Last week the Nevada State Legislature handed Governor Sandoval an opportunity to provide the U.S. Senate a template for modifying the Affordable Care Act.

The Nevada Legislature approved a bill and sent it to the Governor’s desk that would allow any Nevadan to “buy in” to their state’s Medicaid program.   If the Governor signs the bill (and if the Centers for Medicare and Medicaid Services – or CMS –  approves the plan) any Nevadan would be allowed to buy managed care health insurance through their state Medicaid program.  The bill would allow the purchase regardless of income. Nevada residents that qualify for their current Medicaid program would continue to receive services as-is.                  

The actual Bill is called Assembly Bill 374.  If it’s signed, the new law would direct the Nevada Department of Health and Human Services to ask CMS for a Waiver allowing their Medicaid agency let Nevadans buy health insurance through their Medicaid managed care program.  If the law is signed by their Governor (and if the approach is approved by CMS) the Medicaid insurance would be available for purchase on the “Silver State Health Insurance Exchange”.  The plan calls for folks who qualify for tax credits under the Affordable Care Act to be able to use their credits to help pay for the coverage. 

Nevadans would need to pay an annual premium “… representing 150% of the median expenditure paid on behalf of a Medicaid recipient during the immediately preceding fiscal year“.   The coverage would be the same as the coverage for NV Medicaid recipients except it wouldn’t cover emergency medical transportation (e.g. ambulance rides).  The measure is written to ensure that no federal funds would be used.

The plan has several advantages that cover many of the consensus areas that most Americans agree with… that folks should have access to reasonably priced health insurance regardless of whether or not they have a pre-existing condition. This relatively simple plan would accomplish that without a complicated overhaul of the healthcare system since all states have existing Medicaid programs. 

I often hear people arguing that a solution to the healthcare debate is to adopt a “Medicare for All” plan…  and I’ve wondered why there’s never been much discussion of a Medicaid buy-in option.  It solves a lot of the issues that the exchanges struggle with because the risk pool is larger and the rate negotiation much bigger than in the individual market today.  That means lower costs and less volatility.

Arizona would be in a good position to lead the way with such a plan.  Our state Medicaid program (called AHCCCS) is widely recognized as an efficient and cost-effective model for providing Medicaid coverage. In addition, AHCCCS’ legislation already provides the enabling statutory language to allow state employees to buy into Medicaid- so the buy-in concept isn’t entirely foreign. 

To make it work, the actuarial rates would need to be calculated in order to set the premium levels for buying in to AHCCCS.  With ACA tax subsidies and cost sharing reductions, the out of pocket costs per person would be competitive or less expensive than plans currently offered in Arizona’s Marketplace, with less year-to-year volatility in pricing.

Sometimes solutions to complicated problems are staring you right in the face.

A couple of weeks ago he nonpartisan Congressional Budget Office (CBO) released its final analysis of the House Republican’s American Health Care Act (AHCA) which was passed by the US House of Representatives by a vote of 217-213 on May 4.  The Vote in the House came before the CBO evaluation of the Bill.

CBO’s new analysis of AHCA estimates that 14 million Americans would lose health insurance in 2018.  By 2026 they estimate that 23 million would lose health insurance under the House version of AHCA. 

The measure would convert federal Medicaid (AHCCCS) funding to a per capita allotment and limit growth beginning in 2020 (using 2016 as a base year).  States could also choose to receive Medicaid funds as a block grant instead of the per-capita allotment. These are troublesome provisions that shift financial risk to AZ from the federal government …  setting up an environment that increases the likelihood that we would have future reductions in eligibility and covered services for Arizonans that get their health insurance through Medicaid (including vulnerable populations).

The Bill would also shift more of the cost of care to consumers through higher out-of-pocket expenses. Premiums could go down for some people, but premiums for low-income Americans and seniors would increase.  Subsidies would shift from income-based to age-based, with subsidies increasing with age.

It would also eliminate the Prevention and Public Health Fund beginning in 2019, block Planned Parenthood from receiving Medicaid reimbursements for services (for one year).

The Kaiser Family Foundation has a very helpful set of resources on their website that helps explain the differences between the current health care law and what would happen if the AHCA were enacted as passed by the US House of Representatives.

The Bill as passed by the US House of Representatives would:

• Convert federal Medicaid (AHCCCS) funding to a per capita allotment and limit growth beginning in 2020 using 2016 as a base year and provide states the option to get a block grant instead of the per-capita allotment. 

• Editorial comment: this provision (in my opinion) the most problematic proposal in AHCA as it would shift financial risk to AZ from the federal government and set in motion a sequence of events that would likely result in reductions in eligibility and covered services for vulnerable Arizonans. 

• Sunset the federal funds that paid for Medicaid expansion (to 133% of federal poverty) on January 1, 2020 except for people enrolled in the expansion population on 12/31/19 and who don’t have a break in eligibility of more than 1 month.

• Replace the current income-based tax credits with flat tax credits adjusted for age. Eligibility for new tax credits phases out at income levels between $75,000 and $115,000.

• Impose late enrollment penalty for people who don’t stay continuously covered.

• Repeal the Prevention and Public Health Fund at the end of Fiscal Year 2018.

• Encourage use of Health Savings Accounts by increasing annual tax- free contribution limit and through other changes.

• Establish a fund ($115 billion over 9 years available to all states), and additional funding of $8 billion over 5 years for states that elect community rating waivers (let insurance companies charge more for people with pre-existing conditions). States could use the money to provide financial help to high-risk individuals, promote access to preventive services, provide cost sharing subsidies, and for other purposes.

Our parent organization, the American Public Health Association,issued a statement highlighting the CBO’s findings and urging the Senate to work in a bipartisan manner that builds on the strengths of the Affordable Care Act.

We’re encouraging AzPHA members to send messages to our Senators urging them to focus on supporting a Senate bill that, first and foremost, protects Medicaid and that also allows folks with pre-existing conditions to be able to continue to have access to affordable health insurance.

Senator John McCain

Washington, DC Office:        202.224.2235

Phoenix Office:                    602.952.2410

Senator Jeff Flake

Washington, DC Office:        202.224.4521

Phoenix Office:                    602.840.1891

Last week the President released the Executive Branch’s FY18 proposed budget… called“A New Foundation for American Greatness.” The proposal outlines the administration’s funding priorities for the upcoming fiscal year… but it’s Congress that has the authority to actually set the budget.  

In a nutshell, the President’s budget requests an additional $54B in military spending next federal fiscal year (about a 9% increase) and proposes paying for the increase with cuts to other domestic discretionary programs (including core public health programs) by the same amount ($54B). 

Obviously, if it were to be enacted by congress as proposed, it would mean pretty substantial reductions in public health spending at the national, state and local level as the cuts would significantly impact public health grant funds to state (and local) health departments here in Arizona. 

Below is a breakdown of the proposed cuts to the CDC & HRSA and here’s a link to the President’s proposed budget:

https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/budget/fy2018/budget.pdf 

Centers for Disease Control & Prevention

The executive budget proposes cutting the CDC’s budget by 17% (from $7.2B to $5.9B) with large specific cuts to several programs.  I’ve broken down the proposal by public health service category below.

Chronic Disease Prevention and Health Promotion

The proposal completely eliminates several line items in the CDC’s budget including:

• tobacco prevention and cessation ($204M cut);
• nutrition, physical activity and obesity ($50M cut);
• heart disease ($103M cut);
• diabetes ($140M cut); and many other line items.

The proposed budget reduces the CDC’s Immunization and Respiratory Disease program by 10%; from the current $782M to $701M.

The proposal calls for cut by 17% funding for HIV/AIDS, Viral Hepatitis, STIs and TB Prevention programs; from the current $1.1B to $934M. In addition, the budget calls for decreases HIV/AIDS Prevention and Research Program by $147M.

A cut of 11% is proposed for Emerging and Zoonic Infectious Diseases; going from $579M to $514M.

The Executive budget completely eliminates the Preventive Health and Health Services Block Grant. Arizona currently over $1.85 million in FY16 from this Block grant, which allows AZ to address our unique public health needs in innovative and locally defined ways.

The budget does propose the creation of a $500M fund called the America’s Health Block Grant to provide flexibility for each state to implement specific interventions to address its population’s unique public health issues. States could theoretically use this funding to support interventions such as tobacco prevention and control; diabetes; heart disease and stroke; nutrition, physical activity and obesity and arthritis.  However, this new Block Grant is slated to be funded via the Prevention and Public Health Fund, which is completely eliminated by the American Health Care Act as passed by the House of Representatives.

Birth Defects, Developmental Disabilities, Disability and Health

The proposed budget eliminates 18 current categorical programs in the birth defects center and directs the CDC to focus its birth defects and developmental disabilities portfolio on core public health activities that “align with CDC’s mission and have proven interventions to make an impact on America’s health.”  It calls for 26% cut to the total programs in this category going down from the $135M to $100M.

Public Health Scientific Services are slated to be cut by $30M to $460M from the current $491M; Occupational Safety and Health is slated for a dramatic 41% cut to $200M from the current $338M.  Public Health Preparedness and Response is slated for a 9% cut ($136M), bringing preparedness funding down to $1.2B including a cut of $107M to the Public Health Emergency Preparedness Cooperative Agreement.

Environmental Health

The budget proposes eliminating the Amyotrophic Lateral Sclerosis Registry and reducing the Environmental and Health Outcome Tracking Network by $9M.  Environmental programs are slated to be cut to $157M, a decrease of $59 million from the current $217M.    

Injury Prevention and Control

Eliminates the elderly falls program and the injury research control centers. It does plan for level funds for opioid abuse and overdose prevention at $74M but cuts total injury prevention by 8% going from to $216 million from the current $235M.

Health Resources & Services Administration (HRSA)              

The executive budget proposes cutting HRSA’s budget to $5.5B from the current $6.15B with large specific cuts to several programs among rural health and primary care.  I’ve broken down the proposal by public health service category below.

Primary Health Care

The budget proposes the elimination of HRSA primary care programs for area health education centers; training diversity; training in primary care medicine; oral health training; public health and preventive medicine programs and other workforce programs.

HRSA workforce programs would be cut by 33% from $1.15B to $771M. I couldn’t tell from the line item whether this represents the match funding for state loan repayment programs for primary care incentives in rural areas or not.

Overall, this category of the HRSA budget would be $5B. There are proposed increases in mandatory funding for Community Health Centers by $89M.

Rural Health

The proposed budget eliminates the rural hospital flexibility (FLEX) grants and the state offices of rural health grants (like our Arizona Center for Rural Health). The Rural Hospital Flexibility Grants and State Offices of Rural Health are discontinued “to prioritize programs that provide direct services”. 

The total HRSA rural health budget would be cut by 50% with whatever funding remaining targeted toward the Rural Health Outreach Network and Quality Improvement Grants, Rural Health Policy Development, and Telehealth.

Maternal and Child Health Bureau

The proposed budget envisions cutting this Bureau within HRSA by $35M to $1.2B. It increases funding for the Title V Maternal and Child Health Block Grant by $30M and increases funding for the Healthy Start program by $10M but eliminates the sickle cell demonstration program; autism and other developmental disorders; heritable disorders; universal newborn hearing screening and emergency medical services for children.

Ryan White HIV/AIDS Program is slated for a $59M cut from the current $2.3B; eliminating the AIDS Education and Training Centers Part F and the “special projects of national significance”

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Remember, these proposed FFY 18 budget cuts by the President are just that, proposed.  Congress is the branch of government that’s authorized to set spending levels, so it’ll be important for us to continue to follow the budget conversations over the coming months and add our voices to others that will be advocating for the protection of important public health programs.

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There’s has never been a better time to join or renew your membership in AzPHA!

Membership Renewal

Individual Membership

Organizational Membership

 

 

 

 

107 years ago Arizona’s founders protected ordinary voters with a state constitution that guaranteed AZ residents the power of referendum, recall and initiatives.

Many of the bold moves to improve public health policy have come via citizens initiatives. A few examples are:

• The Smoke Free Arizona Act;
• The TRUST Commission for tobacco education and prevention;
• First Things First;
• Proposition 204 (from 2000) which extended Medicaid eligibility to 100% of federal poverty

This legislative session, Arizona’s legislative and executive branches passed and signed two bills (HB2244 and HB2404) that will impair our ability to use voter initiatives to improve public health in the future.

• HB 2404 prevents signature gatherers from getting paid by the signature (for voter initiatives), making it more difficult to provide the work incentive needed for gatherers to be efficient.  This will be a barrier to getting the large number of signatures needed to put citizens initiatives on the ballot in the future.

• HB2244 changes the citizen’s initiative compliance standard from “substantial compliance” to “strict compliance” with the requirements for putting initiatives on the ballot. This new law will make it easier to reject petitions if there are any errors on the document.

Fortunately, a new non-partisan political committee called The Voters of Arizona www.votersofarizona.com is challenging these new limits on voter initiatives. Their goal is to collect 75,000 signatures by August 12 in an effort to keep these new laws on hold (called a referendum) until the Arizona voters have an opportunity to weigh in during the November 2018 election.

As an ordinary Arizona citizen, you can help preserve the current voter initiative process. To learn more about the referendum effort or to collect signatures visit www.votersofarizona.com

If you’d like to help gather signatures for this important effort you can click here.

“This is part of what Arizona is supposed to be about, what we always have been about. The people serve as a check on the government and in particular, the Legislature. It’s pretty clear to me that this Legislature is doing what it can to try to take that power away from the public so we’re not going to let them get by with it.“

– Grant Woods, Co-Chair, Voters of Arizona

The Arizona State Legislature’s 2017 Regular Legislative Session ended yesterday.  We had some solid gains in terms of public policy that influences public health.  We also had some missed opportunities and some losses (especially when it comes to future voter initiative possibilities), but on the whole, lots of good things happened.

A big thank you to Eddie Sissions and all of the members of the AzPHA Public Policy Committee for their work tracking and advocating for and against bills this session.  Thank You!

Access to Care

Emergency Dental Care

The biggest public health win came inside the Budget.  Arizona will shortly be providing all of the matching funds needed to ensure that all adult Medicaid members have access to emergency dental services (up to a cap of $1,000 per person per year).  Adult Medicaid members that are members of AHCCCS’ Arizona Long Term Care System had emergency dental services restored last year, so this year’s action fills the last gap in dental emergency care for adults.  Kids that have their insurance through AHCCCS have comprehensive dental coverage that includes preventative services. 

Primary Care Loan Repayment

The state budget authorized an additional $350K per year to go into the state’s loan repayment program, bringing the total funds to $1M per year… which will potentially qualify Arizona for up to an additional $1M in federal funds.  These new resources are timed perfectly to take advantage of the revamping of the program over the last few years.  In a nutshell, this program gives primary care and other front line health practitioners an opportunity to get significant relief for their student loan debt by practicing in rural and underserved AZ.

Newborn Screening

The state budget includes a measure allowing the Arizona Department of Health Services to increase their newborn screening fees by $6 per test so the AZ State Lab can afford to test babies for Severe Combined Immune Deficiency syndrome.  Babies born with Severe Combined Immunodeficiency look normal at birth but they can’t fight infections. They often die before 1 year of age without medical treatment.  But if SCID is caught at birth (before the onset of infection) a bone marrow transplant can successfully treat the disorder.  It’s especially important to test for SCID in Arizona because the disorder is much more common in certain populations in Arizona: 1/2,000 among Navajo’s and Apache’s and about 1/20,000 among Latinos.

Clarifying Certified Registered Nurse Anesthetist Practice

Nurse anesthetists are a kind of registered nurse who is skilled in the administration of anesthesia and pain management.  They are a key practitioner all across Arizona, especially in rural areas.  Some disconnects with respect to the supervision of nurse anesthetists and prescribing and administration authority had been causing access to care problems especially in rural AZ.

In a nutshell, SB 1336 outlines medication orders and prescribing authority for nurse anesthetists and makes it clear that a physician isn’t liable for anesthetic administration by a nurse anesthetist.  It also modifies the definition of “presence” (relating to supervision) of these folks, and outlines medication orders and prescribing authority.  This new law got through the process with some hard work and compromise by folks who kept their eye on the access to care ball in AZ.

Outpatient Occupational Therapy for Adult Medicaid Members

AHCCCS currently provides coverage for occupational therapy services in an inpatient hospital setting to all of their members (when medically necessary), for outpatient members under 21, and for adults that are enrolled in the Arizona Long Term Care System portion of AHCCCS.  The state budget funds AHCCCS so that it can start providing coverage for occupational therapy as an outpatient health service for all their enrollees (when it’s medically necessary).

Involuntary Commitment Procedures

Existing state law has procedures for civil commitment of a person for mental health treatment if a court finds enough evidence that the person (as a result of mental disorder), is a danger to self or others, or has a disability in need of treatment but won’t or can’t accept voluntary treatment.  The court can then order the patient to undergo treatment.

Last year, the State Supreme Court amended the rules for enforcement of Tribal Court Involuntary Commitment Orders to allow the enforcement of tribal court orders upon the acceptance by the clerk of the filing of the tribal court order rather than upon the certification of the order.  In other words- some tribal members had delays in getting treatment because of the new rules. 

HB2084 will allow a mental treatment facility to admit a patient for involuntary treatment for a mental health disorder pending the filing of a tribal courts involuntary commitment order, providing a mechanism for a more smooth access to care- especially for tribal members. 

Tools for Schools

Asthma Management

Schools will be better able to help kids with asthma to manage their symptoms next school year thanks to the passage of HB 2208.  It will let trained school staff to administer (or help administer) an inhaler for a student in respiratory distress.   The new law also outlines the training required and provides immunity from civil liability (lawsuits).

The old statute allowed kids to have & use inhalers if it was prescribed by a doctor and the school had an annual written documentation from the parent or guardian authorizing the student to have and self-administer their inhaler.  The new law will let trained school district and charter school staff to help the child to use their inhaler. 

UA’s Western Region Public Health Training Center has Stock Albuterol Inhaler Training for School Personnel available on their website already… and the e-learning course provides the training needed for schools to implement this new law. 

Sunscreen Use at Schools & Camps

Schools, parents and kids will be better able to protect children from damaging UV rays as a result of the passage of HB 2134 which will make it clear that kids can take and use sunscreen at school and camps… and that school, preschool and camp staff can help them put it on. 

Why was this needed, you ask?  The FDA regulates sunscreen as an over-the-counter drug.  School districts set their own policies concerning the administration of “medication” (including over the counter sunscreen) to kids.  Some school districts and camps prohibit the administration of “over-the-counter drugs” (e.g. sunscreen) unless a parent provides written consent and an order from a physician.  This new law will make it clear for schools, camps, and day cares that it’s OK for kids to have and use sunscreen.  It’ll also give schools, camps and day cares protection from lawsuits.

Injury Prevention

Distracted Driving

Arizona will shortly join the 47 other states that have laws on the books restricting the use of smart phones while driving.  SB 1080 will ban brand-new teen drivers from using their smart phone while driving for the first 6 months of their license (if they’re under 18).  Using the phone in an emergency will still be OK.  Tickets can only be issued if the driver committed another violation.  The new law allows sound only smart phone functions under specified conditions.  Prior to this, the only other limitation in AZ to this kind of distraction was for school bus drivers. 

Drug Overdose & Poisoning Prevention

HB 2493 sets up a drug overdose review team at the ADHS (much like the child fatality review team).  It’ll be a 21-member consisting of nine heads of various government entities (or their designees) and 12 members appointed by the ADHS Director to:

• Develop a data collection system regarding drug overdoses;
• Conduct an annual analysis relating to drug overdose fatalities;
• Develop standards and protocols;
• Provide training and technical assistance to local Teams;
• Develop investigation protocols for law enforcement and the medical community;
• Study state and local laws, training and services in order to recommend policies to decrease drug overdose fatalities; and
• Educate the public regarding drug overdose fatalities.

Looks like a good opportunity to get some better surveillance, standards, protocols, and explore new laws that could help with the ongoing opioid painkiller epidemic.

Safety Net

HB2091 was passed at the very end of the Session and will (assuming it’s signed) remove the requirement that SNAP (food stamp) recipients file fingerprints prior to becoming eligible for benefits.  This had been a barrier for seniors to participate in the program because of perceived stigma.

HB2372 was also passed in the waning minutes of the Session and (if signed) will extend the Temporary Assistance for Needy Families program to 2 years lifetime participation from the current 1 year.

New Laws Posing Public Health Challenges

Changes to the Voter Initiative Process

Many of the bold moves to improve public health policy have come via the citizens initiative process that’s written into Arizona’s constitution.  A few examples are the Smoke Free Arizona Act; the Tobacco, Revenue, Use, Spending and Tracking Commission (Proposition 303 from 2002) for tobacco education and prevention; First Things First; and Proposition 204 from 2000 which extended Medicaid eligibility to 100% of federal poverty for childless adults and creating the AZ Area Health Education Centers.  Future citizens initiatives geared to improve public health will be more difficult to get on the Arizona ballot as a result of the passage of 2 new laws:  HB 2404 & HB 2244.

• HB 2404 prevents signature gatherers from getting paid by the signature (for voter initiatives), making it more difficult to provide the work incentive needed for gatherers to be efficient.  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.

• House Bill 2244 changes the citizens initiative compliance standard to “strict compliance” with all of the requirements regarding the entire process of getting on the ballot.  The previous criteria meant that citizens initiatives needed to be in “substantial compliance” with the requirements.  This new law does require the Secretary of State generate a rule handbook with the requirements. 

A group of folks will be organizing to collect 75,000 signatures by August 12 in an effort to keep these new laws on hold (called a Referendum) until the voters of Arizona have an opportunity to weigh in during the November 2018 election.  We’ll stay in touch with the groups organizing this effort and we’ll keep our AzPHA members informed regarding how they can participate in the signature gathering process.

Family Planning

One component of the state budget requires the Arizona Department of Health Services to apply to become the Title X family planning grantee in Arizona. Federal Title X funds provide about $5M in family planning resources statewide.  When I was the ADHS Director we never applied to be the Title X grantee because the Arizona Family Health Partnership (an Arizona nonprofit) did such a good job administering the grant.

The challenge that this new law poses is that if ADHS is successful becoming the Title X grantee, they’dbe prohibited by state law (ARS 35-196.05) from contracting with Planned Parenthood of Arizona to provide the family planning services- and many many Arizonans rely on Planned Parenthood a their access point for family planning.

Missed Opportunities

There were several missed opportunities to improve public health that were proposed but failed to get through the legislative process:

• Voluntary Certification for Community Health Workers
• Comprehensive oral health coverage for pregnant Medicaid members
• Requirements for recess time for physical activity in schools
• Requirement for hospitals to offer influenza vaccines to seniors in hospitals
• Regulation of tanning bed studios
• Changing the age at which folks can but tobacco products and e-cigarettes to 21 from 18

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Note: according to state law, most of these changes won’t come into effect until 90 days after the end of the legislative session- which is in mid August.  

I’ll be doing a webinar at 12 noon on May 25 summarizing this year’s legislative session.  Tiffany has sent out a couple of notices inviting people to register- and we’ll send out a couple more.

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Our Public Policy Committee will continue to meet over the phone on an ad-hoc basis the rest of the year to talk about policy at the federal level and issues that may relate to AHCCCS waiver requests.  We will also be following efforts to collect signatures to suspend implementation of the voter initiative laws until voters have an opportunity to approve or deny the laws at the ballot box in November 2018.  Our materials will continue to be posted on Basecamp.  For information about participating in the committee activities contact tiffany@azpha.org

From all indications, it looks like this year’s legislative session is about to wrap. Most of the bills besides the budget bill have been through the legislative process and either have been passed and signed or have died. The last bolus of work is to pass and sign a state budget for the next fiscal year.  That will happen in the next few days- maybe even before the end of the week.  

We’re still hopeful that the budget will include funding for adult emergency dental services for all Medicaid members. Right now kids that have their insurance through AHCCCS get comprehensive dental coverage- which is a good thing.  

Adult Medicaid members that are part of the Arizona Long Term Care System have coverage for emergency dental treatment up to $1,000 per year, but other adult Medicaid members don’t have any dental care coverage- which leads to poor oral health outcomes.  We’re crossing our fingers that the financial match will be provided for this in the final state budget.

Here’s a summary of where we are with the various bills that relate to public health this legislative session:

Good New Public Health Laws

Asthma Management

HB 2208 was passed and signed a few weeks ago.  Once it becomes effective later this summer, it will authorize trained school districts and charter schools to administer (or help administer) an inhaler for a student in respiratory distress.   The new law also outlines the training required and provides immunity from civil liability (lawsuits).

The old statute allowed kids to have & use inhalers if it was prescribed by a doctor and the school had an annual written documentation from the parent or guardian authorizing the student to have and self-administer their inhaler.  The new law will let trained school district and charter school staff to help the child to use their inhaler.  The new law will also protect the school from lawsuits.

Lucky for Arizona, we’re ready to implement this already thanks to AzPHA members Dr. Lynn Gerald at the UA’s Mel and Enid Zuckerman College of Public Health and Dr. Doug Taren at the UA’s WesternRegion Public Health Training Center. The Training Center has Stock Albuterol Inhaler Training for School Personnel available on their website already.  

The e-learning course provides the training needed for schools to implement this new law.  Thank you Dr.’s Gerald & Taren for your leadership in this area of public health!

Sunscreen Use at Schools & Camps

HB 2134 will become law 90 days after the end of the legislative session. It’ll  make it clear that kids can take and use sunscreen at school and camps… and that school, pre-school and camp staff can help them put it on. 

Why was this needed, you ask?  Well, the FDA regulates sunscreen as an over-the-counter drug.  School districts set their own policies concerning the administration of “medication” (including over the counter sunscreen) to kids.  Some school districts and camps prohibit the administration of “over-the-counter drugs” (e.g. sunscreen) unless a parent provides written consent and an order from a physician.  
 
This new law will make it clear for schools, camps, and day cares that it’s OK for kids to have and use sunscreen.  It’ll also give schools, camps and day cares protection from lawsuits.  Hooray.

Involuntary Commitment Procedures

The Governor signed HB2084 which will allow a mental treatment facility to admit a patient for involuntary treatment for a mental health disorder 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.

State law already has requirements and procedures for civil commitment if a court finds enough evidence that the person (as a result of mental disorder), is a danger to self or others, or has a disability in need of treatment but won’t or can’t accept voluntary treatment.  The court can then order the patient to undergo treatment.

Currently, an order from an Arizona tribal court is recognized by the other courts in AZ and enforceable by any court of record in this state, subject to the same procedures, defenses and proceedings for reopening, vacating or staying as a judgment of the court. 

Current statute says a patient committed to a state mental health treatment facility by a tribal court order is subject to state jurisdiction.  Last year, the State Supreme Court amended the rules for enforcement of Tribal Court Involuntary Commitment Orders, to allow the enforcement of tribal court orders upon the acceptance by the clerk of the filing of the tribal court order rather than upon the certification of the order.  In other words- some tribal members had delays in getting treatment because of the new rules. 

This new law will fix that delay in treatment, which is a good thing for public health we think.

Nurse Anesthetists  

SB 1336 was passed and signed a couple of weeks ago.  In a nutshell, the new law outlines medication orders and prescribing authority for nurse anesthetists and ill make it clear that a physician isn’t liable for anesthetic administration by a nurse anesthetist.  It also modifies the definition of “presence” (relating to supervision), and outlines medication orders and prescribing authority for a nurse anesthetis.  

AzPHAsupported this Bill and submitted information to the committee providing information about how this bill would be good for access to care in rural AZ- which had been facing challenges as a result of the existing laws.

Teen Texting & Driving

SB 1080 was signed by the Governor last week and will ban brand-new teen drivers from using their smart phone for the first 6 months of their license – if they’re under 18.  Using the phone in an emergency will still be OK.  Tickets can only be issued if the driver committed another violation.  It allows anaudible tool like Mapquest under specified conditions.

The only other limitation in AZ to this kind of distraction is for school bus drivers.  Arizona will now join 48 other states that restrict smart phone use!

Drug Overdose Review Team

HB 2493, which sets up a drug overdose review team at the ADHS (much like the child fatality review team) will also become law later this summer.  The new law sets up a21-member consisting of nine heads of various government entities (or their designees) and 12 members appointed by the ADHS Director.

The Mission for the Team is to:

• Develop a data collection system;
• Conduct an annual analysis relating to drug overdose fatalities from the preceding year;
• Aid in the development of local Teams;
• Develop standards and protocols;
• Provide training and technical assistance to local Teams;
• Develop investigation protocols for law enforcement and the medical community;
• Study state and local laws, training and services in order to determine if changes are needed to decrease drug overdose fatalities and, as appropriate, take steps to implement these changes; and
• Educate the public regarding drug overdose fatalities.

Looks like a good opportunity to get some better surveillance, standards, protocols, and explore new laws that could help with the ongoing opioid painkiller epidemic.

Good Public Health Bills Not Yet Passed

Emergency Dental Coverage for Medicaid Members

We’re still hopeful that the budget will include funding for adult emergency dental services for all Medicaid (AHCCCS) members. Right kids that have their insurance through AHCCCS get comprehensive dental coverage- which is a good thing. 

Adult Medicaid members that are part of the Arizona Long Term Case System have coverage for emergency dental treatment up to $1,000 per year, but other adult Medicaid members don’t have any dental care coverage at all- which has led to all sorts of bad oral health outcomes among adult Medicaid members (they had emergency dental coverage before the Recession- but that funding was a casualty of the recession).  We’re crossing our fingers that the financial match will be provided for this in the final state budget.

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. 

Babies born with Severe Combined Immunodeficiency look normal at birth but they can’t fight infections. They often die before 1 year of age without medical treatment, but if caught at birth,  before the onset of infection, a bone marrow transplant can successfully treat the disorder.  It’s particularly important to test for SCID in Arizona because the disorder is much more common in certain populations in Arizona: 1/2,000 among Navajo’s and Apache’s and about 1/20,000 among Latinos. 

Bills Good for Public Health that Died

Community Health Workers

Sadly, HB 2426, which would have set up a pathway for Community Health Workers in AZ, appears to be dead for this year.  Had it passed, it would have set up a pathway for Community Health Workers in AZ to voluntarily become certified… which would be a big step forward for this important health profession.  It would have  expanded  the use of CHWs in Arizona’s healthcare system in part by making it easier to get reimbursement for their services.

The Arizona Community Health Workers Association did a great job of organizing and is in a solid position to keep the momentum going next legislative session.  

Influenza Vaccines in Hospitals

HB 2090 which would have required hospitals to offer influenza vaccines to seniors during the cold and flu months appears dead for whatever reason.  It would’ve provided an additional access point for getting a flu vaccine among a high risk population- but alas- it won’t become law this year (although hospitals could of course elect to offer the vaccines if they want).

Physical Activity

HB 2082, which would have required that schools have some recess time went down in flames.  To be honest, I think it would have passed but didn’tbecause of a heated remark made by the Bill’s sponsor made on social media about the school voucher bill that the Governor signed.  Here’s the story about it in the AZ Republic.   Lesson: relationships are important.

Tanning Beds

HB 2194 which would have prohibited kids under 18 from using tanning beds and prevents studios from claiming that tanning beds are risk-free is effectively dead for this year, again. 

Bills Bad for Public Health that Luckily Died

Traffic Safety Cameras

Let’s face it. Getting a ticket in the mail for speeding or running a red light is no fun.  But evidence suggests that photo enforcement of red lights is an effective public health intervention, which is why we advocated against HB2525.  It would have banned traffic safety cameras in AZ.  While it passed out of the House, it stalled and died in the Senate. 

It’s sure to be back next year.  My advice to some towns that are over-using photo enforcement is to tone it down- or you’ll end up ruining it for everybody.

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.