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Last week Senators Hatch and Wyden introduced bipartisan legislation to reauthorizethe Children’s Health Insurance Program (CHIP)- which is the parent ofArizona’s KidsCare program.

The Bill (called S.1827) proposes a 5-year reauthorization of the program and maintaining the current 23% increase in the federal matching funds rate through FY 2019, but reducing thematching rate in FY 2020… and returning to the standard state-federalmatching rate in FY 2021-2022.

While it looks like this reauthorization bill won’t be voted in this week, it’s not dead.  It can still be approved in thecoming weeks.  The lack of a reauthorization introduces some uncertainty to states (all 50 states have a CHIP program) butas long as it gets voted on in the near future most states will probably holdfast and keep the program going for the time-being.

The issue in the long-run is that the Hatch/Wyden bill drops the federal matching rate in FY 2020 below the threshold that’s wired into state law for fundingAZ’s share of the program.  But, that’s something that could be changed in either the 2018 or 2019 AZ Legislative Sessions.

Congratulations to the ADHS and all the Stakeholders that helped the team achieve national accreditation through the Public Health Accreditation Board (PHAB). The national accreditation program improves public health system performance by transforming the quality and performance of the nation’s state, local, tribal, and territorial public health departments.

PHAB Accreditation is a multi-year process that ADHS began in 2010 with the development of an agency strategic plan in 2011 and the first ever State Health Assessment in 2014.  Next was building the Arizona Health Improvement Plan.  Along the way, Accreditation includes developing, reviewing, and submitting documentation that supports the accreditation standards evaluate processes and services, outcomes, and progress toward specific goals and objectives.

The entire public health system including numerous Stakeholders need to be involved to achieve this recognition.  Congratulations to AZ’s public health system for this remarkable achievement.

The state health department joins Maricopa, Mohave, Pima, and Yavapai counties as national accredited public health agencies in Arizona.

The Children’s Health Insurance Program (CHIP) is a program that provides health insurance coverage for uninsured children in families with incomes that are modest but too high to qualify for Medicaid (AHCCCS). To continue operating, the CHIP program needs to be reauthorized by Congress by September 30.

In our state, CHIP is called KidsCare. AHCCCS offers health insurance through KidsCare for kids (under age 19) who aren’t eligible for other AHCCCS health insurance. There are several eligibility criteria- but the basic income criteria is a family income less than 200% of the federal poverty level.  Right now, about 23,000 kids are insured through Kids Care.  AZ also gets CHIP matching funds that covers an additional 73,000 kids via AHCCCS.

Arizona law requires AHCCCS to freeze enrollment if the federal match goes below its current level, meaning that there would be an enrollment freeze if Congress lowers the federal match below 100% as part of a funding reauthorization.

Last week there was an agreement struck in the Senate Finance Committee between Senators Hatch and Wyden on extending CHIP funding for 5 years but with a scaling down of the federal match.  So far, my understanding is that starting in FFY 2020, the federal matching rate would be reduced bump will be reduced and beginning in 2021 the federal match will go back to the regular CHIP match (for Arizona that’s 79% federal and 21% state match). 

Bottom line is that if this amendment goes through with the reauthorization bill, it would probably mean that KidsCare would continue as is through September 30, 2019.  After that, the program would freeze enrollment unless a state law is changed allowing for an alternative federal matching rate.  If the reauthorization doesn’t go through at all I’m not sure what would happen.

Please urge Senators McCain and Flake to reauthorize full funding of the Children’s Health Insurance Program (KidsCare in Arizona) and to keep the federal match rate at 100%.

Contact Senator John McCain and Senator Jeff Flake:

     Sen. John McCain: (202) 224-2235 or (602) 952-2410

     Sen. Jeff Flake: (202) 224-4521 or (602) 840-1891

Senator McCain indicated that he looks to the Governor for guidance. Please contact the governor’s office to urge the governor to support reauthorization of CHIP funding at 100% match.

     Gov. Ducey: (602) 542-4331 or (520) 628-6580

A last-ditch effort is underway in the US Senate to repeal the Affordable Care Act and replace it with an alternative plan.  It’s called the Graham-Cassidy bill. Before October 1 the Bill could pass the Senate with only 51 votes.  After that, it would take 60 votes, meaning that changes to the ACA would need to be bipartisan.

The Congressional Budget Office (CBO) – which evaluates the impact of health bills in terms of cost and impact on private insurance coverage and Medicaid- will need several weeks for it to evaluate the Bill’s impact, so it’s unknown how many fewer people could be insured under it or what the impact on premiums may be.

Even though the bill won’t have a CBO evaluation & its impact on commercial and group insurance and Medicaid as well as the fiscal impact have no objective estimates, the US Senate is poised vote on the bill in the coming days. 

What would Graham – Cassidy do?  In a nutshell, it would:

·       End Medicaid expansion funding, turning the federal funding for Medicaid expansion into a block grant. States would be given a lump sum of money and decide what to do with it (e.g. help enrollees pay their premiums, set up a high-risk or reinsurance pools);

·       Send states a fixed amount of money per Medicaid enrollee (a per-capita cap) starting in 2020.  States could also opt to receive Medicaid funding as a block grant – a fixed amount of federal funding each year- regardless of how many participants are in the program (states couldn’t take a block grant for persons with disabilities);

·       Repeal the ACA individual and employer mandates;

·       Repeal ACA cost-sharing subsidies that lower marketplace premiums by 2020, and roll the funds into a block grant to states;

·       Loosen the ACA’s requirements that plans cover pre-existing conditions;

·       Allow everyone in the individual market to buy catastrophic plans;

·       Repeal ACA taxes on over-the-counter medicine, health savings accounts and medical devices;

·       End federal funding for Planned Parenthood for 1 year; and

·       Double maximum contributions to health savings accounts.

We’re encouraging our members to use APHA’s action alert to let Senator McCain know what you think of the bill itself (especially the profound changes to Medicaid) and the process that’s being used to debate and approve this Bill.  Here’s the text of the short letter that AzPHA sent to Senator McCain yesterday.

Dear Senator McCain:

The Arizona Public Health Association and our members urge you to trust your instincts regarding the process that is being used in the Senate regarding the Graham-Cassidy Bill.

We agree with your previous statements and commitments suggesting that Regular Order is the best policy for debating and passing key legislation, especially legislation that impacts Arizonans in a profound and personal way like access to health care.

As you know, legislation that goes through the time-tested processes of debate and input from all sides is more likely to build buy-in and consensus.  Legislation and public policy built together is much more likely to be successful in the long-run.

Now more than ever, we need solutions to our Nation’s problems that are built together, with input from all.

We thank you for your leadership and your statesmanship.

Sincerely, 

Will Humble, MPH

Executive Director, 

Arizona Public Health Association

The Arizona Supreme Court announced this week that they’ll hear the Biggs v. Betlach case.  The lawsuit was filed by a group of legislators challenging the method used by the legislature to authorize AHCCCS’ hospital assessment.  It’s a charge to hospitals that’s used annually to draw down the federal match required to pay the state’s share for covering “childless adults” under our state’s Medicaid program (covering them was a pre-requisite to expanding Medicaid eligibility to 138% of poverty).

The Plaintiffs basically argue that the assessment is a tax rather than an assessment charged by the Agency.  Raising a tax requires a super majority while authorizing an agency director to, by rule, assess a fee only takes a simple majority.  The hospital assessment used the latter mechanism.

There’s plenty of agency practice history in assessing fees based on authority that came from a simple majority vote…  and some good case law too.  For example, when I was the ADHS Director, we raised the fees (in 2009) for our licensed facilities in order to pay for all of our licensing programs’ operations.  That authorization came via a simple majority vote budget bill.

We’re probably going to be OK, but you never know.  No date has been set for the Hearing.

A final push to “repeal and replace” the Affordable Care Act is underway in the US Senate. Today Senators Bill Cassidy & Lindsey Graham along with Senators Heller and Johnson unveiled a revised version of their legislation to repeal and replace the Affordable Care Act (ACA). A window of opportunity until September 30 is available for the supporters of the Amendment (for this federal fiscal year). 

It’s called the Cassidy-Graham proposal and it’s essentially an Amendment to the Better Care Reconciliation Act that failed awhile back. Here’s a summary of the content of the Bill, it would:

• Eliminate the ACA’s marketplace subsidies and enhanced matching rate for the Medicaid expansion and replace them with a block grant. Block grant funding would be well below current law federal funding for coverage, would not adjust based on need, would disappear altogether after 2026, and could be spent on virtually any health care purpose, with no requirement to offer low- and moderate-income people coverage or financial assistance.

• Convert Medicaid’s current federal-state financial partnership to a per capita cap, which would cap and cut federal Medicaid per-beneficiary funding for seniors, people with disabilities, and families with children.

• Eliminate federal subsidies to purchase individual market coverage;

• Eliminate the ACA’s individual mandate to have insurance or pay a penalty; and

• When the Bill’s block grant period ends in 2026, it would repeal the ACA’s major coverage provisions with no replacement.

At the same time, the Senate Health, Education, Labor and Pensions Committee is trying to develop a bipartisan health bill that likely would focus on marketplace stability, including assuring that health insurers receive the cost sharing subsidies. Because insurers will soon be setting their 2018 insurance rates, there’s interest in trying to finalize legislation this month, but it is not clear whether an agreement will be reached in the Senate—and then with the House.

Depending on what happens in the next couple of weeks we may issue an Action Alert for our members.

During the 2015 Legislative Session, the Legislature passed and the Governor signed a bill requiring AHCCCS to annually submit an Amendment to their 1115 Demonstration Waiver asking permission to implement the following requirements for “able-bodied adult” Medicaid members:

• 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;
• Require most members to verify monthly any changes in family income; and
• Ban eligible persons from enrolling in AHCCCS for 1 year if a member knowingly fails to report a change in income.

The Obama Administration officials denied these waiver requests in 2016, but the landscape in that regard looks very different today.

AzPHA submitted our response letter on this year’s 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 of the commenters expressed support for the waiver request.

Here are links to the Individual Comments, Organization Comments, and Tribal Comments.

Arizona’s 2017 request to the federal government to tighten its Medicaid eligibility has been delayed by about 5 months, but all indications are that AHCCCS will submit the directed waiver to CMS in the near future.  Signals from CMS suggest that all or most of the request will be approved this time (see this letter this letter from Seema Verma of CMS & and Secretary Price to governors for details).

Stephanie Innes from the AZ Daily Star wrote a good article over the weekend diving into how Arizona is Moving Ahead With Proposal To Add AHCCCS Work Requirements.

Stay tuned- although there’s not much our members can do to influence the outcome at this point.

Obesity remains one of America’s most pervasive, expensive and deadly health problems.  Obesity increases the risk of developing high blood pressure, heart disease, type 2 diabetes, stroke, arthritis, liver disease, kidney disease, Alzheimer’s disease, gallbladder disease and mental health issues, as well as many types of cancer.  During pregnancy it increases the chances of complications, including diabetes, cesarean delivery and stillbirth.  Each year, obesity is associated with more than 100,000 premature deaths in the US (2,000 in Arizona).

These days more than one-third of U.S. adults are obese (29% in Arizona).  Back in 1990 only 10% of adults were obese.   Needless to say- a Big problem.

The causes of obesity are complicated but the bottom line is that most Americans don’t eat enough healthy food or get enough physical activity.  Communities designed for transportation by cars, jobs that require hours sitting behind a desk, and entertainment revolves around watching a screen all encourage a sedentary lifestyle. Processed food and sugar-sweetened beverages are heavily advertised, and often less expensive and more readily available than healthier alternatives.  In lots of places there aren’t grocery stores where people can buy affordable and nutritious food.

What can be done?

A new report from the Trust for America’s Health Trust for America’s Health does a really good job documenting the extent of the surveillance and public health problems posed by obesity- but more importantly- it provides a host of evidence based (and practical) state and local policies that are being implemented that are making a difference.  These tools provide states and communities with info so that they don’t need to reinvent the wheel.

State policies play a big role in improving access to healthy food and increasing physical activity.  THAH has developed a new feature that tracks the status of each state’s efforts on more than two dozen policies aimed at preventing obesity and supporting health.  

Here’s where you can view state policies to prevent obesity– excellent information that our members can use to advocate for the advancement of state laws and policies that can make a difference.

Over the past 15 years the number of prescription opioid painkillers has gone up by 400% yet the amount of pain or disability that Americans experience has remained unchanged.   From 2000 to 2014, more than 165,000 people in the US have died from overdoses related to prescription opioid use.

One critical component to turning the corner on this epidemic is to identify higher risk populations that rely heavily on opioids.  That info can give us important information which can be used to craft targeted interventions among high risk folks.  

There was a super interesting study published in the Journal of the American Board of Family Medicine last week that found more than half of all opioid prescriptions in the US are written for people with anxiety, depression, and other mood disorders.

People with mood disorders are at increased risk of abusing opioids, yet they received many more prescriptions than the general population, according to an analysis of data from 2011 and 2013.

The study, Prescription Opioid Use among Adults with Mental Health Disorders in the United States concluded that the 16% of Americans who have mental health disorders receive over half of all opioids prescribed in the United States.

The study found that 19% of the 38 million Americans with mood disorders use prescription opioids, compared to 5% percent of the general population — after controlling for physical health, level of pain, age, sex and race.

These findings are surely applicable to Arizona as well – and it provides really important information that we can surely use to augment the findings of the Arizona Department of Health Services’ report that was published this week outlining the results of their enhanced surveillance and recommended policy interventions.