AzHHA Thoughtful Life Conversations

The Arizona Hospital and Healthcare Association (AzHHA) has made their Thoughtful Life Conversations one of their priority programs this year.  It’s an affiliation of healthcare leaders, providers and community representatives with a shared commitment and a sense of accountability to improving end of life care for Arizonians.   

The Thoughtful Life Conversations program mission is to empower Arizonans to make known their life wishes and care directives and to equip their healthcare teams with resources to honor them.  Our vision is for Arizonans to have thoughtful life conversations that result in honored healthcare wishes and goals and improved care towards end of life.

Having conversations about serious illness, end of life care, and advanced care planning is important and challenging, even scary and uncomfortable for clinicians to initiate.

To facilitate these kinds of Thoughtful Life Conversations they’re holding several “Communications in Serious Illness” trainings. The trainings are free and space is limited so please be sure and register quickly!  I’ve added the series of training opportunities to our AzPHA Calendar of Events at or you can visit

Community Paramedicine Continues to Mature in AZ

Community paramedicine has been a paradigm shift for the use of paramedics in the US- and Arizona has been a national leader.  It’s a new model in which paramedics function outside their usual emergency response & transport roles- delving into the world of primary care.  As the health care world increasingly shifts toward prevention and well care- the system will increasingly demand more folks that can function in a community health (primary care and prevention) role.  Community paramedicine is increasingly being recognized as a promising solution to efficiently increase access to care (especially for underserved populations). 

For example- paramedics could shift from a sole focus on emergency response to things like: 1) providing follow-up care for folks recently discharged from the hospital to prevent unnecessary readmissions; 2) providing community-based support for people with diabetes, asthma, congestive heart failure, or multiple chronic conditions; and/or 3) partnering with community health workers and primary care providers in underserved areas to provide preventive care. 

One component of Community Paramedicine is known as “Treat and Refer” and it has really taken a step forward in the last couple of years in Arizona.  A couple of years ago the initiative was launched under the leadership of AzPHA Members David Harden, Terry Mullins, Dr. Ben Bobrow and others at the ADHS.

It’s called the Arizona Treat and Refer Recognition Program and was developed in partnership with the ADHS Bureau of EMS & Trauma Systems, AHCCCS, and the EMS community. Organizations that earn Treat and Refer recognition implement the program under the direction of their medical director and chief executive.  Once recognized, the EMS Agency can seek reimbursement from AHCCCS for the services they provide.  You can check out the AHCCCS website to learn more about provider registration.

Five EMS agencies have now been recognized as Treat & Refer EMS agencies. The T&R Program establishes a means for recognized EMS agencies demonstrating optimal patient safety and quality of care by matching treatment, transport, and care destination options to the needs of the 9-1-1 patient; and provide recognized EMS agencies the opportunity to seek reimbursement from AHCCCS.

The ADHS Bureau of EMS & Trauma Systems offers a pre-application technical review service to EMS agencies considering applying for recognition. The service includes a comprehensive review of EMS agencies’ education modules, standing orders, patient follow-up process, and performance improvement/quality assurance process.

Arguments Due Wednesday for November’s Ballot Propositions

Do you feel strongly about any of the upcoming voter initiatives or referendums that will be on the November ballot?  Do you have some solid arguments that could persuade fellow Arizonans to see things your way? 

If so, you’re in luck.  The AZ Secretary of State’s Office has made it easier than ever for you to post an argument for or against any of the measures- but you’ll need to act before Wednesday at midnight. 

Arguments for or against proposed ballot measures for the 2018 General Election can now be submitted electronically through the new Ballot Measure Argument Submission Portal available at

The fee is just $75 per argument and can be paid online.  They also dropped the notarization argument that had previously existed.  Your ballot measure argument will be printed in the publicity pamphlet that is mailed out to registered voters. I submitted comments in favor of the Clean Energy Amendment and the Campaign Disclosure Initiative- (on behalf of myself) and the process was simple and straightforward.

Here’s the listing of the 2018 Initiatives, Referenda & Recall Applications.  I’ve summarized the measures that submitted sufficient signatures last week:

The Stop Political Dirty Money Constitutional Amendment PDF establishes voters’ right to know the identity of all major contributors who are trying to influence the outcome of Arizona elections. Contributors will no longer be able to hide by transferring their money through intermediaries. Anyone spending more than $10,000 to oppose or support candidates or ballot measures must disclose everyone who contributed $2,500 or more promptly, publicly and under penalty of perjury.

The Clean Energy for a Healthy Arizona Amendment PDF requires affected electric utilities to provide at least 50% of their annual retail sales of electricity from renewable energy sources by 2030. The Amendment defines renewable energy sources to include solar, wind, small-scale hydropower, and other sources that are replaced rapidly by a natural, ongoing process (excluding nuclear or fossil fuel). Distributed renewable energy sources, like rooftop solar, must comprise at least 10% of utilities’ annual retail sales of electricity by 2030. The Amendment allows electric utilities to earn and trade credits to meet these requirements.

The Invest in Education Act PDF increases the classroom site fund by raising the income tax rate by 3.46% on individual incomes over a quarter million dollars (or household incomes over half a million dollars), and by 4.46% on individual incomes over half a million dollars (or household incomes over a million dollars); designates 60% of new funds for teacher salaries and 40% for operations; and adds full day kindergarten and pay raises for student support services personnel as permitted fund uses. 

Save Our Schools PDF asks voters whether to validate a 2017 Bill passed by the Legislature (Chapter 139 SB 1431) that greatly expanded Empowerment Scholarship Accounts (commonly referred to as private school vouchers) and removed the existing ESA enrollment cap, increasing it annually by 0.5% of total public school enrollment through 2022 and capping ESA enrollment in 2023.

The Protect AZ Taxpayers Act PDF would amend the Arizona Constitution to prohibit state government, as well as county, municipal and other political subdivision governments and taxing districts, from imposing or increasing any transaction-based taxes, fees, stamp requirements, or assessments on any service performed in Arizona, or on the gross receipts of sales or gross income derived from any service performed in Arizona.

AZ Vaccination Exemptions Continue to Increase

Despite numerous interventions in the last year designed to improve immunization rates among AZ school children- we continue to lose ground.  Last week the ADHS released their latest school reporting data on vaccine exemption rates (medical, personal and religious).  Here’s a 2 page summary of some of the results.  This year’s report covers the 2017-2018 school year (the data was submitted by the schools to the Department in the Fall of ’17). The data show that:

  • Immunization rates have decreased across age groups from 2012 to 2017;

  • Non-medical exemption rates continue to be highest in public charter schools, followed by private and public schools in 2017; and 

  • Non-medical (e.g. personal and religious) exemption rates have increased from 2016: going from 3.9% to 4.3% for pre-school; 4.9% to 5.4% for Kindergarten and 5.1% to 5.4% among 6th graders.

The Arizona Public Health System has done a remarkable job turning the data reported by schools into actionable information.  My favorite is the Personal Belief Exemptions Map.  Parents can also look up the exemption rates in individual schools.  But there are also data for: Arizona Reporting Schools Coverage; County Kindergarten Coverage; County 6th Grade Coverage; County Child Care Coverage; Whooping Cough Immunization Coverage Map; and a Measles Immunization Coverage Map.


Interventions to Reduce Vaccine Exemptions

The ADHS has significantly overhauled their vaccine exemption form to better inform parents about the risks that they are taking for their child and for their child’s classmates and the community by choosing not to vaccinate their kid. Other interventions (by the Arizona Partnership for Immunizations) have included working with school administrators to help parents overcome any barriers that might be preventing them from getting their children vaccinated and by reducing “convenience exemptions,” in which parents sign a waiver because they can’t get their children immunized in time to meet school requirements.

I’ve also heard that there is an Immunization Education Course under development by the ADHS that’s designed to serve in lieu of a new exemptions form has been built and piloted at some schools in Maricopa County.

During the 2015 legislative session, Representative Mendez sponsored HB 2466 which would have required all public schools (including charter schools) to maintain a website to post the rates of their pupils’ immunizations against vaccine preventable diseases.  It never even received a committee hearing.  Back in 2012 a Bill that would have required a doctor’s signature to get a personal exemption failed. 

A couple of years ago California eliminated personal exemptions entirely.  While the rate for personal exemptions rose after the personal exemption was eliminated, a study In study in JAMA back in 2017 found that the rate of medical exemptions for immunizations for incoming kindergartners rose the year after California eliminated the personal-belief exemption, but vaccination rates did improve substantially – especially in high income enclaves that had the highest personal exemption rates. 

By the way- last week the Second District Court of Appeal in Los Angeles found that California didn’t violate freedom of religion or the right to an education when it eliminated most exemptions.  The court said that… “Compulsory immunization has long been recognized as the gold standard for preventing the spread of contagious diseases”.  The court said the new law was not discriminatory and was a valid measure to protect public health.

Major Changes Proposed for Family Planning Grants

A few weeks ago HHS issued new proposed regulations for Title X (family planning) grants in the Federal Register. The new regulations would make many changes to the requirements for Title X projects and could profoundly change how family planning services are provided by significantly limit the network of providers who can qualify for funds; restricting the ability of participating providers from discussing and referring for abortion; and making other programmatic changes that could dramatically reshape the program and provider network available to low-income women.

If fully implemented, the proposed changes to Title X would shrink the network of participating providers and have major repercussions for low-income women in AZ that rely on these services for their family planning care.

Here’s an informative Issue Brief about the planned changes. The new proposed regulations and the place to submit comments are up on the Federal Register website through July 31.

Courts Overrule CMS’ Approval of KY’s Medicaid Work Requirements- Ruling Could Influence AZ’s Request

Kentucky was the first state to have a work requirement waiver approved by CMS (it was set to take effect yesterday- July 1, 2018).  But last Friday, a federal District Court Judge ruled that Kentucky’s CMS approved waiver which would have implemented work/community engagement requirements failed to address the purpose of the Medicaid program- to provide coverage and care. Medicaid is obligated under federal law to consider whether a waiver proposal advances the program’s objectives. 

Specifically, toward the end of the Decision, the court concludes that “…the Secretary must adequately consider the effect of any demonstration project on the State’s ability to help provide medical coverage. He never did so here.”  

When you read the Decision, you’ll see that the court basically concluded that when CMS approved the waiver, they didn’t consider its impact on the primary objective of the Medicaid program- which is to provide medical coverage and care. The court vacated CMS’ approval of the waiver and remanded it back to HHS (CMS).

While Kentucky’s waiver request isn’t exactly the same as  Arizona’s work and community engagement waiver request, there are many similarities. Both require some Medicaid members to meet work or community engagement requirements (AZ has more exempted populations than KY), both have reporting requirements, and both include lockout provisions for folks that don’t comply. The specific standards and exemptions are different, but both include the same basic requirements (except that KY includes some premium payments- which isn’t included in Arizona’s waiver request). 

This is certainly the beginning of a longer legal battle, but last week’s Ruling could very well influence CMS’ upcoming decision about whether (or when) to approve Arizona’s waiver request.

Legal Defense of the Affordable Care Act

A few months ago, Texas and 19 other states (including AZ) launched a new legal effort to eliminate the Affordable Care Act.  Fortunately, California and 15 other states intervened as defendants in the lawsuit, because they were worried that the President’s administration wouldn’t defend the ACA.

Earlier this month the Department of Justice filed a pleading that agreed with TX, AZ and the other 18 states.  Instead of defending the ACA as is customary, the DOJ argued that several crucial provisions of the ACA are unconstitutional and announced that it would not defend those provisions in court (3 career DOJ attorneys removed their names from the brief and one quit a few days later).  CA and other states will be defending the ACA and argue on its behalf in court. 

If the Intervenor states lose the case, insurers could invoke pre-existing conditions to refuse coverage or increase premiums and could underwrite coverage based on gender, age, and occupation.  

Here’s a useful summary of the case written by the National Health Law Program.