AHCCCS to Begin Covering Pre-Exposure Prophylaxis for HIV

Last month the United States Preventive Services Task Force (USPSTF) listed Preexposure Prophylaxis for the Prevention of HIV Infection (PrEP) as a Category A Preventive Health Service.  That’s an important designation because it means that PrEP will now be included (at no cost to consumers) in all Qualified Health Plans during the next contract year. The final recommendation statement can also be found in the June 11 issue of JAMA.

The task force found convincing evidence that PrEP is of substantial benefit in decreasing the risk of HIV infection in persons at high risk of HIV acquisition.  They conclude that PrEP is associated with small harms, including kidney and gastrointestinal adverse effects and that (with high certainty) the benefit of PrEP (with oral tenofovir disoproxil fumarate–based therapy) is substantial.

Pre-exposure prophylaxis (or PrEP) lowers the chances of getting infected with HIV even if the person otherwise engages in risky sexual behavior.  PrEP can stop HIV from taking hold and spreading through the body and is highly effective for preventing HIV if used as prescribed (but it is much less effective when not taken consistently).  Daily PrEP reduces the risk of getting HIV from sex by more than 90%. Among people who inject drugs, it reduces the risk by more than 70%.

This week AHCCCS announced that they’ll be covering PrEP medications as a benefit for their members beginning on October 1, 2019…  a solid public health move that will lower the transmission of HIV in Arizona. The move will likely produce a positive return on investment also, as preventing HIV is much less expensive than treating persons infected with the virus. PrEP (Truvada) will be on their preferred drug list without Prior Authorization starting 10/1/19.

Maricopa County Seeking Hepatitis A Intervention Strike Team Volunteers 

AHCCCS Policy Change Assisting the Response

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

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

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

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

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

Federal 5th Circuit Court Signals New Threat to the ACA

Health Care Increasingly Looking Like a Major Campaign Topic for 2020

Background on the 2012 Ruling Upholding the ACA

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

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

The Texas v Azar Challenge

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

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

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

Protections at Risk

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

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

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

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

Supreme Court Forecast

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

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

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

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

Healthcare’s Link to the 2020 Election

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

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

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

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

AZ Can Prepare for a Post ACA Arizona

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

Prior to the ACA, the standards to protect people with pre-existing conditions were determined at the state level.  Most states including AZ had very limited protections. Many insurers maintained lists of up to 400 different conditions that disqualified applicants from insurance or resulted in higher premiums.  35% of people who tried to buy insurance on their own were either turned down by an insurer, charged a higher premium, or had a benefit excluded from coverage because of their preexisting health problem.

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

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

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

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

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

Medicaid Work/Community Engagement Requirements May Be Phased In

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

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

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

  • Former Arizona foster youth up to age 26

  • Members of federally recognized tribes

  • Designated caretakers of a child under age 18

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

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

  • Members who are medically frail

  • Members who have an acute medical condition

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

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

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

  • Survivors of domestic violence

  • Individuals who are homeless

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

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

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

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

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

The idea behind the phase in is to:

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

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

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

States Lowering Marketplace Premiums with 1332 Waivers

One of the successes of the Affordable Care Act was the development of the health insurance Marketplace.  States can have can have a significant impact on what the premiums are on their state's Marketplace plans by using some of the policy tools available in the ACA. 

For example, Section 1332 waivers in the ACA allow states to implement innovative market driven solutions to lower premiums and protect coverage at the same time.  The goal of Section 1332 waivers is to allow states to experiment with alternative payment and delivery models

Recent CMS guidance changed several components of the 1332 waiver processes including allowing executive orders or state regulations to pursue 1332 waivers.

Many states have recently taken administrative action to lower the Marketplace premiums in their states by implementing reinsurance waivers.  Reinsurance programs allow states to reimburse insurers for certain high-cost claims, allowing them to lower premiums overall. In essence, reinsurance (insurance for insurance) creates a backstop for insurers for super-expensive claims - which makes insurance for everybody more affordable. 

So far this year, CMS has approved Section 1332 reinsurance waivers in Alaska, Hawaii, Maine, Maryland, Minnesota, New Jersey, Oregon, and Wisconsin. There are reinsurance waiver applications pending in Colorado (following their passage of HB 19-1168) and North Dakota (following their enactment of HB 1106).

More 1332 waiver applications are on the way too.  Delaware, Montana, and New Mexico enacted legislation authorizing reinsurance 1332 waiver applications - so those waiver applications should be on the way in the near future.   Maryland passed HB 1098 which authorizes (but doesn't require) their state to submit a 1332 reinsurance waiver by January 1, 2020.

Basically, 1332 waivers offer states the opportunity to implement reinsurance waivers that have a direct and beneficial effect on Marketplace premiums that benefit their residents. Seems like a no-brainer in terms of smart public policy. 

Will Arizona be next in line to seek a reinsurance waiver to help reduce Marketplace premiums in AZ? 

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?

Arizona's Community Health Worker Workforce:

Assessment of the Integration and Financing of Community Health Workers within Arizona Medicaid Health Plans

Now that the process is under way to provide voluntary certification of community health workers (via the ADHS Rulemaking), an important next is to engage Arizona health plan leadership in conversations about the integration and sustainability of the CHW workforce within Arizona’s Medicaid contracted health plans and provider networks. 

To that end, the Center for Health Equity Research at NAU through funding from the ADHS and in collaboration with the UA Prevention Research Center (AzPRC) wrote a report that was released this week which provides insight into innovative strategies for integrating, sustaining and scaling of the CHW workforce within AHCCCS.

The new report provides direct insight to this pathway via conversations with health plan leadership including topics on:

1. Current and Projected Utilization

2. Roles, Competencies and Skills

3. Recruitment and Training

4. Financing and Payment Models

5. Healthcare and Workforce Policy

The report found that Arizona health plan leaders recognize that Community Health Workers can play a significant role in improving patient outcomes and reducing system costs for health care. Many health plan leaders already actively support their contracted provider networks to better integrate and finance CHWs to meet HEDIS measures.

In fact, 4 AHCCCS Health Plans and 10 of 22 Federally Qualified Community Health Centers currently employ CHWs to link patients to community resources to promote self-management.

The research team found that health plan leadership expects that the new Arizona Complete Care Contracts will fundamentally expand the need for CHWs and the core competencies, roles and skills as plans expand their services and seek creative approaches to meeting membership medical and non-medical needs.

This week's report sheds light on important next steps toward building CHWs into the care network.

Congratulations and thanks to AzPHA member Dr. Samantha Sabo, Louisa O’Meara, and Katie Castro for their work on this important roadmap document.

Arizona Medicaid Members Get a Lyft

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

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

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

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

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

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

Tools to Align Public Health & Medicaid Polices

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

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

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

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

Flagstaff City Council Voting on a Tobacco 21 Ordinance Tuesday (2/2/19)

The Flagstaff City Council has a Tobacco 21 ordinance up for a final vote at their Tuesday, July 2nd 4:30 PM council meeting.  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 would limit the sale of tobacco including electronic cigarettes to only people over 21, requires retailers that sell tobacco and e-cigs to get a license (the city will do compliance checks), and includes fines for violations.  I couldn’t tell exactly what the effective date for the ordinance would be (should it pass).  More to come.

Great News for Arizona Kids & Families

As a part of the state budget recently passed, the legislature finally granted the Department of Economic Security the authority to expend $56 million in new annual federal childcare money. ADES moved swiftly to begin using these new dollars to increase scholarship rates and to serve more children.

The ADES has already implemented a provider rate increase with the funds (the first since the since before the recession). The childcare wait list has also been suspended, meaning that families that are eligible for childcare assistance will be able to begin services immediately (this is the first time since 2009 there has been no wait list).

Thank you to all the parents, champions, and partners who called for investment of these funds in these three changes. Advocacy works!

New USPSTF Recommendations for HIV Will Have a Powerful Public Health Impact

Ever since the passage of the Affordable Care Act, a prevention model of health has been increasingly weaving its way into the fabric of traditional models of care.  That's because the ACA expanded the role of preventive services in the US health care delivery system via various incentives. 

For example, the “Category A & B” preventive services that are recommended by the United States Preventive Services Task Force (USPSTF) are now included (at no cost to consumers) in all Qualified Health Plans. In addition, many employer-based and state Medicaid programs routinely cover Category A & B services once they're recommended by the USPSTF. 

The USPSTF is an independent, volunteer panel of experts in prevention and evidence-based medicine. The Task Force works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications.

The Task Force analyzes priority preventive health services and assigns the a letter grade (an A, B, C, or D grade or an "I Statement") based on the strength of the evidence and the balance of benefits and harms of the preventive service.

Currently, the USPSTF recommends 51 Category A & B Preventive Health Services - which include things like screening tests, counseling, immunizations, and preventive medications for adults, adolescents, and children. 

The preventive services that have an A or B grade are presented in alphabetical order and by the date they were recommended on the Task Force website.

This month they added 2 new recommendations related to HIV: 

You can browse the USPHS website and check out the preventive services that they have evaluated but got a lower grade. Most of the services are broken down by age, gender and other risk factors.

Should Pharmacists Prescribe PrEP as Part of the Solution for HIV Prevention

As I mentioned above, the U.S. Preventive Services Task Force this week put out their final recommendation statement on preexposure prophylaxis (PrEP) for the prevention of HIV infection. The Task Force found that clinicians should offer PrEP to persons at high risk for HIV.
The task force found convincing evidence that PrEP is of substantial benefit in decreasing the risk of HIV infection in persons at high risk of HIV acquisition.  They conclude that PrEP is associated with small harms, including kidney and gastrointestinal adverse effects and that (with high certainty) the benefit of PrEP (with oral tenofovir disoproxil fumarate–based therapy) is substantial. They classified it as a Category A intervention.

The final recommendation statement can also be found in the June 11 issue of JAMA. The impact of the Category A recommendation is important because PrEP will now be included (at no cost to consumers) in Qualified Health Plans offered on the Marketplace.  In addition, many employer-based and state Medicaid programs routinely cover Category A & B services once they're recommended by the USPSTF. 

This week there was an article in the American Journal of Public Health that makes an argument that pharmacists should have a role in HIV prevention related to preexposure prophylaxis (PrEP), postexposure prophylaxis (PEP), and HIV testing and harm reduction.

The authors make a compelling case that, because PrEP and PEP require a prescription, control of the epidemic face hurdles like limited network capacity, physician shortages, and other access to care barriers. They argue that pharmacists are an untapped resource that are more easily accessible and available without appointment. Also, because pharmacies and pharmacists aren’t linked to specific health conditions, the setting is considered largely free of HIV-related stigma.

Of course, expanding into this role would require pharmacists to work within each jurisdiction’s scope of practice laws and policies, ensure HIV literacy through pharmacist training programs and continuing education courses and building infrastructures for billing and reimbursement, and health information technology.

Interesting idea for sure.

What’s with the New EPA Coal Burning Plant Rule?

There's a good chance you heard that the EPA changed their coal power plant environmental regulations this week. Here's a quick summary of what those changes are.

The story starts in 2013 when the EPA (under the Obama Administration) issued regulations that applied to new coal fired electricity generation plants.  The rules were called “New Source Performance Standard” or “NSPS.”

The NSPS required that any new generation units fueled by natural gas meet a limit of 1,000 pounds of CO2 per megawatt-hour and allowing new coal plants to emit 1,100 pounds of CO2 emissions per megawatt-hour of electricity generated.  The coal industry didn’t like the rule because the most advanced coal-fired power plants emit 1,700 pounds per megawatt-hour.
The EPA then issued a 2nd rulemaking in 2015 with the “Existing Source Performance Standard” or “ESPS” Rules.  The ESPS rule aimed to reduce overall emissions of CO2 from the nation’s power sector by 32% from 2012 to 2030. Under the 2015 rules, existing coal plants would have had to comply with a 1,300 pounds of carbon per megawatt hour standard (this irritated the industry because the best plants can only achieve 1,700 lbs per megawatt hour).

The U.S. Chamber Litigation Center filed a lawsuit challenging the EPA’s 2015 rules and the US Supreme Court issued a stay on the rules which halted implementation of those 2015 ESPS rules. 

This week the EPA repealed and replaced the ESPS rules (for existing plants) with what they call the Affordable Clean Energy (ACE) rule- which essentially gives states three years to create their own plans to cut emissions at existing plants mainly by encouraging coal-fired power plants to improve their efficiency. The old carbon standards were eliminated. 

The new rules set some guidelines for states to develop performance standards for power plants that boost the amount of power produced per ton of carbon. The original draft proposal would have allowed new coal plants to skip the federal permitting process and use the new “ACE” process, but that was dropped from the final ACE rule.

Arizona has 5 coal burning plants: the Apache Generating Station (Cochise County), the Cholla Power Plant (Navajo County), the Coronado Generating Station (Apache County), the Navajo Generating Station (Apache County & closing later this year), and the Springerville Generating Station in Apache County.  Under the new rules issued this week, these facilities will now be subject to state regulation via the new ACE standards- presumably by ADEQ.

Over the long run, the percentage of energy generation that comes from coal in the US will continue to decline because coal power generation  is simply more expensive than natural gas and solar and wind sources.

To look at the cost of generation for the various approaches you can visit this US Energy Information Administration Document which compares the capital, operational and transmission costs for various forms of energy generation-  and you'll see that coal is way more expensive than natural gas, wind, and solar technologies. 

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.

U of A Study Examines Emergency Department Use During the Recession

AzPHA member Patrick Wightman from the UA Center for Population Science and Discovery recently published an Issue Brief examining the impact that the freeze on “childless adult” enrollment in AHCCCS during the Great Recession had on the use of hospital and emergency department services. 

Because Arizona conducted a natural experiment by freezing Medicaid enrollment among childless adult, and the fact that data are available to measure the effect of those policy changes, Patrick was able to compare people’s behavior with health insurance to their behavior without it.  The fact that the freeze lasted years allowed him to examine any impact of pent-up demand following the lifting of enrollment freeze.

Here’s a link to the entire Issue Brief , which includes the entire results including several useful graphs, but here’s the Summary from the Issue Brief.

“While the trends presented here are descriptive, they occur in the framework of two significant “natural experiments”, the first drastically restricting low-income individuals’ access to public health insurance, and the second once again expanding that access.  Because these policy changes happen at the state and federal levels, beyond the control of beneficiaries, it can be inferred that, in large part, they are the cause of the beneficiaries’ behavior, in this case their health care utilization.

In this context, the patterns shown here provide strong evidence that health care utilization, at least in the form of ED visits and hospitalizations, follows the availability of health care, in the form of health insurance.  While this finding is not unanticipated in the case of hospital visits, in the case of ED visits it is perhaps somewhat surprising, at least to the extent that ED visits represent “legitimate” medical emergencies.”