Public Health

Public Health Bills So Far

There aren't very many public health related bills proposed yet, but they're on the way.  Here's what we have so far:

SB 1009 Electronic Cigarettes, Tobacco Sales

Expands the definition of tobacco products to include e-cigarettes. Among other things, it'll make it clear that it's illegal to sell e-cigarettes to minors. The penalty for selling to minors remains at $5K. 

HB 2024 Electronic Cigarettes. Smoke Free Arizona Act

Includes e-cigarettes in the definition of tobacco products and smoking for the purposes of the Smoke Free Arizona Act.  Because the Act was voter approved- this modification to the law will require a 3/4 majority of both houses. 

SB 1040 Maternal Mortality Report

This bill would require the Child Fatality Review Team subcommittee on maternal mortality to compile an annual statistical report on the incidence and causes of "severe maternal morbidity" with recommendations for action.  The current law requires a review of the data but no report.

‘Opportunity Zones’ & Public Health

When you think about the tax bill passed by congress last year you probably think about the permanent reduction in corporate tax rates and changes in the person income tax standard deductions and stuff like that.  But there was a sleeper provision in the law that could influence the built environment and therefore public health.  It’s a provision in the law called ‘Opportunity Zone’ investment tax deferment.

The ‘Opportunity Zones’ part of the new tax law provides incentives to investors to put their money into areas designated by states as low income or underdeveloped.  The law lets investors defer (or eliminate) their capital gains tax obligation when they invest the money in a designated ‘Opportunity Zone’. If they hold the investment for 7 years, 15% of their capital gains liability can be written off.  If they hold the investment for 10 years, then their entire capital gain tax liability can be written off.

The theory is that geographically targeted tax cut opportunities will encourage new clusters of economic activity to form which has the potential to improve conditions that influence the social determinants of health within the designated ‘Opportunity Zones’.

There are very few conditions that are put on the program in terms of what is a qualifying investment, except that the investment must be within a state designated Opportunity Zone.  Developers must make a substantial improvement on the property in the first 30 months.  Investors need to show that 70% of their capital is in the opportunity zone and 50% of their activities.

The governor of each state decides where the Opportunity Zones are (they can name 25% of the qualifying low-income Census tracts as Opportunity Zones).  Our Governor delegated that decision to the Arizona Commerce Authority.  Arizona’s Opportunity Zone nominations were submitted to the US Treasury Department a few months ago and have already been approved.  Here’s the map of the Opportunity Zones Arizona selected.

A couple of months ago the U.S. Department of the Treasury released their guidance on the Opportunity Zone tax law provisions.  The Internal Revenue Service issued proposed regulations in October. 

The AZ Commerce Authority has some material on their website with a more in-depth view of Opportunity Zones including a Guidance Update Webinar Presentation and an Opportunity Funds Guidance Update Webinar Video October 2018.

One thing is clear- the incentives built into the Opportunity Zone parts of the tax bill are huge- and there will be billions of dollars moving into these Opportunity Zones in the coming years.  What remains to be seen is what impact the program will have on the built environment and economic opportunities in these areas and what public health impacts will occur – both good and bad – as a result of the investments that are made in these communities. 

Very few guardrails exist for what kinds of developments qualify for the tax deferral- and no doubt there will be some good things (affordable housing) and bad things (investments that don’t improve conditions) in Opportunity Zone communities in the coming years.

Recently Passed Federal Public Health Legislation

Congress has passed several bills in the last few weeks related to public health.  Here’s a quick summary and links to the laws.

Improving Access to Maternity Care HR 315

This bill requires HRSA to identify maternity care health professional target areas and publish data comparing the availability of and need for maternity care health services in health professional shortage areas and areas within those areas.

Preventing Maternal Deaths Act of 2018 HR 1318

This bill authorizes HHS grants to states to review maternal deaths, publish reports with the results.

PREEMIE Reauthorization Act of 2018  S 3029

This bill increases federal research on preterm labor and delivery, improve the care, treatment, and outcomes of preterm birth and low birthweight infants. 

Agriculture Improvement Act of 2018 – The Farm Bill HR 2

The Farm Bill reauthorizes food security programs through FY23 including Supplemental Assistance Program (SNAP) and SNAP nutrituon education.  It also removes hemp from the Controlled Substances Act, which would legalize hemp production and therefore changes how CBD is regulated.

State Offices of Rural Health Reauthorization Act: S 2278

This bill reauthorizes $12.5M annually through FY22 for the Federal Office of Rural Health Policy to make grants to each state office of rural health to improve health care in rural areas. This bill was approved by both the House and Senate but is not yet signed.

The Action for Dental Health Act of 2018

This bill provides an opportunity to improve oral health across the country.  The bill will provide additional resources to the CDC to increase funding for groups and organizations to qualify for federal grants that develop programs and expand access to oral health education and care in states and tribal areas

CDC will still need to flesh out the grant guidance in the coming months before they put out their announcement with the application and expectations. 

PEPFAR Extension Act of 2018  HR 6651

This bill extends certain provisions of the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003.

Sickle Cell Disease Research, Surveillance, Prevention, and Treatment Act of 2018  S 2465

This bill reauthorizes a sickle cell disease prevention and treatment program and to authorizes funding for grants for research, surveillance, prevention, and treatment of heritable blood disorders.

Infrastructure for Alzheimer's Act S 2076

This bill would create an Alzheimer's public health infrastructure across the country to implement effective Alzheimer's interventions focused on public health issues such as increasing early detection and diagnosis, reducing risk and preventing avoidable hospitalizations.

State Agency Budget Requests

Here’s a summary of some of the budget requests that were made by state agency directors for the upcoming fiscal year:

Department of Health Services

  • Seeks increased compensation for “key” positions to reduce turnover & vacancy rates.  No dollar figure is attached.

  • Requests an increase of $4.1 M lump sum from Health Licensing Fund & ongoing Radiation Regulation appropriation increase of $600,000 from Health Service Licensing Fund to cover administrative expenditures & ongoing growth & workload for Licensing Division.

  • Asks for $550,000 from the General Fund for an “administrative shortfall” at the Arizona State Hospital.

  • Requests $500,000 from the ADHS Indirect Fund for the public health emergency fund.

  • Seeks $200,000 from the Land Fund to pay for higher costs for services at the State Hospital for pharmacy, dietary, EHR, housekeeping, etc.

  • Asks for an appropriation increase of $600,000 from the Newborn Screening Fund to cover administrative costs.

  • Asking for a $240,000 in state general funds for the Behavioral Risk Factor Surveillance Survey (under a cooperative agreement with CDC).



  • Requesting a net increase of $44.7 M over the current year.

  • Seeks an overall acute capitation rate increase of 1.9% over the blended rates from the prior year

  • Asks for overall weighted capitation rate increase of 2.5% over baseline across all populations.

  • Anticipates the FMAP rate (federal matching rate percentage) for the acute traditional members of 69.48%

  • Includes a $7.9M dollar figure if state law is modified to prevent freezing KidsCare (because of the reduction in federal payments (FMAP) moving from the current 100% to 90% beginning October 1, 2019)


AZ Department of Economic Security

  • Requests $41.6 M in increased funding to help providers cover some of the costs that providers of services for folks with developmental disabilities to cover costs for the coming increase in the minimum wage next fiscal year. 

  • Pursues use of federal Child Care Development Block Grant of $55.8 M (OF) which would allow child care rates to increase from 2000 to 2010 market rate and serve an additional 5,000 children

Merger of CVS & Aetna Finalized

Last week CVS Health completed their acquisition of Aetna. You know CVS through their pharmacy stores- and Aetna through their health insurance businesses (in AZ that includes Mercy Care and Mercy Maricopa Integrated Care). 

Aetna will be a stand-alone unit within CVS and led by members of its current management team.  It’s essentially a vertical integration- as it combines Aetna (primarily a health care insurer) with CVS (primarily a retailer).

The US Justice Department required Aetna to divest its Medicare prescription drug business to WellCare Health Plans before approving the merger.

One of the goals of the merger is to integrate Aetna's medical information and analytics into CVS Health's pharmacy data- creating a new model of care delivery.

The new company says they’ll be introducing new programs to target more efficient management of chronic disease with services focusing on self-management for patients with chronic conditions, expansion of chronic care management services at MinuteClinic, nutritional and behavioral counseling and benefit navigation support.  The plan includes expanded preventive health screenings to better manage high cholesterol, high blood pressure and diabetes.

A major focus will be on better managing five chronic conditions: diabetes, cardiovascular disease, high blood pressure, asthma and behavioral health.

There are some academics and other analysts that suggest the merger is anticompetitive and won’t result in better care or outcomes- but it looks to me like it has a pretty good chance of improving outcomes- especially if they focus on better management of chronic medical conditions combined with more convenient and numerous service sites.

CVS has been moving their mission from its traditional pharmacy business model for some time- bringing it more in line with providing health care and other services.  Several years ago- as this new model was emerging, CVS decided to stop selling cigarettes etc. as they rightly saw those sales as inconsistent with that of a business focusing on improving health outcomes.

Global Climate Change Research Program Report

Profound Public Health Impacts Identified

The Global Change Research Act of 1990 mandates that the U.S Global Change Research Program deliver a report every 4 years to analyze the effects of global change on the natural environment, agriculture, energy demand, land and water resources, transportation, human health and welfare, human social systems, and biological diversity.  The statutory charge for the report is to “… inform decision-makers, utility and natural resource managers, public health officials, emergency planners, and other stakeholders by providing a thorough examination of the effects of climate change on the United States”.  The 2018 report was issued on the day after Thanksgiving. 

The Report issued last week focuses on the elements in their statutory mandate for 10 regions and 18 topics.  Chapter 14 focuses on public health.  Many of the public health challenges and impacts in the report are things readily observable today.  For example, one of the acute is the public health and policy struggles this year will be surrounding prioritization, use and conservation of increasingly limited water supplies here in Arizona.   As the Colorado River basin continues to have less snow pack and earlier melting- there’s no doubt that allocating a permanently reduced water supply.  We’re likely to see these negotiations play out at the national and state level in the coming months.

At first, I was planning to write my own summary of the public health chapter- but the Executive Summary of that chapter does a pretty good job- so I’ll paste that section for you instead:

Climate-related changes in weather patterns and associated changes in air, water, food, and the environment are affecting the health and well-being of the American people, causing injuries, illnesses, and death. Increasing temperatures, increases in the frequency and intensity of heat waves (since the 1960s), changes in precipitation patterns (especially increases in heavy precipitation), and sea level rise can affect our health through multiple pathways. Changes in weather and climate can degrade air and water quality; affect the geographic range, seasonality, and intensity of transmission of infectious diseases through food, water, and disease-carrying vectors (such as mosquitoes and ticks); and increase stresses that affect mental health and well-being.

Changing weather patterns also interact with demographic and socioeconomic factors, as well as underlying health trends, to influence the extent of the consequences of climate change for individuals and communities. While all Americans are at risk of experiencing adverse climate-related health outcomes, some populations are disproportionately vulnerable.

The risks of climate change for human health are expected to increase in the future, with the extent of the resulting impacts dependent on the effectiveness of adaptation efforts and on the magnitude and pattern of future climate change. 

Obviously, there is allot more in the report that really requires a deeper dive.  The report is certainly worth book marking in your Favorites section for reference as you conduct your public health work.

2018 Child Fatality Review Report Published

The death of any child is a tragedy – for the family and for the community. Everybody wants to prevent childhood deaths. But making policy interventions to prevent childhood deaths requires information in order to develop effective policy interventions.  That’s where the Arizona Child Fatality Review State Team comes in.

More than 25 years ago the state legislature passed a law establishing the Arizona Child Fatality Review Program (A.R.S. § 36-342, 36-3501-4).  It’s a great example of establishing public policy designed to build data and evidence so policy makers can use evidence to build future interventions.

The State Team includes representatives from the Academy of Pediatrics and from the ADES Divisions of Developmental Disabilities and Children and Family Services, as well as from law enforcement and the ADHS. The team’s role is to review all childhood deaths in AZ and produce an annual report to the Governor and legislature with a summary of findings and recommendations based on promising and proven strategies regarding the prevention of child deaths.

In past years this focus has raised the awareness about child drowning and the importance of putting babies to sleep on their backs or making sure all children are always secured in car seats. Other recommendations included taking action to reduce the number of uninsured, decrease medical complications of pregnancy and increase safe sleep practices.

The 2018 Child Fatality Review Report was published last week- and as usual it provides a host of data and recommendations that are directly tied to evidence. Here are some examples from this year’s report.

Child suicides increased an astonishing 32% and accounted for 6% percent of all child deaths. A history of family discord was the most commonly identified preventable factor in suicides followed closely by a history of recent break-up, drug/alcohol use and an argument with a parent. 

Firearm deaths increased 19% from the previous report.  Suicides and homicides accounted for 88% of firearm-related deaths in 2017. Fifty-one percent of firearm related deaths were a result of suicide (n=22) and 37% of firearm related deaths were homicides (n=16).

Injury deaths increased 4% from the previous reporting period and comprised 23% of all child deaths. The leading cause was car crashes and 31% of the injury deaths were among kids less than 1 year old… and important piece of data considering Arizona has yet to adopt a law requiring kids under 2 years old to be in a rear facing car seat.

The number of unsafe sleep deaths increased 5% from the previous year.  60% were bed sharing with adults and/or other children. Child fatalities due to maltreatment decreased 4% and accounted for 10% of all child deaths in Arizona.   Substance use was a factor in 65% of maltreatment deaths.

Drowning deaths increased 30% over the period and accounted for 4% of all child deaths. 63% occurred in a pool or hot tub. Lack of supervision was a factor in 69% of drowning deaths.

Substance use was a factor in 17% of all child fatalities (n=136).  The majority of substance use related deaths involved the child or the child’s parent as the main user contributing to the death of the child. In 49% of substance use related deaths, the parent was misusing or abusing alcohol or drugs.

The full report covers each of these areas including some recommendations for policy and program interventions in each area.  Sometimes the recommendations are more related to increasing awareness but many are more policy based.

Lots of work went into this report- so if you're somebody in a position to influence either lawmakers or agency officials to implement preventative policies in these areas- please get familiar with this   important research product - it will really help inform your advocacy efforts.

Research Published about Vaccine Exemption Policies

It’s no secret that many states including Arizona are struggling to maintain enough vaccination coverage to achieve “herd immunity”.  Herd immunity simply means that you have enough vaccination coverage to protect the entire community - including people that for medical reasons can’t be vaccinated and folks who’ve been vaccinated but still may be susceptible (because vaccines aren’t 100% effective).

Requiring kids in public school to be vaccinated is one of the most important public policy tools to ensure herd immunity.  Arizona does that through statutes labeled ARS-872 & ARS-873 - which require kids to be vaccinated if they attend public school (unless they have an exemption). In Arizona, there are medical, religious, and “personal” exemptions. The problem over the last few years is that more and more parents are exercising the personal exemption option.

Arizona’s immunizations rates continue to decline: 1) immunization rates have decreased across all age groups from 2012 to 2017; 2) personal exemption rates continue to be highest in charter schools, followed by private and public schools in 2017; and 3) overall personal exemption rates increased in the last year- 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.

Of course- when looking toward interventions to stem the tide it’s important to look to the scientific literature to see what’s going on in other states.  A very informative article about personal vaccine exemptions was published recently entitled The state of the antivaccine movement in the US: A focused examination of nonmedical exemptions in states and counties.

The researchers conducted a detailed analysis of personal exemptions within each of the 18 states that allow nonmedical exemptions to their school vaccine requirements. Here’s a map of which states allow non-medical school exemptions.

The researchers found that several counties, especially those with large metropolitan areas, are at high risk for vaccine-preventable pediatric infection epidemics.  Since 2009, personal exemptions have risen in 12 of the 18 states that currently allow philosophical-belief exemptions.  On average, states that allow non-medical exemptions have 2.5 times higher exemption rates.

The also dove into the data and found that there is a direct correlation between higher personal exemption rates and lower vaccination rates.  That might be intuitive- but it’s important because it shows that personal exemption rates for school requirements is a good measure of real immunization rates.

The discussion portion of the article discusses the efficacy of interventions in various states, and basically found that more aggressive approaches – like eliminating personal exemptions entirely- are more effective at long term improvements in vaccination rates than softer approaches.

Definitely worth a read.

AZ Develops Pain & Addiction Curriculum for Clinicians

It's no secret that getting a public health handle on the opioid crisis will take a multi-pronged effort for an extended period.  Part of the solution was the policy development, passage and implementation of the Arizona Opioid Epidemic Act.  Other elements include developing and implementing new Opioid Prescribing Guidelines and developing new regulations for pain management clinics.

Another huge element is changing the culture of pain and addiction care.  ADHS has completed a Arizona Pain and Addiction Curriculum that approaches pain and addiction in a new way - as complex, interrelated, public-health issues. 

The curriculum was jointly developed by Deans and Curriculum Representatives from every MD, DO, NP, PA, ND, DMD and DPM program in Arizona.  The program stresses not only the new evidence base of pain and addiction care.

Resources for programs consist of both a Pain and Addiction Curriculum and a Pain and Addiction Faculty Guide.  Because it was created and facilitated by public health, it’s accessible online at any time, to the appreciation of other teaching programs across the country.

Kudos to ADHS and the dozens of stakeholders for this novel work and especially AzPHA member Lisa Villarroel MD.  Work on this scale hasn’t been done before in the US - so kudos to our Arizona teaching programs for being so open and collaborative. This is another example of the stakeholder driven innovative work being done right here in Arizona that's likely to be adopted as a best practice in other states.

The People Speak. Will Public Health Policy Follow?

By now all of you know the results of the federal and state election results so I won't recap them here - except to link the results to the prospects for public health policy.

The results in the US House of Representatives suggest that it's unlikely there will be another effort to repeal the Affordable Care Act.  That doesn't mean that the ACA is no longer in jeopardy. There's still an outstanding lawsuit challenging the mandate for health insurance plans to cover preexisting conditions as well as other provisions in the ACA (AZ is on the list of states challenging the law). The US Justice Department will presumably continue to decline to defend the ACA in court.

The fact that the US House will be controlled by the Dems means that there will be an opportunity for additional oversight of the decisions that the federal agencies are making with respect to public heath and health care (e.g. CMS, EPA, DHS, USDA etc.).  That oversight authority can be used to ensure that the administrative decisions made by the federal agencies are consistent with their statutory authority.

There will be no party changes in the executive branch here in Arizona and we will continue to have the same governor and presumably the same agency heads. The makeup of the state legislature looks like it will shift a little- but party control won't change. The Senate will likely remain 17-13.  In the House it looks like the new split will be a razor thin 31-29. 

Many of the bills that we supported last year passed with bipartisan support- and it remains important to look toward public health policies that are founded with evidence and for us to continue to frame the issues in a way that builds bipartisan support for sound public health policy.

Educating Parents to Improve Vaccination Rates

It’s no secret that many states including Arizona are struggling to maintain enough vaccination coverage to achieve “herd immunity”.  Herd immunity simply means that you have enough vaccination coverage to protect the entire community - including people that for medical reasons can’t be vaccinated and folks who’ve been vaccinated but still may be susceptible (because vaccines aren’t 100% effective). Generally, herd immunity happens when a community has a vaccination rate above 95%.

A couple of months ago 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 show that:

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

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

  • Overall personal exemption rates increased in the last year- 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.

Requiring kids in public school to be vaccinated is one of the most important public policy tools to ensure herd immunity.  Arizona does that through statutes labeled ARS-872 & ARS-873 - which require kids to be vaccinated if they attend public school (unless they have an exemption). In Arizona, there are medical, religious, and “personal” exemptions. The problem over the last few years is that more and more parents are exercising the personal exemption option.

According to our current statute, parents can get a personal exemption if they “… sign a statement to the school administrator stating that (they) have received information about immunizations provided by the ADHS and understand the risks…” (as defined in R9-6-701-708). Despite numerous interventions to improve immunization rates among AZ school children- we continue to lose ground. In several parts of the state and among certain demographic groups (high income zip codes and some charter schools for example) we’ve lost herd immunity- which means we’re at real risk for outbreaks.

Arizona’s public health system has been doing some creative work to improve our immunization rates. One of my favorites is an innovative on-line immunization education course that’s designed to serve as part of a potential new personal exemption process. The Maricopa County Department of Public Health worked with a University of Arizona medical student and the ADHS Immunizations Program to design and conduct the test pilot program. The new education course was piloted at 16 schools in Maricopa County (8 elementary, 5 middle or junior high and 3 high schools) last school year.  The pilot objectives were to:

  • Learn how to best implement the immunization education module developed by ADHS in Maricopa County schools;

  • Get feedback from school staff regarding the use of the module to ensure a smooth rollout in the future; and

  • Identify whether parents learned new information about vaccine preventable diseases and vaccines using a brief anonymous pre-and post-knowledge assessment survey.

The pilot was small & wasn't designed as a formal study and therefore wasn't able to draw any conclusions about the effectiveness of the modules- but it’s a promising intervention that has a good chance of helping improve immunization rates.

There’s a lot of interest among a host of public health stakeholders in continuing to pursue this educational (informed consent) process as part of the personal exemption process.  I’m optimistic that executive branch decision-makers will recognize the value that a more robust parent education policy can have in improving rates and that AZ will continue to develop and implement this innovative intervention.

Part of what makes me optimistic are comments that the Governor recently made during an interview with the Arizona Republic in which (about 25 minutes into the interview) he states that "This is a public-health issue, I’m a big believer in freedom and choice on a lot of issues, but… if your kid’s going to be in the public-school system in Arizona, they’re going to be vaccinated."

The bottom line is that despite our work to date, vaccination rates continue to decline and are below the herd immunity threshold in some parts of the state and among some demographic groups.  Additional interventions are clearly needed.  Perhaps the education modules will help.  But it may be that the only real solution is to look to other states that have eliminated the personal exemption.  California provides a promising case study.

Here's Why We Endorse the Clean Energy for a Healthy Arizona Initiative

The AzPHA Board of Directors has endorsed Proposition 127- the Clean Energy for a Healthy Arizona ballot initiative. Proposition 127 would increase the state's renewable portfolio standard (RPS) which is a mandate that electric utilities acquire a minimum amount of electricity from renewable energy sources. Here's the actual  Proposition 127 Ballot Language

As of 2018, Arizona's renewable portfolio standard (RPS) is 15% renewable by 2025. Proposition 127 would increase our RPS each year until reaching 50% in 2030.

The Initiative defines renewable energy as electricity generated by  solar, wind, certain hydropower, geothermal, and landfill gas energy.  The definition of renewable energy under the initiative doesn’t include nuclear power. For our state, most of the new renewable energy that would be created would probably mostly be solar.

APS reports it currently generates about 12% of its energy from renewable sources which includes utility-owned plants and power being generated by customers through rooftop solar.  Tucson Electric Power reports 13%. Right now, Arizona gets 6% of its electricity from solar power.

It’s no secret that Arizona Public Service (APS) doesn’t want Proposition 127 to pass.  Their current strategic plan  is to mostly meet future electricity needs by building new gas-fired power plants.  You can see the resource plan APS filed at the Arizona Corporation Commission in 2017 and APS’ recent RFP for new power plants to get an idea about their current strategic plan.

This is an over-simplification- but the public policy question posed by Prop 127 is whether it’s in the public’s best interest to meet future generation demand with mostly natural gas plants or solar.

There are compelling health reasons why Proposition 127 makes sense from a public health perspective. Burning fossil fuel, including natural gas, creates air emissions (oxides of Nitrogen and volatile organic compounds) that form ozone. Ozone adversely affects human health by increasing cardiovascular and respiratory disease.  It can decrease lung function and causes more people to visit emergency rooms or even be admitted to the hospital because of asthma or allergy related illnesses. Some studies have even linked preterm birth to air pollution.

But, if it turns out that the health benefits from cleaner air come at the cost of higher electricity prices- then the health gains from the improvement in air quality would need to be weighed against the public health costs to low income folks who already struggle to pay their electric bills- worsening the social determinants of health for low income people.

Before we took a position on Proposition 127, I and our Board carefully examined what impact the initiative might have on future electricity prices.  After all, income is a primary driver of health status, and if the Initiative were to increase electricity prices more rapidly than under the current RPS standard, then it could end up having a net negative impact on public health among low income Arizonans.  That’s why we carefully examined the cost issue before taking a position.

One of the best and most objective sources of information about the relative costs of generating electricity I found is the US Energy Information Administration’s 2018 report entitled  ”Levelized Cost and Levelized Avoided Cost of New Generation Resources in the Annual Energy Outlook 2018”.   The report examines capital, operational and transmission costs as well as off sets from the tax credits.  It takes a little time to read but worth the effort.

The bottom line is that solar energy generated using photovoltaic cells is on par or slightly cheaper than energy generated with natural gas.  Solar plants have a higher capital cost but lower variable (operational cost) because they don’t need fuel (free photons are the fuel).  Solar also benefits from tax credits- which is part of the cost equation.

One of the reasons why solar power is now slightly cheaper than natural gas energy is that the cost of solar panels has decreased rapidly in recent years (in part because of increased global solar panel manufacturing capacity in China).  The cost of utility-scale solar has fallen 77% since 2009.  The cost of battery storage fell 79% between 2010 and 2017.  Another reason why solar costs less in the long run is because of the federal tax credits that are available to utilities that use solar to generate electricity.

Prop 127 also requires 20% of renewable energy eventually be “decentralized” - basically roof-top solar.  That means incentives will be created to encourage solar installation. Done thoughtfully, that could provide an opportunity to prioritize installation of panels on homes in lower income areas, relieving pressure on monthly budgets of families who most need that relief while increasing the value of their property.

The bottom line is that after reviewing as many objective facts as we could find, we concluded that Proposition 127 provides net health and environmental benefits.  That's why we’re supporting Proposition 127.

Immigration Status, Public Benefits & Access to Care

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 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 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 above, immigration officials consider the likelihood of individuals and families becoming a “public charge,” which can result in denied admission to the US or status as a lawful permanent resident.

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

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.

Center for Public Health Law & Policy


The Center for Public Health Law and Policy  is the cornerstone of the Sandra Day O’Connor College of Law’s nationally-ranked health law program. The Center brings together students, leading scholars, practitioners, and policymakers to address critical issues in law, ethics, policy, and the public’s health. The Center explores a wide range of issues, including national health care reform, communicable disease control, human subject research protection, emergency legal preparedness, obesity and injury prevention, health information privacy, and vaccination law and policy.

The Center for Public Health Law and Policy is also the home to the Western Region Office of the national Network for Public Health Law, funded in part by the Robert Wood Johnson Foundation. Led by Professor James G. Hodge, Jr., the Western Region Office provides technical assistance and other vital resources to public health practitioners, officials, attorneys, and advocates across 11 Western states and nationally. Since its inception in September of 2010, the Western Region Office has fulfilled nearly 3000 requests nationally, over 1000 of which directly aided requesters in the office’s home state of Arizona.

This fall the Network for Public Health Law is organizing the 2018 Public Health Law Conference, to be held October 4-6, in Phoenix, AZ. For more information, please visit:

Conflicting Rulings on Voter Initiative "Strict Compliance Standard"

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

  • The Smoke Free Arizona Act;
  • The TRUST Commission for tobacco education and prevention;
  • First Things First;
  • Establishment and funding of the Area Health Education Center programs; and
  • Proposition 204 (from 2000) which extended Medicaid eligibility to 100% of federal poverty.

In 2017 the State Legislature passed and Ducey signed HB2244 which changed the citizen's initiative compliance standard from "substantial compliance" to "strict compliance" for putting initiatives on the ballot. This law made it easier to reject petitions if there are any errors on the document, making it more difficult to put measures on the ballot in the future that are good for public health.

Last week there were conflicting court rulings regarding whether the standard set in  HB2244 is constitutional.  Maricopa County Superior Court Judge James Smith ruled that the Strict Compliance standard imposed by HB2244 is not constitutional (this was a case related to the ballot measure to fund schools).  However, in the very same day, Maricopa County Superior Court Judge James Kiley reached the opposite conclusion (on the clean energy initiative). 

Last week’s conflicting rulings mean that the AZ Supreme Court will likely need to settle the matter (and soon).  The result will have a big impact on voter’s ability to put future measures to voters to improve public health.

Take Your Understanding of Health Policy Beyond the Classroom

ASU’s College of Nursing and Health Innovation is excited to announce our new  Health Policy Academy.  It’s a 4-week program designed for new and transitioning professionals interested in the policy, politics and advocacy affecting public health today.  There is 3 weeks of intensive online training and three days of in-person experience at the Arizona State Capitol, and participants will receive practical tools to better navigate and impact the world of health policy.  This inaugural cohort will take place from September 10 - October 4, 2018. 

The Health Policy Academy is now accepting applications and the deadline for applying is Friday, August 31, 2018. Come join this talented group and develop the skills and connections to effect meaningful change!   Learn More about the Health Policy Academy

Program Particulars:

  • September 10-30, 2018 – Online Self-Guided Modules
  • October 2-4, 2018 – In-person Workshop at Arizona State Capitol
  • Price: $550  Apply Here

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. 

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


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.