Final 2017 AzPHA Public Health Policy Update


AHCCCS Submits Work Requirement Waiver

An AZ law (from 2015) requires AHCCCS to annually ask the Centers for Medicare and Medicaid Services (CMS) for permission to require work (or work training) and income reporting for “able bodied adults” as well as a 5-year lifetime limit on AHCCCS eligibility. 

The work requirement and 5-year limit requests that were turned in during the Obama Administration were denied, but the new administrator CMS has publicly said (and written) that they’re receptive to proposals from states to require work or community engagement for people who want to receive Medicaid.

This week AHCCCS submitted their official waiver request asking permission to implement the following requirements for certain adults receiving Medicaid services: 

  • A requirement to become employed, actively seek employment, attend school, or partake in Employment Support and Development (ESD) activities (with exceptions below);
  • A requirement to bi-annually verify compliance with the requirements and any changes in family income or other eligibility factors; and
  • Limit lifetime coverage for able bodied adults to five years (with exceptions below).

    Here are the proposed exempted groups:

    • People 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;

    • 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 who are older than 18 years old;

    • Full-time college or graduate students;

    • Victims of domestic violence;

    • People that are homeless;

    • People who have 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.

    Able-bodied adult members will be required to meet the following activities or combination of activities, for at least 20 hours per week to qualify for AHCCCS:

    • Be employed;

    • Attending school; or

    • Attending an ESD program (e.g. English as a Second Language courses, parenting classes, disease management education, courses on health insurance competency, and healthy living classes. 

    People looking for a job and meeting the requirements to receive unemployment benefits would be deemed as meeting the work requirements.

    Community service hours may count toward the required 20 hours per week for people transitioning from the justice system, living in an area of high unemployment, or who otherwise face a significant barrier to employment.

    The entire waiver request is 678 pages long- but don’t let that scare you off.  The meat of it is only 13 pages long.

    P.S. I didn’t see a request to change the reimbursement scheme for community health centers or the limitations on non-emergency medical transportation in the waiver request.


    New Tax Law Repeals Penalties for Not Having Health Insurance

    The new federal tax law that will be signed shortly eliminates the penalties that people currently need to pay for choosing not to have health insurance. The penalty elimination begins on January 1, 2019…  so, there will still be a financial penalty for not having health insurance during 2018. 

    The tax penalty for not having health coverage in 2017 is $695 per adult and $347 per child, or 2.5% of one’s household income, whichever is greater. About 4 million US taxpayers paid the penalty in 2016 (an 80,000 Arizonans paid the tax penalty that year).

    The CBO estimates that eliminating of the mandate will result in 80,000 more Arizonans becoming uninsured during the first year of implementation (2019).  By 2027 they estimate that the number of uninsured will rise by 13 million people nationally (260,000 in Arizona).

    The change is also expected to increase premiums on the Marketplace by an unknown amount in 2019 because younger and healthier people are expected to disproportionately elect not to buy health insurance.  Part of that increase may be mitigated if congress chooses to restore the Cost Sharing Reductions and if they authorize a reinsurance program


    CDC Submits Much Smaller Budget Request

    This week the CDC turned in their FY 18 budget request.  The overall request is 17% smaller than last year’s agency budget.  If enacted as requested, the funding cut would have big implications for state and county health departments.  The request is for $6B in budget authority which is $1.2B less than the FY 2017 Continuing Resolution (CR) level (a 17% reduction).  Here’s a link to the actual budget request

    Here are the bullet’s identified as an introduction to the request from the CDC Director:

    •  Creation of the new America’s Health Block Grant, reforming the model of existing state-based chronic disease programs to increase flexibility

    • Reform of public health preparedness and response activities, including a greater emphasis on risk in the state grant program.

    • Enhanced support for vector-borne disease outbreaks

    • Critical investments to improve our laboratories and facilities

    • Continued efforts to reduce deaths due to opioid abuse, misuse, and overdose

    The budget request is too long and complicated to characterize fully here- but I’ve picked out a few highlights.

    America’s Health Block Grant Program ($500 million)

    The FY 2018 budget request includes a new $500 million “America’s Health Block Grant” to increase flexibility on the leading chronic disease challenges specific to each State, which could include preventing and better managing heart disease and diabetes—two of the most common and costly chronic diseases—as well as arthritis, the leading cause of disability in the United States. 

    The request proposes to eliminate the following programs completely:

    • Preventive Health and Health Services Block Grants (-$160.0 million)

    • Racial and Ethnic Approaches to Community Health (-$51.0 million)

    • Prevention Research Centers (-$25.4 million)

    • Cancer Prevention and Control (-$18.1 million)

    • Hospitals Promoting Breastfeeding (-$8.0 million

    • National Early Child Care Collaboratives (-$4.0 million)

    • Health Promotion (-$10.5 million)

    • Occupational Safety and Health (-$138.5 million) – eliminating funding for state and academic partners for conducting, translating, or evaluating research

    • Education and Research Centers (-$28 million)

    The following programs would be significantly scaled back (but not eliminated in their entirety):

    • Chronic Disease Prevention and Health Promotion (-$222 million) – the agency says that the America’s Health Block Grant could make up a portion of this cut if states prioritize these activities in their block grant

    • Public Health Preparedness and Response (-$136.3 million)- with large reductions in the state cooperative agreements

    • Immunization Program (-$89.5 million) – CDC would continue to provide funding to the 64 immunization awardees for state infrastructure awards, vaccine direct assistance, and laboratory capacity- but at a substantially reduced level.

    • Emerging and Zoonotic Infections (-$64.9 million)

    Remember that this is the agency’s budget request- not a final funding decision by congress.  In all likelihood, the agency was directed by the Executive to submit a budget that’s 17% smaller- reflecting the goals of the President’s budget.  As such- the CDC Director (Brenda Fitzgerald, MD) may not really want to make these cuts- but when you work for an Executive you gotta to follow their instructions (or quit- in which case someone else will).

    You can weigh in regarding the proposed CDC budget with your Representative and Senators by sending a message via this: APHA FCDC Funding Action Alert Tool.


    Innovative Community Health Worker Strategies: Medicaid Payment Models for Community Health Worker Home Visits

    By Tina Kartika December 19th, 2017

    Due to mounting evidence that community health workers (CHWs) can improve health outcomes, increase access to health care, and control medical costs,[1] states are increasingly engaging their CHW workforce to replicate those successes at the state level. However, the policies and programs that regulate and pay for CHWs differ dramatically across states,[2] and states facing difficulties advancing CHW initiatives can gain insights from the experiences of other programs across the country.

    The National Academy for State Health Policy (NASHP) recently updated its State Community Health Worker Models Map, and is currently identifying innovative state strategies that have helped CHW initiatives meet their goals. This case study, which explores payment models for CHWs conducting home visits in Minnesota, New York, Utah, and Washington State, is the second in a series of products that highlight those CHW program strategies.

    Community Health Workers and Home Visits

    Health outcomes are influenced by many factors, one of which is physical environment. Living in an unhealthy home environment can cause or exacerbate health issues. For example, exposure to lead in the home from lead paint or contaminated drinking water, “affects the brain’s ability to control impulses and process information,” which can lead to children’s underperformance in school and later in the workplace.[3] Exposure to dust mites, mold, and cockroaches can trigger asthma attacks.[4]

    In addition to improving health outcomes and quality of life, addressing health hazards in the home environment can yield positive economic results. Remediating lead paint hazard in homes built before 1960 is estimated to generate $3.5 billion of earnings, health and education savings, and quality-adjusted life year benefits for 311,000 low-income children.[5] Home visiting services targeting asthma are estimated to generate $1.39 to $5 of savings for every dollar invested.[6] Assessing the home environment is a critical first step to reduce these hazards, and CHWs can be trained to conduct healthy home assessments,[7] educate, and connect patients to resources during home visits.[8]

    Payment Models

    Low-income households are more likely to live in unhealthy homes with significant lead-based paint hazards and indoor allergens.[9] Although Medicaid covers many low-income children and adults,[10] few state Medicaid programs directly reimburse CHWs to provide in-home services that address healthy home environments. The following are examples of payment models used by several states to finance home-based preventive services provided by CHWs:

    §  Medical expenditure: In Minnesota, home-based preventive services provided by CHWs can be reimbursed under Medicaid as long as the services qualify as diagnostic-related patient education and the CHWs work under the supervision of a licensed medical professional. Beneficiaries can receive up to 12 hours of these services each month.

    §  Administrative expenditure: Some accountable care organizations (ACOs) in Utah are covering the costs of home-based preventive services through administrative payments.[11] According to a National Center for Healthy Housing case study, Medicaid managed care organizations (MCOs) in New York can also choose to provide home-based asthma services and bill the services as administrative expenses.

    §  Incentive payment: Under the authority of 1115 waivers, 12 states have implemented Delivery System Reform Incentive Payment (DSRIP) programs that “restructures Medicaid funding into a pay-for-performance arrangement in which providers earn incentive payments outside of capitation rates for meeting certain metrics or milestones based on state-specific needs and goals.”[12] New York’s and Washington’s DSRIP programs in particular include projects that incentivize participating provider entities to provide CHW home visits to their members.

    §  In New York, 8 out of 25 participating Performing Provider Systems (PPSs) have implemented a project that expands asthma home-based self-management programs and includes home environment assessment, remediation, and education. During a meeting in February 2017, five of those eight PPSs reported engaging CHWs to meet the goals of the project.[13]

    §  Similarly, Washington’s Accountable Communities of Health (ACHs) can choose to implement a DSRIP project on chronic disease prevention and control and pay CHWs to conduct home visits for asthma services using DSRIP funding.


    Minnesota, New York, Utah, and Washington provide examples of using Medicaid dollars to finance CHW home-based services. States can enable providers to bill certain CHW home visits as medical expenses, encourage MCOs to cover these services as administrative expenses, and use incentive payments to fund these services. States seeking sustainable CHW programs can explore these models to determine what fits their needs and goals.

    Acknowledgements: The author thanks Anna Guymon, the New York State DSRIP Team, Jill Rosenthal, and Amy Clary for their helpful comments and contribution to this case study. This case study was made possible by support from the National Center for Healthy Housing.

    AzPHA Public Health Policy Update- December 13, 2017

    More Evidence that Physical Activity Improves Grades

    It’s no secret that physically active kids are healthier, but a state study released Wednesday found that they also do better on reading and writing, and even school attendance.

    Fourteen schools in central and northern Minnesota each received $10,000 to implement three-year physical activity programs under a study conducted by the state’s departments of Health and Education.

    Most schools went beyond merely beefing up the traditional physical education class. Instead, they incorporated physical activity throughout the day — before and after school as well as movement within the classroom.

    Researchers found that students who were physically fit were much more likely to score better on state standardized tests. They were 27% more likely to be proficient in math and 24% more likely to be proficient in reading.

    Each school chose its own set of activities. For example, one school took  two 10-minute breaks each day to move around, sometimes using internet programs such as GoNoodle. They also had before- and after-school activities such as running, yoga, cross-country skiing and snowshoeing.


    Minnesota Adopting Physical Activity Standards for Schools

    Legislation passed in 2016 requires the Minnesota Department of Education to adopt the national physical education standards and “modify them according to state interest.” 

    Using the SHAPE America National Standards as a base, they are in the process of making changes to the national standards address state statutory requirements and best practices in physical education. 

    The new standards will replace the state’s current standards, the National Standards for Physical Education, which were developed by the National Association for Sport and Physical Education, adopted by Minnesota in 2010, and implemented in all schools in the 2012-2013 school year. 

    Here are their current Physical Education Standards Draft Rules 


    E-cigs quadruple probability of smoking tobacco
    A newly published study found that young adults using electronic cigarettes quadruple their chance of smoking tobacco within 18 months. 

    The study, published in the American Journal of Medicine monitored young adults aged between 18 to 30 years – who had never smoked conventional cigarettes for a year.  Of the participants who said they vaped e-cigarettes in the first questionnaire, 47% had started smoking cigarettes 18 months later compared to 11% percent of those who didn’t use e-cigarettes.


    Arizona WIC Implements Electronic Benefit Transfer

    Arizona’s Women, Infant, and Children implemented an electronic benefits system last week, providing enhanced (and more secure) service and benefits to participants, clinic staff, and WIC vendors (grocery stores authorized to accept Arizona WIC benefits).  

    The program began moving away from paper benefits back in checks to an electronic system thanks to a $5M grant they received from the USDA in 2014.  It’s basically an electronic system that replaces paper vouchers with a card for food benefit issuance and redemption at authorized WIC grocery stores. Stores in Arizona that participate in WIC services sell about $150M in healthy foods to participants each year.  

    WIC is a national nutrition and breastfeeding program that serves low income women, infants, and children and provides nutrition education, breastfeeding information and support, referrals to community services, and healthy foods. The Arizona WIC Program serves more than 160,000 women, infants, and children each month with services provided by 21 local agencies.

    Congratulations to Celia Nabor and her entire team, including the folks in I.T. that made EBT transfer a reality.  From now on all current and future WIC members (and vendors of course) will benefit from the team’s work. Accomplishments like this are the things that make public service jobs so rewarding.


    ADHS’ Opioid Surveillance Rulemaking

    The ADHS initiated a rulemaking last week for opioid surveillance and reporting requirements. The draft rules are based on the emergency rules currently in effect.  They plan to host some meetings to solicit input on the draft rules prior to proposing formal rules. They’re also accepting comments through their online portal.

    AzPHA Public Health Policy Update- December 6

    Newborn Screening Policy Success Story

    In 2014 a bipartisan group of AZ lawmakers passed a bill charging the ADHS with expanding their newborn screening program to include newborn pulse oximetry screening in hospitals. The test gives the baby’s doctors quick information about whether the newborn might have a congenital heart abnormality. Quick info like that gives them a chance to do early interventions that can save lives and improve outcomes. The agency and hospitals collaborated to implement the new testing and reporting procedures in 2015.

    A new study this week in the Journal of the American Medical Association found that states that had our kind of congenital heart disease screening program (based on pulse oximetry) had 33% fewer infant deaths from critical congenital heart disease compared to states without screening policies.

    Kudos to our public health partners at the American Heart Association in AZ for raising awareness with our legislators and for that body to recognize and pass this important evidence-based intervention.  This new study demonstrates that it’s saving lives.


    Medicaid Work Requirements & 5 Year Limit on Horizon

    An AZ law (from 2015) requires AHCCCS to annually ask the Centers for Medicare and Medicaid Services (CMS) for permission to require work (or work training) and monthly income reporting for “able bodied adults” as well as a 5-year lifetime limit on AHCCCS eligibility. 

    The work requirement and 5 year limit requests that were turned in during the Obama Administration were denied, but the new administrator CMS has publicly said (and written) that she’s receptive to proposals from states to require work or community engagement for people who want to receive Medicaid.

    We’re getting closer to having these requirements become part of AZ’s Medicaid program with a transmission of a concept letter from AHCCCS to CMS about the upcoming 2017 request.

    A few months ago, AHCCCS floated a draft waiver for public comment that outlined the following requirements for “able-bodied adults” receiving Medicaid services:

    • A requirement for all able-bodied adults to become employed or actively seeking employment or attend school or a job training program;
    • A requirement for able-bodied adults to monthly verify compliance with the work requirements and any changes in family income;
    • The authority to ban people from enrollment for 1 year if they fail to report a change in family income or lie about compliance with the work requirements; and
    • Limit lifetime coverage for all “able-bodied” adults to 5 years (except for certain circumstances). 

    Hundreds of comments were turned in urging AHCCCS to change the initial waiver request.  AzPHA submitted a response letter back in February.  Several hundred people and organizations turned also in comments.  

    While AHCCCS hasn’t released the content of their final waiver request, they did issue a letter last week outlining what they intend to include in the Waiver (after considering the public comments).  

    It’s a lengthy letter and I can’t summarize it all here – but interestingly – it includes a wider list of persons that would be exempt from the eligibility restrictions and the 5 year benefit limit (which already included folks with disabilities) including:

    • People over age 55
    • Women for three months after a pregnancy
    • Former foster youth up to age 26
    • People diagnosed with a serious mental illness
    • People receiving temporary or permanent long-term disability benefits
    • Full-time high school students over age 18
    • Full-time college or graduate students
    • Victims of domestic violence
    • Homeless individuals
    • People impacted by a death of family members in their immediate household
    • A parent or caregiver of a child under age 13
    • A caregiver of a family member in the Arizona Long Term Care System
    • People considered medically frail under state law
    • American Indians

    There are other areas covered in the letter that go beyond the requirements of the 2015 law including:

    • Freezing the current base payment rates for community health centers and choosing an alternative inflation factor for future payments; and

    • Limits on paying for emergency medical transportation.

    If some (or all) of the items in the waiver are approved (which appears likely) how AHCCCS implements the reporting requirements, coordinates with other agencies like ADES, and determines compliance with the eligibility requirements will have a profound impact on access to care for this population.

    We’ll continue to track this when the actual waiver request is turned in.


    Community Health Worker Training Program Accredited

    The Arizona Community Health Worker Association (AzCHOW) approved Central Arizona College’s CHW curriculum and training program last week, a key milestone toward building a robust CHW workforce in Arizona.

    Their CHW program is approved for 5 years, at which time the program will be reviewed for renewal. The CHW curriculum provides the core competencies and skills students need for employment opportunities. Students are introduced to community and public health topics like chronic disease management, health communication, health literacy, counseling and motivational interviewing, wellness and health advocacy. 

    The program can be completed in 1 year through distance learning and includes a 90- hour internship which can be completed.

    The CHW training program was implemented in August of 2016 and the first cohort of students graduated in August of this year.  The second cohort of students is working towards the CHW certificate, and will graduate in August of 2018. 

    For more information on the Community Health Worker Certificate Program and application form, please visit or call Kim Bentley at 480-677-7780.  


    Tax Bill Could Have Public Health Implications

    The Senate approved their version of tax reform by a 51-49 vote last week. Last month, the House approved their version by a 227-205 vote. In the next couple of months, they’ll resolve differences between the two bills and produce a conference bill.

    The Senate version repeals the individual mandate for people to have health insurance or pay a fine.  The Congressional Budget Office estimates that repealing of the individual mandate could increase the number of uninsured by 4 million by 2019 and 13 million in 2027. They also estimate that the repeal will increase health insurance premiums by 10% per year but also save the federal government $338 billion (e.g. fewer advance premium tax credits).

    The Pay-As-You-Go Act of 2010 (PAYGO) requirement could threaten the Prevention and Public Health Fund and other public health programs. Congress will need to waive the PAYGO requirements separately to prevent these cuts from moving forward. Senator McConnell reportedly assured Senator Collins that the PAYGO waiver will happen, but waiving it will take 60 votes in the Senate.


    Affordable Care Act – too big to fail and too big to ignore

    By: Jana Granillo in the November 30, 2017 AZ Capitol Times 

    How does the Affordable Care Act affect me and my community? Well, that is a big question with a big answer. ACA is big, it is more than the marketplace and mandates – which, by the way, is still the law. It is a whole system of care and infrastructure and problem solving intended to make us healthier as a nation.

    When I think of the ACA, what churns to the top of my thoughts are vulnerable populations, my neighbors, my own insurance, and where I live.

    When I hear students playing in the schoolyard, I know many are economically disadvantaged. We have a shockingly large percentage of students on Free and Reduced Lunch. How many of those children are on AHCCCS/Medicaid or participate in the ACA Marketplace?

    When I commute, I drive by community health centers, also known as Federally Qualified Health Centers. ACA funding impacts these clinics.

    When I grocery shop, I see seniors counting their pennies with clipped coupons. Which seniors will endure a fall or become victim to MRSA, a staph infection?  How many of them are Medicare and Medicaid dual eligible?

    When I hear a first-responder siren, I think about behavioral health.  According a recent report on the opioid crisis, my community is on a data map and it is colored red. Does the siren tell of another victim? Does that victim have behavioral health options or even a treatment bed for evaluation?

    When I choose doctors, I wonder if they were part of the National Service Corp.

    What about treatment options? Is there a new medication on the horizon for a chronic condition or disease by the National Institute of Health? Will my elderly relative have to travel to Phoenix to get treatment that is not available in the rural areas?

    Will the county hospital financially be in the “green” this year or do we take a hit on our property taxes to support the district? Will they receive Disproportionate Share Payments  for serving the underserved? What funding will be available?

    What about all those medically served by the fire department, especially those who don’t have a point of care – who pays for that?

    Finally, I ponder, will our family (employer) insurance be there tomorrow? I can’t afford a premium without help.

    So, does ACA affect me, my family and my community? Answer: BIG yes!

    How do we go forward? The answer is to include experts from multiple health disciplines to define reform around a common goal: affordable quality health care systems that are responsible, provide short-term stabilization and long-term solutions that protect all us.

    — Jana Lynn Granillo is a AZPHA member and community health

    Senate Bill 1092 was passed in 2015 requiring AHCCCS to apply the Centers for Medicare and Medicaid Services (CMS) for a waiver or amendments to the current Section 1115 Waiver to allow the State to implement new eligibility requirements for “able-bodied adults”.

    AHCCCS initially proposed implementing the following requirements for “able-bodied adults” receiving Medicaid services:

    • The requirement for all able-bodied adults to become employed or actively seeking employment or attend school or a job training program.
    • The requirement for able-bodied adults to verify on a monthly basis compliance with the work requirements and any changes in family income.
    • The authority for AHCCCS to ban 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.
    • The authority for AHCCCS to limit lifetime coverage for all able-bodied adults to five years except for certain circumstances.

    Hundreds of comments were submitted urging the agency to consider modifications to the initial waiver request.  While AHCCCS hasn’t released the content of their final waiver request, they did issue a letter last week (link below) outlining what they intend to include in the Waiver.

    It’s a lengthy letter and I can’t summarize it all here- but interestingly- it includes a wider list of persons that would be exempt from the initial eligibility restrictions (which already included persons with disabilities) including:

    • Persons over 55 years old;
    • Foster persons up to 26 years old;
    • Full time college and graduate students;
    • Victims of domestic violence;
    • Homeless persons; and
    • Parents of kids less than 13 years old.

    We’ll continue to track this when the final waiver request is released.

    AzPHA Public Health Policy Update: November 29, 2017

    Community Health Worker “Sunrise” Passes Committee!

    The Joint Health Committee of Reference heard detailed testimony on the Sunrise Applications turned in by the Community Health Workers Association, the Arizona Naturopathic Medical Association, and Dental Care for AZ.

    They gave a favorable recommendation for the Community Health Worker and Dental Therapist applications but didn’t approve the Arizona Naturopathic Medical Association request.

    The Community Health Workers are asking for a pathway to set up a process for voluntary registration of CHWs; the Arizona Naturopathic Medical Association would like permission for Naturopaths to sign medical waivers from the state’s school vaccination requirements and Dental Care for AZ asks for authorization from the legislature to license a new class of dental professionals called Dental Therapists.

    We took positions for the CHW proposal and against the Naturopath’s proposal.  We were neutral on the dental therapy application.

    The committee’s recommendations will be sent to the Governor, President of the Senate, and Speaker of the House of Representatives.  This week’s vote doesn’t mean that Community Health Worker Voluntary Certification will become law.  For that to happen, the proposal needs to be put into a Bill format, get a sponsor, pass the House and Senate and then get signed by the Governor.

    Congratulations to the Arizona Community Health Workers Association for their diligent work preparing their Sunrise Application and for working with stakeholders and partners to set up the infrastructure needed to implement their vision including developing core competencies, training and certificate education, and internship opportunities.  

    Also, a huge shout out to the Vitalyst Health Foundation for financially supporting this kind of community health initiative through their grant programs!

    Next step- Voluntary Certification!


    AHCCCS Finds Temporary Solution for KidsCare

    AHCCCS found a temporary contingency plan to keep Arizona’s Kids Care program going for the next few months.  AZs KidsCare program covers about 24,000 kids in lower income families.  The program provides low-cost health insurance to children whose parents earn too much to qualify for Medicaid but still make less than 200% of the federal poverty level (about $40,840 for a family of 3).  It’s not free, but premiums are reasonable (less than $50/month for one kid or $70 for multiple children.

    Hopefully Congress will take action to extend the current CHIP Program (our CHIP program is called Kids Care) in the next few weeks. In the mean-time, AHCCCS has indicated that that they’ll use money from their regular Medicaid program to support the current program.  They indicated this week that there are only enough funds in the account to keep the KidsCare premiums paid into March 2018.

    You can urge Senators McCain and Flake to reauthorize full funding of the Children’s Health Insurance Program by contacting  Sen. McCain at: (202) 224-2235 or (602) 952-2410 and Sen. Flake at: (202) 224-4521 or (602) 840-1891.


    CDC CME on Seasonal Influenza Vaccine Recommendations

    CDC has a new and free continuing education opportunity regarding updated recommendations from the Advisory Committee on Immunization Practices on the use of seasonal influenza vaccines.  Here’s a description for Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2017–18 Influenza Season.

    The learning objectives for the CME are to:

    1.   Describe available influenza vaccines for the 2017–18 season, based on updated ACIP recommendations;

    2.   Describe new and updated information and recommendations regarding influenza vaccination during the 2017–18 season, based on updated ACIP guidance; and

    3.   Describe contraindications and precautions regarding influenza vaccination during the 2017–18 season, based on updated ACIP recommendations. 

    You can access this free activity by visiting:

    You can register for free or login without a password and get unlimited access to all continuing education activities and other Medscape features.


    Non-addictive Painkillers as Effective as Opioids
    In a new study of patients who showed up to an emergency department, researchers found that a cocktail of two non-addictive, over-the-counter drugs relieved pain just as well as – and maybe just a little better than – a trio of widely prescribed opioid pain medications.

    The trial involved 416 patients who entered Montefiore Medical Center’s Emergency Department in the Bronx with painful injuries. About 20% of them were diagnosed with a bone fracture. The rest suffered injuries such as a sprained ankle, a dislocated shoulder or a banged-up knee. Upon arrival, the patients were assigned to one of four groups. 

    One group got a combination ibuprofen/acetaminophen tablet, containing the medications found in Advil and Tylenol. The other groups got a drug that contained a prescription narcotic, such as Percocet, Vicodin or Tylenol No. 3. Researchers asked patients to rate their pain upon arrival and two hours after they got their medication. Patients who got the acetaminophen/ibuprofen treatment reported pain relief just as substantial as did the patients who got one of the opioid painkillers.

    Click here for the study and here for a news report.

    AzPHA Public Health Policy Update – November 22, 2017

    Az Supreme Court Upholds Hospital Assessment & Medicaid Restoration

    There was a super important ruling last week by the State Supreme Court.  They decided that the hospital assessment authorized by the Legislature and enacted by AHCCCS to pay the state match for restoring “childless adult” eligibility back in ’13 was legal.  The effect of the ruling is that Governor Brewer’s initiative to restore and expand Medicaid stands.

    Here’s an excerpt of what the court decided in their ruling last week.

    “We hold that the hospital assessment is not subject to article 9, section 22 of the Arizona Constitution, which generally requires that acts providing for a net increase in state revenues be approved by a two-thirds vote in each house of the legislature.  This requirement does not apply to statutorily authorized assessments that “are not prescribed by formula, amount or limit, and are set by a state officer or agency.”  Ariz. Const. art. 9, § 22(C)(2).  Because the exception applies here, we reject the constitutional challenge to the assessment.”

    The issue is now finally put to rest with last week’s ruling because the state’s highest court has found that the hospital assessment is a “… statutorily authorized assessment that is not prescribed by formula, amount or limit, and is set by a state officer or agency”.


    Preventing and Controlling Infectious Disease Takes a Village

    The public health system is an interconnected group of folks that use evidence based practices to improve the health of communities.  At first, one might think that the public health system consists of the CDC and state and county health departments.  The public health system is a whole lot bigger than that.

    A public health system not only includes public health agencies at state and local levels, but also includes healthcare providers of all types, public safety and first responders, healthcare institutions, clinical and public health labs, human service and charity organizations, education and youth development organizations, recreation and arts-related organizations, economic and philanthropic organizations, and environmental agencies and organizations.

    In many ways, the public health’s system to prevent and control the spread of infectious disease reflects some of the complexity of the public health system. The Arizona Department of Health Services published new rules (called Administrative Code) to govern infectious disease prevention and control that go into effect on January 1.  A review of those rules gives you a picture of the various players that assist the public health system to prevent and control the spread of infectious diseases.


    New Communicable Diseases Reporting Rules

    For the last 18 months the ADHS has been working with stakeholders in the public health system on revisions to the “Communicable Diseases and Infestation Reporting” rules for reporting and controlling infectious diseases.  The new rules will go into effect on January 1.

    What are the rules? They determine which communicable diseases need to be reported, by whom, how quickly, and what information needs to be included (Article 2).  They also outline the intervention measures that various players should follow to prevent further disease spread (Article 3).  You’ll see that the interventions (described in Article 3) are the responsibility of many different entities: local public health departments, healthcare providers and institutions, and vector control agencies, among others.

    One thing that’s really striking is how much of the heavy lifting is done by the local health departments.  One glance at the “control measures” shows you how much of the boots on the ground public health work is done at the local health department level in coordination with healthcare providers, schools, restaurants, and patients and their families.

    Why were the rules changed? They were updated to include emerging diseases (e.g. Zika), account for changes in technology like new laboratory methodologies and electronic reporting, and to remove unnecessary requirements and improve clarity.

    What will change? Reporting requirements for healthcare providers and clinical laboratories have been modified, with the removal of several conditions (e.g., aseptic meningitis, genital herpes; the addition or clarification of others (e.g., Zika, spotted fever rickettsiosis, carbapenem-resistant Enterobacteriaceae); and changes in timeframes for reporting of various specific conditions or organisms. 

    For control measures, changes include: requiring inter-facility notification when persons with an active infection of a multidrug-resistant organism are transferred to a new healthcare facility; modifying the testing and criteria allowing persons in certain jobs to return to work after an illness (e.g. food handlers); giving more discretion to local public health officials for determining when people with certain illnesses can return to their usual activities; exclusions from aquatic venues (e.g. pools) for people with certain enteric illnesses; environmental assessments for several emerging mosquito-borne infections; and language to help county health departments issue additional control measures.  

    Who should report? Health care providers, health care institutions and correctional facilities; and schools, child care establishments and shelters should report to their local health department

    Clinical laboratories report to the ADHS.  These groups each have their own reporting requirements (see Article 2). State and local health departments work closely to use these reports to maintain statewide surveillance, conduct case investigations, and implement control measures. 

    Where to find more information? More information about communicable disease reporting requirements can be found at  A copy of the new rules can be found at New Article 2 and 3 Rules, effective January 1, 2018 until published by the Secretary of State.   

    Below is an example of what some of the reporting and control regulations look like.  I used Measles as an example because it gives a dynamic picture of the things that need to be done when there is a case of measles in the community.

    R9-6-355. Measles (Rubeola)

    Case control measures:

    An administrator of a school or child care establishment, either personally or through a representative, shall:

    ·         Exclude a measles case from the school or child care establishment and from school- or child-care-establishment-sponsored events from the onset of illness through the fourth calendar day after the rash appears; and

    ·         Exclude a measles suspect case from the school or child care establishment and from school- or child-care-establishment-sponsored events until the local health agency has determined that the suspect case is unlikely to infect other individuals.

    A diagnosing health care provider or an administrator of a health care institution, either personally or through a representative, shall isolate and institute airborne precautions for a measles case from onset of illness through the fourth calendar day after the rash appears.

    An administrator of a health care institution, either personally or through a representative, shall exclude a measles:

    ·         Case from working at the health care institution from the onset of illness through the fourth calendar day after the rash appears; and

    ·         Suspect case from working at the health care institution until the local health agency has determined that the suspect case may return to work.

    A local health agency shall:

    ·         Upon receiving a report under R9-6-202 or R9-6-203 of a measles case or suspect case, notify the Department within 24 hours after receiving the report and provide to the Department the information contained in the report;

    ·         Conduct an epidemiologic investigation of each reported measles case or suspect case;

    ·         For each measles case, submit to the Department, as specified in Table 2.4, the information required under R9-6-206(D); and

    ·         Ensure that one or more specimens from each measles case or suspect case, as required by the Department, are submitted to the Arizona State Laboratory.

    An administrator of a correctional facility or shelter, either personally or through a representative, shall comply with the measles control measures recommended by a local health agency or the Department. When a measles case has been at a school or child care establishment, the administrator of the school or child care establishment, either personally or through a representative, shall:

    ·         Consult with the local health agency to determine who shall be excluded and how long each individual shall be excluded from the school or child care establishment, and

    ·         Comply with the local health agency’s recommendations for exclusion.

    ·         A local health agency shall determine which measles contacts will be quarantined or excluded, according to R96-303, to prevent transmission; and provide or arrange for immunization of each non-immune measles contact within 72 hours after last exposure, if possible.

    An administrator of a health care institution shall ensure that a paid or volunteer full-time or part-time worker at a health care institution does not participate in the direct care of a measles case or suspect case unless the worker is able to provide evidence of immunity to measles through one of the following:

    ·         A record of immunization against measles with two doses of live virus vaccine given on or after the first birthday and at least one month apart;

    ·         A statement signed by a physician, physician assistant, registered nurse practitioner, state health officer, or local health officer affirming serologic evidence of immunity to measles; or

    ·         Documentary evidence of birth before January 1, 1957.


    November Month’s AZ Asthma Coalition Meeting

    Wednesday, November 29th from 3:00 – 5:00 pm

    Super-Brain Approach to Tobacco Cessation

    Mercy Care Plan and Mercy Maricopa Integrated Care developed a “gold standard tobacco cessation program” in partnership with ASHLine. During this presentation, you’ll learn about this system-level program and the importance of partnerships to achieve a collective impact which Mercy Care refers to as the Super-Brain Approach to tobacco cessation.

    Date:    Wednesday, November 29, 2017 from 3:00 to 5:00 p.m.

    Location: Vitalyst Health Foundation, 2929 N Central Ave, Suite 1550, Phoenix

    Join at or Telephone: US: +1 646 876 9923 or +1 669 900 6833 or +1 408 638 0968

    AzPHA Public Health Policy Update- November 16, 2017

    AZ’s New Minimum Wage Law Expected to Improve Infant Mortality

    We’ve known for a long time in public health that a primary driver of health status is family income.  More family resources generally result in better health outcomes. New data suggest (not surprisingly) that increases in the minimum wage result in lower infant mortality.

    Could the passage of Proposition 206 in November of 2016 be an evidence-based public health intervention that will lower infant mortality in Arizona?  The answer is yes!

    In 2014, Arizona’s infant mortality rate was 6.2 deaths per 1,000 live births- well above other comparable countries including Japan (2.1), France (3.5), and the UK (3.9).  The national rate in the US is 5.8/1,000.  Here are Arizona’s Infant Mortality Rates: PDF | Excel

    A team of researchers recently published a study in the American Journal of Public Health examining the effects of state minimum wage laws on infant mortality and low birthweight rates.  They found that a $1 increase in the minimum wage is associated with a 4% decrease in infant mortality and a 1% to 2% decrease in low birthweight births.  They concluded that…  “if all states in 2014 had increased their minimum wages by $1 dollar there would likely have been 2,790 fewer low birthweight births and 518 fewer post-neonatal deaths for the year.”

    This research adds to a growing scientific literature on the beneficial effects of various income supports on improved birth outcomes and reinforces the fact that social determinants of health related to income have a significant impact on population and public health outcomes.

    Of course, there are many factors at play when it comes to infant mortality and low birth weight- but it looks like Proposition 206, which raised the minimum wage in AZ to $10 this year and to $12 by 2020 will help us on our quest to improve Arizona’s infant mortality and low birth weight rates. 


    AzPHA’s Positions on the Sunrise Hearings

    Whenever health related professions ask to be regulated or want to expand their scope of practice a state law says that the regulation needs to be done only to protect the public interest.  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 the House of Representatives.

    In a nutshell, the Community Health Workers Sunrise Application asks for a pathway to set up a process for voluntary registration of CHWs; the Arizona Naturopathic Medical Association would like permission for them to sign medical waivers from the state’s school vaccination requirements; and the Dental Care for AZ Sunrise Application asks for authorization from the legislature to license a new class of dental professionals.

    Here are AzPHA’s statements to the House and Senate Committee of Reference for the upcoming November 28 Sunrise Hearings.  We’re taking positions on the CHW and Naturopath Sunrise Applications (but not the Dental Therapist application).


    Arizona Community Health Workers Association

    We urge the Committee to recommend approval of the application submitted by the Arizona Community Health Workers Association for Certification/Registration for Community Health Workers.

    Community Health Workers (CHWs) are an established group of health professionals that build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy. 

    A variety of agencies use CHWs to serve communities in ways including access to primary care, prenatal care, chronic disease self-management, long-term care, utilization of services, and behavioral health.  CHW services are effective at improving health outcomes and reducing costs and providing a unique opportunity for provider groups as they increasingly adopt value-based purchasing practices.

    There is currently no simple way for health care providers and members of the community to verify that a CHW is proficient in core competencies. Certification and registration will assure that CHWs meet minimum standards including education, continuing education, training, experience, and other qualifications. With certification and registration, payors reimbursing CHWs for services would have clarity about CHWs core competencies and their scope of practice allowing this workforce to become integrated with a medical team and/or in the community.

    CHWs work with vulnerable populations. Registration of CHWs meeting minimum standards is essential for patient safety by assuring that CHWs have a background check, follow HIPAA regulations, and safeguard against inappropriate actions and/or behaviors.

    In short, we are supportive of this application because CHW services are effective at improving health outcomes and reducing costs. In the absence of certification/registration, the community cannot be assured of CHWs’ core competencies, scope of practice, and that procedures are in place to safeguard patients.


    Arizona Naturopathic Medical Association

    We urge the Committee to recommend denial of the application submitted by the Arizona Naturopathic Medical Association to expand their scope to include medical exemptions from Arizona’s school vaccination requirements.

    The Arizona Public Health Association is concerned about several aspects of this application, most importantly, that it could further erode Arizona’s vaccination rates resulting in the loss of herd immunity. 

    We believe that medical exemptions are an important component of Arizona’s school vaccine requirement system. However, medical exemptions should be signed by physicians that are current with the latest scientific literature regarding vaccines. New vaccinations and combinations of vaccinations are approved on an ongoing basis by the Food and Drug Administration and are evaluated consistently by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP).

    Guidance and recommendations from the CDC and ACIP are critical for physicians to understand the nuances of the various vaccines, their complex schedules, and data regarding evidence-based reasons for medical exemptions.  Medical exemptions are best signed by physicians that are current with these resources.

    Our review of data regarding vaccines suggest that Naturopathic Physicians provide very few vaccinations in Arizona (less than 0.01% of all vaccinations in Arizona are provided by Naturopaths).  Because so few Naturopathic Physicians (NDs) provide vaccines, our concern is that they will not be well informed about when a medical exemption is appropriate, and that some NDs will err on the side of signing medical exemptions rather than study the detail provided by the FDA, CDC and ACIP. There is also a risk that a relatively small number of NDs could sign large numbers of medical exemptions and jeopardize herd immunity.

    We urge the Committee to recommend denial of the application submitted by the Arizona Naturopathic Medical Association to expand their scope to include medical exemptions from Arizona’s school vaccination requirements.


    Restaurant Calorie Labeling Back on Track?

    One of the things that was tucked into the Affordable Care Act was a provision that requires restaurants with 20 or more locations to post calorie content information for standard menu items directly on the menu and menu boards- a potentially powerful public health intervention in our effort to reduce obesity.

    The FDA issued proposed draft regulations way back in 2011… but various delays have kept the rules from being implemented (by both the Obama and Trump Administrations).  Some places have been voluntarily posting nutrition information- but it’s still not officially required.

    This kind of nutrition clarity is a real opportunity for public health change.  Not only will the new labels give the public key information to help them make better decisions about what they buy for themselves and their families- it’ll give pause to restaurants before they label their menus- giving them an opportunity to change ingredients to lower calorie counts.  It may even spur a trend away from “super-sizes” and toward more appropriate and reasonable serving sizes.  With 32% of the calories consumed in the US tied to eating outside the home- this is an important opportunity.  

    Last week the FDA released draft implementation guidance addressing menu labeling issues like caloric disclosure, compliance and enforcement, and marketing materials.  The new guidance suggests that the compliance start day will now be May of 2018.

    The new draft guidance includes expanded and new interpretations of policy, and identifies places where FDA intends to be more flexible in its approach. It also includes many graphical depictions conveying the FDA’s thinking on various topics and provides examples of options for implementation.

    The new guidance addresses calorie disclosure signage for self-service foods like buffets, various methods for providing calorie disclosure information (including pizza which has been a big hang-up because its’ so often delivered), and compliance and enforcement.


    President Nominates New HHS Secretary
    The President selected Alex Azar, a former pharmaceutical executive and a top health official during the George W. Bush administration, to lead HHS. Azar also served as president of Lilly USA (an affiliate of Eli Lilly and Co.) and as a health-care consultant. During the Bush administration he was chief counsel a deputy director.

    He has been highly critical of the ACA and supports converting Medicaid from an entitlement program into block grants. However, Dr. Georges Benjamin (Executive Director of the American Public Health Association, said “Azar is far less partisan than his predecessor. He’s smart, practical, listens to all sides…  We’ve got somebody whose heart is in the right place.” Time will tell.


    Open Enrollment for Marketplace Health Insurance

    The Affordable Care Act remains the law, and insurance enrollment for Arizonans runs through 12/15.  The University of Arizona Center for Rural Health (AzCRH) has certified staff (Navigators) to answer questions and help you enroll in health insurance coverage. Navigator services are free

    AzPHA Public Health Policy Update: November 9

    AzRHA & AzPHA Webinar Tomorrow RE 2018 Legislative Session

    Tomorrow we’ll be participating in a joint webinar regarding next year’s legislative session entitled: “Anticipating 2018!!! Arizona’s Fifty-Fourth State Legislature”.  It’s organized by the Arizona Rural Health Association in cooperation with AzPHA and the UA’s Telemedicine Program. You can tune in from 1-2:30 pm Thursday by visiting

    More information is on AzRHA’s website or by contacting Claudia Gonzalez at


    National Opioid Commission Recommendations

    Last week the President’s Commission on Combating Drug Addiction and the Opioid Crisis released its final report setting out 56 recommendations for addressing the national opioid crisis. The recommendations address issues like federal funding and programs, opioid addiction prevention like prescribing guidelines, prescription drug monitoring programs, and supply reduction and overdose reversal.

    You’ll remember that the Acting Secretary for HHS declared that the national opioid epidemic is a Public Health Emergency. Here’s the Secretary’s one sentence declaration.  Presumably some of the recommendations from last week’s final report will make their way into the various HHS agency policies (e.g. CMS). The report is quite long so I didn’t have time to read it all – but this did catch my eye:

    “A key contributor to the opioid epidemic has been the excess prescribing of opioids for common pain complaints and for postsurgical pain. Although in some conditions, behavioral programs, acupuncture, surgery, as well as FDA-approved multimodal pain strategies have been proven to reduce the use of opioids, while providing effective pain management, current CMS reimbursement policies create barriers to the adoption of these strategies. In the third Commission meeting, the Commission heard about the need for proper reimbursement of non-opioid pain medications to increase uptake among healthcare providers and limit the use of opioids.”


    Free Online CME Credits for Arizona Prescribers

    There’s increasing evidence that opioid medications are over-prescribed and poorly managed because prescribers aren’t aware of appropriate opioid risk management strategies and non-opioid approaches to treating chronic pain. A new and free Continuing Medical Education course is now available to familiarize prescribers with current guidelines for opioid use and prescribing & educate prescribers about non-opioid strategies for pain management.

    Opioid Prescribing CME Courses: Responding to the Public Health Emergency Available Online at:

    Learning Objectives:

    • Manage acute and chronic back pain
    • Assess the functional effects of pain in patients.
    • Appropriately utilize a range of therapeutic options when managing patients with chronic pain.
    • Comply with current opioid risk-management practices, including the use of pain contracts and urine drug testing.
    • Educate patients on the proper use, storage, and disposal of opioid medications.

    Cost: FREE for Arizona Prescribers   

    Arizona Prescribers Registration:

    Supported by a grant through the Governor’s Office for Children, Youth and Families. Developed in Partnership with Arizona Prescription Drug Misuse & Abuse Initiative, University of Arizona College of Public Health, University of Arizona College of Medicine & ADHS.


    Information about HHS’ Proposed Rules RE: Marketplace Insurance

    HHS published an annual set of proposed rules for the Affordable Care Act marketplaces on October 27. Called the “Notice of Benefit and Payment Parameters,” the rules set out expectations for insurers and the states that regulate them.  

    It’s a really long proposed Rule and I haven’t been able to find the time to analyze it all (nor am I really capable of doing a detailed analysis) but I found a pretty good summary regarding the proposals.  The proposed Rule changes focus on: 1) Essential Health Benefits; 2) Qualifying Health Plan Certification Standards; 3) Rate Reviews; 4) Medical Loss Ratios; and 5) Risk Adjustment.


    New Bulletins from CMS about Waiver Reviews & Approvals

    Last week CMS released two information bulletins outlining activities they say they’ll undertake to improve the transparency and efficiency of the various processes for Medicaid Waivers and State Plan Amendment review and approvals. The 2 bulletins are procedural commitments to move waivers and SPAs more quickly through the review and approval process.

    The “State Plan Amendment and 1915 Waiver Process Improvements to Improve Transparency and Efficiency and Reduce Burden” bulletin and the “Section 1115 Demonstration Process Improvements” bulletin are both online at


    First Things First Parent Kit

    From the day a child is born, the care, attention, love and support they experience lays the foundation for their future. The First Things First Parent Kit is online to help you meet the challenges of being a parent and do your best in supporting the healthy development of your baby, toddler or preschooler.

    You’ll find information and resources on child development, health and safety, quality child care and school readiness:  Go to the Parent Kit.

    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, or by contacting the project manager at 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 first (rather than because the assisters and navigators at 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 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.