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