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AHCCCS Waiver Request

AHCCCS received several hundred comments regarding their proposed waiver request as required by Senate Bill 1092.  The law requires AHCCCS to annually apply the Centers for Medicare and Medicaid Services (CMS) for an Amendment to their Demonstration Waiver that would implement the following requirements for “able-bodied adults” receiving Medicaid services:

• Limit lifetime AHCCCS coverage for all able-bodied adults to 5 years except for certain circumstances.
• Require all able-bodied adults to become employed or actively seeking employment or attend school or a job training program and require them to verify on a monthly basis compliance with the work requirements and any changes in family income.
• Ban eligible persons from enrolling in AHCCCS for 1 year if the person knowingly failed to report a change in family income or made a false statement regarding compliance with the work requirements.

AzPHA submitted our response letter on the waiver application back in February.  Several hundred people and organizations turned also in comments regarding the waiver request.  More than 90% of the commenters expressed concerns about the various items in the waiver including the 5 year limitation on benefits, monthly income reporting and other proposed requirements.  Five percent (5%) of the commenters expressed support for the waiver request.

Here are links to the: 

• Individual Comments
• Organization Comments
• Tribal Stakeholder Comments

CMS will now consider whether or not to approve the request (CMS has the final say regarding whether to approve any or all of the pieces of the waiver).  My guess is that the discussions will be on-going between CMS and AHCCCS this Summer.  

CMS denied a similar request last year, but for obvious reasons many of us in the public health world are concerned that this year’s request may be approved – given the changes in leadership at CMS in the last few months.

State Legislative Update

Activity at the Arizona State legislature is pretty much just focused on the development of a budget for the next fiscal year.  We’re still hopeful that the budget will include funding for adult emergency dental services for all Medicaid (AHCCCS) members; authorization to raise the fees needed to add Severe Combined Immune Deficiency (SCID) to Arizona’s Newborn Screening Panel; added funds for state’s loan repayment program which would enable the state to qualify for a full $1M in matching funds.

Nurse Anesthetists  

SB 1336 was passed and signed last week, clarifying the scope of practice for nurse anesthetists.  We’ve been in support of the bill because it will be good for access to care in rural AZ.  Hospitals have had increasing difficulty recruiting physicians due in part to a lack of clarity in Arizona law that leads doctors to believe they’ll be held liable for the work of  nurse anesthetists. At a time when we already face a shortage of nurses and physicians – particularly in rural and underserved communities, our focus should be eliminating red tape and empowering these health care professionals to do their jobs 

Teen Texting & Driving

SB 1080, which would ban brand-new teen drivers from using their smart phone (for the first 6 months of their license – if they’re under 18) continued it comeback last week.  It passed through the House Rules Committee and the full House and is headed back to the Senate for a final approval before going to the Governor for consideration.

Between 2012 and today the US has been conducting a natural experiment on herself.  The US Supreme Court ruling on the Affordable Care Act allowed states to decide whether or not to expand Medicaid to 133% of federal poverty.  Some stated did it and some didn’t….  so we have a kind of case control study.  Now that it’s been several years, let’s look at the data and see who made the better decision.  

The Kaiser Family Foundation recently conducted a comprehensive review of the scientific literature and found that states that expanded Medicaid under the ACA had did better than their peers that didn’t expand.  In a nutshell, the report found that the states that expanded Medicaid improved healthcare insurance coverage, access to care, utilization, and health care affordability.  Interestingly (for me at least) was the fact that states that expanded had better economic outcomes than those that didn’t… including positive effects on state budgets, employment and the labor market.

Additionally, a New Health Affairs article found that there were no significant increases in spending from state funds as a result of expanding Medicaid (in the states that expanded).  The Health Affairs study found that “… expansion states did not experience any significant increase in state-funded expenditures, and there is no evidence that expansion crowded out funding for other state priorities.”  

Statistically, states that expanded Medicaid had budget savings, revenue gains, and higher overall economic growth when compared to their peers that didn’t expand Medicaid.  Studies also found that expansion states had lower Medicaid spending per enrollee for the new ACA adult eligibility group compared to per-enrollee spending across all groups.

Medicaid expansion resulted in health insurance coverage gains among the low-income folks including specific vulnerable populations.   Most research found that Medicaid expansion improved access to care, utilization of services, the affordability of care, and financial security among the low-income population (just as you’d expect). 

The report is really well referenced.  It’s a great resource for folks looking for a one stop shop for data on the impact that Medicaid expansion has had over the last few years.  

Above all, it’s great information for policy makers as it provides objective evidence regarding the impact that Medicaid expansion had in states that expanded v those that chose not to expand.

Take a look and bookmark these two studies.

The big news this week is really about the changes to the voter initiative that were passed and signed last week.  The reason why we consider these bills as laws that impact public health is that the voter initiative process is sometimes the only real vehicle to get through policy based public health interventions.  

For example, the Smoke Free Arizona Act was passed by Initiative in 2006.  Prior to that, there had been no traction in the legislature to pass a statewide smoke free law.  Another really important voter initiative that had a big impact on public health (access to care) was Proposition 204 about a dozen years ago- which brought Arizona’s Medicaid eligibility threshold up to 100% of federal poverty.  Without that pre-existing intervention- it would have been much harder to expand Medicaid eligibility back in 2013.  

Here’s a summary of what’s been happening to the voter initiative process lately:

• Last week, the Governor signed into law HB 2404 which will prevent signature gatherers from getting paid by the signature (for voter initiatives- not for candidate signatures).  This will make it more difficult to get the large number of signatures that are needed to get citizens initiatives on the ballot in the future.

• The Governor also signed House Bill 2244 over the weekend, which will change the compliance standard for voter initiatives to “strict compliance” with standards from the previous (judicially determined) “substantial compliance”.  It also requires that the Secretary of State generate a rule handbook with the requirements.  This new law will make it harder to get initiatives on the ballot (including future initiatives with public health policy implications).

• Senate Bill 1236 is almost completely through the legislative process but hasn’t been totally signed off on yet as it hasn’t had a final vote yet in the Senate (it passed the House last week).  It’s complicated- but it basically puts in a series of regulations regarding who can be a petition circulator (e.g. no felony convictions) and the regulates how they keep and submit their records plus alot more.  Here’s the latest Fact Sheet on the latest amended version. 

Teen Texting & Driving

SB 1080, which would ban brand-new teen drivers from using their smart phone (for the first 6 months of their license – if they’re under 18) came back to life last week!  It had been looking good until it hit a roadblock in the House Rules Committee- as Rep. Phil Lovas had decided that he wasn’t going to hear it in committe.  But last week, he accepted a job in the Trump administration and the new Rules chair (Rep. Mesnard) put it on the agenda today (Monday 4/17) at 1 pm in HHR1.  

We’ve signed in support and I’ve sent this NHTSA summary document to the members that shows that teens are the largest age group reported as distracted at the time of fatal crashes and have the highest prevalence of cell phone use while driving.  One of the nice things about SB 1080 is that the bill hits the mark on the highest risk population – and at a time when their driving habits are developing.

Physical Activity

HB 2082 is in trouble I think.  It would have required that schools have some recess time to help them get some physical activity.   To be honest, I’m a little worried about this one now because of a heated remark made by the sponsor on social media about the school voucher bill that the Governor signed.  Here’s the story about it in the AZ Republic.   Sometimes things like this can derail bills. Lesson: relationships are important.

Nurse Anesthetists  

SB 1336 is waiting for the “Final Read” in the Senate.  Still looking OK though.  AzPHA is in support and submitted information to the committee talking about how this bill would be good for access to care in rural AZ.

Newborn Screening for SCID

SB 1368, which would authorize the ADHS to collect the newborn screening fees needed to add Severe Combined Immune Deficiency syndrome to the list of newborn screening tests still needs House Rules Committee approval, but isn’t on the agenda again this week.  We have no reason to believe that it’s in trouble.  

There are only 3 states left that don’t test for it or don’t have plans in place to test for it (including AZ), and with Arizona having so many high risk folks (American Indians of Askabathan descent) we clearly need to get this done.  Like I said though, no signs of trouble.

Sunscreen Use

HB 2134 would make it clear that kids can take sunscreen to school and camps… and that school and camp staff can help them put it on.  It’s basically in the process of getting concurrence between the Senate and House versions. No sign of trouble really.

Drug Overdose Review Team

HB 2493 would set up a drug overdose review team at the ADHS (much like the child fatality review team).  It  passed the Senate Health & Human Services Committee last week but still needs to get through the Committee as a Whole and then the full Senate, but it will need to go back to the House because it was amended slightly to clarify an issue related to naloxone administration (a rescue drug for opioid poisoning).  No signs of trouble, really.

Arizona Budget

Not much public news about the AZ budget this week….  but when the tumblers click – they click fast!   

We’re in support of proposals in the (executive) budget to: 

1) fund adult emergency dental services for all Medicaid (AHCCCS) members – up to $1,000 annually (this had been a benefit prior to the Great Recession); 

2) add Severe Combined Immune Deficiency (SCID) to Arizona’s Newborn Screening Panel;  and 

3) increase funding to the state’s loan repayment program by $350K (potentially allowing the state to qualify for a full $1M in matching funds from HRSA).   

We believe that these are all important proposals that will improve public health in Arizona. Our Public Policy Committee will be paying close attention to the budget process and will advocate for these important initiatives.

Teen Texting & Driving

SB 1080, which would ban brand-new teen drivers from using their smart phone (for the first 6 months of their license – if they’re under 18).  It passed the Senate and passed the House Transportation and Infrastructure Committee on March 1 but has been stuck in the House Rules Committee ever since.  There was a public statement in the Capitol Times by the Committee Chair (Rep. Phil Lovas) that he doesn’t intend to hear the bill in the House Rules Committee (which would kill the bill).  

Through my years in public health I’ve always been sensitive to make sure that our policies and interventions are careful not to infringe on civil liberties.  It’s pretty clear to me that this proposal would improve public safety by imposing a reasonable behavior expectation for new drivers. The only other limitation in AZ to this kind of distraction is for school bus drivers- this seems like a modest bill that will help set a good expectation for new drivers.  We’re encouraging AzPHA members that live in Rep. Lovas’ district to reach out and encourage him to hear the bill in the House Rules committee.  I sent a note to him and other committee members last week and will do another one this week. 

Physical Activity

HB 2082 which would enhance recess time in Arizona is looking good but still has a ways to go.  It passed its hearing in the Senate Education Committee (but was amended to eliminate the 50 minute per day requirement).  The Bill was heard in Senate Rules on 3/27 but still needs to go back to the House since it was amended to just require the recess period without the 50 minute time requirement.

Nurse Anesthetists  

SB 1336 passed the Senate last week and, after a compromise amendment, passed through the House Health and Rules Committee but still awaits a floor vote in the House.  AzPHA is in support and submitted information to the committee talking about how this bill would be good for access to care in rural AZ.

Newborn Screening for SCID

SB 1368, which would authorize the ADHS to collect the newborn screening fees needed to add Severe Combined Immune Deficiency syndrome to the list of newborn screening tests passed through the Senate and the was unanimously approved by the House Health Committee.  It still needs House Rules Committee approval and then would go to a house floor vote.  It wasn’t on the Agenda for today’s House Rules Committee.  We haven’t heard that there is any trouble with the bill, but we’re keeping our ears to the ground.  

Sunscreen Use

HB 2134 would make it clear that kids can take sunscreen to school and camps… and that school and camp staff can help them put it on.  It passed the full Senate last week but was transmitted back to the house on 4/4/17 because it was amended in the Senate.  No sign of trouble really.

Drug Overdose Review Team

HB 2493 would set up a drug overdose review team at the ADHS (much like the child fatality review team).  It  passed the Senate Health & Human Services Committee last week but still needs to get through the Committee as a Whole and then the full Senate, but it will need to go back to the House because it was amended slightly to clarify an issue related to naloxone administration (a rescue drug for opioid poisoning).

Arizona Budget

Not much public news about the AZ budget this week.  Much of the work happens behind closed doors in meetings among folks that are appointed to important positions in the Executive Branch and members of the legislature- especially those in the Appropriations Committees.

We’re in support of proposals in the (executive) budget to: 1) fund adult emergency dental services for all Medicaid (AHCCCS) members – up to $1,000 annually (this had been a benefit prior to the Great Recession); 2) add Severe Combined Immune Deficiency (SCID) to Arizona’s Newborn Screening Panel;  and 3) increase funding to the state’s loan repayment program by $350K (potentially allowing the state to qualify for a full $1M in matching funds from HRSA).   

We believe that these are all important proposals that will improve public health in Arizona. Our Public Policy Committee will be paying close attention to the budget process and will advocate for these important initiatives.

Trump Administration Budget Proposal & Call to Action

A few weeks ago the President submitted his FY 2018 budget blueprint.  If the proposal were approved as-is, it would have a significant impact on public health resources in Arizona.  The proposal calls for cutting more than $15 billion from the Department of Health and Human Services (HHS) which is an 18% decrease from 2017 levels.  Many of the Agencies that provide grant funds to Arizona’s public health system are located in HHS.

While the budget doesn’t provide specific funding levels for the Centers for Disease Control and Prevention (CDC) or the Health Resources and Services Administration (HRSA), spending reductions of this magnitude would certainly force significant cuts to many if not all public health programs if the proposal moves forward as it stands.  The proposed budget also would cut 31% from the Environmental Protection Agency’s current budget- which could have implications for clean air/water/waste assurance.

The APHA issued a statement opposing the budget proposal and also issued a statement opposing proposed cuts to FY 2017 public health and prevention programs.  APHA-led coalitions, the Friends of HRSA and the CDC Coalition, sent letters to House and Senate Labor-HHS-Education appropriations subcommittee leaders urging support for adequate funding for HRSA and CDC in the FY 2018 appropriations process. 

We’re encouraging AzPHA members to send a message to their members of Congress opposing the proposed budget cuts by visiting APHA’s action alerts page.

Not much has changed with respect to individual health-related bills since last week…  with a couple of exceptions, so you can read last week’s update for the most part to find out where things stand.  The Governor did sign a couple of health-related bills last week- so I’ll touch on those and then transition to the state budget.

Involuntary Commitment Procedures

The Governor signed HB2084 which will allow a mental treatment facility to admit a patient for involuntary treatment pending the filing of a tribal courts involuntary commitment order.  We advocated for this bill because it provides a mechanism for a more smooth access to care- especially for tribal members.  Now that it’s been signed, it’ll become law 90 days after the legislative session ends.

Deliveries

The Governor also signed  SB 1367 (abortion; live delivery; report; definition).  It’ll become law 90 days after the end of session as well.  Under already existing law, when a baby is “delivered alive” during an abortion, doctors are required to ensure that “all available means and medical skills are used to promote, preserve and maintain the life” of the baby.  But, the existing law didn’t specifically provide a definition of the words “delivered alive” leaving room for professional judgment.  The bill that was just signed specifically defines “delivered alive” as showing one or more of these signs of life: breathing, a heartbeat, umbilical cord pulsation or definite movement of voluntary muscles.

Now that it will become law later this year, the Arizona Department of Health Services will be required to set policies that clinics, hospitals and physicians will need to follow to care during a procedure or delivery thatfits the new definition of “delivered alive”.  The requirements will include having neonatal emergency equipment and trained staff in the room for all abortions performed at or after 20 weeks of pregnancy.  Many people expressed concerns that it will require doctors to perform unproductive medical procedures on a fetus born early because of fatal abnormalities.  Healthcare providers represented by the Arizona Medical Association and the AZ Chapter of American College of Obstetrics and Gynecology also expressed these concerns. 

State Budget

Each year the Governor of AZ submits a proposed budget for all the activities of state government including the operation of all the state agencies.  The budget process and outcome is is always very important in terms of public health- because so much of the budget directly and indirectly impacts things that influence public health.

Much of the real action on the budget happens behind closed doors in meetings among folks that are appointed to important positions in the Executive Branch and members of the legislature- especially those in the Appropriations Committees.

AzPHA is in firm support of proposals in the (executive) budget to: 1) appropriate the funding needed to bring back adult emergency dental services among all Medicaid (AHCCCS)  members – up to $1,000 annually (this had been a benefit prior to the Great Recession); 2) add Severe Combined Immune Deficiency (SCID) to Arizona’sNewborn Screening Panel;  and 3) increase funding to the state’s loan repayment program by $350K (potentially allowing the state to qualify for a full $1M in matching funds from HRSA).   

We believe that these are all important proposals that will improve public health in Arizona. Our Public Policy Committee will be paying close attention to the budget process and will advocate for these important initiatives.