Family Planning

Call to Action: Labor HHS Education Bill Cuts to Family Planning

Call to Action: Labor-HHS-Education Appropriations Bill

For the first time in more than 20 years, Congress is on track to pass a Labor-HHS-Education spending bill before the end of the fiscal year. Last week, the House agreed to move to conference with the Senate to work out the differences between each chamber’s version of the  bill. The bills contains a number of bad funding cuts.

The House version eliminates funding for the Title X family planning program and the HHS Teen Pregnancy Prevention Program. I can't tell whether the Senate version does the same or not.  The House bill also cuts all funding for the CDC's Climate and Health program and once again fails to fund CDC research into firearm morbidity and mortality prevention. The bill also weakens the Affordable Care Act by blocking funds for implementing the law. 

Congress only has a few legislative days left to finalize the Labor-HHS-Education spending bill before the end of the fiscal year. If they don't pass something they'll probably pass a continuing resolution to keep key public health agencies operating (actually- not a bad outcome honestly). 

Now is the time to Speak for Public Health! You can use this link to Contact your members of Congress and ask them to support robust funding for key public health agencies and programs, and urge them to reject any controversial policy riders that would threaten public health.

Leveraging Doulas to Improve Birth Outcomes

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

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

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

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

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

Major Changes Proposed for Family Planning Grants

A few weeks ago HHS issued new proposed regulations for Title X (family planning) grants in the Federal Register. The new regulations would make many changes to the requirements for Title X projects and could profoundly change how family planning services are provided by significantly limit the network of providers who can qualify for funds; restricting the ability of participating providers from discussing and referring for abortion; and making other programmatic changes that could dramatically reshape the program and provider network available to low-income women.

If fully implemented, the proposed changes to Title X would shrink the network of participating providers and have major repercussions for low-income women in AZ that rely on these services for their family planning care.

Here’s an informative Issue Brief about the planned changes. The new proposed regulations and the place to submit comments are up on the Federal Register website through July 31.

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!


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: 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.”


Ebola, Family Planning, Public Charge, & Medicaid Network Standards

Ebola Outbreak in Democratic Republic of the Congo

WHO Policy Body Concludes it’s Not a Public Health Emergency of International Concern (yet)

The Democratic Republic of the Congo’s (DRC) Ministry of Health has confirmed 45 cases of Ebola Virus Disease in the last few weeks. Most of them have been in the remote Bikoro health zone, but 1 case is in Mbandaka, a city of 1.2 million, which is bad because of the city's size and because it's next to the Congo river- a major transportation corridor for people and trade. Large cities that are also transportation hubs can serve as a distribution channel for the virus.

The WHO’s Emergency Committee met last week and heard about the DRC’s surveillance & interventions. The Committee concluded that “… the interventions underway provide strong reason to believe that the outbreak can be brought under control, including: enhanced surveillance, establishment of case management facilities, deployment of mobile laboratories, expanded engagement of community leaders, establishment of an airbridge, and other planned interventions.  In addition, the advanced preparations for use of the investigational vaccine provide further cause for optimism.”

The Committee concluded that “… the conditions for a Public Health Emergency of International Concern (PHEIC) have not currently been met.” They advised against travel or trade restrictions as interventions.  Despite not being classified as a PHEIC, resources are still available to the DRC from the WHO consistent with the WHO’s Emergency Response Framework

Activities include distribution of vaccine to Congo (4,000 doses so far and 3,000 more coming), cold chain resources, prepositioning of additional vaccine in Mali and support and treatment and surveillance staff from WHO & Medecins Sans Frontieres. They are using a ring vaccination strategy around cases and contacts.  Surprisingly I don't see anything on the CDC's website about the outbreak right now, but hopefully they're engaged.

Let’s hope that the WHO Emergency Committee is right and the Ministry has the resources, expertise and logistical support they need to quickly identify cases and conduct the needed interventions to stop the spread before this becomes a regional or international epidemic like it did in 2014.  


HHS to Restrict Title X Family Planning Program

Last week the President announced that the US Department of Health and Human Services will be changing federal family planning programs (Title X) to “ensure that taxpayers do not indirectly fund abortions”.  The statement suggested that HHS would be shortly proposing regulations that would ban Title X family planning providers from referring patients to abortion clinics.

Title X was enacted almost 50 years ago to provide quality family planning care to those who may not be able to afford it on their own.  Federal funds through Title X already can’t be used for abortion services. The funds are dedicated to access to medically accurate comprehensive healthcare for low-income individuals and families. The reproductive healthcare and family planning services include contraception, cancer and STD testing as well as counseling and education and more.  Title X funding has contributed to the recent and significant decline in unintended and teen pregnancies as well as unplanned births and has reduced abortions.

I searched all over the HHS website and I can’t find the proposed rule change anywhere, so the proposed changes haven’t been released yet. We don’t know if they’ll propose an emergency rule (hitting Title X networks immediately) or go through a normal rulemaking process.  The normal process (including posting the proposed rule in the Administrative Register and a comment period) would be slower because the public would have the chance to comment, and comments would need to be reviewed before the rule could be finalized.

This has already been a chaotic year for Title X applicants for family planning service providers. It’s normally a 3-year funding cycle for Title X providers, but the Administration has changed that to a 1-year cycle- and applications for the coming year are due this Thursday (5/24).

If the proposed rule is the same one that was proposed by the Reagan Administration (and later rescinded by Clinton), it would prevent any provider from referring or providing information on abortion services.  We don’t know the fine points of the rule yet, and cannot speculate about its structure, but we will keep you updated as we learn more. 


AzPHA Comments on AHCCCS’ Network & Appointment Standards

AHCCCS is rolling out new integrated care contracts on October 1, and most members will be receiving services for both acute and behavioral care from these managed care organizations.  One of the keys to making sure that members have access to a health care provider when they need it is for AHCCCS to make sure each managed care organization has an adequate network of contracted providers. 

AHCCCS sets their network adequacy standards in what’s called their “AHCCCS Contractors Operations Manuals”, or ACOMs for short.  From now through May 28, 2018 AHCCCS is accepting public comment on their proposed manuals for network expectations for the integrated care contracts that start on October 1.

Our Public Health Policy Committee reviewed the proposals and submitted comments (available on my blog at In short- we commented that we liked the fact that the new proposed network standards are more easily measured and therefore easier to ensure compliance.  We also encouraged them to ask the plans to contract with the county health departments for services like vaccinations, sexual transmitted disease testing and treatment, reproductive health, and tuberculosis prevention and control. 

We also asked that when Plans ask for and receive exemptions from the standards that the information be posted on enrollment websites so members have that info as they make enrollment decisions.  Anybody can comment on the proposed standards at this website before May 28.


Kaiser Family Foundation “Public Charge” Issue Brief

A few weeks ago I wrote about a change that the US Department of Homeland Security is mulling to allow the federal government to take into account the use of federal health, nutrition, and other non-cash public programs like Medicaid, the Children’s Health Insurance Program, and WIC when making a determination about whether someone is likely to be a “public charge.”  Under these changes, use of these programs by an individual or a family member, including a citizen child, could result in a person being denied lawful permanent resident status or entry into the U.S.

Such changes would apply to coverage provided to legal immigrants and their citizen children, leading to decreased participation in Medicaid, CHIP, Affordable Care Act marketplace coverage and other programs, even though they would remain eligible for them.

The Kaiser Family Foundation published a new issue brief this week that provides an overview of the 10.4 million kids in the U.S. that have a non-citizen parent (the parent is the person that would be affected by the changes).  Then issue brief presents different scenarios of disenrollment from Medicaid and CHIP to illustrate the potential effects on their health coverage and discusses the implications for their health.

How do Lava & Seawater Make Acid Mist?

I heard on the radio that when lava coming from the Kilauea volcano hits the ocean it’s forming an acid mist that’s dangerous to the lungs.  I got curious how the acid forms.  It turns out that the acid comes from 2 different sources.  About 30% of the acid is trapped in the molten lava as a gas and escapes when the lava cools fast in the ocean water. 

The bigger source (70%) is a chemical reaction in which the salt dissolved in the ocean (NaCl and H2O) – in the presence of super-hot lava- forms NaOH (sodium hydroxide) and HCl (hydrochloric acid).  Of course- it’s more complicated than that (a lot more complicated).  If you’re interested in the particulars you can check out this journal article.


I’m doing my best to populate our “Upcoming Events” section of our AzPHA website.  If you have an upcoming public health related event- let me know and I’ll get it up on our website at:


Grand Canyon University is developing a Bachelor of Science in Public Health and they would like to gather input from the public health professional community to help inform the curriculum. Please take a few minutes to provide them some feedback on this Grand Canyon University Bachelor of Public Health Policy Survey


ADHS EMS Regulatory Services Section Chief Post Open

The ADHS Bureau of Emergency Medical Services and Trauma Systems is recruiting for a senior management position in the Bureau of EMS and Trauma System to lead a team of professionals in several functional areas including, statutory committee support, EMS and trauma data collection, system of care performance improvement analysis and reporting, EMS and trauma system initiatives, community paramedicine, and strategic planning and communication

Responsibilities include:

  • Supporting a diverse multi-cultural workforce that reflects the community, promotes equal opportunity at all levels of ADHS, and creates an inclusive work environment that enables all individuals to perform to their fullest potential free from discrimination

  • Assisting in policy and rule development with Bureau and Department leadership

  • Leading a highly motivated, professional team

  • Guiding, monitoring and ensuring success of numerous projects and deliverables

  • Creating and editing EMS and trauma-related reports and plan

  • Ensuring successful meetings of Governor and Director-appointed advisory meetings

  • Seeking out and sharing resources to enhance the Arizona EMS and trauma system

  • Traveling to a limited number of national, state or local meetings

Salary: up to $60,354   Apply Here


AzPHA Member Kelli Donley on Horizon Thursday RE Her Latest Book

AzPHA member Kelli Donley will be on Horizon this Thursday at 5:30pm (May 24) to talk about her newest book called COUNTING COUP. The book is about the Phoenix Indian School, and like her other novels, has a strong public health theme. Here’s a short description of her book, which you can order from Amazon:

Happily consumed with her academic career, Professor Avery Wainwright never planned on becoming sole guardian of her octogenarian Aunt Birdie. Forced to move Birdie—and her failing memory—into her tiny apartment, Avery’s precariously balanced life loses its footing. 

Unearthed in the chaos is a stack of sixty-year-old letters. Written in 1951, the letters tell of a year Avery’s grandmother, Alma Jean, spent teaching in the Indian school system, in the high desert town of Winslow, Arizona. The letters are addressed to Birdie, who was teaching at the Phoenix Indian School. The ghostly yet familiar voices in the letters tell of a dark time in her grandmother’s life, a time no one has ever spoken of. 

Torn between caring for the old woman who cannot remember, and her very different memories of a grandmother no longer alive to explain, Avery searches for answers. But the scandal and loss she finds, the revelations about abuses, atrocities, and cover-ups at the Indian schools, threaten far more than she’s bargained for. 


Most of you know Dr. Bob England, who's been on the AZ public health scene for the last 30 years including 12 years as the Director of the Maricopa County Public Health Department.  Bob's been living for the last couple of months just outside of London. 

He's writing some entertaining travelogues- with a splash of public health of course. Take a few minutes when you're on a comfortable couch and enjoy Travelogue 1 & 2: Getting Settled and Travelogue 3: Nutrition. Here’s the 5th installment: Interlude.  Back to the 4th Travelogue next week.