Affordable Care Act

Several More Insurers Enter AZ Marketplace

Consumers who buy their health insurance from the federal marketplace at www.HealthCare.gov will have new options and new prices to consider before they make a decision for 2019 coverage. During the upcoming open enrollment period (November 1 through December 15)  there will be 4 companies to choose from with several different plans.  Pima County will go from 1 to 3 companies for 2019 and the remaining 13 counties will continue to have BlueCross BlueShield of Arizona as their HealthCare.gov insurance company.

Because financial assistance for Affordable Care Act plans is tied to the price of the price of a Silver plan in each county or zone, Arizonans will generally see more financial assistance and little, if any, change in their current monthly premium. 90% of Arizonans who get coverage from HealthCare.gov receive financial assistance in the form of refundable tax credits to help lower their monthly premium.

November 1 to December 15 is open enrollment this year at www.healthcare.gov.  Free local help from unbiased health insurance Assisters is available by calling 1-800-377-3536 or by visiting www.CoverAZ.org/Connector.

Kids Care & ACA Advocacy

Election season is upon us and KidsCare and healthcare generally are key issues we want candidates for state office to weigh in on.  The Children’s Action Alliance has a helpful election’s page up and running now!  On it you can link to it to point the communities your organization serves to where they can contact candidates, see where candidates stand on issues, and register to vote. CAA is also launching a digital ads campaign around the key questions for candidates today.

Here’s is a fact sheet from Families USA explaining what’s at stake for people with pre-existing conditions in Arizona. The issue is a bit complicated to understand, but here goes for anyone that’s interested. Currently, there is a lawsuit, Texas v Azar, making its way through the courts that challenges the ACA as unconstitutional. 

Arizona Attorney General Mark Brnovich has signed Arizona on as a plaintiff state. If the lawsuit is successful, the protections for people with pre-existing conditions, along with other parts of the ACA, will be repealed.  

We don’t know the timetable on a final court decision, but we do know that, if the lawsuit is successful, Arizona’s law is set up so that these protections will essentially be repealed simultaneously in state statute.

State Action to Stem Rising Prescription Drug Costs

By Association for State and Territorial Health Officials Staff

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

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

 

Drug Price Transparency

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

 

Price-Gouging and Rate Setting Requirements

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

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

 

Drug Importation

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

 

Generic Drugs

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

 

Pharmacy Benefit Managers

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

 

Other State Policies

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

 

Future Opportunities

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

Legal Defense of the Affordable Care Act

A few months ago, Texas and 19 other states (including AZ) launched a new legal effort to eliminate the Affordable Care Act.  Fortunately, California and 15 other states intervened as defendants in the lawsuit, because they were worried that the President’s administration wouldn’t defend the ACA.

Earlier this month the Department of Justice filed a pleading that agreed with TX, AZ and the other 18 states.  Instead of defending the ACA as is customary, the DOJ argued that several crucial provisions of the ACA are unconstitutional and announced that it would not defend those provisions in court (3 career DOJ attorneys removed their names from the brief and one quit a few days later).  CA and other states will be defending the ACA and argue on its behalf in court. 

If the Intervenor states lose the case, insurers could invoke pre-existing conditions to refuse coverage or increase premiums and could underwrite coverage based on gender, age, and occupation.  

Here’s a useful summary of the case written by the National Health Law Program.

Policy Update: Family Planning, ACA Lawsuit, Work Requirements and Assault Weapons

Summer & Fall Public Health Activities in AZ

Interested in finding out about the various public health conferences, meetings and events this Summer and Fall?  

Bookmark our AzPHA Upcoming Events webpage.  It’s as simple as that.  If I’ve missed something- let me know at willhumble@azpha.org!

 

Proposed Title X Funding Changes Likely to be a PH Burden

The US Department of Health and Human Services has proposed changes to the rules for the federal family planning services program, known as Title X.  If the new rules are adopted as proposed, it’ll require Title X family planning services to be physically and financially separate from abortion services.

Many family planning clinics offer both family planning and abortion referral services, and if the changes are ultimately implemented many of the programs would likely decide not to take Title X funding, which would have a big impact on the network of available services and they’d have fewer resources available for STD screening, treatment and outreach.

BTW: Title X funds have never been allowed to be used for abortions. The proposed rule is available for public comment until the end of July.  You can read more about the proposed rule and comment by visiting the Federal Rulemaking Portal: http://www.regulations.gov. Just follow the instructions to submit.  Your comments might not influence the outcome, but at least you’ll have done your part. That and voting this Fall.

 

Federal Government Won’t Defend the Affordable Care Act in Court

So far, the Affordable Care Act has survived the 2 court challenges that made it to the US Supreme Court.  Back in 2012 the ACA was upheld by the Supreme Court for the first time (by a 5-4 margin) in the National Federation of Independent Business v. Sebelius case.   It was upheld again in 2015 when (in a 6-3 decision) the Supreme Court upheld ACA’s federal tax credits for eligible Americans living in all 50 states (not just the 34 states with federal marketplaces).

But, there are additional challenges out there that haven’t made it to the Supreme Court yet. One that’s progressing through the courts is a challenge filed by 20 states (including Arizona) arguing that the ACA’s individual mandate is unconstitutional and key parts of the act — including the provisions protecting those with pre-existing conditions — are invalid. 

This week Attorney General Jeff Sessions acknowledged that while "the Executive Branch has a longstanding tradition of defending the constitutionality of duly enacted statutes if reasonable arguments can be made in their defense," the Attorney General will not defend the ACA from this challenge.  

The implications could be profound.  The ACA could potentially be completely overturned- or portions that require health plans to cover pre-existing conditions could be eliminated along with the mandate that persons have health insurance.

 

Medicaid Work/Community Engagement & Reporting Requirements

Any day now, the Centers for Medicare and Medicaid Services (CMS) will be approving Arizona’s request to include work requirements and/or community engagement and reporting requirements as a condition of Medicaid enrollment.  The request filed by AHCCCS is required by Senate Bill 1092 (from 2015) which requires them to ask CMS’ permission to implement new eligibility requirements for “able-bodied adults”.

AHCCCS initially proposed implementing the following requirements for able-bodied adults receiving Medicaid services including: 1) a requirement for all able-bodied adults to become employed or actively seeking employment or attend school or a job training program; 2) requiring able-bodied adults to verify monthly compliance with the work requirements and any changes in family income; 3) banning an eligible person from enrollment for one year if the eligible person knowingly failed to report a change in family income or made a false statement regarding compliance with the work requirements; and 4) limiting lifetime coverage for all able-bodied adults to five years except for certain circumstances.

Hundreds of comments were submitted (including comments from AzPHA) urging the agency to consider modifications to the initial waiver request.  AHCCCS later issued a final waiver request which includes exemptions for:

  • Those who are at least 55 years old;
  • American Indians;
  • Women up to the end of the month in which the 90th day of post-pregnancy occurs;
  • Former Arizona foster youths up to age 26;
  • People determined to have a serious mental illness (SMI);
  • People receiving temporary or permanent long-term disability benefits from a private insurer or from the government;
  • People determined to be medically frail;
  • Full-time high school students older than 18 years old;
  • Full-time college or graduate students;
  • Victims of domestic violence;
  • Individuals who are homeless;
  • People recently been directly impacted by a catastrophic event such as a natural disaster or the death of a family member living in the same household;
  • Parents, caretaker relatives, and foster parents; or
  • Caregivers of a family member who is enrolled in the Arizona Long Term Care System

A subsequent letter from the AHCCCS Administrator suggested that they (AHCCCS) are suspending their request for a 5-year limitation on lifetime benefits (for some members) for now.  Here’s our letter from back in February of 2017. 

 

Kaiser Family Foundation Issue Brief on Work Medicaid Requirements

Last month the Kaiser Family Foundation published an Issue Brief regarding CMS’ recent decisions to grant states the ability to experiment with their Medicaid programs that condition Medicaid eligibility on work or community engagement. The Issue Brief examines evidence of the effects of the Medicaid expansion and some changes being implemented through waivers.

Many of the findings on the effects of expansion are drawn from the 202 studies included in our comprehensive literature review that includes additional citations on coverage, access, and economic effects of the Medicaid expansion.

Regarding work requirements, the Brief concludes that “state-specific studies in Colorado, Kentucky, Michigan, Pennsylvania and most recently Montana and Louisiana have documented or predicted significant job growth resulting from expansion. No studies have found negative effects of expansion on employment or employee behavior. In an analysis of Medicaid expansion in Ohio, most expansion enrollees who were unemployed but looking for work reported that Medicaid enrollment made it easier to seek employment, and over half of expansion enrollees who were employed reported that Medicaid enrollment made it easier to continue working.  Another study found an association between Medicaid expansion and increased volunteer work in expansion states.

Furthermore, “work requirements have implications for all populations covered under these demonstrations. Those who are already working will need to successfully document and verify their compliance and those who qualify for an exemption also must successfully document and verify their exempt status, as often as monthly. States would incur costs to pay for the staff and systems to track work verification and exemptions.”

If you’re interested in the public health policy implications of our upcoming work/community engagement and reporting requirements, the KFF Issue Brief is a must-read.

 

Court Challenge to Kentucky’s Work Requirements being Heard this Week

Oral arguments are being heard this week in DC challenging Kentucky’s requirements that members work or participate in "community engagement" activities such as job training, school or volunteering. The case was filed in January by the National Health Law Program, the Kentucky Equal Justice Center and the Southern Poverty Law Center.  The outcome could have implications for AZ’s upcoming requirements.

Read National Health Law Program's guide on what to expect from oral argument.

American Medical Association Endorses Assault Weapon Ban

The American Medical Association – Nation’s largest physician group – endorsed a ban on assault weapons as part of a package of measures aimed at combating the epidemic of gun violence in the US. The member driven initiative was endorsed at their annual policy conference. They also endorsed a ban on bump stocks, which basically turn semi-automatic rifles into automatic weapons. 

In a statement AMA Immediate Past President David O. Barbe, MD, MHA said: “People are dying of gun violence in our homes, churches, schools, on street corners and at public gatherings, and it’s important that lawmakers, policy leaders and advocates on all sides seek common ground to address this public health crisis, in emergency rooms across the country, the carnage of gun violence has become a too routine experience.”

 

AZ Public Health Policy Update: April 23, 2018

Feds Overhaul Essential Health Benefit Options

The Affordable Care Act required all health insurance policies sold on the Exchange and in the small group & individual markets to cover as set of “essential health benefits”.   Each Governor selects their state’s essential health benefits by choosing among options like their state employee plan, a small group market plan etc.  Each state has 10 options to pick from.  Governor Brewer selected the state employee plan as Arizona’s benchmark and Ducey did the same a couple of years ago.  Not a bad choice, because the benefits are generally robust- except that since the state employee plan doesn’t cover abortion services the state benchmark doesn’t either (although non-Medicaid plans can elect to cover those services).

Last week the Centers for Medicare & Medicaid Services issued an annual "Notice of Benefit Payment Parameters for 2019“. It outlined a big change.  Beginning in 2019 CMS will be giving Governors a lot more flexibility in selecting their state’s essential health benefit package.  Instead of 10 options, states will be able to choose among any of the essential health benefit benchmark plans used by any other state.  The new rules could have a profound impact on health insurance access and benefits.

It remains to be seen whether our Governor will choose a different benchmark plan moving forward.  Here’s a list of the various states’ insurance benefits benchmark mandates: [EHBs by State]

Legislative Session Update

The Governor vetoed 10 bills last Friday - apparently to send a message to the legislature that he wants the "20% by 2020" teacher funding bill on his desk forthwith. 

Luckily, the Community Health Worker voluntary certification bill needed to go back to the House for a Final Read- or it’s quite possible that it would have been veto number 11.  He did veto a good bill HB 2089 which would have required school districts to develop guidelines, information and forms on the dangers of heat-related illnesses, sudden cardiac death and prescription opioid use.

Last week was a busy one for the bills that we’re working on, so this update will be long again.  Once the session is over my updates will get shorter, I promise!

SB 1389   HIV; needs assessment; prevention was signed by the Governor last week.  It requires the ADHS to establish and implement an HIV Action Program to: 1) complete a statewide HIV Prevention and Care Needs Assessment (Assessment) of target populations (by November 1, 2020); 2) identify community-based agencies that serve the HIV population and that are outside of the known HIV service system; 3) conduct outreach to increase community involvement in HIV prevention, education and stigma reduction; 4) develop a social media initiative to engage at-risk populations to be tested for HIV infection; and 5) analyze data from the Assessment annually to develop and implement HIV training and education initiatives.

SB 1445 AHCCCS Dental care, pregnant women cleared the full Senate but still needs a House Rules hearing and a floor vote. It'll need an appropriation (to provide oral health coverage to pregnant Medicaid members)… so much of the discussion right now is about how much it would cost.

The direct cost to AHCCCS is estimated to be a little less than $268K/year.  However, the Joint Legislative Budget Committee (JLBC) believes that it could have secondary costs. Their thinking goes something like this: pregnant Medicaid enrollees that are not yet receiving prenatal care will discover that there's an oral health benefit and will make a dental appointment. The hygienist or dentist will discover the pregnancy and inform their health plan about the pregnancy. At that point, their eligibility category would switch to one with a higher state match rate (and presumably begin receiving prenatal care- which if it happened would be a good thing). 

The JLBC analysis assumes that 25% of the estimated 5,000 pregnant women currently enrolled in the expansion population but not receiving prenatal care will, because of the new benefit, go to the dentist- causing their eligibility to change (to a category called SOBRA), generating a $3.7M refinancing cost. 

Honestly, it seems unlikely to me that women who aren’t getting prenatal care will present to a dentist or hygienist for a cleaning.  I can see it if they have a toothache, but any secondary cos from a dental emergency would be associated with last year’s emergency dental benefit - not this new (proposed) preventative oral health benefit.  We’ll see what happens during the upcoming budget process.

A new problem is that the effort to raise teacher’s pay is probably going to jeopardize many programs that may have otherwise been funded, like this one.  It’s still possible that this might happen- but it’s a lot less likely now because of the effort to raise teacher’s salaries 20% by 2020.

HB 2159 traffic violations; traffic survival school has been languishing for the last few weeks.  Last week the bill passed the House and has been assigned a Conference Committee to resolve the differences with the Senate version.  This would prohibit drivers from “using a portable wireless communication device to read, write, or send an electronic message while driving” (unless the car is stopped).  The first violation would be a petty offense with a fine between $25 and $99.

HB 2228 Annual waiver, applicability was signed by the Governor this week.  It’s good. It will direct AHCCCS to exempt tribes from their directed waiver request that asks for CMS permission to implement work requirements for some Medicaid members.  The recently submitted Waiver request includes an exemption for American Indians, however, this would place the exemption into statute.

HB 2235 dental therapy; regulation; licensure has had a long and somewhat bizarre trip through the legislature.  The original bill (SB 1377) would have set up a new licensed class of dental professionals called a Dental Therapist.  Their scope of practice would be somewhat less than a DDS, but they could do some procedures like filling cavities.  They could also practice anywhere.  The original bill passed the Senate but died in the House Health committee.  It came back to life a couple of weeks ago as what’s called a Strike Everything Amendment but stalled out again.  Then, this week, an amendment to the amendment was offered that seems to please everybody- and it passed the Senate 30-0.  It still needs to go back to the House, but it has a real chance now.

The Senate version limits dental therapists to only practicing at a Federally Qualified Community Health Center (or look-alike), or a nonprofit dental practice or organization that provides dental care to low-income and underserved individuals, or a private dental practice that provides dental care for CHC patients of record.  The amended bill also prohibits a dental therapist from performing nonsurgical extractions of permanent teeth unless under the direct supervision of a dentist.

The “school safety” bill called SB 1519 protective orders; schools; appropriations was proposed late last week by Senator Smith. Here’s a link to the introduced version.  It contains many of the things outlined by the Governor a few weeks ago related to firearms, schools and protection orders. A centerpiece is something called a “Severe Threat Order of Protection” which outlines a process to restrict firearm access for people who are a danger to themselves or others. There are also measures that would require AHCCCS to develop and post suicide prevention training and a statewide school safety hotline would also be established. 

There’s no provision in the bill for comprehensive background checks or restrictions on things called “bump stocks” which makes guns fire quicker. There are some other troublesome parts of the bill. 

Our folks in the Public Health Policy Committee (including AzPHA member Jean Ajamie who is a school safety expert) has been doing some analysis of the bill (you can see that stuff on our Committee Basecamp- let me know if you’d like to join that group). We haven’t taken a position yet- most likely we’ll remain neutral.  The bill passed the Senate Commerce and Public Safety Committee this week. Next week will be the Senate Rules Committee.  There’s no mirror bill in the House at their point.  Stay tuned.

HB 2323  Schools; inhalers; contracted nurses was signed by the Governor this week.  This bill adds contracted nurses to the list of people who are authorized to provide emergency inhaler medication in case of respiratory emergencies. Some charter and independent schools don’t employ nurses directly but engage them through contracts.

HB 2324 Community health workers; voluntary certification was passed by the Senate this week (24-6)!  It passed the Senate in an amended form (including a provision to ensure that state procurements don’t favor contracting with certified vs non-certified CHWs).  There are two important steps left.  Because the Senate amended the House bill, it needs to go back to the House where Rep. Carter will likely formally concur with the Senate changes.  Then it needs a “Final Read” vote in the House to formally agree with the amendments the Senate added.  Assuming it passes the House again, then it’s on to the Governor for his approval (hopefully) The Senate amendments got the Goldwater Institute to be neutral- so I think we’re in good shape for a signature.

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Here’s a snapshot of where the various bills we’re working on are in the system. 

HB 2038 Drug overdose review teams; records (Signed into Law)

HB 2071 Rear-facing car seats (Stalled in Senate)

HB 2084 Indoor tanning; minors; restricted use (Now called SB 1290 as Striker) 

HB 2127 Children's health insurance program (Now called SB 1087 as Striker)

HB 2197 Health professions, workforce data (Ready for Senate Floor Vote)

HB 2208 Prohibition, photo enforcement (Effectively dead)

HB 2228 Annual waiver, applicability (Signed by Governor)

HB 2323 Schools; inhalers; contracted nurses (Ready for Senate Floor Vote)

HB 2324 Community health workers; voluntary certification (Senate floor vote this week)

HB 2389 Syringe access programs; authorization (Basically dead)

HB 2484 local food tax; equality (Signed by Governor)

SB 1022 ADHS; homemade food products (Signed by Governor) 

SB 1083 Schools; recess periods (Signed by Governor)

SB 1245 Snap Benefit Match (Needs Rules Committee & Budget Line)

SB 1261 Texting while driving (Now HB 2159 traffic violations; traffic survival school)

SB 1420 Medical marijuana; inspection; testing; appropriation (Needs House Rules)

SB 1445 AHCCCS Dental care, pregnant women (Needs House Rules Committee)

SB 1377 Dental therapy, licensure, regulation (Failed in House now HB2235 in Senate)

SB 1394 Abortion reporting (Signed by Governor)

SCR 1005 Voter Initiative Sunset (striker in the House)

 

Public Health-related bills that have been passed and signed:

HB 2038 Drug overdose review teams; records was passed and signed.  Once it takes effect later this year, law enforcement agencies will now be required to provide unredacted reports to the chairperson of a local Drug Overdose Fatality Review Team on request. 

HB 2228 Annual waiver, applicability was signed by the Governor.  It’s good. It will direct AHCCCS to exempt tribes from their directed waiver request that asks for CMS permission to implement work requirements for some Medicaid members.  The recently submitted Waiver request includes an exemption for American Indians, however, this would place the exemption into statute.

HB 2323  Schools; inhalers; contracted nurses was signed by the Governor.  This bill adds contracted nurses to the list of people who are authorized to provide emergency inhaler medication in case of respiratory emergencies. Some charter and independent schools don’t employ nurses directly but engage them through contracts.

HB 2484 local food tax; equality, which will ban Arizona cities and counties from taxing sugary drinks as a public health intervention.

SB 1022  DHS; homemade food products ADHS will be required to establish an online registry of food preparers that are authorized to prepare "cottage food products" for commercial purposes. Registered food preparers would be required to renew the registration every three years.

SB 1083 Schools; recess periods was passed and signed!  Beginning next school year K-3 will need to have at least 2 recess periods. Grades 4 and 5 will need to have 2 recess periods the year after that.

SB 1389  HIV; needs assessment; prevention was signed by the Governor last week.  It requires the ADHS to establish and implement an HIV Action Program. 

SB 1394 Abortion reporting was passed by the House and signed by the Governor.  It will require the ADHS to collect and report additional data regarding abortions that are performed in AZ.

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House Bills

HB 2038 Drug overdose review teams; records                

Passed and Signed

Law enforcement agencies will now be required to provide unredacted reports to the chairperson of a local Drug Overdose Fatality Review Team on request.  All information and records acquired by a Team are confidential and not subject to subpoena, discovery or introduction into evidence in a civil or criminal proceeding or disciplinary action.

HB 2071 Rear-facing car seats         

Stalled in Senate

This Bill would require kids under 2 years old to be in a rear-facing restraint system unless the child weights at least 40 pounds or is at least 40 inches tall.  We’ve signed up in support of this bill.  No action has yet been taken in the Senate so this bill is effectively dead.

HB 2084 Indoor tanning; minors; restricted use

Passed House but Stalled in Senate- now SB1290

This bill had been languishing in the Senate after passing the House by a 45-15 vote. Because of its lack of movement in the Senate it had appeared to be dead again this year.  However, this week it reappeared as a Strike All amendment in the House again as SB 1290.  It has now passed the House and has been sent back to the Senate.

HB 2127 Children's health insurance program

Stalled in Senate- now SB 1087 in House

After passing the House, this bill had been languishing in the Senate and appeared dead.  However, it was resurrected this week in the form of SB 1087 and was passed again by the House Health Committee last Thursday.  It still needs another House floor vote before it goes back to the Senate again.  It would remove the trigger that automatically freezes the KidsCare program if FMAP (the federal contribution) drops below 100%. 

It allows the state to freeze it if costs are more than the state or federal allotment. The bill does not require the state to appropriate any money for a state share.  We’ve signed up in support of this bill because it provides a pathway to keep KidsCare if the federal government drops its contribution level. 

HB 2197 Health professions, workforce data

Ready for Senate Floor Vote

This bill is looking good and ready for a final Senate floor vote.  It would require AZ health licensing boards to collect certain data from applicants (beginning January 2020) to get better data about health professions workforce distribution and needs.  The data would be confidential.  Over the long-term this bill would be helpful in providing better data with which to improve the distribution and capacity of the public health workforce in Arizona.

HB 2208 Prohibition, photo enforcement

Died in Senate

This one would prohibit cities and other jurisdictions from having photo enforcement of red light and speeding violations.  While nobody likes getting a ticket in the mail, the data suggest that photo enforcement saves lives and prevents injuries (especially red-light photo enforcement).  We’ve signed up in opposition to the bill.  This bill passed the House 31-27 but stalled in the Senate.  Honestly, it looks dead.

HB 2228 Annual waiver, applicability

Signed by Governor

This would direct AHCCCS to exempt tribes from their directed waiver requests to CMS asking permission to implement work requirements for some Medicaid members.  The recently submitted Waiver request includes an exemption for American Indians, however, this would place the exemption into statute.

HB 2323   Schools; inhalers; contracted nurses

Signed by Governor

This bill adds contracted nurses to the list of people who are authorized to provide emergency inhaler medication in case of respiratory emergencies. Some charter and independent schools don’t employ nurses directly but engage them through contracts.

HB 2324 Community health workers; voluntary certification

Needs Final Read in House

This was passed by the Senate this week (24-6)!  It was in an amended form (including a provision to ensure that state procurements don’t favor contracting with certified vs non-certified CHWs).  There are two important steps left.  Because the Senate amended the House bill, it needs to go back to the House where Rep. Carter will likely formally concur with the Senate changes, and then it needs a “Final Read” vote in the House to formally agree with the amendments the Senate added.  Assuming it passes the House again, then it’s on to the Governor for his approval (hopefully) The Senate amendments got the Goldwater Institute to be neutral- so I think we’re in good shape for a signature.

HB 2389 Syringe access programs; authorization 

Dead

This basically looks dead for this year. The bill that passed the House was great- providing clear decriminalization of needle exchange programs (needle exchange programs are technically a class 6 felony right now).  The version that passed the Senate only decriminalizes syringe exchange programs when and where the ADHS declares a public health emergency because of the rapid spread of infectious diseases.

It went to a Conference Committee this consisting of Rivero, Navarrete, Udall, Borelli, Brophy McGee, and Mendez… but Wednesday, Brophy McGee was replaced with Petersen, basically killing the House version- and the bill was dropped from the Conference Committee agenda- basically killing it.  Honestly, the Senate version of the bill wouldn’t have helped public health much if it all. Maybe next year.

HB 2484 local food tax; equality

Signed by Governor

The Governor signed this bill, which bans Arizona cities and counties from taxing sugary drinks as a public health intervention. The bill doesn’t specifically mention taxes on sugary drinks, but states that any tax on food needs to be uniform.  products must be uniform. Right now, there aren’t any Arizona cities or counties that are taxing soda and other sugary drinks, and this new law will ensure that it stays that was. 

 

Senate Bills

SB 1022    DHS; homemade food products            

Signed by Governor

ADHS will be required to establish an online registry of food preparers that are authorized to prepare "cottage food products" for commercial purposes. Registered food preparers would be required to renew the registration every three years. This is a sensible addition to the current cottage industry food law and we’ve signed up in support.

SB 1083    Schools; recess periods

Signed by Governor

This was passed and signed!  Beginning next school year K-3 will need to have at least 2 recess periods.  Grades 4 and 5 will be added the following year. This makes AZ a national leader in state school recess policy. A big shout out to AzPHA member Scott Turner and Christine Davis from Arizonan’s for Recess for their heavy lifting to make this happen!

SB 1245 Snap Benefit Match

Needs House Rules Committee and Budget Line Item

This Bill needs House Rules review before a House floor vote (and of course needs to make it through the budget process). This good Bill would appropriate $400K to ADES to develop a produce incentive program within the Supplemental Nutrition Assistance Program for members to buy Arizona-grown fruits and vegetables.  It would also provide matching funds to SNAP-authorized vendors as an incentive to participate in the fruits and vegetable program. 

SB 1261 Texting while driving

Now HB 2159 and Moving Again in House

This has been languishing for the last few weeks because it hasn’t been called up for a floor vote in the Senate.  Last week, the language from SB 1261 was added as an amendment onto HB 2159 traffic violations; traffic survival school.  This bill, with the addition of the texting language, passed the House and is headed back to the Senate and has been assigned a Conference Committee.

This would prohibit drivers from “using a portable wireless communication device to read, write, or send an electronic message while driving” (unless the car is stopped).  The first violation would be a petty offense with a fine between $25 and $99.

SB 1377 Dental therapy, licensure, regulation

Moving Again in Amended Form

This has had a long and somewhat bizarre trip through the legislature.  The original bill (SB 1377) would have set up a new licensed class of dental professionals called a Dental Therapist.  Their scope of practice would be somewhat less than a DDS, but they could do some procedures like filling cavities.  They could also practice anywhere.  The original bill passed the Senate but died in the House Health committee.  It came back to life a couple of weeks ago as what’s called a Strike Everything Amendment but stalled out again.  Then, this week, an amendment to the amendment was offered that seems to please everybody- and it passed the Senate 30-0.  It still needs to go back to the House, but it has a real chance now.

The Senate version limits dental therapists to only practicing at a Federally Qualified Community Health Center (or look-alike), or a nonprofit dental practice or organization that provides dental care to low-income and underserved individuals, or a private dental practice that provides dental care for CHC patients of record.  The amended bill also prohibits a dental therapist from performing nonsurgical extractions of permanent teeth unless under the direct supervision of a dentist.

SB 1394 Abortion reporting

Signed by Governor

This one would require the ADHS to collect and report additional data regarding abortions that are performed in AZ. The data would be collected and reported by providers and would include the reason for the abortion (economic, emotional health, physical health, whether the pregnancy was the result of rape or incest, or relationship issues etc.).

SB 1420 Medical marijuana; inspection; testing; appropriation

Needs House Rules Approval

This would require the ADHS to set up testing standards for medical marijuana and begin enforcing the standards beginning in 2019.  We’re supporting this legislation.  It passed the full Senate last week and was given a Pass recommendation by the House Military, Veterans & Regulatory Affairs Committee this week.

SB 1445 AHCCCS Dental care, pregnant women

Needs House Rules and Floor Vote & a Budget Line Item

This unanimously cleared the House Appropriations committee last week.  We were hoping to get a Rules committee hearing next week, but it’s not on the agenda, sadly.  The big hurdle will be getting an appropriation to cover the state match into the budget.

SB 1470  Sunrise process; health professions

After a dramatic start, this bill looks like it will have a consensus ending.  The sunrise process bill stakeholders negotiated changes to the current scope of practice sunrise process that everybody seems to be able to live with.  It passed in House this week by a 59-0 vote. It’s now ready for the Senate to concur in the House’s amendment.

AzPHA Public Health Policy Update- November 2, 2017

ASU’s Executive Fellowship in Health Policy Accepting Applications

ASU’s College of Nursing and Health Innovation has developed a new fellowship program for health professionals interested in policy and advocacy and is taking applications through November 30th. The Executive Fellowship in Health Policy is a one-year cohort-based program, providing health leaders in-depth insights into the public policy world. Fellows will build connections and skills enabling them to lead change within their organizations to advocate for the work that they do and the populations they serve.

Fellows will also learn about health policy directly from the people who shape it. Through in-person immersions, webinar presentations, and online modules, lawmakers and health advocates from around the country will provide an intimate look at the politics and policy changes actively shaping our health systems today. Faculty mentors will guide and support Fellows to further develop their skills as effective health advocates through the creation of a tangible project based on a real-world situation from their organization.

The program has been developed by Faculty Director and Assistant Dean Heather Carter, EdD. Her vision for this new program is to empower health professionals to be more involved in the health policy arena. In addition to her work at ASU, Dr. Carter serves as an Arizona State Representative & Chairwoman of the House Health Committee.

The program is currently accepting applicants through November 30, 2017. Program tuition is $16K for the year, plus travel expenses for two in-person immersions located in Phoenix, AZ and Washington, D.C.

More information about the Fellowship and the application process can be found at efhp.asu.edu, or by contacting the project manager at efhp@asu.edu or 602-496-0414.

 

North Country HealthCare Receives Accreditation for Residency Program

Congrats to North Country HealthCare for achieving final accreditation last week from the Accreditation Council for Graduate Medical Education for their Family Medicine Residency Program.  The new program will improve access to comprehensive, affordable, culturally competent primary care across northern Arizona by increasing the number of practicing primary care physicians for years to come.

The program will engage family medicine residents in rotations throughout North Country HealthCare’s service region of Coconino, Mohave, Navajo and Apache Counties with rural rotations in Tuba City, Polacca and Whiteriver.

This novel residency program will help prepare family medicine physicians for autonomous practice in rural and frontier northern Arizona and will be the only graduate medical education program in the country with a required rotation in Indian Country.

A huge shout out to AzPHA member and NAHEC Executive Director Sean Clendaniel, MPH who’s the brain-child and work-horse behind the effort. Next we need to replicate the model in other areas of rural AZ. 

We all know that we have an acute physician shortage in rural AZ- and rural residency programs are probably the single most effective long-term tool we have to intervene- because where a physician does their residency has a huge impact on where they decide to practice.

 

Open Enrollment for Marketplace is Here through December 15

Open enrollment for the Marketplace insurance plans under the Affordable Care Act started today and runs through December 15.  We're recommending that folks that are interested in getting their health insurance through the federal Marketplace by going to  coveraz.org/connector first (rather than healthcare.gov) because the assisters and navigators at coveraz.org/connector are more familiar with the AZ products as well as our state's Medicaid programs.

Make sure everyone who needs coverage knows this: a convenient assister appointment is just clicks away, at coveraz.org/connector or by calling the Coalition’s statewide assistance line at 800-577-3536.

 

CMS Proposes New Rule Letting States Define their Own “Essential Health Benefits”

Late last Friday the Centers for Medicare and Medicaid Services released a proposed rule that would allow states to define the minimum essential health benefits that health insurers selling plans on the Affordable Care Act exchanges are required to offer. 

The proposed rule would give states greater latitude in choosing which benefits insurers must cover.  Perhaps most significantly, it would allow states to choose a benchmark plan from wider pool of existing plans including health plans from other states. Each state’s “benchmark plan” defines what essential benefits other Marketplace plans must cover. Right now, Governors choose each state’s benchmark plan from a list of existing state plans in various categories.  Governors Brewer & Ducey each chose the State of Arizona EPO Employee Health Plan as Arizona’s benchmark.

CMS' stated goal is to give states more flexibility that could potentially lead to more affordable health plan options in 2019. They concede the changes some states will make will result in less comprehensive plans and dropped services.

The ACA requires health plans on the individual and small group markets to cover 10 minimum essential health benefits including emergency services, hospitalization, prescription drug coverage, maternity care and care for mental health and substance abuse disorders.  What this new proposal essentially does is allow states to weaken (but not eliminate) the 10 essential services. The proposal bars states from making their essential health benefits more generous than they are currently.

For example, if the new rule is implemented, states could choose an employer plan with 5,000 enrollees that excludes inpatient mental health services or coverage for HIV or AIDS as their benchmark- and that plan would be considered OK.

The proposed rule is almost 400 pages long.  AzPHA is planning to work with other stakeholders in Arizona and coordinate comments to CMS on their proposed rule.

 

House Vote this Week Would Cut the Prevention & Public Health Fund

This week the U.S. House will be voting on a bill that will cut critical funding from the Prevention and Public Health Fund to offset the cost of funding community health centers and other important health programs that have expired.

Established in 2010 as the nation’s first funding stream dedicated to improving public health, the Fund invests over $9 million per year to protect Arizona from disease outbreaks and to reduce downstream health care costs.  We wrote a report that examines the Fund’s investments in Arizona, which include immunizations, smoking cessation, diabetes prevention, opioid treatment, and more.

While AzPHA supports reauthorizing funding for community health centers and the National Health Service Corps, we don’t support doing it at the expense of the prevention fund and the important public health programs that already depend on this funding.

Take the time to contact your representative and tell them to oppose the CHAMPION Act and any future effort to undermine the integrity of the Prevention and Public Health Fund!

 

HHS Acting Secretary Declares Opioid Epidemic a Public Health Emergency

Last week the Acting Secretary for HHS declared that the national opioid epidemic is a Public Health Emergency under Section 319 of the Public Health Service Act. Here’s the Secretary’s one sentence declaration.

Section 319 authorizes the HHS Secretary to lead federal public health and medical response to public health emergencies, determine that a public health emergency exists, and assist states in their response activities.

The Secretary’s declaration was only one sentence long- so there’s not much detail about what they might do, but among the things that HHS could do are: 1) waive or modify certain requirements under Medicare, Medicaid and HIPAA; 2) waive certain prescription and dispensing requirements; and 3) adjust Medicare reimbursement for certain Part B drugs.

The most meaningful things that they could do include;

  • Removing the Medicaid Institutions for Mental Diseases (IMD) exclusion to allow facilities to receive reimbursement for substance abuse treatment (the IMD exclusion prohibits the use of Medicaid financing for care provided to most patients in residential treatment facilities larger than 16 beds);

  • Allowing Medicaid to pay for substance abuse treatment in correctional facilities; and

  • Allowing physicians to treat more patients with Suboxone.

Right now we don’t know which if any of these things HHS will choose to do because they haven't disclosed their plans and the one sentence emergency declaration provides no detail.

AzPHA Public Health Policy Update - October 24, 2017

Health Profession Sunrise Applications to be Heard November 28

Whenever health related professions ask to be regulated or want to expand their scope of practice a state law (A.R.S. § 32-3103) says that the regulation needs to be done only to protect the public interest.  Here are the standards that define “public interest”:

  • If the unregulated practice harms or endangers the public, health safety or welfare and the potential for harm is easily recognizable and not remote or dependent on tenuous agreement;
  • If the public needs and can reasonably be expected to benefit from an assurance of initial and continuing professional ability; and
  • If the public can’t be effectively protected by other means in a more cost beneficial manner.

Applicants that want to go through the process need to submit a report to the state legislature explaining the factors demonstrating that their request meets these standards. A “Committee of Reference” studies the sunrise applications and delivers its recommendations to House and Senate leadership. 

This year there are 3 applications in the hopper and they’ll be heard on Tuesday, November 28 starting at 9 am in one of the rooms over at the legislature (I don’t know where yet).  I’ve included links below to the 3 sunrise applications for this year.

In a nutshell the Community Health Worker application asks for a pathway to set up a process for voluntary registration of CHWs; the Naturopath application would like permission for them to sign medical waivers from the state’s school vaccination requirements; and the Dental Therapist application asks for authorization from the legislature to license a new class of dental professionals.

We’re for sure in favor of the CHW application.  We’re going to dig a little deeper before making a decision about the other two.  We’re in the process of setting up a Policy Committee call next week to discuss the Naturopath and Dental Therapist applications.

 

Huge Hearing this Week in State Supreme Court

There’s a super-important hearing this Thursday in the State Supreme Court.  The outcome of the Biggs v. Betlach case will decide whether thousands and thousands of current Arizona Medicaid members (childless adults) will lose their AHCCCS eligibility and possibly causing a cascade of events jeopardizing coverage for the Medicaid expansion population (FPL of between 100 – 138%).

Oral Arguments on the Biggs v. Betlach case are Thursday, October 26 starting at 9 am at the Arizona Supreme Court at 1501 West Washington in Phoenix (Case CV-17-0130-PR).  In a nutshell- the case is about whether the hospital assessment that’s used to fund the state match for “childless adults” enrolled in AHCCCS is a fee or a tax.

When Arizona expanded our Medicaid program (AHCCCS) to cover people up to 138% of poverty we used a provision in the ACA that allows states to expand coverage with the federal government absorbing all the cost at first.

To qualify, AZ had to first restore coverage for “childless adults” that have income below the federal poverty level (a group that lost AHCCCS coverage during the recession).  AZ paid for covering the childless adults with an assessment (fee) on hospitals set by AHCCCS (right now it’s about $264M).

The bill that authorized the hospital assessment barely passed with just over 50% of the House and Senate.  Many of the lawmakers that voted “no” (and the Goldwater Institute) believe that the assessment is not a fee, but a tax, and requires a supermajority of 2/3 of each chamber in order to pass (a voter initiative requires laws that raise taxes to have a supermajority).

If the Court agrees with the Plaintiffs that the assessment is a tax and not a fee, AHCCCS wouldn’t be able to collect the $264M hospital assessment and there won’t be enough money to fund the childless adults…  which could also jeopardize our coverage for the expansion population (people between 100 – 138% of the federal poverty level). 

Unless the legislature were to vote by a 2/3 majority to fund the program, the only path to keeping the coverage would be via a voter initiative- which just got a lot harder with the passage and signing of HB 2404 (preventing signature gatherers from getting paid by the signature) and HB2244 (changing the citizen's initiative compliance standard from "substantial compliance" to "strict compliance").

 

Leaders Across Borders Applications Due 11/10/17

The U.S.-Mexico Border Health Commission was is currently seeking candidates for the 2018 Leaders across Borders Program.   Leaders across Borders (LaB) is an advanced leadership development program funded by the U.S.-Mexico Border Health Commission aimed at building the binational leadership capacity of public health, health care, and other community professionals working to improve the health of communities in the U.S.-México border region. 

This program is intended for public health, health care, and other community-sector leaders who meet the following requirements:

  • Are proficient in English and Spanish with an understanding of both languages, translation will not be provided at in-person learning event;
  • Have at least five years’ experience working in the U.S.-México border region;
  • Committed to working with vulnerable populations and promoting health equity, eliminating health disparities, and increasing quality of life within the U.S.-México border region; and
  • Seeking to enhance their leadership and health diplomacy skills, professional networks, and understanding of binational public health assets, challenges, and systems as a means to identify solutions

U.S. candidates must me formally nominated by their employers or professional organizations.  The nomination process is quick and easy and can be found on the U.S.-Mexico Border Health Commission website.

Please note that November 10, 2017 is the application deadline.

 

Community Health Center and Nat’l Health Service Corps Funding Hanging

Representatives Stefanik (R-NY) and Tsongas (D-MA) are leading bi-partisan Health Center effort seeking action to extend Health Center and National Health Service Corps funding and fix the cliff by passing the “CHIME Act” ( S. 1899 in the Senate and HR 3770 in the House). The CHIME Act lays out a five-year extension to Health Center funding to fix the Health Center and National Health Service Corps funding cliff without cutting the Prevention and Public Health Fund (like the Champion Act does).

You can Send your Members of Congress a message through the Health Center Advocacy Network asking them to co-sponsor the CHIME Act – click here to send your message and call your Representative using the toll-free Advocacy Hotline 1-866-456-3949 and ask that they co-sign the Stefanik-Tsongas Health Center Cliff Letter addressed to House Leadership asking for immediate action to fix the cliff.

 

Kids Care Extension Update

The US House of Representatives is in a holding pattern and is delaying consideration of a bill to extend funding for the Children’s Health Insurance Program (called Kids Care in Arizona). The hope is to reach a bipartisan agreement on paying for KidsCare- probably in November. 

The main drama isn’t whether to extend CHIP (KidsCare), it’s how to pay for it.  There are some that want to reduce the Prevention and Public Health Fund as an offset (which we oppose).

Word on the street is that AHCCCS still has funding for a few more weeks to keep KidsCare going, so it’s not an emergency to get the federal funding on board again- but we’re running out of time for sure.  We’ll keep tracking this.