance claims to keep the doors open- which is why the 330 grant funding is so critical.

This new Bill (the CHIME Act) is better than the previously introduced called the CHAMPION Act- because the CHAMPION Act would have cut the Prevention & Public Health Fund by 57% (a cut of $6.35B over the next 10 years). 

You can express your opinion to your Representative and Senators by sending your Members of Congress a message

Family Planning Lost Traction this Week

Contraception and family planning are among the most significant public health interventions of all time- and among the top of the list when it comes to return on investment.

Family planning and contraception are key to reducing teen pregnancies and inter-generational poverty.  It’s no secret that poverty is a key driver for a host of poor health outcomes.  Family planning is also a high return on investment intervention for improving preconception health because it allows women to make more deliberate decisions about the spacing of babies- which improves the health status of mom and baby.  Family planning is also good for businesses, because it allows employees to plan their families in a way that improves their work-life balance, improving attendance and retention.

The Affordable Care Act initially required that health insurance plans cover no-cost contraception services, a big win for public health. A couple of years ago the US Supreme Court ruled that family owned and other closely held companies can opt out of these ACA’s provisions.  The owners of the Hobby Lobby had objected on the grounds of religious freedom.

This week things slipped further, when Attorney General Sessions expanded the religious exemption for employers who object to providing insurance coverage for birth control because of their religious or moral beliefs.  His “religious liberty directive" instructs federal agencies to do as much as possible to accommodate those who claim their religious freedoms are being violated, effectively lifting a burden from religious objectors to prove that their beliefs about marriage or other topics that affect various actions are sincerely held.

Here’s the Attorney General’s guidance and his implementing memo

AZ State Agency Budget Request Summary

Each Fall state agencies turn in requests for changes in their funding to the Governor’s Office for consideration in his or her proposed budget.  These requests are then evaluated by the executive branch and synthesized into a final budget proposal from the Governor, which is usually released in mid-January.

Here’s an abbreviated snapshot of what ADHS, AHCCCS and ADES turned in this year:

AHCCCS

  • AHCCCS is estimating an average Capitation Rate increase of 3.1% across all lines of business.  They turned in cap rate increases for special populations of 12% for Children’s Rehabilitative Services, 9.6% for behavioral health and a 3.5% decrease for the Comprehensive Medical and Dental Program (a state program for providing quality care for kids in the foster care system); 
  • This request would add $72M from the state General Fund to cover costs for enrollment growth, capitation rate increases and state-federal match rate changes;
  • Maintaining current state funds dedicated to the state’s behavioral health Crisis System ($14M) non-Title XIX services for persons with a serious mental illness ($78.8M) & $5.3M for Supported Housing; and
  • They're asking that behavioral health costs be blended into the acute care and ALTCS (long term care) line items.

Arizona Department of Health Services

  • ADHS is requesting $500K to continue funding for response to public health emergencies;
  • Seeking $750K to maintain minimum standards for health care licensure staff and responses to growing demand for services because of the growth and workload in licensing; and
  • Requesting funds to respond to new responsibilities to oversee the AZ Radiation Regulatory Agency with a 1-time request for $500K for proper handling and disposal of radioactive materials.

Arizona Department of Economic Security

  • Seeking $3.9M to respond to ongoing Adult Protective Services caseload growth;
  • Adding $10M to accommodate a 2% capitation increase & accommodate a caseload increase of 4.9% for persons with Developmental Disabilities in the Arizona Long Term Care System (ALTCS);
  • Addressing DDD structural shortfall by adding $6.4M to cover Long Term Care services for non-XIX services of room & board;
  • Requesting $3.3M for targeted case management services for the state-only DDD clients; and
  • Responding to mandates imposed by Prop 206 on the minimum wage by adding for DDD $11.6M to assure network sufficiency.

Family Planning Services Lose Traction

Contraception and family planning are among the most significant public health interventions of all time- and among the top of the list when it comes to return on investment.

Family planning and contraception are key to reducing teen pregnancies and inter-generational poverty.  It’s no secret that poverty is a key driver for a host of poor health outcomes.  Family planning is also a high return on investment intervention for improving preconception health because it allows women to make more deliberate decisions about the spacing of babies- which improves the health status of mom and baby.  Family planning is also good for businesses, because it allows employees to plan their families in a way that improves their work-life balance, improving attendance and retention.

The Affordable Care Act initially required that health insurance plans cover no-cost contraception services, a big win for public health. A couple of years ago the US Supreme Court ruled that family owned and other closely held companies can opt out of these ACA’s provisions.  The owners of the Hobby Lobby had objected on the grounds of religious freedom.

This week things slipped further, when Attorney General Sessions expanded the religious exemption for employers who object to providing insurance coverage for birth control because of their religious or moral beliefs.  His “religious liberty directive" instructs federal agencies to do as much as possible to accommodate those who claim their religious freedoms are being violated, effectively lifting a burden from religious objectors to prove that their beliefs about marriage or other topics that affect various actions are sincerely held.

Here’s the Attorney General’s guidance and his implementing memo

Prevention & Public Health Fund Back on Chopping Block

Just when we thought the Prevention and Public Health Fund (PPHF) was going to be OK because of the downfall of the ACA repeal efforts, along comes the “Champions Act” which would cut this important public health fund by 57%.

The “Community Health & Medical Professionals Improve Our Nation Act” of 2017, or CHAMPION Act, would do some good things like support “330” grant funding for Community Health Centers, continue to fund the National Health Service Corps and Teaching Health Center Graduate Medical Education. 

But, the legislation pays for the extension by cutting the Prevention & Public Health Fund by 57% (a cut of $6.35B over the next 10 years). 

The ACA established the Fund to establish a framework for prevention, wellness, and public health initiatives to reduce long-term health costs. It focuses on preventing expensive chronic medical conditions by providing expanded and sustained national investment in public health programs that improve health and restrain the rate of growth in health care costs.

This investment in public health infrastructure is evidence-based. Research suggests that funding for community-based public health has a 5.6 to 1 return on investment. In other words, every dollar invested in evidence-based prevention programs results in a $5.6 in savings in overall health care costs.

Arizona state and county public health programs have received more than $52.6M via the Fund since 2010. This $9.3 million annual investment is at work in Arizona, providing critical resources that support evidence-based, community prevention activities tailored to meet community health needs and preferences. Evidence-based investments in Arizona include:

  • Building immunization services to prevent serious infectious disease outbreaks;

  • Prescription painkiller (opioid) and heroin use prevention;

  • Health security funds for bioterrorism, disease outbreaks, and disasters;

  • Promoting better detection and response to disease threats;

  • Lead poisoning prevention;

  • Reducing tobacco use; and

  • Reducing diabetes, heart disease, and obesity.

Here’s a report we wrote with the Vitalyst Health Foundation that details the public health programming that’s at risk again.

We’ll continue to track this bill and issue an Action Alert when the time is right.

KidsCare in Limbo

Funding for KidsCare (CHIP) expired last week.  This program (run by AHCCCS) currently covers about 23,000 kids with a pretty good set of benefits and reasonable premiums.  It’s only available for kids in families that don’t qualify for regular Medicaid and who live in a family that makes under 200% of poverty.

Even though the program hasn’t been reauthorized by the October 1 deadline, most states have reserved enough funding for the next three months. AHCCCS apparently has funding to continue the for a few weeks past the October 1 expiration date.

There is light on the horizon. The Senate Finance Committee introduced a CHIP funding proposal (Hatch/ Wyden) that would extend funding to states through FY 2022 but gradually reduce federal contributions. 

Enough matching funds would remain for Arizona to keep the program as-is through FY 2019 but after that our KidsCare program could be at risk because the federal contribution will be less than what’s currently wired into state law for funding AZ’s share of the program. 

But, that’s something that could be changed in either the 2018 or 2019 AZ Legislative Sessions.

 

State Supremes to Hear Challenge to Medicaid Expansion October 26

When Arizona expanded our Medicaid program (AHCCCS) to cover people up to 138% of poverty we used a provision in the ACA that allows states to expand coverage with the federal government absorbing all the cost at first.

But that meant we had to first cover all “childless adults” below the federal poverty level- a group that lost AHCCCS coverage during the recession.  We paid for covering the childless adults with an assessment (fee) on hospitals (right now it’s about $264M).

AHCCCS set the assessments using a formula that made sure each hospital chain would be OK with the assessment because their fee would be lower than what they stood to gain by the reduction in uncompensated care.

The bill that authorized the assessment and Medicaid expansion barely passed with just over 50% of the House and Senate.  Many of the lawmakers that voted “no” believe that the bill should have required a supermajority because of a voter approved initiative that requires tax increases to pass by 2/3 of each chamber.

The Executive Branch believes that the assessment is not a tax, but a fee set by an agency director.  That’s the crux of the Biggs v. Betlach suit that challenges our Medicaid expansion.

The Goldwater Institute filed new documents this week with the Arizona Supreme Court, who will ultimately decide if the assessment is a fee or a tax. 

If the Court ultimately agrees with the Plaintiffs, AHCCCS wouldn’t be able to collect $264M hospitals pay and there won’t be enough money to fund the childless adults or the expanded coverage.  Unless the legislature were to vote by a 2/3 majority to fund the program, the only path to keeping the coverage would be via a voter initiative- which just got a lot harder to do with the passage of HB 2404 (preventing signature gatherers from getting paid by the signature) and HB2244 (changing the citizen's initiative compliance standard from "substantial compliance" to "strict compliance").

There will be Oral Arguments on the Biggs v. Betlach case on Thursday, October 26 starting at 9 am at the Arizona Supreme Court (Case CV-17-0130-PR).

ADHS EMS Bureau Scores Opioid Intervention Grant

ADHS’ Bureau ofEmergency Medical Services and Trauma System has been awarded $3.1 million by the Substance Abuseand Mental Health Services Administration for development of a comprehensive first responder opioid/naloxone program in partnership with the University of Arizona and the Arizona Peace Officer Standards and Trainingboard. Naloxone is a medication that can counteract an opioid overdose.

This joint initiative will implement a statewide naloxone delivery system to provideaccess to naloxone for first responders, an acute opioid overdose recognitionand naloxone administration training program for first responders, and addressa targeted first responder opioid screening, brief intervention, and referralto treatment curriculum to instruct first responders how to recognize actual orpotential opioid-related substance abuse and to provide appropriateinterventions and referrals to care.

Adult AHCCCS Members now have Access to Emergency Dental Services!

The budget approved by the Legislature last session provided the funding for AHCCCS to cover emergency dental services for all adult members (over 21) up to $1,000 per year beginning October 1. AHCCCS turned in a plan to the Centers for Medicare and Medicaid fortheir approval a few weeks ago.

The next public health question is “what is the definition of Emergency Dental Services” so folks can know what’s covered. 

AHCCCS posted proposed language that defines what will be covered awhile back (the comment period ended September 21).  In it, they proposed covering dental servicesfor: “…an acute disorder of oral healthresulting in severe pain and or infection as a result of pathology or trauma.”

The proposed language is posted at 310-D1 – Dental Services for Members21 Years of Age and Older and also clarifies what kinds of procedures meet the criteriafor treating an “acute disorder of oral health resulting in severe pain and orinfection as a result of pathology or trauma”. 

I couldn’t tell whether this is going to be the final definition and list ofprocedures or not that will shortly become covered.  I’ll keep my eye out for that.

Children up to age 21 enrolled in AHCCCS have had (and continue to have) access to comprehensive and even preventative oral health coverage under the program.

KidsCare Still in Flux

Last week Senators Hatch and Wyden introduced bipartisan legislation to reauthorizethe Children's Health Insurance Program (CHIP)- which is the parent ofArizona’s KidsCare program.

The Bill (called S.1827) proposes a 5-year reauthorization of the program and maintaining the current 23% increase in the federal matching funds rate through FY 2019, but reducing thematching rate in FY 2020… and returning to the standard state-federalmatching rate in FY 2021-2022.

While it looks like this reauthorization bill won’t be voted in this week, it’s not dead.  It can still be approved in thecoming weeks.  The lack of a reauthorization introduces some uncertainty to states (all 50 states have a CHIP program) butas long as it gets voted on in the near future most states will probably holdfast and keep the program going for the time-being.

The issue in the long-run is that the Hatch/Wyden bill drops the federal matching rate in FY 2020 below the threshold that’s wired into state law for fundingAZ’s share of the program.  But, that’s something that could be changed in either the 2018 or 2019 AZ Legislative Sessions.

 

ADHS Earns Accreditation

Congratulations to the ADHS and all the Stakeholders that helped the team achieve national accreditation through the Public Health Accreditation Board (PHAB). The national accreditation program improves public health system performance by transforming the quality and performance of the nation’s state, local, tribal, and territorial public health departments.

PHAB Accreditation is a multi-year process that ADHS began in 2010 with the development of an agency strategic plan in 2011 and the first ever State Health Assessment in 2014.  Next was building the Arizona Health Improvement Plan.  Along the way, Accreditation includes developing, reviewing, and submitting documentation that supports the accreditation standards evaluate processes and services, outcomes, and progress toward specific goals and objectives.

The entire public health system including numerous Stakeholders need to be involved to achieve this recognition.  Congratulations to AZ’s public health system for this remarkable achievement.

The state health department joins Maricopa, Mohave, Pima, and Yavapai counties as national accredited public health agencies in Arizona.

Crunch Time for KidsCare Too

The Children's Health Insurance Program (CHIP) is a program that provides health insurance coverage for uninsured children in families with incomes that are modest but too high to qualify for Medicaid (AHCCCS). To continue operating, the CHIP program needs to be reauthorized by Congress by September 30.

In our state, CHIP is called KidsCare. AHCCCS offers health insurance through KidsCare for kids (under age 19) who aren’t eligible for other AHCCCS health insurance. There are several eligibility criteria- but the basic income criteria is a family income less than 200% of the federal poverty level.  Right now, about 23,000 kids are insured through Kids Care.  AZ also gets CHIP matching funds that covers an additional 73,000 kids via AHCCCS.

Arizona law requires AHCCCS to freeze enrollment if the federal match goes below its current level, meaning that there would be an enrollment freeze if Congress lowers the federal match below 100% as part of a funding reauthorization.

Last week there was an agreement struck in the Senate Finance Committee between Senators Hatch and Wyden on extending CHIP funding for 5 years but with a scaling down of the federal match.  So far, my understanding is that starting in FFY 2020, the federal matching rate would be reduced bump will be reduced and beginning in 2021 the federal match will go back to the regular CHIP match (for Arizona that’s 79% federal and 21% state match). 

Bottom line is that if this amendment goes through with the reauthorization bill, it would probably mean that KidsCare would continue as is through September 30, 2019.  After that, the program would freeze enrollment unless a state law is changed allowing for an alternative federal matching rate.  If the reauthorization doesn’t go through at all I’m not sure what would happen.

Please urge Senators McCain and Flake to reauthorize full funding of the Children’s Health Insurance Program (KidsCare in Arizona) and to keep the federal match rate at 100%.

Contact Senator John McCain and Senator Jeff Flake:

     Sen. John McCain: (202) 224-2235 or (602) 952-2410

     Sen. Jeff Flake: (202) 224-4521 or (602) 840-1891

Senator McCain indicated that he looks to the Governor for guidance. Please contact the governor’s office to urge the governor to support reauthorization of CHIP funding at 100% match.

     Gov. Ducey: (602) 542-4331 or (520) 628-6580

Last Ditch Effort to Repeal the ACA Underway Next Week

A last-ditch effort is underway in the US Senate to repeal the Affordable Care Act and replace it with an alternative plan.  It’s called the Graham-Cassidy bill. Before October 1 the Bill could pass the Senate with only 51 votes.  After that, it would take 60 votes, meaning that changes to the ACA would need to be bipartisan.

The Congressional Budget Office (CBO) - which evaluates the impact of health bills in terms of cost and impact on private insurance coverage and Medicaid- will need several weeks for it to evaluate the Bill’s impact, so it’s unknown how many fewer people could be insured under it or what the impact on premiums may be.

Even though the bill won’t have a CBO evaluation & its impact on commercial and group insurance and Medicaid as well as the fiscal impact have no objective estimates, the US Senate is poised vote on the bill in the coming days. 

What would Graham – Cassidy do?  In a nutshell, it would:

·       End Medicaid expansion funding, turning the federal funding for Medicaid expansion into a block grant. States would be given a lump sum of money and decide what to do with it (e.g. help enrollees pay their premiums, set up a high-risk or reinsurance pools);

·       Send states a fixed amount of money per Medicaid enrollee (a per-capita cap) starting in 2020.  States could also opt to receive Medicaid funding as a block grant - a fixed amount of federal funding each year- regardless of how many participants are in the program (states couldn’t take a block grant for persons with disabilities);

·       Repeal the ACA individual and employer mandates;

·       Repeal ACA cost-sharing subsidies that lower marketplace premiums by 2020, and roll the funds into a block grant to states;

·       Loosen the ACA’s requirements that plans cover pre-existing conditions;

·       Allow everyone in the individual market to buy catastrophic plans;

·       Repeal ACA taxes on over-the-counter medicine, health savings accounts and medical devices;

·       End federal funding for Planned Parenthood for 1 year; and

·       Double maximum contributions to health savings accounts.

We’re encouraging our members to use APHA’s action alert to let Senator McCain know what you think of the bill itself (especially the profound changes to Medicaid) and the process that’s being used to debate and approve this Bill.  Here’s the text of the short letter that AzPHA sent to Senator McCain yesterday.

AzPHA Letter to Senator McCain regarding the Graham-Cassidy Bill

Dear Senator McCain:

The Arizona Public Health Association and our members urge you to trust your instincts regarding the process that is being used in the Senate regarding the Graham-Cassidy Bill.

We agree with your previous statements and commitments suggesting that Regular Order is the best policy for debating and passing key legislation, especially legislation that impacts Arizonans in a profound and personal way like access to health care.

As you know, legislation that goes through the time-tested processes of debate and input from all sides is more likely to build buy-in and consensus.  Legislation and public policy built together is much more likely to be successful in the long-run.

Now more than ever, we need solutions to our Nation’s problems that are built together, with input from all.

We thank you for your leadership and your statesmanship.

Sincerely, 

Will Humble, MPH

Executive Director, 

Arizona Public Health Association

 

AZ Supreme Court to Hear Challenge to Medicaid Restoration & Expansion

The Arizona Supreme Court announced this week that they'll hear the Biggs v. Betlach case.  The lawsuit was filed by a group of legislators challenging the method used by the legislature to authorize AHCCCS' hospital assessment.  It's a charge to hospitals that's used annually to draw down the federal match required to pay the state's share for covering "childless adults" under our state's Medicaid program (covering them was a pre-requisite to expanding Medicaid eligibility to 138% of poverty).

The Plaintiffs basically argue that the assessment is a tax rather than an assessment charged by the Agency.  Raising a tax requires a super majority while authorizing an agency director to, by rule, assess a fee only takes a simple majority.  The hospital assessment used the latter mechanism.

There's plenty of agency practice history in assessing fees based on authority that came from a simple majority vote...  and some good case law too.  For example, when I was the ADHS Director, we raised the fees (in 2009) for our licensed facilities in order to pay for all of our licensing programs' operations.  That authorization came via a simple majority vote budget bill.

We're probably going to be OK, but you never know.  No date has been set for the Hearing.

Final Push Underway in Senate to Repeal the ACA

A final push to “repeal and replace” the Affordable Care Act is underway in the US Senate. Today Senators Bill Cassidy & Lindsey Graham along with Senators Heller and Johnson unveiled a revised version of their legislation to repeal and replace the Affordable Care Act (ACA). A window of opportunity until September 30 is available for the supporters of the Amendment (for this federal fiscal year). 

It’s called the Cassidy-Graham proposal and it’s essentially an Amendment to the Better Care Reconciliation Act that failed awhile back. Here's a summary of the content of the Bill, it would:

  • Eliminate the ACA’s marketplace subsidies and enhanced matching rate for the Medicaid expansion and replace them with a block grant. Block grant funding would be well below current law federal funding for coverage, would not adjust based on need, would disappear altogether after 2026, and could be spent on virtually any health care purpose, with no requirement to offer low- and moderate-income people coverage or financial assistance.

  • Convert Medicaid’s current federal-state financial partnership to a per capita cap, which would cap and cut federal Medicaid per-beneficiary funding for seniors, people with disabilities, and families with children.

  • Eliminate federal subsidies to purchase individual market coverage;

  • Eliminate the ACA’s individual mandate to have insurance or pay a penalty; and

  • When the Bill's block grant period ends in 2026, it would repeal the ACA’s major coverage provisions with no replacement.

At the same time, the Senate Health, Education, Labor and Pensions Committee is trying to develop a bipartisan health bill that likely would focus on marketplace stability, including assuring that health insurers receive the cost sharing subsidies. Because insurers will soon be setting their 2018 insurance rates, there’s interest in trying to finalize legislation this month, but it is not clear whether an agreement will be reached in the Senate—and then with the House.

Depending on what happens in the next couple of weeks we may issue an Action Alert for our members.