Medicaid

Intermediate Care Facilities Like Hacienda de los Angeles are Exempt from State Licensing Requirements

By now you’ve heard the disturbing story of a 29-year-old resident of Hacienda de los Angeles who gave birth a couple of weeks ago. What’s troubling about the birth is that the mother was unable to give consent because of the nature of her medical condition. In short, it means she was raped and delivered a baby while under the care of Hacienda de los Angeles.

Quite honestly, it’s astonishing that the facility and its staff apparently failed to detect – or report -- the sexual assault or pregnancy until after the baby was born and in medical distress.  Arizona law (ARS 46-464) requires people that have responsibility to care for a vulnerable adult to report any abuse or neglect that they suspect.  Failure to report is a Class 1 misdemeanor.

With such resources now deployed with the various investigations including the Phoenix Police Department, we will eventually most likely learn whether Hacienda staff knew but did not report the pregnancy or whether the care being provided was such that staff did not discover the pregnancy until the woman gave birth.  

Arizona and local law enforcement officials are investigating the matter – but they may be impeded by this troubling fact: Hacienda de los Angeles isn’t required to have a state license (and doesn’t have one).

How is this possible?

Hacienda de los Angeles is classified as an intermediate care for persons with intellectual disabilities. Facilities in this class provide more intensive services than a residential group home for persons with intellectual disabilities but different services than a skilled nursing facility.

When I learned through the media of the assault and birth, I went to the ADHS’ AZ Care Check    website to look at the regulatory compliance record for the facility. I was puzzled when I discovered that the facility didn’t have an ADHS License number. They have an identifying number for their Certification to get paid by the Centers for Medicare and Medicaid Services (CMS) -- but no state license.

In digging deeper- I discovered that this class of facility doesn’t require a license from the ADHS.  They are specifically exempt. The exact statutory language is located in ARS 36-591(E) where it states that: “An intermediate care facility for persons with an intellectual disability that is operated by the division or a private entity is not required to be licensed under this section if the facility is certified pursuant to 42 Code of Federal Regulations section 483.400”.

That’s not to say that there’s no oversight of the facility.  There is. ADHS has conducted annual certification inspections under a contract from CMS every year for the last several years, and you can see that there are several deficiencies that have been identified (and corrected) over time.

What’s problematic is that the state has no direct regulatory authority over the facility because they’re not required to have a state license (if they’re CMS certified).  That means there’s no direct mechanism to compel compliance with state care regulations – because there’s no license to suspend, put on provisional status, or to revoke. 

With information that will be discovered in the coming days and weeks, the federal government could elect to decertify the facility and to no longer pay for services provided there, and/or our state Medicaid agency could decide to no longer approve placement of their members at the facility- but the state has no direct authority to compel compliance -- again, because there’s no state license to use as leverage to compel compliance with state licensing requirements.

Intermediate care facilities were exempt from state licensing requirements back in 1997 when HB 2247 was passed by the legislature and signed by Governor Hull.

Perhaps this case provides an opportunity for our state elected officials to re-examine the wisdom of exempting intermediate care facilities from having a state license.

Maternal Mortality: A Tragic Trend Continues in the US and AZ

The US has the highest maternal mortality rate of any developed country.  Sadly, it’s getting worse each year.  About 800 American women die and 65,000 almost die during pregnancy or childbirth.

The number of deaths in AZ jumped from around 10 in 2015 to about 30 in 2016 (the last year for which ADHS has data posted). The numbers are rounded for statistical reasons (called cell suppression in the public health statistics trade.)

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

Fortunately, there are public health policy leverage points that can make a difference within state health departments and Medicaid agencies.  Medicaid is a leverage point because it pays for over half of all births each year in 25 states including Arizona.  

All states provide Medicaid coverage for women with incomes up to 133% of poverty during pregnancy and for 60 days after delivery.  But the scope of services covered before and after delivery vary between states.  As a result, some women lose coverage or Medicaid eligibility in certain states after that 60-day period (mostly in states without Medicaid expansion).

In Medicaid expansion states (like AZ) women have more opportunities to achieve better preconception health because they’re more likely to be able to access contraception and plan their pregnancies, receive primary care services to manage chronic conditions prior to and between pregnancies and access prenatal and perinatal care once pregnant.

Evidence-based policy making is a key.  Twenty-nine states (including Arizona) have committees that review maternal deaths and make public policy recommendations.  Back in 2011, Arizona passed, and the Governor signed a bill that amended our child fatality review statutes by adding reviews of maternal deaths.

The statute charges our existing Child Fatality State Teams to review maternal deaths (called the Maternal Mortality Review Subcommittee) and make policy recommendations. The primary goal is to identify preventive factors and make recommendations for systems change. The existing statute doesn't require an annual report- and the last report was published in 2017. Note: we've heard that there may be a Bill this session that will require an annual report of the committee's work.

Here are some of the recommendations from the most recent ADHS report (published in 2017):

  • All pregnant women should have access to prenatal care;

  • Encourage maternal care professionals, organizations, and health facilities to update their standards of practice and care to include all recommended guidelines for the prevention of medical complications;

  • Promote public awareness of the importance of healthy behaviors and women’s overall health prior to pregnancy;

  • Women should always wear proper restraints when riding in cars;

  • Maternal health-care systems require strengthened, prepared, and educated communities to improve deliveries in health facilities, particularly in rural areas;

  • Increase and streamline access to behavioral health services statewide, including training and education for advanced practice nurses in behavioral health services;

  • Support and implement community suicide prevention and awareness programs, such as Mental Health First Aid;

  • Health care providers should screen frequently for perinatal depression and domestic violence;

  • Institute and follow recommended California Maternal Quality Care Collaborative guidelines (www.cmqcc.org) for the timely transfer and transport to a higher-level care facility for any complications using regional transport services; and 

  • Educate providers on the availability of maternal postpartum resources such as home visiting programs.

Some states have gone further. For example, South Carolina’s Medicaid agency formed the South Carolina Birth Outcomes Initiative to advance reductions in early elective deliveries; incentivize Screening Brief Intervention and Referral to Treatment; promote long-acting reversible contraception; and support vaginal births.  One outcome of the SC initiative was to reimburse for long-acting birth control (LARC) devices provided in a hospital setting. 

Fortunately, Arizona has also included LARC reimbursement in a hospital setting post-partum.  This is an important policy intervention because it provides women with a long-acting and reversible option, so they can better plan future pregnancies – improving opportunities for preconception health, which is a key to improving health outcomes.

The Intersection of Public Health and Housing

Affordable, safe, and stable housing directly impacts an individual’s health and well-being and improves people’s ability to manage chronic diseases and mental conditions, access education and employment, and build healthy relationships.  Persons that are homeless face illness at three to six times the rate of housed individuals and are three to four times more likely to prematurely die than the general population.

Ensuring that patients have stable housing can also reduce healthcare costs.  An analysis of Oregon Medicaid claims data found people placed in stable and affordable housing reduced their overall Medicaid expenditures by 12%. Housing placement also correlated with a 20% increase in primary care visits and an 18% decrease in emergency department visitations among Oregon Medicaid members. 

It’s no surprise then that hospitals and health systems are increasingly interested in supporting access to stable and quality housing as a strategy to reduce downstream healthcare spending, especially as they move toward value-based payment models.

CMS is catching on too.  A couple of years ago they released a bulletin emphasizing the importance of designing Medicaid benefits packages that incorporate the social determinants of health. They outlined allowable coverage of housing-related activities and services for individuals with disabilities and older adults requiring long-term services and supports, like conducting individual tenant housing assessments, assisting with the housing search and application process, or offering tenancy sustaining services.

Last month the HHS Secretary suggested that CMS will be introducing a payment model allowing hospitals to directly pay for housing and other social services using federal Medicaid dollars. The statement suggests that this shift stems from a broader interest in better alignment between health and human services and that such a model would be tested by the Center for Medicare and Medicaid Innovation (CMMI).

While direct spending on room and board still isn’t allowed under the Medicaid statute, several state Medicaid programs are pursuing demonstration waivers that allow for innovations or flexibilities in Medicaid-managed care programs to address housing needs or other social determinants of health.

North Carolina recently received approval of its Section 1115 waiver which will allow their Medicaid managed care contractors to cover evidence-based, non-medical interventions that have a direct impact on members health outcomes and costs. The pilots will be implemented regionally to address housing, food security, transportation, employment, and interpersonal safety. I think North Carolina is the first state to receive this type of waiver, but I'm not 100% sure about that.

CMMI is also exploring the impact of screening and referrals for health-related social needs (including housing) of Medicaid and Medicare dual beneficiaries. They’ll be measuring whether screenings and referrals to community-based organizations and social services generate improvements in health outcomes and reductions in healthcare spending. The model is being piloted through 31 organizations in 23 states including at AHCCCS.

Jami Snyder Appointed AHCCCS Director

Jami Snyder was appointed to the post of the Director of AHCCCS effective this Friday.  She has been serving as the as deputy director of AHCCCS since December of 2017. Prior to that she was the Medicaid Director in Texas and as Chief Operating Officer of the University of Arizona Health Plans. She also previously held posts as  a Bureau Chief at the Arizona Department of Health Services. 

Jami is a 2013 Flinn-Brown Civic Leadership Academy Fellow, and graduated with a BS in political science from Gustavus Adolphus College and went on to earn a master’s degree in political science from ASU.

I really think Jami is a terrific choice for this important job. She has a good reputation in the public health world and is known as somebody that understands the linkages that public health and health care can forge in designing and implementing interventions that improve public health outcomes while reducing costs.

Congratulations Director Snyder! 

US Supreme Court Declines to Hear Appeal Regarding Reproductive Health

This week the US Supreme Court declined to hear a case that would have given them an opportunity to overturn a lower court ruling that found that Medicaid agencies can’t exclude providers offering preventive reproductive health services like annual health screens, contraceptive coverage and cancer screening because they also offer abortion services.  Lower federal courts had ruled that while states have broad authority to ensure that Medicaid health care providers are qualified, that power has limits. 

The case isn’t about elective abortion services per se (the Hyde Amendment from 1977 makes it clear that federal funds can’t be used to pay for abortions except in cases of rape, incest, or life endangerment). The question is whether providers can be excluded from Medicaid contracts for preventive services like annual health screens, contraceptive coverage and cancer screening because they also separately offer abortion services outside of their public dollar contracts. 

The Supreme Court’s decision to decline the case will have implications here in Arizona. In 2016, Governor Ducey signed a bill giving the director of the AHCCCS the power (at his or her discretion) to disqualify any provider that doesn’t fully segregate the public dollars they get and ensure that none of those funds went toward providing elective abortions- including overhead expenses like rent, lights and A/C.

While that law is still on the books (as ARS 36-2930.05), it hasn’t been implemented. After a lawsuit was filed back in '16, attorneys for AHCCCS agreed not to implement the law and stipulated that AHCCCS won’t try to cut family planning dollars from Planned Parenthood or any other organization because it hasn’t fully segregated out the costs of abortion services to the satisfaction of the director.  The implementation hold agreed to in the stipulation was until Rules (Administrative Code) could be adopted- which they estimated would take about 2 years.

In exchange, the attorneys for the providers agreed to drop their lawsuit challenging the legality of the measure until there are actual rules in place.  I checked on the AHCCCS and Secretary of State’s website and can’t find any Rules fleshing out the criteria- but I might have missed them.

In any event- the fact that the US Supreme Court this week declined to hear a case similar to Arizona’s suggests that- at least for now- the status quo remains...  and Arizona’s Managed Care Organizations that contract with AHCCCS are free to contract with Planned Parenthood or other providers even though they may not be segregating expenses as required in ARS 36-2930.05.Of course- that could change at any time if the Supreme Court changes their mind and agrees to hear a similar case in the future.

Public Health Ballot Measures Approved in Other States

Here’s a summary of what voters approved in other states that link to public health policy.  There are a few surprises in here- at least things that I found surprising.

Idaho, Nebraska, and Utah voted to expand their Medicaid programs (up to 138% of the federal poverty level).  Idaho’s Proposition 2 was approved by 61% of voters and Nebraska’s passed with 53% approval (called Initiative 427 to expand Medicaid). Interestingly, neither of those states established a funding mechanism.  

Utah’s Proposition 3 was approved by 54% of voters and funds the expansion with a 0.15% increase to the state’s sales tax. There are now 14 states  left that haven’t expanded Medicaid.  With gubernatorial party changes in Wisconsin & Kansas perhaps those states may be next.

Proposals related to marijuana were on the ballot in five states. Utah voters approved a medical marijuana initiative (Proposition 2) by a 53-47 percent margin. Interestingly, it will be a strictly “edibles” based program (prohibits the medical marijuana). 

Missouri voters approved Amendment 2 (with 66% of the vote) that gives the Missouri Department of Health & Senior Services oversight of the state’s new medical marijuana program. 

Michigan approved a measure to allowing adults to use marijuana for non-medical purposes and a retail sale program.  Proposal 18-1 directs Michigan’s Department of Licensing and Regulatory Affairs to oversee the commercial production and retail sale of marijuana. 

Wisconsin Medicaid Work Requirement Approved

CMS approved Wisconsin’s Medicaid work requirement waiver, making them the 5th state to have their work requirement waiver approved.  Wisconsin is the 1st state to receive approval for work requirements since a federal court ruled them unconstitutional in Kentucky.

Medicaid members between the ages of 19 and 49 will be required to work, volunteer, be in school or in a job training program for at least 80 hours a month. Recipients who don’t comply after 48 months will lose their eligibility.  The state is also allowed to charge premiums for what is normally free and to raise those premiums for people with riskier health behaviors like smoking.

Of the four other states CMS has given the greenlight to, only Arkansas has implemented work requirements. Indiana and New Hampshire will start enforcing them in January, and Kentucky's have been sent back to CMS for review.

Arizona’s Work Requirement 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. 

Late last year AHCCCS submitted their annual official waiver request 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 hasn't yet ruled on the AZ request.

HB 2228 requires AHCCCS to exempt of tribal members from the work requirements but CMS has suggested that they won’t be approving waiver requests that exempt tribal members because they believe exempting them could raise civil rights issues.  

For now it's status quo.

New Federal Opioid Intervention Becomes Law

A couple weeks ago congress passed and the president signed the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act. Much like Arizona’s Arizona Opioid Epidemic Act – approval of the bill was bipartisan, with a House vote of 393-8 and 98-1 in the Senate.

The final bill creates, expands and reauthorizes programs and policies across several federal agencies, and focuses on prevention, treatment and recovery. The text of the Act is extremely long, but you can view a high level summary on this landing page.

Some of the provisions are in line with recommendations in the 2017 ADHS Opioid Response Report like calling for changing an old federal regulation that prohibited Medicaid from covering patients with substance abuse disorders who were getting treatment in a mental health facility with more than 16 beds. The effect of the former law limited the number of beds available for low-income patients suffering from addiction- so hopefully the network of treatment facilities will expand as a result of this change in the law. The new federal law allows for 30 days of residential treatment coverage.

The new law allows nurse practitioners and physician assistants to prescribe buprenorphine, which is an anti-addiction medication that requires a special license and extra training.  For the next 5 years, it will also allow nurse anesthetists, nurse midwives and clinical nurse specialists to prescribe buprenorphine.  Right now, only about 5% of doctors are licensed to prescribe it.  It’ll take time for the inventory of prescribers to increase because of the training that’s required- but over time this provision will help network capacity especially in rural areas.

The Act also creates a grant program for comprehensive recovery centers that include housing and job training, as well as mental and physical health care. It will also increase access to medication-assisted treatment.

Some aspects of that law that relate to Medicaid include:

  • Temporarily requires coverage of medication-assisted treatment under Medicaid;

  • Prohibiting the termination of Medicaid eligibility for juveniles who are inmates of public institutions;

  • Requiring CMS to establish a demonstration project to increase provider treatment capacity for substance-use disorders;

  • Requiring state Medicaid programs to establish drug management programs and drug-review and utilization requirements for at-risk members; and

  • Extending enhanced federal matching rate for expenditures regarding substance-use disorder health-home services under Medicaid.

Interestingly, the bill includes a provision to help stop the flow of black-market opioids into the country by mail, especially synthetic fentanyl and its analogs.  The US Postal Service will need to provide the name and address of the sender and the contents of at least 70% percent of all international packages, and 100% of packages from China.

All international shipments will need to have the name and address of the sender by the end of 2020.  The Postal Service was also given the authority to block or destroy shipments for which the information isn’t provided.

The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act is long and comprehensive so I can’t cover everything….  But the bottom line is that public health policy – both here in AZ and now nationally is beginning to address the epidemic.

More States Implementing School-based Nutrition & Physical Activity Policies

Obesity remains a complex health issue in the United States. Several factors—including behavioral, environmental, and genetic—interact and contribute to increasing obesity rates. Approximately 19% of children and adolescents aged 2-19 years old are obese and face a greater risk of developing chronic and other conditions like diabetes, heart disease, cancer, high blood pressure, asthma, and sleep apnea. By 2012, the estimated annual cost of obesity in the United States was $147 billion, in addition to other social and emotional costs.

The causes of childhood obesity include unavailability of healthy food options, easy access to unhealthy foods, lack of physical activity, as well as policy and environmental factors that do not support healthy lifestyles. Schools play a significant role in diet and activity through the foods and drinks offered and the opportunities for physical activity provided.

Recognizing the unique position of schools, states have enacted and proposed legislation to prevent and reduce childhood obesity by: (1) ensuring that nutritious food and beverages are available at schools, and (2) establishing physical activity and education standards at schools. Below is an overview of current laws and recent state and territorial legislative activities to increase the availability of healthy foods and opportunities for physical activity in schools.

School Nutrition Legislation

Children and adolescents consume much of the food they need each day while at school. Children may receive meals from federal programs like the National School Lunch Program and the School Breakfast Program, or they may purchase competitive food and drinks (i.e., food that’s purchased from school-based vending machines, snack bars, or concessions outside of the school’s food service program). Many states have adopted policies to make competitive foods healthier, set limits on food for rewards, and impose restrictions on food and beverage marketing in schools.

A Colorado statute prohibits public schools from making available any food or beverage that contains any amount of industrially produced trans-fat on school grounds. In Kentucky, each school must limit access to retail fast foods in cafeterias to no more than one day each week. Laws in New Jersey prohibit the sale of foods of minimal nutritional value, all food and beverage items listing sugar as the first ingredient, and all forms of candy on school property during the school day.

In 2017, California’s governor approved a bill limiting the advertisement of food and beverages during the school day in schools, school districts, or charter schools participating in federal lunch and breakfast programs. California also prohibited participation in corporate incentive programs that reward children with food and beverages that do not comply with nutrition standards. New Hampshire proposed similar legislation prohibiting the advertisement of any food or beverage that does not meet the minimum nutrition standards as set forth by the school district, as well as participation in a corporate incentive program that rewards children with food and beverages.

Recognizing that many schools lack the necessary equipment to support the storage, preparation, and service of minimally processed and whole foods, the Washington State legislature introduced a bill that would establish a competitive equipment assistance grant program for public schools to improve the quality of food service meals that meet federal dietary guidelines and increase the consumption of whole foods. In 2017, Puerto Rico proposed a bill requiring that vending machines located in public schools only contain products of high nutritional value according to the standards imposed by the federal government.

Physical Activity Legislation

According to CDC, children and adolescents should have one hour or more of physical activity every day. State policymakers often target physical activity and education curriculums in K-12 schools to combat the childhood obesity epidemic. Promising trends include: improving physical education curricula, integrating physical activity into the school day and maximizing recess opportunities, as well as enhancing physical activity opportunities in school-based after-school programs.

Many states have statutes in place or have proposed legislation imposing physical activity and education requirements in schools. Last legislative session, Arizona approved a new law mandating that public schools include recess in their curriculum. Other states have gone further. 

Iowa, Louisiana, North Carolina, and Texas require 30 minutes of physical activity each school day. Arkansas requires 90 minutes of physical activity each week for grades K-6. South Carolina sets a minimum standard of 150 minutes per week for grades K-5. Colorado requires 600 minutes of physical activity each month for full-time elementary students.  Tennessee amended its statute to require a minimum of 130 minutes of physical activity per full school week for elementary school students and a minimum of 90 minutes for middle and high school students.

National Medicaid Performance Measures for Kids Released

Medicaid and the Children’s Health Insurance Program serve nearly 46 million children which is 33% of the kids in the US- which means that these programs are a huge leverage point for improving health outcomes.  Measuring the effectiveness of these programs is critical to improving their performance and in providing the information needed to design policy interventions.

The Centers for Medicare & Medicaid Services plays a key role in promoting quality health care and as part of their accountability standards they have a core set of health care quality measures for children in Medicaid and CHIP that by applying a standardized set of measures designed to measure and improve the quality of care. 

The 2017 Child Core Set includes 27 measures among the following domains of care: 1) Primary Care Access and Preventive Care; 2) Maternal and Perinatal Health; 3) Care of Acute and Chronic Conditions; 4) Behavioral Health Care; and 5) Dental and Oral Health Services. 

CMS released this year’s “Chart Pack” last week, which includes an analysis of state performance on 19 of the reported measures.  Arizona reported data from 11 of the indicators.  I Haven’t had the time to dive into the details, but if you’re interested in learning more you can explore the performance measures and the results in the September Report

US DHS Proposed Regulations Chill Programs that Address Social Determinants

Last Saturday the US Department of Homeland Security Secretary Kirstjen Nielsen proposed new rules that (when adopted) will consider a much wider range of public benefits when they evaluate applications for an immigration change of status or extension of stay request.  

DHS already uses information about whether applicants for legal permanent residency receive Temporary Assistance for Needy Families and Supplemental Security Income (SSI) when they evaluate applications.  After these new rules are adopted, they’ll also consider whether applicants receive Medicaid (AHCCCS), Medicare Part D Low Income Subsidy, the Supplemental Nutrition Assistance Program (food stamps), and Section 8 Housing program.  Once adopted, applicants that receive any of these benefits will be far less likely to be approved for a status change or stay extension.  I didn’t see any exemptions for children- so presumably benefits used by any noncitizen family member including kids would count.

Here are some take-aways from the draft: 

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

  • The use of public benefits by citizen children would not be considered a public charge;

  • This does not directly impact green card holders (the public charge test is not applied to green card holders applying for citizenship);

  • The proposed rule is not retroactive – meaning the public benefits received before the rule is final will not be counted as a public charge; and 

  • The proposed rules would not apply to refugees because existing statute prevents DHS from using the criteria for refugees.

A few months ago, DHS issued a discussion draft of the rule change that would have also included programs like Women Infant and Children (WIC) program, school lunch programs, subsidized marketplace health insurance and even participation in the Vaccines for Children program.

Even though the new draft doesn’t include vaccinations (VFC), WIC and marketplace insurance- many families will believe that the regulations do include these benefits and will elect not to use these important safety net benefits- as doing so will risk their immigration status.  As a result, families will have a more difficult time improving the health status of their families.  

The proposed new rules are 447 pages long- but a key place to look are pages 94-100 (that’s where the outline the new list of benefits that they intend to include).  The official proposal will be published in the Federal Register in a few weeks.  Once it’s officially published, the public will be able to comment on the proposed rule for 60 days.  The official version in the Federal Register will contain information about how to submit comments. I’ll keep my eye out for that.

History of Considering Public Benefits

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

In 1999, the INS (DHS didn’t exist yet) issued Rules to "address the public’s concerns about immigrant fears of accepting public benefits for which they remained eligible, specifically medical care, children's immunizations, basic nutrition and treatment of medical conditions that may jeopardize public health.” Here's that final Rule from 1999, which didn't include Medicaid our housing benefits in the public charge definition.

Kids Care Included in the AHCCCS Budget Request

Good news.  AHCCCS’ 2020 budget request includes a general fund request of $7.9 million for KidsCare. The request was made under the assumption that the KidsCare trigger law will be amended this coming legislative session, preventing a freeze to CHIP enrollment.

There’s a trigger in state law that automatically freezes the Arizona KidsCare program if FMAP (the federal contribution) drops below 100%.  Under current federal law, the match rate is scheduled to go down to about 90% (9 federal dollars for every state dollar) on October 1, 2019.  So, if the current law isn’t changed during this next legislative session then we’ll likely have an enrollment freeze of the Kids Care program again this time next year.

The fact that AHCCCS included the $7.9M in state matching funds in the budget is encouraging, but the budget request isn’t enough to solve the problem- the legislature would need to change the statute and appropriate the funds to prevent an enrollment freeze.

Kids Care is run by AHCCCS and currently covers about 30,500 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.

US Senate Proposes Opioid Crisis Response Act

Last week the US Senate released the Opioid Crisis Response Act of 2018, a bipartisan package to address the opioid epidemic. The Act authorizes funding to expand prevention, research, treatment, and recovery programs- but even if it passes as-is, it would still need to go through the actual appropriations process.

The Senate is expected to vote on the Bill soon without the opportunity for amendments and it’s expected to be approved on a broad bipartisan basis (much like the Arizona Opioid Epidemic Act was). But, after that, it’s unclear whether the House will vote on this version or the Bill or move to conference the Opioid Crisis Response Act with the recently House-approved “SUPPORT for Patients and Communities Act (H.R.6)”.  Here’s a summary of what’s in the bill as it sits today:

Medicaid 

  • Clarifies flexibilities around Medicaid’s "Institutions for Mental Disease" (IMD) exclusion where in some cases managed care plans may provide alternative services in lieu of other services that are not permitted under the state plan. 

  • Modifies IMD exclusion for pregnant and postpartum women to address a subset of the prohibition on Medicaid from paying for otherwise coverable services for certain adults while in institutions for mental disease. 

  • Codifies regulations permitting managed care plans to cover treatment in an IMD facility for a certain number of days in a month in lieu of other types of services.

  • Clarifies states’ ability under Medicaid to provide care for infants with neonatal abstinence syndrome (NAS) in residential pediatric recovery centers.

  • Directs CMS to issue guidance to states on options for providing services via telehealth that address substance use disorders under Medicaid.

  • Directs CMS to issue guidance on states’ options for treating and managing pain through non-opioid pain treatment and management options.

  • Clarifies states’ ability to access and share data from prescription drug monitoring program databases consistent with the parameters established in state law.

  • Directs HHS to provide technical assistance to states to develop and coordinate housing-related supports and services under Medicaid, either through state plans or waivers, and care coordination services for Medicaid enrollees with substance use disorders. 

Prevention

  • Authorizes CDC’s work to combat the opioid crisis through the collection, analysis, and dissemination of data, including through grants for states, localities, and tribes.

  • Authorizes funding through CDC from FY19 - FY24 for states to improve their prescription drug monitoring programs and implement other evidence-based strategies.

  • Authorizes funding from FY19 - FY21 for CDC to support states’ efforts to collect and report data on adverse childhood experiences through existing public health surveys.

  • Authorizes a HHS grant program through 2026 to allow states to develop, maintain, or improve prescription drug monitoring programs and improve their with other states and with other health information technology.

  • Authorizes data collection and analysis through 2023 on neonatal abstinence syndrome or other outcomes related to prenatal substance abuse and misuse, including prenatal opioid abuse and misuse. 

  • Creates an interagency task force to make recommendations regarding best practices to identify, prevent, and mitigate the effects of trauma on infants, children, youth, and their families.

 

Treatment and Recovery

  • Allows physicians who have recently graduated in good standing from medical schools to prescribe medication-assisted treatment (MAT).

  • Authorizes a grant program from FY19-FY23 to support development of curriculum that will help healthcare practitioners obtain a waiver to prescribe MAT.

  • Codifies the ability of qualified physicians to prescribe MAT for up to 275 patients if the practitioner meets certain requirements. 

  • Authorizes a grant program from FY19 - FY23 through SAMHSA for entities to establish or operate comprehensive opioid recovery centers that serve as a resource for the community.

  • Requires HHS to issue best practices for emergency treatment of known or suspected drug overdose, use of recovery coaches after a non-fatal overdose, coordination and continuation of care, and treatment after an overdose and provision of overdose reversal medication as appropriate.

  • Requires HHS to provide technical assistance to hospitals and other acute care settings on alternatives to opioids for pain management and authorizes a grant program to support hospitals and other acute care settings that manage pain with alternatives to opioids. 


Some of these policy measures were also recommended in the ADHS' set of federal policy recommendations in their 2017 report.  Sadly, nothing in here directs HHS to drop its policy of not funding syringe access but all in all this Senate bill looks like it's pretty good public health policy.  Nice to see.

Health Insurance for People w Pre-existing Conditions in Jeopardy Again

A main driver for passing and implementing the Affordable Care Act was to ensure that people with pre-existing health conditions could buy health insurance.  Prior to the ACA- people with pre-existing medical conditions like diabetes faced real challenges getting health insurance.

Indeed, one of the most consistently popular parts of the ACA are the provisions that help people get  coverage regardless of health status.  The ACA prevents health insurance companies from denying someone a policy because they have a preexisting condition (called the “guaranteed issue” requirement), refusing to cover services that people need to treat a pre-existing condition (called “preexisting condition exclusions”), or charging a higher premium based on a person’s health status (called the “community rating” provision).   

You can think of pre-existing conditions exclusions, guarantee issue, and community rating as the three legs of the ACA stool.  Despite these largely popular provisions, there are people that want to knock over the stool.  Back in February, 20 states (including Arizona) filed a lawsuit in Texas federal court seeking to invalidate the 3 legs of the stool: preexisting condition exclusions, community rating, and guaranteed issue.

This most recent legal attack argues that the removal of the individual mandate penalty by the most recent federal tax cut legislation makes the ACA unconstitutional (the US Supreme Court upheld the ACA several years ago, in part, because the tax penalty provision provided a statutory hook for the ACA to rest on).  The lawsuit argues that because the mandate is an essential feature of the ACA, the rest of the law must be struck down too.  If the lawsuit eventually succeeds these central provisions of the ACA would go away and an estimated 17 million people could become uninsured again.

During the Obama Administration, the federal government defended the ACA from lawsuits like these.  Those days are over.  A couple of months ago, the U.S. Department of Justice announced that they agree with the plaintiff States that the ACA’s individual mandate is unconstitutional. The administration urged the court to strike down the law’s guaranteed issue, preexisting condition exclusion, and community rating provisions.

Prior to the ACA, standards to protect people with preexisting conditions were primarily determined at the state level.  Most states including AZ had very limited protections. Before the ACA, many insurers maintained lists of up to 400 different conditions that disqualified applicants from insurance or resulted in higher premiums.  35% of people who tried to buy insurance on their own were either turned down by an insurer, charged a higher premium, or had a benefit excluded from coverage because of their preexisting health problem.

If the Federal courts (ultimately the US Supreme Court probably) rule in favor of the plaintiffs, States could still play as a regulator of insurance, as they could enact and enforce their own laws to protect residents from discrimination due to preexisting conditions.  In fact, several states already have their own laws to incorporate some or all of the ACA’s protections (Arizona does not). 

Oral arguments have been scheduled for next week in the Texas lawsuit. Arguments are scheduled to take place next Monday before Judge Reed O’Connor.  Whatever the Federal TX Court rules, the result will likely be appealed to the UA Appellate Court and eventually probably the US Supreme Court.

State Action to Stem Rising Prescription Drug Costs

By Association for State and Territorial Health Officials Staff

The high cost of prescription drugs is a persistent problem in the United States, with about 10 percent of overall health spending attributed to prescription drugs. In recent years, there has been increased interest among states to address the rising cost of prescription drugs. Just this year, 24 states passed 37 bills to stem rising drug costs. In total, state legislatures have introduced 160 bills targeting prescription drug costs in 2018.

States have pursued a wide range of strategies to tackle the high cost of prescription drugs, including policies that address drug price transparency, rate setting requirements to prevent price gouging, drug importation programs, generic drugs companies, and pharmacy benefit manager transparency.

 

Drug Price Transparency

Controlling healthcare costs is one of the three elements of the Triple Aim, along with improving population health and patient care experience. As a first step toward controlling costs, states are seeking more price transparency requirements from drug manufacturers. In 2018, six states passed legislation addressing drug price transparency. Many of these laws adopt more stringent transparency policies requiring drug manufacturers to justify price increases over certain thresholds. For example, Connecticut requires drug manufacturers to justify price increases for specific drugs if the price increases by 20 percent or more in a year or 50 percent over three years.

 

Price-Gouging and Rate Setting Requirements

Anti-price gouging and rate setting requirements use information collected from transparency laws to allow states to impose penalties for excessive drug price increases. Currently, Maryland is the only state with an anti-price gouging law. The policy allows the state Medicaid agency to notify the state’s office of the attorney general when an essential off-patent brand name drug or generic medication has an excessive price increase.

Maryland’s attorney general can then request justification from manufacturers for the price increase. If the rationale of the price increase is deemed unjustified by “the cost of producing the drug, or the cost of appropriate expansion of access to the drug to promote public health,” the state can impose civil penalties or use other mechanisms to penalize the manufacturer. However, a lawsuit has since been filed in federal court by drug manufacturers asserting violations of Constitutional law as it relates to interstate commerce. To date, twelve other anti-price gouging bills have been introduced in states, although none have been enacted.

 

Drug Importation

Earlier this year, Vermont became the first state to pass a drug importation bill, allowing the state to import wholesale prescription drugs from Canada for use by all state residents. The law requires the designation of a state agency to become a licensed drug wholesaler, or to contract with a licensed drug wholesaler. Several steps remain before Vermont’s program can go into effect, including the state health department receiving federal approval from HHS by July 2019. In addition, although the Utah legislature failed to pass a bill that would have created a program for importing drugs from Canada, the legislature requested that the Utah Department of Health conduct a feasibility study associated with drug importation.

 

Generic Drugs

Recently, Maine passed a law requiring brand name manufacturers to make samples of drugs available to generic drug manufacturers, with the intention of promoting competition by increasing access of information for companies developing lower-cost generic drugs. The law states that, “In order for there to be competition in the prescription drug market, developers of generic drugs and biosimilar biological products must be able to obtain quantities of the reference listed drug or biological product with which the generic drug or biosimilar biological product is intended to compete.”

 

Pharmacy Benefit Managers

Several states have passed bills regarding pharmacy benefit managers (PBMs), which require increased transparency and disclosure of information on drug rebates and concessions. For example, Nevada passed a law in 2017 requiring PBMs to disclose the amount of rebates received from drugs used to treat diabetes. Connecticut’s drug price transparency law also requires PBMs to provide information on rebates and other price concessions received from drug companies. Mississippi passed a law preventing PBM gag clauses, which stop pharmacists from sharing information with patients on lower-cost drug options.

 

Other State Policies

In Montana, the legislature passed a bill establishing an interagency committee to study state drug pricing and spending trends, which will make recommendations to the state legislature on drug pricing policies in late 2018. In addition, New York implemented an annual cap on drug spending in its Medicaid program. Under the law, if spending projections extend beyond the cap, the state health department must identify the costliest drugs and attempt to negotiate additional rebates with manufacturers. This law also gives the state the authority to develop an independent panel that can penalize manufacturers through various mechanisms.

 

Future Opportunities

Emerging state legislation to address the rising cost of drug prices in demonstrates potential paths forward to address drug prices at the state level. The National Academy of State Health Policy (NASHP) has developed model legislation to address drug price transparency, drug importation, rate setting, and pharmacy benefit managers. The NASHP resource includes model legislation for states, bill text from states that have already passed legislation, and relevant briefing documents.

Congress is Back in Session: Important Bills in the Balance

Members of the U.S. House of Representatives return to Washington D.C. this week.  They’ll be discussing important public health bills including the Labor-HHS-Education appropriations bill for fiscal year 2019 and the reauthorization of the Farm Bill.

Last week the Senate passed H.R. 6157 which is the combined Defense and Labor, Health and Human Services, Education and Related Agencies appropriations bill for FY19.  This one is the eighth and ninth out of 12 spending bills to be passed by the Senate for FY19.  The legislation includes increased NIH funding and boosted resources for opioid treatment, prevention, and recovery programs.  Here’s a list of some of the adopted amendments:

  • Schumer-Collins amendment to increase funding for Lyme disease activities (3759).
  • Cortez-Masto-Ernst amendment to provide for conducting a study on the relationship between intimate partner violence and traumatic brain injury (3825).
  • Peters-Capito amendment to ensure youth are considered when the Substance Abuse and Mental Health Services Administration follows guidance on the medication-assisted treatment for prescription drug and opioid addiction program (3870).
  • Heitkamp amendment to provide funding for the SOAR (Stop, Observe, Ask, Respond) to Health and Wellness Program (3893).
  • Casey amendment to provide funding for the Secretary of Health and Human Services to establish the Advisory Council to Support Grandparents Raising Grandchildren (3875).
  • Schatz-Hirono amendment to assess the ongoing mental health impact to the children and families impacted by a volcanic eruption covered by a major disaster declared by the President in calendar year 2018 (3897).
  • Heller-Manchin amendment to provide additional funding for activities related to neonatal abstinence syndrome (3912).
  • Heitkamp-Murkowski amendment to improve obstetric care for women living in rural areas (3933).
  • Durbin-Grassley amendment to provide for the use of funds by the Secretary of Health and Human Services to issue regulations on direct-to-consumer advertising of prescription drugs and biological products (3964).

The House hasn’t adopted its FY19 Labor, Health and Human Services, and Education appropriations bill. It’s unclear how both chambers will resolve differences in funding levels between their bills. The House could work on its Labor, Health and Human Services, and Education bill or skip a floor vote and start negotiations with the Senate.  The Farm Bill, which funds WIC & SNAP also hangs in the balance. Here's a summary of the Farm Bill.   The current legislation is scheduled to expire Sept 30th.

Bottom line: with only a few legislative days before the end of FY18, it’s likely that a continuing resolution will keep the government funded into FY19.

The APHA has several tools that you can use to get the attention of your Representative or Senator.  They’ve developed APHA’s Speak for Health advocacy resources, including state-specific fact sheets to help you be a better advocate.  They also have tools to help you meet with your members of Congress or their staff or invite them to visit you and Email or call your members of Congress using the APHA action alert as a phone script or email message. It’s quick and easy.

Leveraging Doulas to Improve Birth Outcomes

Doulas are professionals who provides physical, emotional, and informational support to a woman throughout pregnancy, childbirth, and postpartum. Doula’s act as a facilitator between the laboring women and her physician by ensuring that mom and dad get the information they need in a way that they understand so they can make informed decisions. 

A growing body of evidence suggests that continuous support from doulas or other non-clinical labor support can improve birth outcomes for both mothers and infants, fewer preterm and low-birth weight infants, and reductions in cesarean sections. In fact, when doula services are included throughout the pregnancy and birth process, births cost less. A recent study found that when a doula is included in the process births cost an average of $986 less - including the doula service fee.

Currently, Minnesota and Oregon take advantage of the fact that doulas can reduce healthcare costs while improving outcomes in their state Medicaid programs. In the 2018 budget, Minnesota increased the reimbursement rates for doulas.  The new law also requires Oregon’s coordinated care organizations (which deliver Medicaid services) to provide information about how to access doula services online and through any printed explanations of benefits. The law tasked Oregon Medicaid with facilitating direct payments to doulas, which was addressed through rulemaking.  

Several organizations, such as DONA International, provide doula training and certification. Women can also choose to become certified as community-based doulas through HealthConnect One. This community-based doula program model, which has been replicated nationwide to serve unique populations, trains doulas to provide culturally sensitive pregnancy and childbirth education to underserved women in their own community. While all doula services can be beneficial, creating a standard for the training and certification of doulas may improve understanding and acceptance of doula care.

Looking for more info? Access this UA Issue Brief on Doula Coverage to Help Minimize Arizona’s Birth Woes

Who's a Doula?

By AzPHA Member Prashanthinie (Prashi) Mohan, MBA

Over the last few years, there has been more and more focus on the triple aim – improving patient experience, reducing costs, and improving population health. Accomplishing these goals requires the system to be creative and actively look for new approaches to lowering costs while improving outcomes.

Doulas are increasingly being recognized as a professional that can do just that. 

Several studies have shown that moms who have doula services during their pregnancy and delivery have fewer cesarean sections and epidurals, reduced premature births, higher rates and a longer duration of breastfeeding. In March 2014, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal medicine issued a consensus statement which explicitly stated that published data has indicated better labor and delivery outcomes when continuous support personnel such as doulas are used.

So, we’ve got better outcomes covered, what about lower costs?

Recent evidence on the return on investment for doulas is encouraging. In addition to improving birth outcomes, doula coverage can also be cost effective (if not cost saving) to Medicaid programs. Doula coverage can help reduce costs by lowering the rate of pre-term and cesarean deliveries. One study conducted across 10 states computed an average savings of $986 per doula supported birth.

Despite the evidence on doula-supported births, only 6% of U.S. women who give birth are estimated to have doula support. Low income women and women of color, who are the most likely groups to want doula services, may not be able to afford doula services, which can cost $500 to $750 per birth in Arizona.  Because few health plans currently reimburse for doula services, most women are unable to take advantage of the improved outcomes and enhanced birth experience that doulas provide.

Licensed and culturally trained doulas who are from the minority communities can not only provide emotional support during the prenatal period and the delivery process, but can also help facilitate key communication between the mother and her care providers.

The question is, what are we waiting for? Doulas have proven to be effective in improving birth outcomes cost effectively in other states in the U.S. It’s time Arizonans start looking into how doula services can be efficiently reimbursed for the mothers in our state.

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 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.