Public Health

State-Level Interventions to Address Social Determinants of Health Catching On

Will Arizona Join the Chorus Next Legislative Session?

The 6th Annual Arizona Health Equity Conference was held last week at Desert Willow in Phoenix. It was a super interesting conference with more than 50 speakers who discussed a whole series of innovative interventions happening in Arizona that advance health equity. Many (actually most) of the presentations focused on the social determinants of health (things like housing, food security, and transportation) which drive the majority of health outcomes in the US.

You can check out the Conference Brochure if you weren’t able to be one of the more than 330 folks that were at the conference.

Along those lines- I thought this week I thought I’d focus on things that other states are doing build healthy environments that improve health and ensure equitable opportunity for wellness.

Housing

Perhaps the most acute social determinant of health in many communities these days is access to affordable housing. An individual’s housing impacts his or her wealth, health, and job opportunities. Lack of access to affordable housing can cause a host of bad health outcomes.

Some states and local jurisdictions are using their decision-making authority to incentivize the construction of affordable housing via something called opportunity zones.  ‘Opportunity Zones’ are part of the new federal tax law and can provide 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.

There are 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 AuthorityHere’s the map of the Opportunity Zones that the Arizona Commerce Authority selected.

Sadly, 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.

Hopefully our Legislature and Executive Branch will do some research to figure out ways that the Opportunity Zone provision can be leveraged to incentivize and facilitate the contruction of affordable housing- a critical (and sorely needed) intervention that will improve health status of vulnerable Arizonans.

Healthy Food Access

Access to affordable healthy foods directly correlates with improved health- and conversely- eating processed foods are associated with chronic conditions such as cancer, heart disease, diabetes, obesity, and high blood pressure. Food deserts, areas of the country with limited access to foods that make up a salubrious diet, compound barriers to accessing nourishing foods.

Earlier this year New Jersey enacted a law implementing the Healthy Corner Store Program, which increases the availability and sales of fresh produce and nutritious foods by small food retailers in rural and urban low-income and moderate-income areas. The program is funded by their Healthy Small Food Retailer Fund operated out of their state health department.

Washington state recently implemented their Fruit and Vegetables Incentives Program which provides fruit and vegetable incentives and food vouchers for low-income shoppers that can be used in grocery stores and farmers markets.

New York passed a law incentivizing increased fresh fruit and vegetable production through community gardens.

Transportation

California recently passed a budget that prioritizes improvements to their infrastructure and roadway safety focusing on providing increased access to transportation for under-resourced communities including an evaluation component that report on performance measures related to projects that prioritize and implement safe and connected facilities for pedestrians, bicyclists, and transit users.

2019 Nobel Prize in Economic Sciences &  Recognizes Research Helpful to Public Health

One of the Nobel Prize awards caught my eye because it has such a direct link to the social determinants of global health.  It's a great example of the importance of doing and using solid research to inform public health interventions.  

The Royal Swedish Academy of Sciences awarded the Nobel Prize in Economics to researchers Abhijit Banerjee, Esther Duflo and Michael Kramer for their work to build the evidence base for methods to reduce global poverty.

The primary driver of bad health outcomes is poverty (not just globally- here too).  More than 700 million people have extremely low incomes and 5 million kids under 5 die of diseases that could often have been prevented or cured with inexpensive interventions.

The researchers that won this year's economics award developed a new way to identify evidence-based strategies to fight global poverty- and improve public health outcomes. 

Much of their research involves breaking down research questions into smaller pieces. Their research (and others that have followed in their footsteps) are having a big influence on organizations that are implementing interventions to fight poverty by measuring the effectiveness of interventions in the areas of health care and prevention, education, agriculture and gender issues. For example: 

  • One of their studies found that immunization rates for children in rural India jumped dramatically (from 5% to 39%) when their families are offered incentives like lentils.

  • Their work in rural Kenya and in India found that providing more textbooks, school meals and teachers didn't do much to help students learn more.

  • They found that providing free health care makes a big difference... only 18% of parents gave their children de-worming pills for parasitic infections when they had to pay for them (even though the price was less than $1). But 75% gave their kids the pills when they were free.

These are just a few examples of how this new research has already helped to alleviate global poverty. It also has great potential to further improve the lives of the worst-off people around the world.

What caught my eye about this award and their work is how important it is to connect academic and executive public health and public policy!

You can learn more about Research to help the world’s poor in this 7-page paper on the Nobel website

Maricopa County Hepatitis A Outbreak Slowing Because of Quick & Effective  Interventions

Maricopa County has 320 hepatitis A cases with 4 deaths predominantly affecting those experiencing homelessness, substance use and/or recent incarceration. A few months ago, Maricopa County Public Health activated its incident command system and have had all hands on deck with not only members of the County Epi team but also contracted staff and many, many volunteers.

Selecting and Executing an Intervention

After reviewing the data and learning from other jurisdictions around the country, the team determined that the most impactful and cost-effective intervention for quelling the outbreak was to focus on a vaccination campaign among high risk folks.

Of course- that means that they would need some funding to support the intervention. Team MCDPH built a proposal and went to the County Board of Supervisors and were able get a $600K appropriation last fiscal year for the intervention. They were also able to get an additional $1.7M for the current fiscal year. 

The intervention has been focusing on 3 main strategies to vaccinate those at highest risk to prevent further spread including 1) Vaccinating everyone who enters the Maricopa County jail system by hiring temporary staff; 2) Providing vaccine to partners who work with those at risk; and 3) Deploying field teams in partnership with cities to vaccinate people where they are.

AHCCCS stepped in to help as well- facilitating reimbursement to Maricopa County for the vaccinations given to Medicaid members.

By working with healthcare, community, faith-based and local government partners, the public health system has vaccinated over 14,000 residents at risk for hepatitis A. The results have been impressive. They have achieved a 66% reduction in the number of new cases since the peak of the outbreak. Vaccination efforts will continue until they can confirm that the outbreak is over.

Return on Investment

Each prevented hospitalization because of Hepatitis A saves about $25K. Emergency Department visits from Hepatitis A cost less but are still expensive- a few thousand dollars.

Persons experiencing homelessness are at much higher risk for hospitalization when they become infected with the Hepatitis A virus. For example, more than 71% of the 1,521 persons involved in a 2017 Hepatitis A outbreak were hospitalized (1,073) and 41 died.

Kentucky had a similar outbreak but they didn’t jump on it nearly as quick as Maricopa County Department of Public Health (MCDPH) and KY ended up with 4,000 cases. MCDPHs quick response likely prevented hundreds, if not thousands of cases- and untold hospitalization costs to say nothing of the lives saved.  BTW- the Hepatitis A Vaccine is $36 per dose.

Partnerships are Key

There are several keys to the success of this response including doing research to determine the most effective evidence-based interventions to use, working community, government and private partners on solutions, and making a compelling case to the Board of Supervisors to invest county funds on the proposed interventions.

Well done! This is a good example of an effective and targeted response to an important public health problem that has been causing bad health outcomes among a very high-risk population- and causing expensive downstream costs for Arizona’s healthcare system.

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.

States Increasingly Implementing Innovative Policy Approaches to Quell the E-Cigarette Use Epidemic Among Kids

Will Arizona Join In?

Electronic cigarette use among kids is a growing concern among some state and federal elected officials, appointees and other policymakers.  E-cigs are the most commonly used tobacco products among kids and young adults.  Nationally, e-cigarette use has grown 900% among middle and high school students from 2011 to 2015.

It’s happening in Arizona too.  Last year’s Arizona Youth Survey found that e-cig use was up dramatically across all three age groups:

  • 8th -graders: 21% reported using e-cigarettes in 2016- that’s up to 28% now

  • 10th-graders: 29.4% 2016, now it’s 39%

  • 12th-graders: 35% 2016, now it’s nearly half- at 46%.

Flavored e-cigs are far and away the most popular kind of e-cig for kids- and the data are clear that flavored e-cigs are attracting (and addicting) kids.  The data are striking.  

According to FDA, 96% percent of kids who started using e-cigs between 2016 and 2017 started with a flavored e-cig. The 2018 National Youth Tobacco Survey data found that 68% of current high school e-cig users used a flavored e-cig.

Those data are compelling- and it’s easy to see why some elected officials and appointed public health officials see regulating the sale of flavored e-cigarettes as  an important strategy to reduce youth e-cigarette use.

Regulating Flavored E-Cigarettes

As I mentioned in my policy update a few weeks ago, the HHS issued a press release announcing that they “intend” to remove all flavored e-cigarette products from the market until manufacturers of those products file premarket tobacco product applications with FDA.

Some Governors and state health officials have also taken executive and regulatory action to regulate flavored e-cigarettes. Last month Michigan became the first state to announce a ban on the sale of all flavored e-cigarettes. She based her decision on leadership from their state health department with their issuance of an emergency finding, and Governor Whitmer directed the agency to issue emergency rules banning the sale of vaping products.

New York's Governor Cuomo has instructed their state health department to convene an emergency session of their Public Health and Health Planning Council to consider banning flavored e-cigarettes. The Council adopted rules banning sales of most flavored e-cigarettes.

In Massachusetts, Governor Baker declared a public health emergency, and their state health department commissioner issued an order prohibiting the sale or display of all vaping products.

Some state legislatures are taking action on flavored e-gigs as well.

North Dakota’s governor signed HB 1477 prohibiting the sale of any flavored e-cigs.  Maine’s governor signed LD 1190 which penalizes the sale of flavored tobacco products, including e-cigarettes and flavoring, to anyone under 21.

The California legislature is considering matching bills (AB 739 and SB 38) that would prohibit tobacco retailers from selling flavored tobacco products including e-cigs.  

A similar Illinois bill (HB 3883) would create the Flavored Tobacco Ban Act which would prohibit the sale of any flavored tobacco product.

Massachusetts introduced companion bills (H 1902 and S 1279) that would prevent the sale of flavored cigarettes (and e-cigs).

Public Health advocates like ourselves can play an important role in building the evidence base and conducting the advocacy necessary to move elected and appointed officials to take action. 

Our administrative advocacy can take several forms- from collaborating with elected officials to develop legislation to take action- to working within state and county health departments to urge appointed officials to take action.  State health departments play a key role in catalyzing a response as well, if they take action.

So far, our Governor doesn’t appear to be supportive of banning the sale of flavored e-cigs in AZ.  He’s quoted in this article in the Arizona Capitol Times as saying “What I don’t want to do is take someone who is addicted (to nicotine), restrict them from finding a product and push them to the black market, so we’re going to have a measured approach.”

Perhaps if he knew that 96% percent of kids who started using e-cigs start with a flavored e-cig and that 68% of current high school e-cig users used a flavored e-cig  it would change his mind?

Please Promote Participation in the Title V Needs Assessment Survey

The 2020-2025 Maternal and Child Health Title V Needs Assessment Survey is underway, and they need your help to make sure they good data from the Assessment! 

This needs assessment is done every 5 years and is super important because the needs assessment results drive decision making and resource allocation for the next 5 years.  Getting good data from the needs assessment can make the difference between getting great public health results and getting just mediocre or even no result.

The Federal Title V MCH Block Grant is a key source of support (including funding) for promoting and improving the health and well-being of mothers, children, adolescents, including children/youth with special needs, and their families.  

In order to accurately identify the needs of Arizona’s women and children, a needs assessment is conducted every five years. The results of the survey help to develop the priorities for the next five years. 

The survey is available in English & Spanish and should take about 20 minutes to complete. The survey data collection period will end on December 31, 2019. All Arizona residents including service providers and families are welcomed to take the survey. 

Please participate in the survey and promote it with your partners and families. They have created two flyers, in English and Spanish that can be shared and distributed. In addition, they can mail printed copies of the flyer to your organization for waiting rooms. Printed flyers can be ordered through here.

Anyone with questions about the survey can contact the ADHS Office of Assessment and Evaluation at 602-542-2233 or at bwch.oae@azdhs.gov.

You Can Be a Part of Increasing the Transparency of Arizona Elections

Elections have profound impacts on public health – good and bad.  Persons that get elected to public office at the federal state and local level routinely make decisions that influence public health.  Elected officials at the federal, state and local level make funding decisions about important agencies that impact public health and pass or fail to pass important national public health policy laws. 

Elected officials also make important appointments at state and federal agencies (like CDC, HHS, HRSA, CMS & EPA at the federal level and ADHS, AHCCCS, ADEQ etc. at the state level).  The persons in those positions set agency priorities, have wide latitude to make important decisions and who to hire.  They also have broad Rulemaking authority and establish or don’t establish public health policy that can has a profound impact on public health.

In short, elections have a big impact on public health. That’s why it’s super important to have an informed electorate, so people can make informed decisions about what they decide in the ballot box- whether it’s a person running for elected office at the state, federal, or local level- or whether it’s about a voter initiative.

Sadly, voters aren’t as informed as they could be about the decisions they make at the ballot box because it’s legal in the US and in Arizona to spend money to influence elections and not disclose whose money it is or why they’re spending it.  Sometimes you might hear this being called “Dirty Money” or “Dark Money” – referring to political spending when the original source remains secret.  All sorts of organizations, corporations, and wealthy individuals spend large sums of money to advertise and otherwise influence elections while the source of those funds remains hidden from the voters.

Since 2010, more political advertising has been secretly funded in Arizona as a percentage of total campaign spending than in any other state.  In part that’s because Arizona law has essentially no requirement that folks disclose political spending.

That’s where the Outlaw Dirty Money voter initiative comes in.  It’s a voter initiative that has been filed with the Secretary of State to change the state constitution that, if passed by the voters, will mean that at least Arizona voters will have a right to know who is spending money to influence elections.  You can read the text here.  Here are the elements of the Initiative:

  • Organizations spending more than $20,000 in state races or $10,000 in local races would be required to report the original source of their funding;

  • Organizations would be required to disclose all original contributors who gave $5,000 or more in an election cycle, removing the existing practice of creating a maze of organizations to hide the original source;

  • The Citizens Clean Election Commission would write and enforce the regulations to implement the Outlaw Dirty Money Constitutional Amendment;

  • Voters can file a complaint directly with the Clean Elections Commission to report violations; and

  • Local governments can pass more stringent requirements than those set forth in this Amendment.

You Can Play a Part

It will take the signatures of 357,000 Arizona voters to put the Outlaw Dirty Money Initiative on the November 2020 ballot.  That’s a lot of signatures.  This is a grassroots effort, so the signature gathering is being done by volunteers- meaning that many people need to be involved in the signature gathering effort.

Terry Goddard, the Chairperson for the Initiative, recently paid a visit to an AzPHA Board Meeting and described the Initiative and provided me with several initiative petitions.  I am already busy gathering signatures for the Initiative, and I’m hoping that you will gather some signatures as well.

Simply contact me at willhumble@azpha.org and I will get you some petitions and describe what you need to do.

UA and Pima County Launching an Academic Health Department

The UA Mel and Enid Zuckerman College of Public Health and the Pima County Health Department have created an Academic Health Department with the goals of enhancing public health education, training and research to improve community health in Pima County.

Some of the elements of the Academic Health Department will include an expansion of internship opportunities at the Health Department for UA Zuckerman College of Public Health students; research poster forums featuring projects developed by interns; training for internship preceptors, faculty advisers, graduate coordinators and undergraduate advisers; and a fellowship program.

There will also be a Mini Public Health School, which will be a monthly lecture series featuring presentations by faculty members and health department staff discussing their research and community-based projects. 

Members of the AHC core team from the UA Zuckerman College of Public Health are: Dr. Rosales and Emily Waldron, community engagement and outreach coordinator. From the Pima County Health Department: Bob England, MD, MPH, interim director; Julia Flannery, organizational development program manager; Paula Mandel, deputy director; and Kristin Barney, MA, division manager. 

For more information, about the Academic Health Department, please contact Dr. Cecilia Rosales at crosales@email.arizona.edu, (602) 827-2205.

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:

A Primer: How Arizona’s Ambulance Licensing System Works

The Basics

Arizona uses a Certificate of Necessity (CON) system to regulate ground ambulance service.  The overall idea is to have a regulatory system that optimally allocates resources, makes sure every place in the State has adequate emergency medical services, and that reduces rates to the extent possible.  

Any entity that wants to run an ambulance service needs to get a CON from the ADHS. It’s basically a license to run an ambulance service. The CON describes the geographic service area, level of service (advanced life support or basic life support), hours of operation, response times, effective date, expiration date for emergency medical services in the specific geographic area.  

An ambulance service that gets a CON is supposed to stick with the criteria on their certificate and operate in accordance to the statutes and rules by which it's governed. 

A common misconception is that Arizona’s CON system is designed to limit the number of ambulance services in Arizona. That’s not the case.  Parts of the State (especially areas with high populations lots of transports) have multiple providers and overlapping service areas where more than one ambulance company can provide services. 

The Statutes and Rules require that people who want to start an ambulance service have to demonstrate that there's "a public necessity" for the proposed service. There are detailed statutes that define what the words “public necessity” mean for the purposes of providing direction to the ADHS Director when she or he decides whether to approve a CON application.  There’s also a guidance document that outlines what the words “other things as determined by the Director” means.

How it Works

When someone wants to get a CON they apply to the ADHS. There are usually competitors that don’t want the applicant to get it (because the new applicant will be taking some of their cheese).  When someone challenges an application (called an intervenor) a hearing is scheduled with the Office of Administrative Hearings (in the ADOA).

A new statute limits that hearing to 10 days of testimony (a big improvement because these hearings used to go on for weeks or even months). The Hearing Officer listens to the testimony and documents and issues an “Order” with their opinion whether the Director should issue the CON. 

The ADHS can take or not take the Hearing Officer’s opinion. She or he can approve the CON, deny it, or approve it with some modifications.  There's a lot of interest among the parties when these CON applications are being considered - mostly because there's a bunch of money at stake. CON applications are quite litigious.

Here's a couple of recent cases that illustrate recent urban and rural CON applications. 

The Case of Community Ambulance (Urban)

An outfit called Community Ambulance applied for a CON to be able to do inter-facility transports (no 911 service) in Maricopa County. The goal was to have a CON that would provide inter-facility service between the Dignity Health facilities in Central AZ.  Dignity Health was supportive of the application because they believe contracting with Community Ambulance would help them more efficiently transport their patients between facilities- improving patient care and reducing costs. 

While the current providers (AMR and a couple others) can and do provide inter-facility transports in Maricopa County, the applicant and their supporters believe that a specific service dedicated strictly to interfacility would improve efficiency (Dignity would have contracted with Community Ambulance for this specific service). 

After reviewing the application and documents, a Hearing Officer at the Office of Administrative Hearings recommended that the ADHS deny the application. Here’s that Opinion. Upon review of the Hearing Officer’s opinion, the ADHS Director agreed with the hearing officer opinion and denied the CON. 

There’s an opportunity to appeal, and Community Ambulance filed a Motion for Review with the Director. The ADHS Director can review the case and change her mind or stay with the initial decision. If the CON remains denied, Community Ambulance can appeal to Maricopa County Superior Court.

The Case of Timber Mesa (Rural)

Back in 2017, an outfit called the Timber Mesa Fire District applied to extend the boundaries of their CON to include the city of Show Low.  An existing CON was in place in Show Low (Show Low EMS- now called Arrowhead Mobile Healthcare).

After hearing the evidence- the Hearing Officer recommended that the ADHS deny the CON application because: 1) Timber Mesa didn’t show that more resources were needed in the service area; 2) the reduction in call volume for Show Low EMS would make Show Low EMS unable to meet their current obligations; and 3) Timber Mesa didn’t prove that Show Low EMS has engaged in substandard performance in either 911 or interfacility service.

The ADHS Director didn’t agree with the Hearing Officer’s recommendation and approved Timber Mesa's CON boundary expansion into Show Low. 

Show Low EMS (now Arrowhead Mobile Healthcare) appealed the ADHS Director’s decision in Superior Court.  Last week, the Superior Court judge in the case agreed with Arrowhead that “the Director exceeded her statutory authority when she "sua sponte" amended CON 111 to include the Expanded Service Area”.  It’s now the ADHS’ job to read the Judge’s decision and figure out what to do next.

Editorial Note: When I was in the Director position, I was reluctant to issue additional CONs in rural areas because adding too many providers in rural areas can jeopardize overall service and increase costs. That’s because when transports are spread “too thin”, one or both ambulance service providers may not be able cover their expenses - which can cause them to ask for rate increases or neglect underpopulated areas which jeopardizes response times.  

In urban and suburban urban areas, I was more inclined to approve CONs that met the basic statutory requirements because there are usually plenty of transports around to ensure that ambulance providers can meet their expenses...  and increasing the number of providers can safely increase competition. In urban and suburban areas there’s a lot less risk that adding additional resources will cause rate increases or result in providers neglecting the less populated parts of the service area.

This primer is just a short summary of the CON system and how it works in Arizona. One can spend an entire career on this subject and still learn something every day- so take this for what it’s intended- a small window into the complicated world of Ambulance service Certificates of Necessity in Arizona.

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.

Using Public Health Policy to Boost Vaccine Coverage

Measles across the country have deteriorated to a level not seen in 30 years, and several states have recently taken direct action to implement policies to boost immunization coverage.

At the beginning of 2019, only California, Mississippi, and West Virginia had state laws that only allowed medical exemptions from their school attendance requirements. Now there are 3 more states like that.  This year Maine and New York passed laws that limit school vaccine exemptions to medical reasons.

 The Maine legislation (which will take effect on September 1, 2021) repeals the state’s religious and philosophical (personal belief) exemptions - but grandfathers in kids that have a non-medical exemption if the parents show that a healthcare provider was consulted about the benefits and risks of vaccinations.

The New York legislation (which took effect immediately) repealed their religious exemption (and has no grandfather clause). NY didn't have a persona exemption, so all they have now is a medical exemption for school attendance requirements.

Washington state removed their former philosophical exemption for the measles, mumps, and rubella vaccine.

I’ve heard through the grapevine that Arizona state government will be working on a “Breakthrough Project” in the coming year that will have a core goal of improving Arizona’s decreasing immunization rates. 

“Breakthrough Projects” are something in the "Arizona Management System" (a Governor's Office Initiative) that is also a state agency scorecard metric.  Breakthrough Projects are supposed to: 1) align with an agency performance measure; 2) result in a sustainable success that addresses a stakeholder concern; and 3) require “a substantial design or re-design of a work process documented with an A3 project plan”.

I’ll stay tuned to get more information about what the ADHS has planned for the Breakthrough Project and include it in a future Policy Update.

Flagstaff City Council Approves Tobacco 21 Ordinance

The Flagstaff City Council approved a Tobacco 21 ordinance last week! Here’s a copy of their ordinance, which follows the national best practices model for Tobacco 21.

The ordinance is a few pages long- but essentially it will limit the sale of tobacco including electronic cigarettes to only people over 21.  It'll require retailers that sell tobacco and e-cigs to get a license (the city will do compliance checks). 

Fines for retailers who violate the ordinance will begin with a $500 fine.  A 2nd violation within 36 days will be a $750 fine (and a loss of the ability to sell tobacco products for a week).  A 3rd violation within 36 days increases the punishment to $1,000 and 30 days of no-sell.  A 4th violation is a $1,000 and the retailer won't be able to sell tobacco products for 3 years.

Perhaps next legislative session a bill will move forward that establishes a statewide Tobacco 21 law.

SNAP: An Underused Lever to Address the Obesity Epidemic

One of the bigger policy levers to improve the nutrition decisions that people make lies with the Supplemental Nutrition Assistance Program or SNAP. By making some policy changes within the program, we could hard-wire better nutrition decisions among program participants.

The thing is that the federal government (congress and USDA) would need to take the lead to implement evidence-based policy decisions – policy changes that would have a profound impact on nutrition and obesity in the US.

To help make the case, the ADHS contracted with the ASU School of Nutrition & Health Promotion back in 2012 to write a White Paper that outlined evidence-based strategies to improve the effectiveness and efficiency of SNAP including: 1) improving access to healthy foods to provide better choices; 2) incentivizing the purchase of healthy foods; 3) restricting access to unhealthy foods; and 4) maximizing education to more effectively reach a larger population of SNAP participants.

That paper, entitled Policy Considerations for Improving the Supplemental Nutrition Assistance Program (SNAP): Making a Case for Decreasing the Burden of Obesity. Back in 2012 the ADHS team presented the recommendations and evidence at the American Public Health Association Annual Meeting that year.

This month the American Journal of Public Health published a paper on a similar topic entitled Support for Supplemental Nutrition Assistance Program (SNAP) Policy Alternatives Among US Adults

The article measures public and participant support regarding some important policy options like removing sugary drinks and candy from the allowable products for purchase list and providing SNAP participants with a supplemental benefit that could only be used for fruits and vegetables. The authors found that most respondents approved of both the restrictive policies (e.g. removing sugar drinks and candy from the buy list) and the supplemental policies tested.

Important information for Congress and the USDA to consider when the Farm Bill comes up for re-authorization next time- which will be in a few years. Honestly, with the obesity epidemic we’re facing- we really should be using all the policy levers we can to dial back obesity- but congress and the USDA have consistently resisted these policy options- perhaps out of fear of the junk food lobby?

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.

Arizona Policies, Resources and Recent Investments are Addressing Rural Healthcare Workforce Shortages

Healthcare workforce shortages often contribute to health disparities in rural AZ.  That’s because rural communities tend to have fewer physicians, nurses, specialists, and other healthcare workers…  and at the same time face higher rates of chronic disease, mental illness, and obesity than urban areas. Having enough healthcare personnel in shortage areas can contribute to those health disparities. 

Additionally, health care providers working in shortage areas can experience isolation from their peers and burnout from seeing a greater number of patients and working longer hours than those in non-shortage areas.

A critical element to ensuring an adequate healthcare workforce is to improve the reach of provider recruitment programs, which can build a strong and diverse healthcare workforce that represents the population served. 

This year was particularly successful at the Legislature as they approved an additional $750K for the state loan repayment program (bringing the total budget to $2.75M) as well as more resources for rural Graduate Medical Education ($1.6M for rural Graduate Medical Education -$5.5M w the federal match)  - which can be use to bolster graduate training in rural AZ (this GME training is really important because it’s a key factor in where a provider practices over the course of her or his career- improving rural networks). There was also an additional $750K that was invested in the North Country GME program.

Arizona Primary Care Office

Arizona is fortunate to have an effective Primary Care Office program at the ADHS’ Bureau of Women and Children’s Health along with public policies that have been passed in the state legislature that help to improve the state program’s effectiveness. 

Our in-AZ resources to improve workforce capacity and access to care in rural and underserved AZ include the Arizona State Loan Repayment Programs, J-1 Visa Waiver Program, and at the national level, the National Health Service Corps and Nurse Corps.

Our state Primary Care Office also manages data collection regarding healthcare provider shortage areas (HPSAs) and information like Primary Care Area Statistical Profiles as well as maps and a host of additional data resources.

UA Center for Rural Health

We also have terrific programs at the UA Center for Rural Health which has rural health programs like the Rural Hospital Flexibility Program (AzFlex), the Small Rural Hospital Improvement Program (AzSHIP), Arizona First Responders Initiative (FR-CARA), The Rural Health Professions Program (RHPP), Workforce Data & Analysis (CRHWorks), Arizona Rural Recruitment and Retention Network (Az3RNet), Students Helping Arizona Register Everyone (SHARE), the Prescription Drug Overdose Program, and Health Insurance Assistance.

Arizona Area Health Education Centers

Arizona also has a unique system of AZ Area Health Education Centers that are established under state law (voter approved) “… enhance access to quality healthcare, particularly primary and preventive care, by improving the supply and distribution of healthcare professionals through educational partnerships between academic and community organizations in rural and urban medical underserved areas.” 

The Program has a state office at the UA and several local AHECs that promote community and educational partnerships to enhance access to quality health care with an emphasis on the needs of rural and urban underserved communities and populations. Their missions also include educational programs in partnership with academic institutions, communities, health care agencies, and other organizations that promote the health of Arizona residents.

Arizona Rural Health Association

We're also fortunate to have the Arizona Rural Health Association (AzRHA) in our state doing advocacy for rural health.  The AzRHA was established in 1994 as an independent organization after serving as the Advisory Committee of the University of Arizona Rural Health Office (RHO) for many years. While AzRHA continues to serve as the RHO advisory body, its functions have been expanded to cover many areas involving advocacy for rural healthcare programs.

Access to healthcare is an essential component of health and wellness. By providing financial incentives for clinicians to practice and train in rural areas and by collecting data on provider shortages and using that data to make policy adjustments, Arizona is increasingly poised to make measurable improvements in rural networks as a result of this year’s legislative session decisions.

What Can You Do this Summer RE Public Health Advocacy?

Send your elected officials a short note thanking them for their service.  The last few days were long and stressful for all.  

  • Invite them to tour your facilities over the interim.  

  • "Like" your elected officials on social media and follow them.  

  • Attend any events they are holding over the summer.  

  • Monthly send them a short note with interesting information about their district and those they serve (who you also serve!)

  • Use this time during the interim to build relationships with your home and work district elected officials so they know who are when session starts January 13, 2020.

This spreadsheet has legislator contact information and committee assignments.  Targeting legislators who serve on committees of interest to us is a good strategy to start with.  This spreadsheet has our member facilities by legislative and congressional district.