Federal Policy Decisions Eroding Health Insurance Stability

It’s been a few weeks since I’ve written about what’s happening with the Affordable Care Act- and there’s been some recent action- so here goes.

First of all, there’s good evidence that stable health insurance coverage helps people get preventive and primary care services that improve outcomes and downstream healthcare spending.  The Affordable Care Act included several provisions that helps people get these kinds of preventive services.  One of the primary goals of the ACA was to create broad access to robust health insurance coverage through: 

  • Employer mandated coverage for large employers;
  • An mandate to be insured or face a tax penalty to encourage full participation;
  • Subsidies and out-of-pocket protections for purchasing in the individual federal marketplaces;
  • Guaranteed issue and community rating of premiums;
  • Expansion of Medicaid to low-income adults; and
  • Ten essential health benefits for all marketplace insurance sold on the individual federal marketplaces, which includes requirements to cover services for mental health, substance abuse, and reproductive health.

It’s been working.  In the last several years the percentage of uninsured working-age adults decreased from 20% in 2013 to 12% by 2016 (nationally).  It would have been an even bigger decrease if all states had expanded Medicaid.  This  coverage expansion has led to increased access to preventive services, higher rates of having a usual source of primary care and increased affordability of care. 

However, progress is now stalling because of policy changes that have been made by the President like:

Cost Sharing Reduction Payments Stopped

In October 2017, the President announced that he was ending cost-sharing reduction payments (a program that previously reimbursed health insurance companies for the out-of-pocket protections available to some individuals who purchased coverage on the individual marketplaces). This caused higher premium rates in the individual marketplaces this year. 

Short Term Health Plans

The President also issued Executive Order 13813, which expanded “association health plans” and short-term, limited duration insurance. These plans create parallel markets in which healthier individuals move to cheaper plans that offer barebones coverage, destabilizing the marketplace.

Last week HHS and the US Department of Treasury followed through on the EO and issued a final rule that will allow consumers to buy short-term health plans to provide coverage for up to 36 months. These plans don’t need to comply with ACA requirements like covering essential health benefits, pre-existing conditions or the requirement to sell to any consumer regardless of health status.

These plans will likely attract younger, healthier and drive them out of the risk pool, which will increase costs in the ACA compliant plans.  It’s estimated that about 600,000 Americans will enroll in these short-term health plans, increasing federal spending on marketplace subsidies by $200M in 2019 and $28B over ten years.

Individual Mandate Effectively Expiring

As part of the new federal tax law, the individual mandate tax penalties will be $0 starting on January 2019, which will further erode the goal of increasing coverage and stabilizing insurance markets. In July 2018, the Commonwealth Fund predicted that eliminating the tax penalty will result in at least 2.8 million fewer Americans with coverage.  The nonpartisan Congressional Budget Office estimates that the number of people with health insurance will decrease 4M by 2019 and 13M by 2027.   CMS also cut funding for the federally-facilitated Exchange Navigator Program which will also contribute to decreased enrollment rates.

Risk Adjustment Payments

CMS announced in July that it would freeze $10.4B in 2017 risk adjustment payments. Luckily CMS released a final rule a couple of weeks ago to reinstate payments, so that’s an additional destabilizing thing that thankfully won’t happen at least for now.

Everyone benefits from access to primary and preventive services (including behavioral and reproductive health services), specialty care, and culturally appropriate care. If the individual insurance market continues to destabilize or doesn’t include affordable plans that offer comprehensive services, consumers may face expensive and inaccessible healthcare options. 

Many of the decisions that the President has been making make that outcome more likely in my opinion.

Loneliness as a Public Health Threat

I was surprised to learn this week that loneliness raises the risk of premature death by up to 50 percent-that makes loneliness a public health hazard on the scale of smoking and alcohol. Yet many medical and public health professionals haven't heard about how many risks it poses.

Loneliness means that a person has a small support network and minimal interpersonal contact, and it becomes more common with age.  When a person’s children move or a spouse dies many people find it harder to engage in social activities. Seniors in rural areas are particularly susceptible. Geographic isolation and lack of public transportation combine to keep them alone.

Lack of human contact has serious physiological consequences. Studies show that without human contact our risk of functional decline increases as does our risk of mobility loss. The risk of clinical dementia goes up by 64%.   These health problems further isolate those suffering from social isolation, threatening a vicious cycle of physical, emotional, and psychological decline.

Better support access to existing services is a good start as an intervention.  For example, programs like Meals on Wheels can identify isolated seniors and connect them with resources to reduce loneliness. Other places like churches and city senior centers also serve as important community connectors and potential evaluation and intervention points for lonesome people.

Medicare could prioritize coverage for programs like SilverSneakers which keeps seniors active and creates opportunities for social connections through group exercise.  The Welcome to Medicare and annual Medicare exams could provide opportunities for screening and interventions.  

Medicare Advantage plans could cover benefits to address social isolation.  With an ROI analysis, interventions to reduce isolation could reducing health care costs (the triple aim) while improving outcomes. Developing a reliable tool to screen seniors for social isolation would help as well. 

There's Hope for More Valley Fever Research Funds

Representatives Kyrsten Sinema and David Schweikert introduced a bill last week that, if it passes, will increase the funding that’s available for valley fever research.  The bill supports new research and incentivizes the development of innovative treatments to fight the disease. The bill would:

  • Provide incentives to researchers working to find new treatments for Valley Fever;
  • Streamline the approval and review process for new treatments of the disease;
  • Direct HHS to conduct research on Valley Fever and sets up a Valley Fever Advisory Committee to oversee the work; and
  • Establish a grant program to facilitate Valley Fever research by universities, hospitals, and non-profits.

Valley fever (Coccidiomycosis) treatment research funds are extremely limited, in part, because it’s a regional illness (unique to the desert southwest).  If the entire country were susceptible to the illness, there would probably be more private research funds invested because there would be a large commercial market for a treatment. 

Basically, that’s why we need an investment of federal funds and policy, because the return on the research investment for valley fever isn’t adequate to recoup costs of developing a treatment because not enough people are susceptible to the illness (because it’s limited to the desert southwest).

Can Medical Marijuana Card Fees Pay for Drug Treatment in AZ?

This week AZ Attorney General Brnovich wrote an Opinion stating that state lawmakers (or presumably the ADHS) can use qualified medical marijuana patient card fees to operate programs to help get people off of other drugs. The Arizona Medical Marijuana Fund (administered by the ADHS) contains more than $44M right now (the fund consists of fees paid by patients for cards, other card fees like dispensary agent cards, and dispensary application fees). 

Here’s a simple Q & A from this week's Opinion:

Q. Could the Legislature, through the budget process, direct the ADHS Director to appropriate some of the Fund monies to help people addicted to drugs?

A. Yes.  The Legislature may direct the ADHS Director to spend Fund monies for programs to help people addicted to drugs if: (1) the appropriation is passed with a three-fourths vote of each legislative chamber; (2) the appropriation does not deplete the Fund and leave insufficient revenues to cover the immediate and future costs of the initiative; and (3) the appropriation furthers the purpose of the AMMA, i.e., it relates, in some way, to medical marijuana.

The AG Opinion states that:

“The Legislature may direct the ADHS Director to expend monies from the Fund for programs to help people addicted to drugs if: 1) the appropriation is passed with a three-fourths vote of each house; 2) the appropriation does not deplete the Fund and leave insufficient revenues to cover the immediate and future costs of the initiative; and 3) the appropriation furthers the purpose of the AMMA.  

To that end, an appropriation for activities related to distinguishing between medical and nonmedical uses of marijuana, protecting patients and providers from criminal prosecution, or carrying out, implementing, or administering the AMMA would meet this criterion.  If these requirements are met, it is not necessary to submit an appropriation request to Arizona’s voters.

CMS Position on Native American Exemptions from State Medicaid Work Requirements Complicates AZ Waiver Request

A 2015 AZ law requires AHCCCS to annually ask the CMS for permission to require work (or work training) and income reporting for “able bodied adults” and a 5-year lifetime limit on AHCCCS eligibility.  The work requirement waiver requests turned in during the Obama Administration were denied, but the new administrator CMS has publicly said (and written) that they're receptive to proposals from states to require work or community engagement for people who want to receive Medicaid.

Late last year AHCCCS submitted their annual official waiver request asking permission to implement the following requirements for certain adults receiving Medicaid services including a requirement to become employed, actively seek employment, attend school, or partake in Employment Support and Development activities (with exceptions) and a requirement to bi-annually verify compliance with the requirements and any changes in family income.  CMS has not yet ruled on the AZ request.

One of the exempted groups in the waiver request is American Indians.  Starting Friday (when HB 2228 takes effect) the exemption of tribal members won’t just be an administrative decision, but one required by Arizona law.  That’s because HB 2228 requires AHCCCS to exempt tribal members from their work requirement waiver requests.  Here’s the exact statutory language:

36-2903.09.  Waivers; annual submittal; definitions

B.  SUBSECTION A OF THIS SECTION DOES NOT INCLUDE OR APPLY TO AMERICAN INDIANS OR ALASKA NATIVES WHO ARE ELIGIBLE FOR SERVICES UNDER THIS ARTICLE, THROUGH THE INDIAN HEALTH SERVICE OR THROUGH A TRIBAL OR URBAN INDIAN HEALTH PROGRAM PURSUANT TO THE INDIAN SELF-DETERMINATION AND EDUCATION ASSISTANCE ACT AND THE INDIAN HEALTH CARE IMPROVEMENT ACT.

However, a letter signed by CMS official Brian Neale suggests that CMS won’t be approving waiver requests that exempt tribal members.  In a letter to tribal members he writes, regarding exempting tribal members from state Medicaid eligibility work requirements “… Unfortunately, we are constrained by statute and are concerned that requiring states to exempt AI/ANs from work and community engagement requirements could raise civil rights issues.”

In a nutshell, (beginning Friday) Arizona law will require AHCCCS to exempt American Indians from their directed work requirement waiver request (they have already administratively elected to do so).  CMS is on record saying that they're constrained by statute and have civil rights concerns about allowing states to exempt American Indians from work requirement and reporting waivers. 

It stands to follow that CMS may very well deny Arizona’s request to exempt tribal members from work and reporting requirements despite our new law (36-2903.09 (B)). If that happens, there will surely be a legal review to determine exactly the intent of 36-2903.09 (B)

New Public Health Return on Investment Report

AzPHA member J. Mac McCullough, PhD, MPH, who serves as an Assistant Professor at Arizona State University and Health Economist at Maricopa County Department of Public Health was commissioned by AcademyHealth to write a research synthesis examining the return on investment for public health funding.

It’s a very nice and concise report.  It’s available online on the AcademyHealth website.  Here are some excerpts from the report

Federal, state, and local agencies spend approximately $250 per person per year on the public health system, whereas more than $10,000 is spent on health care per person per year. Public health spending has been falling as proportion of total health spending since approximately 2000 and falling in inflation-adjusted terms since the Great Recession. These declines have resulted in cuts to the public health workforce and to public health program portfolios.

While linking public health and health care spending to improved health outcomes can be tricky, the body of evidence supporting prevention is strong. For example, we know that investment in tobacco cessation can save $2-3 for every $1 invested and that childhood vaccinations can save $5-11 for every $1 invested.

One especially relevant set of studies utilized a unique dataset of public health department expenditures in California. Researchers used instrumental variables to show that a $10 increase in per capita spending led to a 0.6 percent increase in the proportion of the population in very good or excellent health4 and reduced all cause mortality by 9.1 per 100,000.23 Researchers monetized these estimates to determine that every $1 invested in public health in California resulted in $67 to $88 of benefits to society.24

a 2017 systematic review of international studies found that spending for individual public health interventions, services, or policies had a median ROI of $14.30 per $1 invested.

New AZ Public Health Laws Take Effect Friday

State legislators passed several new laws that will influence public health last session- but almost all of them won’t take effect until Friday (August 3). The Legislature has developed a report that report that summarizes all of this year’s bills. The health-related bills are on pages 99-108.  Here’s a snapshot:

  • HB 2088 will require school districts to: 1) develop intervention strategies to prevent heat-related illnesses, sudden cardiac death, and prescription opioid use; 2) notify parents when kids are bullied; and 3) tell parents if a student is suspected of having a concussion.  An ADHS concussion training & management report is due at the end of 2018.

  • HB 2196 will limit ambulance certificate of necessity (CON) hearings to 10 days unless the Administrative Law Judge determines that there’s an extraordinary need for more hearing days.  Hearings had previously gone on for many weeks or even months.

  • HB 2197 requires AZ health licensing boards to collect certain data from applicants (beginning January 2020).

  • HB 2228 directs AHCCCS to exempt tribal members from work requirement waiver requests (more on this later in the update).

  • HB2235 will set up a new licensed class of dental professionals called a Dental Therapist.  The next step is for the AZ Board of Dental Examiners to develop the scope of practice and license regulations.

  • HB 2323 authorizes contracted nurses to provide emergency inhaler medication in case of respiratory emergencies (takes effect this semester).

  • HB 2324 charges the ADHS with implementing a voluntary certification for Community Health Workers. The next steps are for the ADHS to establish the advisory committee and begin the Rulemaking to set up the certification process.

  • HB2371 sets up statewide licensure for food trucks. The licenses will have reciprocity in all county health and environmental service departments.

  • SB 1083 will require public schools (K-3) to have at least 2 recess periods beginning this semester.   Grades 4 and 5 will be required to have 2 recess periods beginning August 2019.

  • SB 1245 will develop a produce incentive program within the Supplemental Nutrition Assistance Program within ADES.

  • SB 1389 requires the ADHS to develop an HIV Action Plan.

  • SB 1465 requires the ADHS to adopt rules and license sober living homes.  It also allows them to contract with a third party to assist with licensure and inspections. They have a 2-year exemption from the regular rulemaking process.

  • Note: SB 1001 - The Arizona Opioid Epidemic Act was in a Special Session and became law several months ago. 

Ballot Measure Analysis Hearing Wednesday Morning

There will be several voter initiatives and some referendum issues for us to vote on in November. We don’t exactly know which measures will make it to the ballot yet because the Secretary of State is still validating the signatures etc. and there are some lawsuits challenging some of the measures too.

If you’ve read your voter publicity pamphlet in the past, you’ll remember that there's an analysis of each ballot measure. The analyses are really important because they convert the statutory language into normal language- and many voters use them in their decision-making.  It’s important that they be objective and accurate.

The language for the Analyses are prepared by the Arizona Legislative Council and evaluated by Council of Legislators, who consider and adopt or amend the draft analyses. ARS 19-124 governs the process.  The analyses are supposed to "... include a description of the measure and shall be written in clear and concise terms avoiding technical terms whenever possible.  The analysis may contain background information, including the effect of the measure on existing law...". 

The Legislative Council is holding a hearing this Wednesday (July 25, 2018) at 9:00 A.M., in House Hearing Room #3 to consider adopting (or amending) the draft analysis language for the Stop Political Dirty Money Amendment (draft analysis); the Clean Energy for a Healthy Arizona Amendment (draft analysis); the “Protect Arizona Taxpayers Act” (draft analysis); and the Invest in Education Act (draft analysis). 

I won’t be able to make it but I’m hoping some of you can take some time and attend.

Professional Development Opportunity: AZ Institute for Healthcare Leadership

Healthcare leaders throughout Arizona can to become better leaders through the Arizona Institute for Healthcare Leadership program. The program formerly known as the Arizona Hospital & Healthcare Leader Association’s Emerging Healthcare Leader Program has been developing healthcare leaders since 2006.

The Arizona Institute for Healthcare Leadership (AIHL) program provides high potential midlevel to senior level leaders within not for profit, for profit and government hospitals and healthcare organizations the necessary skills to become exceptional leaders. Participants have richly diverse backgrounds from many clinical and nonclinical aspects of healthcare including: IT, nursing, ambulatory care, rehab, pharmacy, physician practices, telemedicine, quality, finance, human resources, case management and more.

Fifty percent of the leaders graduating from the Arizona Institute for Healthcare Leadership in the past three years have been promoted, several to Chief Executive Officer. As the pace of change in healthcare accelerates and current leadership is promoted or leaves, these graduates will take their place. Arizona healthcare organizations with an eye to the future have been sending top talent to the AIHL program for over a decade. AIHL develops healthcare professionals with leadership skills including emotional intelligence, communication and the ability to deal with change; all needed to grow their career to the next level.

“Through this experience I became more aware of my emotional intelligence and its impact on the success of the organization, being a senior leader. I also learned to handle my inner Gremlin better as a female, minority leader. In addition, I learned so much from my peers in the program, their similar struggles and successes made me feel I am not and my organization is not alone working through the immense and unprecedented challenges of healthcare and generational leadership transitions.”

A 2016 graduate

“The content of this course has proven very valuable. It helped me to become more cognizant of how emotional intelligence influences my approach to the work, and the positions I pursue.  It provided tools and resources that are helpful in dealing with situations ranging from normal every day events, navigating an organization through crisis situations, and managing a multi-generational workforce. The ability to apply what I learned in this program to real-time, real-world scenarios led to my getting a promotion to a larger, more complex organization.  I strongly encourage participation in this program.”

A 2015 graduate

The full fee is $5,500, participants can save $250 by being an association member and another $250 by applying by Sept. 20 bringing the cost down to $5,000. With the class time, executive coaching, outside reading and project the average person will spend 10-20 hours a month, not including travel for the session each month.

Applications are being accepted now for the 2019 cohort (which runs from January - October 2019. Deadline to apply is 11/16/18.

Program overview and applications are available at www.RisingStarsLLC.com/AIHL For more information contact Joanne Schlosser at Joanne@RisingStarsLLC.com or call 480-840-6024. 

Behavioral Health Advocacy Training Institute: Apply Now

The Eric Gilbertson Advocacy Institute for Behavioral Health (aka Institute) is designed for service recipients/participants, family members, Board Members, and individuals concerned about quality behavioral health in Arizona.  The goal of the training is to provide you a comprehensive overview of the Arizona behavioral health system and to assist participants in becoming effective advocates for those receiving behavioral health services.

The Institute provides information, training, and resources to participants on behavioral health issues at the individual, provider, and system level. The Institute will provide participants with opportunities to meet and talk with leaders and advocates in the Arizona behavioral health system.  As a participant, you’ll have an opportunity to meet and unite with others who have a similar interest in creating a powerful voice on important issues. You’ll also learn how various state agencies are responsible for the delivery of behavioral health services and how the legislative process works at the state and national levels to impact behavioral health policy. 

The Training Institute will cover the History of the Disability Movement and the Role of ADHS, ADES, AHCCCS, ADOE, the Courts & Corrections, the Role of the Regional Behavioral Health Authorities (RBHAs) & Complete Care Contractors Community Supports State & Federal Policy Legislative Process Organizing for Change.  The Application deadline is August 15.  For more information visit http://azabc.org/eg_institute/

Families USA Issue Brief: Adult Dental Services

States have great latitude to determine the scope of dental benefits they cover for adults through their Medicaid programs. Some states cover comprehensive benefits, others cover emergency dental care and some none (AZ provides emergency coverage up to $1000 per year for all adults and comprehensive coverage for kids).  This variation in coverage matters. Without adequate dental coverage, people face barriers to getting care they need to stay healthy.

To better understand the consequences of insufficient dental coverage, Families USA conducted a survey of states that cover emergency-only dental services.  In the issue brief Families USA found:

  • States that cover emergency dental services generally cover some services to address severe pain including extractions. But most don’t provide restorative care nor cleanings that would address underlying disease.
  • In some states, Medicaid managed care plans provide plan-specific “value added” benefits.
  • State Medicaid programs pay for hospital emergency department visits when appropriate dental services are not available.
  • More comprehensive benefits and fewer prior authorization requirements would encourage provider participation.
  • Low-income seniors and people with disabilities who rely on Medicaid and Medicare for health coverage are among those affected by the lack of dental coverage.

The Families USA Issue Brief concludes that emergency-only dental coverage is a start, but states should invest in comprehensive Medicaid dental coverage for adults if they want to effectively keep their populations healthier and reduce other health care costs. Here’s the full the full issue brief.

Substance Abuse Prevention Needs Assessment

AHCCCS is conducting a Statewide Substance Abuse Prevention Needs Assessment to better understand what prevention activities are going on and what the prevention needs in our communities are and about the experiences of folks who work or volunteer in substance abuse prevention. 

If you fit the bill, it would be great if you could take 10 minutes to support this important effort by taking this Arizona Substance Use Prevention Workforce Survey

Immigration Status, Public Benefits, Health & Access to Care: A Primer

With all the attention on immigration status and its intersection with public benefits and access to health care- I thought I’d take a crack at summarizing these issues for our membership.  Here goes:

Noncitizens make up about 7%  percent of the US population. It’s not surprising that they’re more likely to be low-income and uninsured than citizens- in part because of the opportunity limitations. In fact, 71% of undocumented adult noncitizens are uninsured.  By and large, many of them rely on Federally Qualified Health Centers for their primary care and other healthcare- in part because FQHCs have sliding fee scale service fees and serve immigrants regardless of their immigration status.

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

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (often referred to as PRWORA or welfare reform) is the federal law that created Medicaid’s “qualified immigrant” standard.

Other federal safety net programs like Temporary Assistance for Needy Families and the Supplemental Nutrition Assistance Program (food stamps) also apply the five-year waiting period for legally present immigrants.

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

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

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

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

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

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

2020 Census Citizenship Question Open for Public Comment

2020 Census Citizenship Question Open to Public Comment

You can weigh in on a controversial decision by federal officials to add a citizenship question to the 2020 census. 

Several lawsuits have been filed challenging this late and untested addition to the decennial questionnaire. In the views of many, the addition of a citizenship question would suppress response rates in immigrant communities, increase costs to taxpayers in administering the census, and lead to misallocation of government resources in ways that hurt businesses, communities, governments, and nonprofits. A question on citizenship, in short, could lead to an unfair, inaccurate, and incomplete count of every person in America.


You can go directly to the Census Bureau comment form or submit prepared comments using the Census Counts website.  The public comment period closes August 7.

AzHHA Thoughtful Life Conversations

The Arizona Hospital and Healthcare Association (AzHHA) has made their Thoughtful Life Conversations one of their priority programs this year.  It’s an affiliation of healthcare leaders, providers and community representatives with a shared commitment and a sense of accountability to improving end of life care for Arizonians.   

The Thoughtful Life Conversations program mission is to empower Arizonans to make known their life wishes and care directives and to equip their healthcare teams with resources to honor them.  Our vision is for Arizonans to have thoughtful life conversations that result in honored healthcare wishes and goals and improved care towards end of life.

Having conversations about serious illness, end of life care, and advanced care planning is important and challenging, even scary and uncomfortable for clinicians to initiate.

To facilitate these kinds of Thoughtful Life Conversations they’re holding several “Communications in Serious Illness” trainings. The trainings are free and space is limited so please be sure and register quickly!  I’ve added the series of training opportunities to our AzPHA Calendar of Events at http://www.azpha.org/upcoming-events/ or you can visit

Community Paramedicine Continues to Mature in AZ

Community paramedicine has been a paradigm shift for the use of paramedics in the US- and Arizona has been a national leader.  It’s a new model in which paramedics function outside their usual emergency response & transport roles- delving into the world of primary care.  As the health care world increasingly shifts toward prevention and well care- the system will increasingly demand more folks that can function in a community health (primary care and prevention) role.  Community paramedicine is increasingly being recognized as a promising solution to efficiently increase access to care (especially for underserved populations). 

For example- paramedics could shift from a sole focus on emergency response to things like: 1) providing follow-up care for folks recently discharged from the hospital to prevent unnecessary readmissions; 2) providing community-based support for people with diabetes, asthma, congestive heart failure, or multiple chronic conditions; and/or 3) partnering with community health workers and primary care providers in underserved areas to provide preventive care. 

One component of Community Paramedicine is known as “Treat and Refer” and it has really taken a step forward in the last couple of years in Arizona.  A couple of years ago the initiative was launched under the leadership of AzPHA Members David Harden, Terry Mullins, Dr. Ben Bobrow and others at the ADHS.

It’s called the Arizona Treat and Refer Recognition Program and was developed in partnership with the ADHS Bureau of EMS & Trauma Systems, AHCCCS, and the EMS community. Organizations that earn Treat and Refer recognition implement the program under the direction of their medical director and chief executive.  Once recognized, the EMS Agency can seek reimbursement from AHCCCS for the services they provide.  You can check out the AHCCCS website to learn more about provider registration.

Five EMS agencies have now been recognized as Treat & Refer EMS agencies. The T&R Program establishes a means for recognized EMS agencies demonstrating optimal patient safety and quality of care by matching treatment, transport, and care destination options to the needs of the 9-1-1 patient; and provide recognized EMS agencies the opportunity to seek reimbursement from AHCCCS.


The ADHS Bureau of EMS & Trauma Systems offers a pre-application technical review service to EMS agencies considering applying for recognition. The service includes a comprehensive review of EMS agencies’ education modules, standing orders, patient follow-up process, and performance improvement/quality assurance process.

Arguments Due Wednesday for November's Ballot Propositions

Do you feel strongly about any of the upcoming voter initiatives or referendums that will be on the November ballot?  Do you have some solid arguments that could persuade fellow Arizonans to see things your way? 

If so, you’re in luck.  The AZ Secretary of State’s Office has made it easier than ever for you to post an argument for or against any of the measures- but you’ll need to act before Wednesday at midnight. 

Arguments for or against proposed ballot measures for the 2018 General Election can now be submitted electronically through the new Ballot Measure Argument Submission Portal available at https://ballotarguments.az.gov/

The fee is just $75 per argument and can be paid online.  They also dropped the notarization argument that had previously existed.  Your ballot measure argument will be printed in the publicity pamphlet that is mailed out to registered voters. I submitted comments in favor of the Clean Energy Amendment and the Campaign Disclosure Initiative- (on behalf of myself) and the process was simple and straightforward.

Here’s the listing of the 2018 Initiatives, Referenda & Recall Applications.  I’ve summarized the measures that submitted sufficient signatures last week:

The Stop Political Dirty Money Constitutional Amendment PDF establishes voters’ right to know the identity of all major contributors who are trying to influence the outcome of Arizona elections. Contributors will no longer be able to hide by transferring their money through intermediaries. Anyone spending more than $10,000 to oppose or support candidates or ballot measures must disclose everyone who contributed $2,500 or more promptly, publicly and under penalty of perjury.

The Clean Energy for a Healthy Arizona Amendment PDF requires affected electric utilities to provide at least 50% of their annual retail sales of electricity from renewable energy sources by 2030. The Amendment defines renewable energy sources to include solar, wind, small-scale hydropower, and other sources that are replaced rapidly by a natural, ongoing process (excluding nuclear or fossil fuel). Distributed renewable energy sources, like rooftop solar, must comprise at least 10% of utilities' annual retail sales of electricity by 2030. The Amendment allows electric utilities to earn and trade credits to meet these requirements.

The Invest in Education Act PDF increases the classroom site fund by raising the income tax rate by 3.46% on individual incomes over a quarter million dollars (or household incomes over half a million dollars), and by 4.46% on individual incomes over half a million dollars (or household incomes over a million dollars); designates 60% of new funds for teacher salaries and 40% for operations; and adds full day kindergarten and pay raises for student support services personnel as permitted fund uses. 

Save Our Schools PDF asks voters whether to validate a 2017 Bill passed by the Legislature (Chapter 139 SB 1431) that greatly expanded Empowerment Scholarship Accounts (commonly referred to as private school vouchers) and removed the existing ESA enrollment cap, increasing it annually by 0.5% of total public school enrollment through 2022 and capping ESA enrollment in 2023.

The Protect AZ Taxpayers Act PDF would amend the Arizona Constitution to prohibit state government, as well as county, municipal and other political subdivision governments and taxing districts, from imposing or increasing any transaction-based taxes, fees, stamp requirements, or assessments on any service performed in Arizona, or on the gross receipts of sales or gross income derived from any service performed in Arizona.

AZ Vaccination Exemptions Continue to Increase

Despite numerous interventions in the last year designed to improve immunization rates among AZ school children- we continue to lose ground.  Last week the ADHS released their latest school reporting data on vaccine exemption rates (medical, personal and religious).  Here’s a 2 page summary of some of the results.  This year’s report covers the 2017-2018 school year (the data was submitted by the schools to the Department in the Fall of ’17). The data show that:

  • Immunization rates have decreased across age groups from 2012 to 2017;

  • Non-medical exemption rates continue to be highest in public charter schools, followed by private and public schools in 2017; and 

  • Non-medical (e.g. personal and religious) exemption rates have increased from 2016: going from 3.9% to 4.3% for pre-school; 4.9% to 5.4% for Kindergarten and 5.1% to 5.4% among 6th graders.

The Arizona Public Health System has done a remarkable job turning the data reported by schools into actionable information.  My favorite is the Personal Belief Exemptions Map.  Parents can also look up the exemption rates in individual schools.  But there are also data for: Arizona Reporting Schools Coverage; County Kindergarten Coverage; County 6th Grade Coverage; County Child Care Coverage; Whooping Cough Immunization Coverage Map; and a Measles Immunization Coverage Map.

 

Interventions to Reduce Vaccine Exemptions

The ADHS has significantly overhauled their vaccine exemption form to better inform parents about the risks that they are taking for their child and for their child’s classmates and the community by choosing not to vaccinate their kid. Other interventions (by the Arizona Partnership for Immunizations) have included working with school administrators to help parents overcome any barriers that might be preventing them from getting their children vaccinated and by reducing “convenience exemptions,” in which parents sign a waiver because they can’t get their children immunized in time to meet school requirements.

I’ve also heard that there is an Immunization Education Course under development by the ADHS that’s designed to serve in lieu of a new exemptions form has been built and piloted at some schools in Maricopa County.

During the 2015 legislative session, Representative Mendez sponsored HB 2466 which would have required all public schools (including charter schools) to maintain a website to post the rates of their pupils’ immunizations against vaccine preventable diseases.  It never even received a committee hearing.  Back in 2012 a Bill that would have required a doctor’s signature to get a personal exemption failed. 

A couple of years ago California eliminated personal exemptions entirely.  While the rate for personal exemptions rose after the personal exemption was eliminated, a study In study in JAMA back in 2017 found that the rate of medical exemptions for immunizations for incoming kindergartners rose the year after California eliminated the personal-belief exemption, but vaccination rates did improve substantially - especially in high income enclaves that had the highest personal exemption rates. 

By the way- last week the Second District Court of Appeal in Los Angeles found that California didn’t violate freedom of religion or the right to an education when it eliminated most exemptions.  The court said that… “Compulsory immunization has long been recognized as the gold standard for preventing the spread of contagious diseases”.  The court said the new law was not discriminatory and was a valid measure to protect public health.

Major Changes Proposed for Family Planning Grants

A few weeks ago HHS issued new proposed regulations for Title X (family planning) grants in the Federal Register. The new regulations would make many changes to the requirements for Title X projects and could profoundly change how family planning services are provided by significantly limit the network of providers who can qualify for funds; restricting the ability of participating providers from discussing and referring for abortion; and making other programmatic changes that could dramatically reshape the program and provider network available to low-income women.

If fully implemented, the proposed changes to Title X would shrink the network of participating providers and have major repercussions for low-income women in AZ that rely on these services for their family planning care.

Here’s an informative Issue Brief about the planned changes. The new proposed regulations and the place to submit comments are up on the Federal Register website through July 31.

Courts Overrule CMS' Approval of KY's Medicaid Work Requirements- Ruling Could Influence AZ's Request

Kentucky was the first state to have a work requirement waiver approved by CMS (it was set to take effect yesterday- July 1, 2018).  But last Friday, a federal District Court Judge ruled that Kentucky’s CMS approved waiver which would have implemented work/community engagement requirements failed to address the purpose of the Medicaid program- to provide coverage and care. Medicaid is obligated under federal law to consider whether a waiver proposal advances the program’s objectives. 

Specifically, toward the end of the Decision, the court concludes that “…the Secretary must adequately consider the effect of any demonstration project on the State’s ability to help provide medical coverage. He never did so here.”  

When you read the Decision, you’ll see that the court basically concluded that when CMS approved the waiver, they didn’t consider its impact on the primary objective of the Medicaid program- which is to provide medical coverage and care. The court vacated CMS’ approval of the waiver and remanded it back to HHS (CMS).

While Kentucky’s waiver request isn’t exactly the same as  Arizona’s work and community engagement waiver request, there are many similarities. Both require some Medicaid members to meet work or community engagement requirements (AZ has more exempted populations than KY), both have reporting requirements, and both include lockout provisions for folks that don’t comply. The specific standards and exemptions are different, but both include the same basic requirements (except that KY includes some premium payments- which isn’t included in Arizona’s waiver request). 

This is certainly the beginning of a longer legal battle, but last week's Ruling could very well influence CMS’ upcoming decision about whether (or when) to approve Arizona’s waiver request.