Medicaid

FY 20/21 State Agency Budget Requests

Each Fall state agencies turn in their official budget requests to the Governor's Office. In my experience while I served in the executive branch, there are usually conversations between the agency directors and governor's office staff before the official requests are turned in- and there was usually governor's office support for the requests 

The AZ state agencies turned in their requests a couple of weeks ago. Below is what they asked for:

Department of Health Services:

  • Asks for an increase of $1.4 M (GF) from their Emergency Medical Services Fund for:

  • Support Operatins within the Bureau of Emergency Medical Services & Trauma System;

  • Enhance funding to the 4 regional Emergency Management Services Councils;

  • Sustain contracted transportation services for high-risk expectant mothers and for physicians that provide follow-up services for uninsured newborns in intensive care centers;

  • Requests one-time funding of $200,000 from the state general fund (not the Newborn Screening Fund) to address aging equipment and ongoing increase of $56,000 for increased costs of reagents.

  • Seeks additional funding for Nursing Care Institution Resident Protection Revolving Fund to allow the agency to relocate residents to other facilities, maintenance of operation of a facility pending corrections of deficiencies or closure and reimbursement of residents for monies lost. The funds would go toward:

  • $100,000 to address pressure ulcers in nursing homes and training for nursing home staff;

  • $70,000 to provide evacuation tracking and staff tracing system to the 148 skilled nursing facilities in AZ; and

  • $25,000 for an annual conference on best practices on infection prevention in a skilled nursing facility.

Department of Economic Security:

  • Asks for an increase of $15M from the General Fund and $35M (Title XIX) to fund a DDD HCBS provider rate increase that emphasizes quality of direct care worker and service delivery;

  • Asks for $30.5 M (CCDF fund) to increase child care assistance rates to serve low income families in quality settings & continue suspense of the child care waiting list;

  • Seeks a $48.9 M (GF) and $116.1 (Title 19) funds to cover growth for 42,800 members of the DD ALTCS program for targeted case management, state-only case management & AzEIP populations this is based on a projected growth of 5% for ALTCS cases, 2% for targeted case management; 5% growth in state-only case management; 3% growth in AzEIP caseload, a 2% growth in ALTCS capitation & a 5% growth in state funded long term care room & board costs; and

  • Requests additional expenditure authority in the DD line items to use federal Title XIX funds for the DD populations.

AHCCCS: 

Requests an overall increase of $15.15B (Total Funds) of which $1.9B is state general fund (GF), $324.6 M in other appropriated funds, $1.8B in other non-appropriated funds & $11 in federal funds.

Changes driven by Caseload Growth in the population:

  • Increases in the ALTCS-EPD population by 4.8% in FY 2020 & FY 2021 by 3.72%

  • Forecasts for the Traditional T-19 growth to be flat;

  • Estimates growth in Prop 204 Population to increase by 4.14% in FY 2020 and decline in FY 2021 by 3.40%;

  • Changes in the Newly Eligible Adults to grow by 3.84% in FY 2021

  • Declines in the CMDP program are slightly for FY 2020 of -0/09% and increase by 0.43% in FY 2021; and

  • Adds KidsCare growth in FY 2021 of 14.83%.

  • Growth in the baseline Capitation Rate for all programs 3.0% due to a rebasing, changes in utilization, savings from pharmacy, provider increases, adjustments to assure actuarial soundness, and other factors;

  • Adjustment in the FMAP (federal match rate) going to 70% and making adjustments for KidsCare & the childless adults FMAP (match);

  • Seeks authorization or $10.5 M (Federal Funds) for the Medicaid School-Based Administrative Claiming Guide;

  • Reduces the hospital assessment fund to $78.8 M which is being used for the restoration of Prop 204 (childless adults, expansion population) populations in FY 2014;

  • Increases $43.1 (Federal Funds) for non-appropriated federal for regular and supplemental Prescription Rebates;

  • Continues expansion of the Graduate Medical Education program by moving forward the allocation from the FY 2020 appropriations act; and,

  • Seeks $11.9 M (GF) to cover federally mandated IT projects of Asset Verification System, Electronic Visit Verification & Provider Management System.

Department of Child Safety:

  • Increases funding for Adoption Services by $16.4 M (GF) due to increases in the caseload by a growth of 7%; reduce the Adoption Incentive funding due to a structural shortfall due to changes in federal computations; and provide incentive pays of a daily rate of $75 for families who adopt a child with a developmental disability or serious mental health issue;

  • Retains the current appropriation for CMDP in the AHCCCS budget but allocate 4 Single Line Items to manage expenditures and provide transparency with these SLIs: Health Service Request, Higher Level of Care, Care Management & Quality, & Administration and adds 104 FTE which is a 33 FTE increase over current CMDP allocation;

  • Enhances by $5.0 M (GF) to continue and Support the Field Structures within DCS;

  • Reauthorizes $5.0 M (Automation Projects Fund) to continue development & implementation of the Guardian (child welfare information system);

  • Requests $2.6 M (GF) for Legal Costs associated with defending DCS in the class action child welfare case;

  • Makes technical adjustments that provide for Extended Foster Care line item for costs of youth aged 18-21; &, consolidate special line item of Records Retention, Overtime, and General Counsel; and,

  • Asks for $5.4 M (Child Care Development Funds) to increase the Child Care Assistance Rates for low income and foster families to assure children are in quality settings and suspends the child care waiting list.

Aligning the Roles of Medicaid and Public Health

Aligning the Roles of Medicaid and Public Health

Medicaid and public health partnerships play an important role in advancing a statewide approach to improving health and reducing health disparities. Collaboration and shared priorities between agencies can play a super important role in improving outcomes.

The Association of State and Territorial Health Officials recently put together this interesting and easy to listen to 30 minute podcast that highlights opportunities to  leverage each agency's respective roles and resources through the CDC’s 6|18 Initiative.  Here are some links to additional resources regarding these kinds of partnerships:

Doula Services Improve Maternal and Child Health Outcomes

Medicaid Programs Increasingly Reimbursing for Doula Services

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. 

Evidence suggests that support from doulas is linked to lower c-section rates and fewer complications. Medicaid finances more than half of all births each year in 25 states, indicating that Medicaid reimbursement policy can be a particularly effective lever to improve maternal health outcomes. Two states have enacted legislation to provide reimbursement for care by doulas as a way to improve maternal health outcomes and address existing maternal mortality disparities.

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.  

New Jersey recently enacted legislation to improve maternal health among disproportionately affected groups of women by permitting the state to seek a state plan amendment or waiver that establishes Medicaid reimbursement for doula services. The legislation follows a recently piloted state doula program aimed at reducing health disparities in communities with high infant mortality rates.

Indiana also enacted legislation ensuring that pregnancy services covered by Medicaid also include reimbursement for doulas. The law incorporates doula services into the state’s obstetrician navigator program through the department of health, as well as the family and social services administration, allowing Medicaid reimbursement for services provided by doulas. Like in New Jersey, this legislation allows the state to apply for a state plan amendment or waiver necessary to implement doula reimbursement in Medicaid.

There's growing momentum to conduct comprehensive reviews of maternal mortality data, which could help better understand the underlying causes of health disparities. Using a health equity lens to develop policy and design clinical interventions could also prove valuable by ensuring that services are culturally competent, affordable, and accessible by populations who need them most. 

Twenty-nine states (including Arizona) have committees that review maternal deaths and make public policy recommendations.  Arizona took a big step forward this last legislative session with the passage of SB 1040 Maternal Mortality Report which establishes a Maternal Fatalities and Morbidity Advisory Committee to explore public health policy interventions to improve maternal outcomes.

Perhaps the Advisory Committee, which meets on Friday August 30 from 9:30am to 12:30 pm at the Arizona State Laboratory, will explore the role that Doulas can play in improving birth outcomes and make some evidence based recommendations to better use their services in Arizona's care network (our Board President Mary Ellen Cunningham will be representing AzPHA on the committee).

Addressing Postpartum Depression with Public Health Policy

As Arizona embarks on an in-depth look at maternal mortality in the coming months no doubt that postpartum depression will be part of the discussion.  

Moms with postpartum depression can have feelings of sadness, anxiety, and exhaustion that may make it difficult to care for themselves and their kids.  Data from the CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS) show that one in nine U.S. women experience symptoms of postpartum depression.

While there's not a single cause of postpartum depression—it likely results from a combination of physical and emotional factors—women are at greater risk for developing postpartum depression if they have one or more of the following risk factors:

  • Symptoms of depression during or after a pregnancy.

  • Previous experience with depression or bipolar disorder.

  • A family member who has been diagnosed with depression or other mental illness.

  • A stressful life event during pregnancy or shortly after giving birth.

  • Medical complications during childbirth.

  • Mixed feelings about pregnancy.

  • Lack of strong emotional support from a partner, family, or friends.

  • Alcohol or other drug use problems.

Legislative approaches to address maternal mental health conditions and postpartum depression include increasing awareness of risk factors for and effects of postpartum depression, increasing access to prenatal and postpartum screening for these risk factors, and increasing access to treatment and support services for women at high risk for postpartum depression.

Below is an overview of state legislative activity in 2019 to address the screening and treatment for maternal mental health conditions and postpartum depression.

Texas passed 2 bills addressing postpartum depression. One (HB 253) requires their health and human services commission to develop and implement a five-year strategic plan to improve access to postpartum depression screening, referral, treatment, and support services.  The other bill (SB 750) instructs the commission to develop and implement a postpartum depression treatment network for women enrolled in the state’s medical assistance program.

In Oklahoma, SB 419, directs the state licensing boards to work with hospitals and healthcare professionals to develop policies and materials addressing education about and assessment of perinatal mental health disorders in pregnant and postpartum women.

Illinois passed HB 2438 which requires that mental health conditions occurring during pregnancy or postpartum be covered by insurers.  HB 3511 (the Illinois Maternal Mental Health Conditions, Education, Early Diagnosis, and Treatment Act) requires their department of human services to develop educational materials for health care professionals and patients about maternal mental health conditions and requiring birthing hospitals to supplement the materials with relevant resources to the region or community in which they are located.

Virginia passed HB 2613, which adds information about perinatal anxiety to the types of information licensed providers providing maternity care must provide to each patient (including postpartum blues and perinatal depression).

Arizona will be exploring strategies to improve maternal health outcomes as part of the implementation of SB 1040 Maternal Mortality Report - which established a Maternal Fatalities and Morbidity Advisory Committee to explore public health policy interventions to improve maternal outcomes.

Perhaps the Advisory Committee, which meets on Friday August 30 from 9:30am to 12:30 pm at the Arizona State Laboratory, will explore the role public policy can play in reducing the public health impact of post-partum depression. Our Board President Mary Ellen Cunningham will be representing AzPHA on the committee.

Arizona Scores $10.5M to Boost Medication Assisted Treatment for Opioid Use Disorder 

On Friday the US Substance Abuse and Mental Health Services Administration announced the release of an additional $10.5M in State Opioid Response funds for Arizona (AHCCCS) to supplement 1st year funding.

SAMHSA expects to also release additional 2nd year continuation awards later this year. The objective of the grant is to expand access to evidence based treatment...  especially to medication-assisted treatment (MAT) with social supports.  There are three medications commonly used to treat opioid addiction:

  • Methadone – clinic-based opioid agonist that does not block other narcotics while preventing withdrawal while taking it; daily liquid dispensed only in specialty regulated clinics

  • Naltrexone – office-based non-addictive opioid antagonist that blocks the effects of other narcotics; daily pill or monthly injection

  • Buprenorphine – office-based opioid agonist/ antagonist that blocks other narcotics while reducing withdrawal risk; daily dissolving tablet, cheek film, or 6-month implant under the skin

Reducing the public health impact from the opioid epidemic will take a combination of evidence based interventions including continued reforming of prescribing practices, increasing treatment options and access, additional community based interventions including syringe access services, increasing access to rescue medications and interventions by law enforcement and the criminal justice system.

This new supplemental award as well as the upcoming 2nd year funding will provide important new opportunities to make additional progress.

Maricopa County Seeking Hepatitis A Intervention Strike Team Volunteers 

AHCCCS Policy Change Assisting the Response

Maricopa County is part of a statewide hepatitis A outbreak mostly affecting folks experiencing homelessness, substance use and/or recent incarceration. 229 people have been reported with the disease and more than 80% have been hospitalized. The Maricopa County Department of Public Health is working with community partners to vaccinate the people at highest risk...  both to protect them from getting sick and to stop the disease from spreading further.  

The public health response consists of: 1) vaccinating everyone in the county jail system for the next 8 months; 2) deploying vaccination and service strike teams (with other organizations); and 3) partnering with cities and parks to go to homeless encampments and offer vaccination in Strike Teams.

They're recruiting volunteer healthcare providers and screeners (no healthcare experience needed) for the vaccine outreach events. If you're interested in volunteering, please contact PHVolunteer@maricopa.gov.

In addition, AHCCCS now covers medically necessary covered immunizations for people 19 years of age and up when the vaccines are administered by AHCCCS registered providers through county health departments. Immunizations are covered even if the AHCCCS registered provider isn't in the member’s health plan network. The list of covered vaccinations includes (but isn't necessarily limited to) Hepatitis A & B and Measles.

Policy changes like this make a big difference in the effectiveness of public health interventions like the ones associated with this Hep A outbreak - and they also sets up a system that will be better able to prevent future outbreaks.

Federal 5th Circuit Court Signals New Threat to the ACA

Health Care Increasingly Looking Like a Major Campaign Topic for 2020

Background on the 2012 Ruling Upholding the ACA

In the 2012 Ruling that upheld the ACA, Chief Justice Roberts wrote that: “… the Affordable Care Act’s requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a taxbecause the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.” 

Roberts rejected the Obama Administration's argument that the federal government's authority to regulate interstate commerce provides the authority needed for the ACA to be constitutional (the Court struck down that argument 5-4).  Fortunately, the court held (5-4) that the ACA was constitutional based on the federal government’s taxing authority.

The Texas v Azar Challenge

Last week the 5th US Circuit Court of Appeals heard the Texas v Azar case which, once again, challenges the constitutionality of the Affordable care Act. Arizona is a party to the case and is supporting the suit (to overturn the ACA).

This latest challenge essentially argues that the ACA is no longer constitutional because the tax penalty for not having health insurance has been eliminated. 

All the media reports that I found about the questions they were asking and the statements they were making suggest that the appellate court may rule that the ACA is unconstitutional (now that the tax penalties for not having insurance are gone) - which would send the case up to the Supreme Court.

Protections at Risk

In addition to the coverage that the ACA provides through Medicaid expansion and the availability of Marketplace Plans with subsidies, the ACA has a ton of health insurance reform measures including preventing commercial health insurance companies from:

1) denying someone health insurance because they have a preexisting condition -called the “guaranteed issue” requirement;

2) refusing to cover individual services that people need to treat a pre-existing condition- called “pre-existing condition exclusions”; and

3) charging a higher premium based on a person’s health status - called the “community rating” provision.

Supreme Court Forecast

Because of the makeup of the 5th Circuit Court of Appeals (and the signals they sent through their questions at the hearing this week) the Court will likely uphold O’Connor’s decision to invalidate the ACA and the case will probably end up with the US Supreme Court…  which has a different cast of characters than it did when the ACA was originally upheld back in 2012 by a 5-4 vote.

Since the 2012 decision upholding the ACA, Gorsuch has replaced Scalia and Kavanaugh has replaced Kennedy.  Both Scalia and Kennedy voted to overturn the ACA- so not much on that score has changed.

Chief Justice Roberts voted with the majority that upheld the law. His argument rested on the ACA’s link to the financial penalties for not having health insurance. But remember, the financial penalties for not having health insurance were removed from the IRS tax codes in last year's federal tax overhaul, pulling out the structure that Roberts used in his argument.

The bottom line is that the ACA, including its protections for folks with pre-existing conditions, may very well be in jeopardy if Roberts views the ACA as fundamentally different now that the financial penalties are gone.

Healthcare’s Link to the 2020 Election

If a decision comes from the 5th Circuit in the next couple of months (as is likely) the US Supreme Court could be hearing the case during their October 2019 – April 2020 schedule…  making access to healthcare a sentinel issue in the November 2020 election.

Pre-existing exclusion exemptions, community rating, guarantee issue of health insurance, the availability of Marketplace plans with subsidies, and Medicaid expansion will all be front and center with the electorate. All very personal issues.

Social science suggests that people feel a loss of a benefit much more acutely than a missed opportunity.  In other words, it’s a lot harder to take something away than to not give it in the first place. 

With the American people now accustomed to the benefits that the ACA provides, there could be a backlash against those that take those benefits away.  Just sayin’.

AZ Can Prepare for a Post ACA Arizona

It's easy to see how the ACA could end up being struck down once this case gets to the highest court. Gone would be the health insurance market reforms like protection for folks with pre-existing conditions, community rating pricing and guarantee issue as well as Medicaid expansion and the health insurance marketplaces.

Prior to the ACA, the standards to protect people with pre-existing conditions were determined at the state level.  Most states including AZ had very limited protections. 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.

Fortunately, Arizona is partially in control of our own destiny if the ACA is struck down. We couldn't do much about Medicaid rolling back to pre-ACA levels or the loss of subsidies on the Marketplace, but we could have some control over the market reforms like pre-existing condition exclusions, community pricing, and guarantee issue.

Several states have enacted their own laws to be consistent with the ACA market reforms. Several states already have their own laws that incorporate some or all the ACA insurance market protections. Arizona could do the same.  Also, CMS released new resources to support states with improving their health insurance markets and making coverage more affordable through section 1332 waivers.

The good news is that we have time before the Texas v. Azar case makes it to the Supreme Court. A good 1st step would be for the Governor to ask our state agencies to generate (or commission) a report outlining the real-life impact in Arizona in the event that the Texas v. Azar suit is successful. The report would put forward options for state-based health insurance market reform laws to require things like prohibiting pre-existing condition exclusions.

Such a report would give the Arizona State Legislature an analysis to evaluate public policy options for state-based market reforms.

I know what you're thinking, it's impossible to pass these kind of market reforms in Arizona.  Maybe, but many thought Arizona's expansion of our Medicaid system back in 2013 was impossible.  That case study shows that with the right kind of leadership on the 9th floor, anything is possible.

Medicaid Work/Community Engagement Requirements May Be Phased In

Back in January CMS approved Arizona’s request to include work requirements and/or community engagement and reporting requirements as a condition of Medicaid enrollment beginning on January 1, 2020.  

The work requirement/community engagement Waiver request was filed back in 2018 and is mandated by Senate Bill 1092 (from 2015) which requires AHCCCS to ask CMS’ permission to implement new eligibility requirements for “able-bodied adults".  Folks that are exempted from the upcoming requirements include:

  • Pregnant women up to the 60th day post-pregnancy

  • Former Arizona foster youth up to age 26

  • Members of federally recognized tribes

  • Designated caretakers of a child under age 18

  • Caregivers who are responsible for the care of an individual with a disability

  • Members determined to have a serious mental illness (SMI)

  • Members who are medically frail

  • Members who have an acute medical condition

  • Members who are in active treatment for a substance use disorder

  • Members with a disability recognized under federal law and individuals receiving long term disability benefits

  • Full-time high school, college, or trade school students

  • Survivors of domestic violence

  • Individuals who are homeless

At last week's State Medicaid Advisory Council meeting, AHCCCS announced some changes that they hope to make in order to make the transition easier for their members that don't qualify for exemptions when implementation begins. 

They're hoping to gradually phase in the AHCCCS Works program by geographic area (subject to CMS approval). If approved, the program will be implemented in three phases- beginning no sooner than 1/1/20:

Phase 1: Most Urbanized Counties: Maricopa, Pima, and Yuma

Phase 2: Semi-Urbanized Counties: Cochise, Coconino, Mohave, Pinal, Santa Cruz, & Yavapai

Phase 3: Least Urbanized Counties: Apache, Gila, Graham, Greenlee, La Paz, & Navajo

The idea behind the phase in is to:

  • Establish community engagement supports for members in regions with limited employment, educational and training opportunities, accessible transportation, and child care services;

  • Give the State time to assess the availability of community engagement resources in rural areas and address gaps; and because 

  • Counties with a higher percentage of urban populations are likely to have sufficient community engagement supports compared to counties with a higher percentage of rural populations. 

Arizona Medicaid Members Get a Lyft

Non emergency medical transportation for doctor appoints can be a covered benefit for Medicaid members that qualify. The benefit is aimed at members that need assistance to get to medical appointments but may not have a drivers license or car etc.

AHCCCS recently became the 1st Medicaid agency to take advantage of the new efficiencies provided by ridesharing services.  AHCCCS Director Jami Snyder was quoted in media report this week as saying  “We are proud to be the first Medicaid program in the country to establish an innovative regulatory approach that seamlessly offers rideshare as a non-emergency medical transportation option for Medicaid beneficiaries.” 

This policy change will help more people get to consultations without having to rely on public transportation. Here's the statement on the AHCCCS website about the new policy: 

Adding rideshare companies as providers of non-emergency medical transportation can add flexibility to the health care delivery system and increase transportation options for Medicaid members. Under the new AHCCCS provider category, rideshare companies are eligible to serve Medicaid members who do not require personal assistance during medically necessary transportation. As such, the training required of these providers is reduced as compared to traditional non-emergency transportation providers.

AHCCCS members will not need to change how they request non-emergency medical transportation, and should continue to contact their health care plan to request service. The health care plan and/or their transportation broker will assess the member’s need and determine whether a Transportation Network Company is a viable option for that particular transportation need.

Non-emergency medical transportation is a covered benefit for AHCCCS members when: the physical or behavioral health service for which the transportation is needed is a covered AHCCCS service; the member is not able to provide, secure or pay for their own transportation, and free transportation is not available; and the transportation is provided to and from the nearest appropriate AHCCCS registered provider. The complete transportation policy is published in the AHCCCS Medical Policy Manual, Chapter 300-BB and available on the AHCCCS website.

Tools to Align Public Health & Medicaid Polices

The Center for Healthcare Strategies has been partnering with the CDC, CMS, ASTHO, and the National Association of Medicaid Directors on a really interesting policy development partnership that aligns and accelerates the adoption of evidence-based prevention strategies between public health and Medicaid for high-cost health conditions like tobacco use, high blood pressure, inappropriate antibiotic use, asthma, unintended pregnancies, and type 2 diabetes.

It’s called the 6|18 Initiative and it’s supporting Medicaid-public health partnerships in 34 states to accelerate adoption of proven prevention strategies (the “18” refers to a set of evidence-based interventions that address the “6” conditions above).  The collaborative has developed practical tools to help Medicaid agencies, state and local health departments, and other payers and purchasers plan, design, implement, and assess CDC’s 6|18 Initiative prevention activities.

The tools are designed to help the collaborative teams (Medicaid and public health officials and managed care organizations) to implement high-opportunity prevention interventions.  Here’s a link to those entity specific tools.

Arizona and many other states are aggressively adopting new value-based payment models to improve health care quality and stabilize or reduce healthcare costs.  CDC’s 6|18 Initiative offers some evidence-based preventive practices and payment and delivery models that offer opportunities for state and local agencies to collaborate on enhancing the coverage, access, utilization, and quality of cost-effective prevention practices.

Legislative Session Wrap Up

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

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

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

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

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

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

Leveraging Managed Care Contracts to Address Social Determinants

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

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

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

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

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

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

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

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

Coding the Social Determinants

ICD-10 diagnosis codes that relate to the Social Determinants of Health can be a valuable source of information to improve health outcomes.  Social Determinants of Health codes can identify the conditions in which people are born, grow, live, work, and age like education, employment, physical environment, socioeconomic status and social support networks- data that can provide managed care organizations information with which to improve outcomes and reduce costs.

AHCCCS is recommending that providers routinely screen for and document the presence of social determinants (as appropriate within their scope of practice) and to document them in claims data. They began monitoring claims for the presence of the codes about a year ago.  You can review the Social Determinant ICD-10 Codes on the AHCCCS website.

AzPHA Action Alert: Support Comprehensive Oral Health Coverage for Pregnant Medicaid Members

The State Legislature is transitioning to focusing on the State budget.  There are a few items we'll need to ask you to press for in the next couple of weeks with the legislators in your district including: 1) preventative and comprehensive oral health services for pregnant Medicaid members; 2) increased investment in funding for the state loan repayment program and health profession residencies (especially for primary care); and 3) for funding Kids Care. This week we'll focus on Oral Health.

Please take a few minutes and send an email (or make a call) to the Senator and Representatives for your Legislative District and to urge them to include funding for preventative oral health coverage for pregnant Medicaid members in the State budget.

To make it easy, we've built a template message for you to send to your Senator and Representatives below. 

You'll need three messages in total because each Legislative District has one Senator and two Representatives.  To find your Senator and Representative go to:  https://www.azleg.gov/findmylegislator/

_________________________________

Here's a draft message for you to send (it helps if you personalize it a bit):

Dear Senator _______ (or Dear Representative _______),

I'm urging you consider adding a dental benefit for pregnant mothers within Arizona's AHCCCS program as you consider funding priorities for the State budget in the next few weeks. 

Adding this important benefit makes both solid public health and economic sense, and there's good evidence.

A new systematic overview of published studies has found a clear relationship between periodontal disease and pre-term birth and low birth weight.

About 7.2% of AZ live births were low birthweight - or about 5,760 of the 80,000 births every year in AZ.  The newly published suggests that periodontal disease is contributing to 1,036 low birthweight weight babies each year in AZ including 520 pre-term babies per year in our state's Medicaid program.

Nationally, the average health care cost for a low birth weight baby during the first year of life is $55,393 compared to $5,085 for a non-low birth weight baby...  meaning that periodontal disease costs the state in the neighborhood of $29M in the first year from low birth weight births that are attributable to periodontal disease compared with only $2.6M for a similar number of non pre-term births.

The small investment for this new benefit (only $178,000 in State funds and $458,000 from the Federal Medicaid authority) will result in healthier mothers and healthier babies while saving the state money.

Legislation supporting this benefit (SB1088) passed the Senate with a wide margin and both the House Health and the House Appropriations Committees have given SB1088 strong bi-partisan support.

This new benefit is strongly supported by the Arizona Public Health Association, the Oral Health Coalition and a large number of affiliated groups including the March of Dimes, the Arizona Dental and Arizona Dental Hygienists Associations, the Alliance of Community Health Centers, the College of Obstetrics and Gynecology, and the Arizona Health Plans Association.

We urge you to put funding for this new program on your list of priorities for the State budget this coming year.

Thank you for your consideration.

Sincerely,

Your name & Legislative District

Legislative Update

The only committees that met last week were Rules and Appropriations. The other standing committees (e.g. Health and Human Services) have finished their work. The House Appropriations was particularly dramatic with several strike-everything bills and tensions running high- but nothing really tied to the public health bills we’re interested in. 

We have a whole bunch of bills that need to make it through the Rules Committees (especially the House Rules Committee) before they can go to the floor (the Rules Committee's job is to basically make sure the bill is constitutional). 

Lots of the bills that we care about will be heard this week in the Rules Committee Monday at 1:30pm (here's the agenda). I put an asterisk by the bills below that will be heard Monday. If they all pass- they could move quickly to floor votes (3rd read) this week. Here's this week's spreadsheet summary of the bills.

Bills that have been amended in the opposite house will need to return to their house of origin for another vote.  If there isn't agreement on the amendments, there may need to be conference committees set up to hammer out a solution.

In other news, we were delighted to see that the Senate Health and Human Services Committee this week unanimously recommended that Jami Snyder’s confirmation by the full Senate to be the new AHCCCS Director.  Her nomination will now go to the Senate floor for confirmation.

Steve Pierce was appointed to fill Representative Stringer's seat in District 1 late in the week- which is why there was no floor action in the House this week. 

Bills that still need Floor Votes (3rd Read)

* Means bill will be heard in the Rules Committee Monday (1:30pm).

* SB 1040 Maternal Mortality Report (Brophy-McGee) – AzPHA Position: YES

Passed the Senate 30-0. Bill Passed the House Health Committee 9-0. Rules Committee this week. 

* SB 1085 Association Health Plans- 

Passed the Senate 24-6.  Passed the House Health and Human Services Committee 6-2-1. Rules Committee this week. 

SB 1088 Dental Care During Pregnancy (Carter) – AzPHA Position: YES

Passed the Senate 27-3.  Passed the House Health & Human Services Committee 8-1.  Passed House Appropriations 7-4. Rules Committee Next. Will still need to get into the final budget.

* SB 1089 Telemedicine Insurance Coverage (Carter) – AzPHA Position: Yes

Passed Senate 30-0. Passed the House Health & Human Services Committee 9-0.  Rules Committee this week. 

* SB 1165 Texting and Driving Prohibition (Brophy McGee) – AzPHA Position: YES

Passed Senate 20-10. Passed the House Transportation Committee 5-1-1.  Rules Committee this week. 

SB 1174 Tribal Area Health Education Center – AzPHA Position: Yes

Passed Senate 30-0. Passed the Senate Education Committee 13-0. Rules Committee Next.

* SB 1211 Intermediate Care Facilities (Carter) AzPHA Position: Yes

Passed the Senate 30-0. Passed the House Health & Human Services Committee 9-0. Rules Committee this week. 

* SB 1247 Residential Care Institutions (Brophy McGee) AzPHA Position: Yes

Passed the Senate 30-0.  Bill passed the House Health Committee 9-0. Rules Committee this week. 

SB 1245 Vital Records- Death Certificates (Brophy McGee) AzPHA Position: Yes

Passed the Senate 30-0.  Passed through all House Committees- ready for a Floor Vote.

SB 1354 Graduate Medical Information & Student Loan Repayment (Carter) AzPHA Position: Yes

Passed Senate 28-2.  Passed House Appropriations Committee 10-1, Withdrawn at the HHS Committee, but can still move forward if it can pass the Rules Committee. This is the most important access to care bills this year- it would do a great deal both in the short-term by boosting the primary care loan repayment program and really enhancing graduate medical education residencies over the coming years (important because where a practitioner does her or his residency greatly influences where they ultimately practice).

HB 2125 Child Care Subsidies (Udall) – AzPHA Position: YES

Passed House 46-13.  Passed the Senate Health and Human Services Committee 7-0-1. Rules Committee Next.

* HB 2488 Veteran Suicide Annual Report (Lawrence) AzPHA Position: Yes

Passed House 60-0. Passed the Senate Health and Human Services Committee 7-0-1. Passed 29-0 in the Senate, sent back to House because it's different than the original bill.  

SB 1009 Electronic Cigarettes, Tobacco Sales (Carter) – AzPHA Position: YES

Passed the Senate 30-0. Assigned to the House Health and Human Services Committee but didn't get a hearing- not a good sign.

* SB 1355 Native American Dental Care – AzPHA Position: Yes

Passed Senate 25-5.  Passed the House Health & Human Services Committee 9-0. Rules Committee this week. 

SB 1456 Vision Screening- AzPHA Position: Yes

Passed Senate 29-0. Passed the House Health & Human Services Committee 9-0. Rules Committee Next.

* SB 1468 Suicide Prevention- Schools- AzPHA Position: Yes

Requires school districts, charter schools, and Arizona teacher training programs to include suicide awareness and prevention training and requires the Arizona Health Care Cost Containment System Administration (AHCCCS) to make suicide awareness and prevention training available. Rules Committee this week. 

SB 1060 (Strike-all Amendment) Electronic Cigarettes. Smoke Free Arizona Act (Carter) – AzPHA Position: YES

Passed the Senate 28-0. Assigned to the House Health and Human Services Committee- but not heard.  Not a good sign. Probably dead.

 

Bills that Have Been Passed & Signed by the Governor

SB 1109 Short Term Limited Health Plans- extension – AzPHA Position: Opposed

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