CMS Position on Native American Exemptions from State Medicaid Work Requirements Complicates AZ Waiver Request

A 2015 AZ law requires AHCCCS to annually ask the CMS for permission to require work (or work training) and income reporting for “able bodied adults” and a 5-year lifetime limit on AHCCCS eligibility.  The work requirement waiver requests 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.

Late last year AHCCCS submitted their annual official waiver request asking permission to implement the following requirements for certain adults receiving Medicaid services including a requirement to become employed, actively seek employment, attend school, or partake in Employment Support and Development activities (with exceptions) and a requirement to bi-annually verify compliance with the requirements and any changes in family income.  CMS has not yet ruled on the AZ request.

One of the exempted groups in the waiver request is American Indians.  Starting Friday (when HB 2228 takes effect) the exemption of tribal members won’t just be an administrative decision, but one required by Arizona law.  That’s because HB 2228 requires AHCCCS to exempt tribal members from their work requirement waiver requests.  Here’s the exact statutory language:

36-2903.09.  Waivers; annual submittal; definitions


However, a letter signed by CMS official Brian Neale suggests that CMS won’t be approving waiver requests that exempt tribal members.  In a letter to tribal members he writes, regarding exempting tribal members from state Medicaid eligibility work requirements “… Unfortunately, we are constrained by statute and are concerned that requiring states to exempt AI/ANs from work and community engagement requirements could raise civil rights issues.”

In a nutshell, (beginning Friday) Arizona law will require AHCCCS to exempt American Indians from their directed work requirement waiver request (they have already administratively elected to do so).  CMS is on record saying that they’re constrained by statute and have civil rights concerns about allowing states to exempt American Indians from work requirement and reporting waivers. 

It stands to follow that CMS may very well deny Arizona’s request to exempt tribal members from work and reporting requirements despite our new law (36-2903.09 (B)). If that happens, there will surely be a legal review to determine exactly the intent of 36-2903.09 (B)

New Public Health Return on Investment Report

AzPHA member J. Mac McCullough, PhD, MPH, who serves as an Assistant Professor at Arizona State University and Health Economist at Maricopa County Department of Public Health was commissioned by AcademyHealth to write a research synthesis examining the return on investment for public health funding.

It’s a very nice and concise report.  It’s available online on the AcademyHealth website.  Here are some excerpts from the report

Federal, state, and local agencies spend approximately $250 per person per year on the public health system, whereas more than $10,000 is spent on health care per person per year. Public health spending has been falling as proportion of total health spending since approximately 2000 and falling in inflation-adjusted terms since the Great Recession. These declines have resulted in cuts to the public health workforce and to public health program portfolios.

While linking public health and health care spending to improved health outcomes can be tricky, the body of evidence supporting prevention is strong. For example, we know that investment in tobacco cessation can save $2-3 for every $1 invested and that childhood vaccinations can save $5-11 for every $1 invested.

One especially relevant set of studies utilized a unique dataset of public health department expenditures in California. Researchers used instrumental variables to show that a $10 increase in per capita spending led to a 0.6 percent increase in the proportion of the population in very good or excellent health4 and reduced all cause mortality by 9.1 per 100,000.23 Researchers monetized these estimates to determine that every $1 invested in public health in California resulted in $67 to $88 of benefits to society.24

a 2017 systematic review of international studies found that spending for individual public health interventions, services, or policies had a median ROI of $14.30 per $1 invested.

New AZ Public Health Laws Take Effect Friday

State legislators passed several new laws that will influence public health last session- but almost all of them won’t take effect until Friday (August 3). The Legislature has developed a report that report that summarizes all of this year’s bills. The health-related bills are on pages 99-108.  Here’s a snapshot:

  • HB 2088 will require school districts to: 1) develop intervention strategies to prevent heat-related illnesses, sudden cardiac death, and prescription opioid use; 2) notify parents when kids are bullied; and 3) tell parents if a student is suspected of having a concussion.  An ADHS concussion training & management report is due at the end of 2018.

  • HB 2196 will limit ambulance certificate of necessity (CON) hearings to 10 days unless the Administrative Law Judge determines that there’s an extraordinary need for more hearing days.  Hearings had previously gone on for many weeks or even months.

  • HB 2197 requires AZ health licensing boards to collect certain data from applicants (beginning January 2020).

  • HB 2228 directs AHCCCS to exempt tribal members from work requirement waiver requests (more on this later in the update).

  • HB2235 will set up a new licensed class of dental professionals called a Dental Therapist.  The next step is for the AZ Board of Dental Examiners to develop the scope of practice and license regulations.

  • HB 2323 authorizes contracted nurses to provide emergency inhaler medication in case of respiratory emergencies (takes effect this semester).

  • HB 2324 charges the ADHS with implementing a voluntary certification for Community Health Workers. The next steps are for the ADHS to establish the advisory committee and begin the Rulemaking to set up the certification process.

  • HB2371 sets up statewide licensure for food trucks. The licenses will have reciprocity in all county health and environmental service departments.

  • SB 1083 will require public schools (K-3) to have at least 2 recess periods beginning this semester.   Grades 4 and 5 will be required to have 2 recess periods beginning August 2019.

  • SB 1245 will develop a produce incentive program within the Supplemental Nutrition Assistance Program within ADES.

  • SB 1389 requires the ADHS to develop an HIV Action Plan.

  • SB 1465 requires the ADHS to adopt rules and license sober living homes.  It also allows them to contract with a third party to assist with licensure and inspections. They have a 2-year exemption from the regular rulemaking process.

  • Note: SB 1001 – The Arizona Opioid Epidemic Act was in a Special Session and became law several months ago. 

Ballot Measure Analysis Hearing Wednesday Morning

There will be several voter initiatives and some referendum issues for us to vote on in November. We don’t exactly know which measures will make it to the ballot yet because the Secretary of State is still validating the signatures etc. and there are some lawsuits challenging some of the measures too.

If you’ve read your voter publicity pamphlet in the past, you’ll remember that there’s an analysis of each ballot measure. The analyses are really important because they convert the statutory language into normal language- and many voters use them in their decision-making.  It’s important that they be objective and accurate.

The language for the Analyses are prepared by the Arizona Legislative Council and evaluated by Council of Legislators, who consider and adopt or amend the draft analyses. ARS 19-124 governs the process.  The analyses are supposed to “… include a description of the measure and shall be written in clear and concise terms avoiding technical terms whenever possible.  The analysis may contain background information, including the effect of the measure on existing law…“. 

The Legislative Council is holding a hearing this Wednesday (July 25, 2018) at 9:00 A.M., in House Hearing Room #3 to consider adopting (or amending) the draft analysis language for the Stop Political Dirty Money Amendment (draft analysis); the Clean Energy for a Healthy Arizona Amendment (draft analysis); the “Protect Arizona Taxpayers Act” (draft analysis); and the Invest in Education Act (draft analysis). 

I won’t be able to make it but I’m hoping some of you can take some time and attend.

Professional Development Opportunity: AZ Institute for Healthcare Leadership

Healthcare leaders throughout Arizona can to become better leaders through the Arizona Institute for Healthcare Leadership program. The program formerly known as the Arizona Hospital & Healthcare Leader Association’s Emerging Healthcare Leader Program has been developing healthcare leaders since 2006.

The Arizona Institute for Healthcare Leadership (AIHL) program provides high potential midlevel to senior level leaders within not for profit, for profit and government hospitals and healthcare organizations the necessary skills to become exceptional leaders. Participants have richly diverse backgrounds from many clinical and nonclinical aspects of healthcare including: IT, nursing, ambulatory care, rehab, pharmacy, physician practices, telemedicine, quality, finance, human resources, case management and more.

Fifty percent of the leaders graduating from the Arizona Institute for Healthcare Leadership in the past three years have been promoted, several to Chief Executive Officer. As the pace of change in healthcare accelerates and current leadership is promoted or leaves, these graduates will take their place. Arizona healthcare organizations with an eye to the future have been sending top talent to the AIHL program for over a decade. AIHL develops healthcare professionals with leadership skills including emotional intelligence, communication and the ability to deal with change; all needed to grow their career to the next level.

“Through this experience I became more aware of my emotional intelligence and its impact on the success of the organization, being a senior leader. I also learned to handle my inner Gremlin better as a female, minority leader. In addition, I learned so much from my peers in the program, their similar struggles and successes made me feel I am not and my organization is not alone working through the immense and unprecedented challenges of healthcare and generational leadership transitions.”

A 2016 graduate

“The content of this course has proven very valuable. It helped me to become more cognizant of how emotional intelligence influences my approach to the work, and the positions I pursue.  It provided tools and resources that are helpful in dealing with situations ranging from normal every day events, navigating an organization through crisis situations, and managing a multi-generational workforce. The ability to apply what I learned in this program to real-time, real-world scenarios led to my getting a promotion to a larger, more complex organization.  I strongly encourage participation in this program.”

A 2015 graduate

The full fee is $5,500, participants can save $250 by being an association member and another $250 by applying by Sept. 20 bringing the cost down to $5,000. With the class time, executive coaching, outside reading and project the average person will spend 10-20 hours a month, not including travel for the session each month.

Applications are being accepted now for the 2019 cohort (which runs from January – October 2019. Deadline to apply is 11/16/18.

Program overview and applications are available at For more information contact Joanne Schlosser at or call 480-840-6024. 

Behavioral Health Advocacy Training Institute: Apply Now

The Eric Gilbertson Advocacy Institute for Behavioral Health (aka Institute) is designed for service recipients/participants, family members, Board Members, and individuals concerned about quality behavioral health in Arizona.  The goal of the training is to provide you a comprehensive overview of the Arizona behavioral health system and to assist participants in becoming effective advocates for those receiving behavioral health services.

The Institute provides information, training, and resources to participants on behavioral health issues at the individual, provider, and system level. The Institute will provide participants with opportunities to meet and talk with leaders and advocates in the Arizona behavioral health system.  As a participant, you’ll have an opportunity to meet and unite with others who have a similar interest in creating a powerful voice on important issues. You’ll also learn how various state agencies are responsible for the delivery of behavioral health services and how the legislative process works at the state and national levels to impact behavioral health policy. 

The Training Institute will cover the History of the Disability Movement and the Role of ADHS, ADES, AHCCCS, ADOE, the Courts & Corrections, the Role of the Regional Behavioral Health Authorities (RBHAs) & Complete Care Contractors Community Supports State & Federal Policy Legislative Process Organizing for Change.  The Application deadline is August 15.  For more information visit

Families USA Issue Brief: Adult Dental Services

States have great latitude to determine the scope of dental benefits they cover for adults through their Medicaid programs. Some states cover comprehensive benefits, others cover emergency dental care and some none (AZ provides emergency coverage up to $1000 per year for all adults and comprehensive coverage for kids).  This variation in coverage matters. Without adequate dental coverage, people face barriers to getting care they need to stay healthy.

To better understand the consequences of insufficient dental coverage, Families USA conducted a survey of states that cover emergency-only dental services.  In the issue brief Families USA found:

  • States that cover emergency dental services generally cover some services to address severe pain including extractions. But most don’t provide restorative care nor cleanings that would address underlying disease.
  • In some states, Medicaid managed care plans provide plan-specific “value added” benefits.
  • State Medicaid programs pay for hospital emergency department visits when appropriate dental services are not available.
  • More comprehensive benefits and fewer prior authorization requirements would encourage provider participation.
  • Low-income seniors and people with disabilities who rely on Medicaid and Medicare for health coverage are among those affected by the lack of dental coverage.

The Families USA Issue Brief concludes that emergency-only dental coverage is a start, but states should invest in comprehensive Medicaid dental coverage for adults if they want to effectively keep their populations healthier and reduce other health care costs. Here’s the full the full issue brief.

Substance Abuse Prevention Needs Assessment

AHCCCS is conducting a Statewide Substance Abuse Prevention Needs Assessment to better understand what prevention activities are going on and what the prevention needs in our communities are and about the experiences of folks who work or volunteer in substance abuse prevention. 

If you fit the bill, it would be great if you could take 10 minutes to support this important effort by taking this Arizona Substance Use Prevention Workforce Survey

Immigration Status, Public Benefits, Health & Access to Care: A Primer

With all the attention on immigration status and its intersection with public benefits and access to health care- I thought I’d take a crack at summarizing these issues for our membership.  Here goes:

Noncitizens make up about 7%  percent of the US population. It’s not surprising that they’re more likely to be low-income and uninsured than citizens- in part because of the opportunity limitations. In fact, 71% of undocumented adult noncitizens are uninsured.  By and large, many of them rely on Federally Qualified Health Centers for their primary care and other healthcare- in part because FQHCs have sliding fee scale service fees and serve immigrants regardless of their immigration status.

Medicaid generally limits eligibility for immigrants to qualified immigrants with refugee status or veterans and people lawfully present in the US for 5 years or more.  State Medicaid programs can elect to provide coverage to legally present immigrants before the 5-year waiting period ends (Arizona does not).

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (often referred to as PRWORA or welfare reform) is the federal law that created Medicaid’s “qualified immigrant” standard.

Other federal safety net programs like Temporary Assistance for Needy Families and the Supplemental Nutrition Assistance Program (food stamps) also apply the five-year waiting period for legally present immigrants.

States can get matching funds from Medicaid (CMS) when they choose to provide Medicaid coverage to legally present immigrants who are children or pregnant women before the end of the 5-year waiting period.  33 states have elected to cover lawfully residing immigrant children, and 25 states cover legally present pregnant women (Arizona does not).

The Affordable Care Act made it possible for the legally present immigrants who are ineligible for Medicaid due to being in the five-year waiting period to qualify for commercial coverage and subsidies on the Federal health insurance marketplace.

Immigrants eligible for Medicaid or employer-sponsored insurance face several coverage and service barriers.  As I mentioned in a blog a few weeks ago immigration officials consider the likelihood of individuals and families becoming a “public charge,” which can result in denied admission to the US or status as a lawful permanent resident.

Fear that using safety net services will mean that they’ll be considered a public charge contributes to some families of mixed immigration status avoiding use of services like TANF, Medicaid, SNAP etc.  Some eligible immigrants avoid services because they think family members will become involved in immigration enforcement actions.

Research findings by the Kaiser Family Foundation found that changes in healthcare use and decreased participation in Medicaid and the Children’s Health Insurance Program because of this immigration policy.

Anyway, it’s a complicated system but I hope this makes it a little clearer.

2020 Census Citizenship Question Open for Public Comment

2020 Census Citizenship Question Open to Public Comment

You can weigh in on a controversial decision by federal officials to add a citizenship question to the 2020 census. 

Several lawsuits have been filed challenging this late and untested addition to the decennial questionnaire. In the views of many, the addition of a citizenship question would suppress response rates in immigrant communities, increase costs to taxpayers in administering the census, and lead to misallocation of government resources in ways that hurt businesses, communities, governments, and nonprofits. A question on citizenship, in short, could lead to an unfair, inaccurate, and incomplete count of every person in America.

You can go directly to the Census Bureau comment form or submit prepared comments using the Census Counts website.  The public comment period closes August 7.