Check Out AzPHA’s Position on Multiple Bills

State Legislature Bill Update

More than 700 bills have so far been proposed by members of the Arizona State Legislature so far.  Our Public Health Policy Committee is busy sifting through them and looking for those that will have a public health impact.  We’ve taken public positions on the www.azleg.gov website on more than 20 bills with links to public health.  Below is a quick summary of those bills and the positions that AzPHA has taken.

Tobacco Bills

SB 1009 Electronic Cigarettes, Tobacco Sales (Carter) – AzPHA Position: YES

Expands the definition of tobacco products to include e-cigarettes. Among other things, it’ll make it clear that it’s illegal to sell e-cigarettes to minors. The penalty for selling to minors remains at $5K. Passed the Senate Health & Human Services Committee last Wednesday.

HB 2024 Electronic Cigarettes. Smoke Free Arizona Act (Kavanaugh) – AzPHA Position: YES

Includes e-cigarettes in the definition of tobacco products and smoking for the purposes of the Smoke Free Arizona Act.  Because the Act was voter approved- this modification to the law will require a 3/4 majority of both houses.

HB 2073 Vapor Products; Regulation (Shope) – AzPHA Position: Opposed

This bill would basically set up a regulatory program at the ADHS to inspect and license electronic cigarette manufacturers in Arizona and specify that only licensed electronic cigarette manufacturers can sell products in Arizona.  It gives no regulatory authority to the ADHS to enforce that vape shops get licensed and they only must do it every 5 years. There are no penalties for noncompliance and penalties are against the purchaser instead of the retailer.

SB 1363 Tobacco Product Sales (Tobacco 21) (Carter) – AzPHA Position: YES

Tis bill would move the tobacco product (and e-cigarette) buy age to 21.  Bill includes definitions and criteria as well as penalties for vendors that sell to people under 21.

 

Maternal & Child Health

SB 1088 Dental Care During Pregnancy (Carter) – AzPHA Position: YES

This bill would expand AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding. This bill passed the Senate Health Committee 8-0 this week!

SB 1040 Maternal Mortality Report (Brophy-McGee) – AzPHA Position: YES

This bill would require the Child Fatality Review Team subcommittee on maternal mortality to compile an annual statistical report on the incidence and causes of “severe maternal morbidity” with recommendations for action.  The current law requires a review of the data but no report. This bill passed the Senate Health Committee 8-0 this week!

HB 2125 Child Care Subsidies (Udall) – AzPHA Position: YES

Makes a supplemental appropriation of $56 million from the Federal Child Care and Development Fund block grant in FY2018-19 to the Department of Economic Security for child care assistance. Another bill, HB 2124 would allocate the money as follows: $26.7 million for provider rate increases, $14 million to serve children on the waiting list, and $13.1 million to increase tiered reimbursement for infants, toddlers and children in the care of DCS. HB 2436 is a similar bill.

 

Vaccines

HB 2162 Vaccine Personal Exemptions (Hernandez) –  AzPHA Position: Yes

This bill would remove the personal exemption option for parents to enroll in school when the child hasn’t had all the required school attendance immunizations.

HB 2352 School Nurse and Immunization Postings (Butler) – AzPHA Position: Yes

School districts and charter schools would be required to post on their websites whether a registered nurse is assigned to each school as well as required reports on immunization rates.

SB 1115 and HB 2471 Informed Consent (Boyer, Barto) – AzPHA Position: Opposed

These bills would add a requirement that physicians provide to parents and guardians the full vaccine package insert and excipient summary for each vaccine that will be administered.  Physicians already provide a Vaccine Information Summary to parents and guardians for each vaccine administered, which is noted in the medical record.  This new requirement would mandate provision of the 12-15 page insert, which is not presented in a format that incorporates health literacy principles.

HB  2472 and SB 1116 Vaccinations- Antibody Titer (Boyer, Barto) – AzPHA Position: Opposed

These bills would mandate that doctors inform parents and guardians that antibody titer tests (which involve a venous draw) are an option in lieu of receiving a vaccination and that there are exemptions available for the state requirements for attending school. 

 

Injury Prevention

SB 1165 Texting and Driving Prohibition (Brophy McGee) – AzPHA Position: YES

This bill prohibits using a hand-held cell phone while driving.  There are some common-sense exemptions for example if the person is using it hands free etc.  Penalties are a civil penalty (no driving points) with the first offense being between $75- $150 and the 2nd offense between $150 and $250.  We are signed up in support of this bill.

HB 2069 Texting and Driving (Kavanaugh) – AzPHA Position: Supporting SB 1165

Makes texting while driving on a highway a nonmoving civil traffic violation.  The penalty for the 1qst violation would be $100 and the second offense would be $300.  If a crash is involved the penalty would be $500 but if someone died it would be $10K.   subject to a civil penalty of $500, except that if the accident results in the death of another person, the civil penalty is $10,000.

HB 2165  Distracted Driving (Townsend) – AzPHA Position: Supporting SB 1165

A person who drives a vehicle while participating in an activity that willfully distracts the person from safely operating the vehicle is guilty of reckless driving, a class 2 (mid-level) misdemeanor.  I’m not sure if texting and driving would qualify or not- it probably does.

HB 2172  Rear Facing Car Seats (Bolding) – AzPHA Position: YES

Kids under two years of age need to be in a rear-facing restraint system unless the child weights at least 40 pounds or is at least 40 inches tall.

HB 2246  Motorcycle Helmets (Friese) – AzPHA Position YES

Motorcycle riders over 18 would be required to wear a helmet unless they pay a fee that would be set by ADOT. Violations would be a $500 civil penalty, but no points or other sanctions. 

HB 2075  Electronic Prescribing (Cobb) – AzPHA Position: Yes

Pushes the electronic prescribing requirement in last year’s Opioid Epidemic Act back to January 2, 2020 in all counties.  Being heard in House Health & Human Services Committee Thursday Feb 24 at 9 am.

Firearm Safety

SB 1219 Domestic Violence Offenses & Firearm Transfer AzPHA Position: Yes

Persons that have been adjudicated and the court rules that they may not possess a firearm must surrender their firearms to a law enforcement agency.  The law enforcement agency may then dispose of the firearm(s) in accordance with law.  People that have an Order of Protection against them must also surrender their firearms, although the law enforcement agency must return the firearm when the Order expires (after a background check).

HB 2247 Bump Stocks (Friese) – AzPHA Position: Yes

This bill would outlaw the sale of bump stocks on firearms.

HB 2248 Firearm Sales (Friese) – AzPHA Position: Yes

This bill would require a background check for all sales at gun shows.

HB 2161 Order of Protection (Hernandez) AzPHA Position: Undetermined

A person who is at least 18 years of age and who is either a law enforcement officer, a “family or household member” (defined), a school administrator or teacher or a licensed behavioral health professional who has personal knowledge that the respondent is a danger to self or others is permitted to file a verified petition in the superior court for a one-year Severe Threat Order of Protection (STOP order), which prohibits the respondent from owning, purchasing, possessing or receiving or having in the respondent’s custody or control a firearm or ammunition for up to one year.

HB 2249  Mental Health and Firearm Possession (Friese) AzPHA Position: Undetermined

An immediate family member or a peace officer is authorized to file a verified petition with a magistrate, justice of the peace or superior court judge for an injunction that prohibits a person from possessing, controlling, owning or receiving a firearm. Any court may issue or enforce a mental health injunction against firearm possession, regardless of the location of the person. Information that must be included in the petition is specified. If the court finds that there is clear and convincing evidence to issue a mental health injunction against firearm possession, the court must issue the injunction. Information that must be included in the injunction is specified.

 

Harm Reduction

HB 2148 Syringe Services Programs (Rivero) AzPHA Position: Yes

Decriminalizes syringe access programs, currently a class 6 felony. To qualify, programs need to list their services including disposal of used needles and hypodermic syringes, injection supplies at no cost, and access to kits that contain an opioid antagonist or referrals to programs that provide access to an opioid antagonist.

SB 1119 Tanning Studios (Mendez) – AzPHA Position YES

Would require people under 18 that want to use a commercial tanning bed service to have permission from their parent or guardian.

Agency Administration

SB 1247 Residential Care Institutions (Brophy McGee) – AzPHA Position: Yes

This good bill will require more robust staffing background checks for facilities that provide services for children and will remove the “deemed status” designation for child residential behavioral health facilities.  Under current law, facilities in this category (e.g. Southwest Key) can be accredited by a third party (e.g. Council on Accreditation) and avoid annual surprise inspections by the ADHS. This intervention will provide more oversight to ensure background checks are done and that the facilities are compliant with state regulations.

HB 2004 Nuclear Management Fund (Kavanaugh) – AzPHA Position: Undetermined

Assesses the Palo Verde nuclear plant $2.55M and gives it to ADEM, ADHS and other jurisdictions to compensate them for off-site nuclear emergency response plan response activities.  Being heard in House Appropriations Committee Wednesday Feb 23 at 2 pm.

HB 2280  Interfacility Ambulance Transports (Weninger) – AzPHA Position: Undetermined

A person may operate an “interfacility transfer ambulance service” by applying to the Department of Health Services for a certificate of operation with defined requirements.   The requirement to transport a patient under medical direction to the nearest, most appropriate facility as defined by federal Medicare guidelines does not apply to an interfacility transfer ambulance service with a certificate of operation.

SB 1011 Information and Referral Service (Carter) – AzPHA Position: YES

Appropriates $1.5 million from the general fund in FY2019-20 to the ADES for a statewide information and referral service for health care services, community services, human services and governmental services.  

 

AHCCCS Coverage & Private Insurance Coverage

HB 2347 Medicaid Buy-in (Butler) AzPHA Position: Undetermined

Would require AHCCCS to set up a program in which eligible people could pay a premium and receive Medicaid health insurance.

HB 2350 HB2513 SB1134 Kids Care (Butler, Brophy-McGee, Cobb) – AzPHA Position: YES

These bills Would appropriate funding so that Kids Care could continue after the federal match rate goes below 100% on October 1, 2019.

HB 2351 Medical Services Study Committee (Butler) – AzPHA Position: Yes

Establishes a 14-member Medical Services Purchase Program Study Committee to research and make recommendations for establishing and implementing a medical services purchase program. The Committee is required to submit a report of its findings and recommendations to the Governor

HB 2120  Chiropractic Coverage (Barto) – AzPHA Position: Undetermined

Would add chiropractic services to the list of reimbursable services under AHCCCS.  Being heard in House Health & Human Services Committee Thursday Feb 24 at 9 am.

SB 1088 Dental Care During Pregnancy (Carter) – AzPHA Position: Yes

This bill would expand AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding.

SB 1089 Telemedicine Insurance Coverage (Carter) – AzPHA Position: Yes

This Bill would put into law specific standards requiring non-Medicaid insurance companies to cover telemedicine.  There are criteria and standards in the law regarding contracting standards. Note: this is all Title 20 language and does not apply to Medicaid (AHCCCS).

Food Safety & Insecurity

HB 2178  Milk Manufacturing License Exemption – AzPHA Position: Undetermined

A restaurant wouldn’t be required to get a license to manufacture or distribute frozen desserts or frozen milk products if the product is manufactured or distributed and sold at the same facility for on-site consumption.

HB 2186  School Meals (Udall) AzPHA Position: Yes

Schools are required to provide a school meal to a student who requests it regardless of whether the student pays for a school meal or owes money for previous meals. Local education agencies are prohibited from taking a list of specified actions relating to unpaid school meal fees, including announcing or publicizing the names of students with unpaid school meal fees, requiring a student who cannot pay for a meal or who owes unpaid meal fees to work for a meal, and attempting to collect unpaid school meal fees from a student. Local education agencies are prohibited from using a debt collector to attempt to collect unpaid school meal fees.

 

Access to Care

HB 2218 State Loan Repayment (Blanc) – AzPHA Position: YES

Makes a supplemental appropriation of $500,000 from the general fund in FY2019-20 to the Department of Health Services to pay off portions of education loans taken out by physicians, dentists, pharmacists, advance practice providers and behavioral health providers participating in the primary care provider loan repayment program.  An additional $500K would be appropriated to pay off education loans taken out by physicians, dentists, pharmacists, advance practice providers and behavioral health providers participating in the rural private primary care provider loan repayment program.

HB 2376  Associated Health Plans (Barto) AzPHA Position: Undetermined

An association health plan is authorized to operate in Arizona if the plan is following federal laws and regulations, and if the plan’s governing documents require the plan to be actuarially sound and the plan is actuarially sound.

Medical Marijuana

HB 2149  Cannabis Definition (Rivero) AzPHA Position: YES

Synchronizes the definitions of marijuana and cannabis in the state criminal code and the Arizona Medical Marijuana Act.  There has been some confusion in certain counties- as medical marijuana patients have been prosecuted for possessing extracts and preparations of marijuana that they bought at dispensaries. The appeal of this prosecutions will be heard by the state supreme court. This would make it clearer in state law that extracts and preparations are included in the Act.

State Legislature Bill Update

More than 700 bills have so far been proposed by members of the Arizona State Legislature so far.  Our Public Health Policy Committee is busy sifting through them and looking for those that will have a public health impact.  We’re not done looking through them yet- but below is a summary of what we know so far.

Tobacco Bills:

SB 1009 Electronic Cigarettes, Tobacco Sales (Carter)

Expands the definition of tobacco products to include e-cigarettes. Among other things, it’ll make it clear that it’s illegal to sell e-cigarettes to minors. The penalty for selling to minors remains at $5K. Being heard in Senate Health & Human Services Committee Wednesday Feb 23 at 9 am.

HB 2024 Electronic Cigarettes. Smoke Free Arizona Act (Kavanaugh)

Includes e-cigarettes in the definition of tobacco products and smoking for the purposes of the Smoke Free Arizona Act.  Because the Act was voter approved- this modification to the law will require a 3/4 majority of both houses.

HB 2073 Vapor Products; Regulation (Shope)

This bill would basically set up a regulatory program at the ADHS to inspect and license electronic cigarette manufacturers in Arizona and specify that only licensed electronic cigarette manufacturers can sell products in Arizona.  It’s unclear what the objective of this bill is and we have not yet taken a position on it yet.

Maternal & Child Health:

SB 1088 Dental Care During Pregnancy (Carter)

This bill would expand AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding.

SB 1040 Maternal Mortality Report (Brophy-McGee)

This bill would require the Child Fatality Review Team subcommittee on maternal mortality to compile an annual statistical report on the incidence and causes of “severe maternal morbidity” with recommendations for action.  The current law requires a review of the data but no report.

 

HB 2125 Child Care Subsidies (Udall)

Makes a supplemental appropriation of $56 million from the Federal Child Care and Development Fund block grant in FY2018-19 to the Department of Economic Security for child care assistance. Another bill, HB 2124 would allocate the money as follows: $26.7 million for provider rate increases, $14 million to serve children on the waiting list, and $13.1 million to increase tiered reimbursement for infants, toddlers and children in the care of DCS. HB 2436 is a similar bill.

HB 2337 Family Planning (Salman)

Would repeal the statute requiring the Department of Health Services to apply for the federal Title X family planning grant.

Injury Prevention:

HB 2069 Texting and Driving (Kavanaugh)

Makes texting while driving on a highway a nonmoving civil traffic violation.  The penalty for the 1qst violation would be $100 and the second offense would be $300.  If a crash is involved the penalty would be $500 but if someone died it would be $10K.   subject to a civil penalty of $500, except that if the accident results in the death of another person, the civil penalty is $10,000.

HB 2165  Distracted Driving (Townsend)

A person who drives a vehicle while participating in an activity that willfully distracts the person from safely operating the vehicle is guilty of reckless driving, a class 2 (mid-level) misdemeanor.  I’m not sure if texting and driving would qualify or not- it probably does.

HB 2172  Rear Facing Car Seats (Bolding)

Kids under two years of age need to be in a rear-facing restraint system unless the child weights at least 40 pounds or is at least 40 inches tall.

HB 2246  Motorcycle Helmets (Friese)

Motorcycle riders over 18 would be required to wear a helmet unless they pay a fee that would be set by ADOT. Violations would be a $500 civil penalty, but no points or other sanctions. 

HB 2075  Electronic Prescribing (Cobb)

Pushes the electronic prescribing requirement in last year’s Opioid Epidemic Act back to January 2, 2020 in all counties.  Being heard in House Health & Human Services Committee Thursday Feb 24 at 9 am.

Firearm Safety

HB 2247 Bump Stocks (Friese)

This bill would outlaw the sale of bump stocks on firearms.

HB 2248 Firearm Sales (Friese)

This bill would require a background check for all sales at gun shows.

HB 2161 Order of Protection (Hernandez)

A person who is at least 18 years of age and who is either a law enforcement officer, a “family or household member” (defined), a school administrator or teacher or a licensed behavioral health professional who has personal knowledge that the respondent is a danger to self or others is permitted to file a verified petition in the superior court for a one-year Severe Threat Order of Protection (STOP order), which prohibits the respondent from owning, purchasing, possessing or receiving or having in the respondent’s custody or control a firearm or ammunition for up to one year.

HB 2249  Mental Health and Firearm Possession (Friese)

An immediate family member or a peace officer is authorized to file a verified petition with a magistrate, justice of the peace or superior court judge for an injunction that prohibits a person from possessing, controlling, owning or receiving a firearm. Any court may issue or enforce a mental health injunction against firearm possession, regardless of the location of the person. Information that must be included in the petition is specified. If the court finds that there is clear and convincing evidence to issue a mental health injunction against firearm possession, the court must issue the injunction. Information that must be included in the injunction is specified.

Harm Reduction:

HB 2148 Syringe Access Programs (Rivero)

Decriminalizes syringe access programs, currently a class 6 felony. To qualify, programs need to list their services including disposal of used needles and hypodermic syringes, injection supplies at no cost, and access to kits that contain an opioid antagonist or referrals to programs that provide access to an opioid antagonist.

SB 1119 Tanning Studios (Mendez)

Would require people under 18 that want to use a commercial tanning bed service to have permission from their parent or guardian.

Vaccines

HB 2162 Vaccine Personal Exemptions (Hernandez)

This bill would remove the personal exemption option for parents to enroll in school even though they haven’t had all the required immunizations.

HB 2352 School Nurse and Immunization Postings (Butler)

School districts and charter schools would be required to post on their websites whether a registered nurse is assigned to each school as well as required reports on immunization rates.

Agency Administration

HB 2004 Nuclear Management Fund (Kavanaugh)

Assesses the Palo Verde nuclear plant $2.55M and gives it to ADEM, ADHS and other jurisdictions to compensate them for off-site nuclear emergency response plan response activities.  Being heard in House Appropriations Committee Wednesday Feb 23 at 2 pm.

 

HB 2280  Interfacility Ambulance Transports (Weninger)

A person may operate an “interfacility transfer ambulance service” by applying to the Department of Health Services for a certificate of operation with defined requirements.   The requirement to transport a patient under medical direction to the nearest, most appropriate facility as defined by federal medicare guidelines does not apply to an interfacility transfer ambulance service with a certificate of operation.

SB 1011 Information and Referral Service (Carter)

Appropriates $1.5 million from the general fund in FY2019-20 to the ADES for a statewide information and referral service for health care services, community services, human services and governmental services.  

AHCCCS Coverage & Services

HB 2347 Medicaid Buy-in (Butler)

Would require AHCCCS to set up a program in which eligible people could pay a premium and receive Medicaid health insurance.

HB 2350 HB2513 SB1134 Kids Care (Butler, Brophy-McGee, Cobb)

These bills Would appropriate funding so that Kids Care could continue after the federal match rate goes below 100% on October 1, 2019.

HB 2351 Medical Services Study Committee (Butler)

Establishes a 14-member Medical Services Purchase Program Study Committee to research and make recommendations for establishing and implementing a medical services purchase program. The Committee is required to submit a report of its findings and recommendations to the Governor

HB 2120  Chiropractic Coverage (Barto)

Would add chiropractic services to the list of reimbursable services under AHCCCS.  Being heard in House Health & Human Services Committee Thursday Feb 24 at 9 am.

SB 1088 Dental Care During Pregnancy (Carter)

This bill would expand AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding.

Food Safety & Insecurity

HB 2178  Milk Manufacturing License Exemption

A restaurant wouldn’t be required to get a license to manufacture or distribute frozen desserts or frozen milk products if the product is manufactured or distributed and sold at the same facility for on-site consumption

HB 2186  School Meals (Udall)

Schools are required to provide a school meal to a student who requests it regardless of whether the student pays for a school meal or owes money for previous meals. Local education agencies are prohibited from taking a list of specified actions relating to unpaid school meal fees, including announcing or publicizing the names of students with unpaid school meal fees, requiring a student who cannot pay for a meal or who owes unpaid meal fees to work for a meal, and attempting to collect unpaid school meal fees from a student. Local education agencies are prohibited from using a debt collector to attempt to collect unpaid school meal fees.

Access to Care

HB 2218 State Loan Repayment (Blanc)

Makes a supplemental appropriation of $250,000 from the general fund in FY2019-20 to the Department of Health Services to pay off portions of education loans taken out by physicians, dentists, pharmacists, advance practice providers and behavioral health providers participating in the primary care provider loan repayment program. 

HB 2376  Associated Health Plans (Barto)

An association health plan is authorized to operate in Arizona if the plan is in compliance with federal laws and regulations, and if the plan’s governing documents require the plan to be actuarially sound and the plan is actuarially sound.

Medical Marijuana

HB 2149  Cannabis Definition (Rivero)

Syncronizes the definitions of marijuana and cannabis in the state criminal code and the Arizona Medical Marijuana Act.  There has been some confusion in certain counties- as medical marijuana patients have been prosecuted for possessing extracts and preparations of marijuana that they bought at dispensaries. The appeal of this prosecutions will be heard by the state supreme court. This would make it more clear in state law that extracts and preparations are included in the Act.

HB 2412  Medical Marijuana Cards (Powers Hannley)

This bill would make medical marijuana cards valid for 2 years instead of the current 1 year.

Governor’s Proposed Budget

The Governor released his proposed FY19-20 budget late last week.  It’s over 500 pages long – but we went through and looked for important items that relate to public health and or social determinants.  Here’s a quick summary.

Kids Care Funding

Happily, the Governor’s budget includes the needed funding to continue our Kids Care program after the federal contribution goes below 100% on October 1, 2019.  KidsCare provides insurance for more than 30,000 children in families with incomes above the limit for Medicaid eligibility but below 200% of the federal poverty level (FPL). Families with children who are insured through KidsCare pay premiums that vary with family size and income from $10 to $70 per month.  Of course- this still needs to work its way through the legislature but it sure is encouraging to see it in the Governor’s budget.

Telemedicine Services for Prenatal Services

The Governor’s proposed budget includes $500K in one-time funding for telemedicine and sonogram equipment to help rural hospitals that lack adequate access to prenatal providers to provide care to expectant mothers. The initiative will allow rural hospitals to buy telemedicine and sonogram equipment and enhance their ability to reach out to urban partners for assistance when providing prenatal care to expectant mothers, reducing the need to travel.  An additional $500K is proposed in one-time funding to provide student loan repayment options for health care professionals who provide prenatal care in one of the designated rural areas.

 

Child Care Subsidies

The federal government is offering Arizona $56M in funding to provide child care subsidies in Arizona.  Last year Arizona did not request this funding- in part because the state legislature did not appropriate these federal funds.  The Governor’s budget this year asks the legislature to appropriate the funds to increase the child care subsidy rate and to serve children on the waitlist.

The program serves three client categories: Temporary Assistance for Needy Families (TANF), Transitional Child Care (TCC), and Low-Income Working (LIW). LIW has a waiting list and limits eligibility to low-income families who are working, teen parents in high school or GED classes, or residents of homeless or domestic violence shelters.

The proposed funding will serve approximately 400 children per month from the waitlist and increase the average child care subsidy rate from $365 per month to $438 per month.

Oral Health Coverage During Pregnancy

There’s no mention of the money that would be needed to cover the state portion of  providing comprehensive oral health services for pregnant Medicaid members- but that’s OK.  As you see below there is a bill that would accomplish that goal.

CMS Approves Work Requirement/Community Engagement & Prior Quarter Coverage Elimination Waivers; Denies 5-Year Eligibility Limit

Last week the Centers for Medicare and Medicaid Services (CMS) approved Arizona’s request to include work requirements and/or community engagement and reporting requirements as a condition of Medicaid enrollment beginning on January 1, 2020.  CMS also approved the request to eliminate prior quarter coverage eligibility effective April 1, 2019.  An accompanying directed waiver request to limit lifetime Medicaid eligibility to 5 years for “able-bodied adults” was denied by CMS. 

CMS’ Letter to Director Snyder is 18 pages long and contains conditions and details- so refer to that letter for the nuts and bolts of what they said.

The work requirement/community engagement Waiver request was filed many months ago and is mandated by Senate Bill 1092 (from 2015) which requires AHCCCS to ask CMS’ permission to implement new eligibility requirements for “able-bodied adults”. 

The program will require some “able-bodied” members between the ages of 19 to 49 years-old to participate in community engagement activities for at least 80 hours per month and report their activities monthly.  Activities can include employment, including self-employment; less than full-time education; job or life skills training; job search activities; and community service.

A member who fails to comply in any given month will be suspended from AHCCCS coverage for 2-months but automatically reinstated after that. Members won’t be terminated for failing to comply.

The people exempted from the requirements include:

  • Pregnant women up to the 60th day post-pregnancy

  • Former Arizona foster youth up to age 26

  • Members of federally recognized tribes

  • Designated caretakers of a child under age 18

  • Caregivers who are responsible for the care of an individual with a disability

  • Members determined to have a serious mental illness (SMI)

  • Members who are “medically frail”

  • Members who have an acute medical condition

  • Members who are in active treatment for a substance use disorder

  • Members with a disability recognized under federal law and individuals receiving long term disability benefits

  • Full-time high school, college, or trade school students

  • Survivors of domestic violence

  • People who are homeless

  • People who receive assistance through SNAP, Cash Assistance or Unemployment Insurance or who participate in another AHCCCS-approved work program

Many things need to happen before the January 1, 2020 start date.  We’re hopeful that a robust evaluation component will be included in the program so that adjustments can be made to the policy over time and so that other states can learn from the Arizona experiment.

Public Health Bills So Far

There aren’t very many public health related bills proposed yet, but they’re on the way.  Here’s what we have so far:

SB 1009 Electronic Cigarettes, Tobacco Sales

Expands the definition of tobacco products to include e-cigarettes. Among other things, it’ll make it clear that it’s illegal to sell e-cigarettes to minors. The penalty for selling to minors remains at $5K. 

HB 2024 Electronic Cigarettes. Smoke Free Arizona Act

Includes e-cigarettes in the definition of tobacco products and smoking for the purposes of the Smoke Free Arizona Act.  Because the Act was voter approved- this modification to the law will require a 3/4 majority of both houses. 

SB 1040 Maternal Mortality Report

This bill would require the Child Fatality Review Team subcommittee on maternal mortality to compile an annual statistical report on the incidence and causes of “severe maternal morbidity” with recommendations for action.  The current law requires a review of the data but no report.

The 2019 Legislative Session Underway 

This year’s state legislative session began on Monday.  Here’s a PowerPoint with our 2019 Legislative Priorities.  Like other years, lots of things will come up during the session that we will support or be opposed to.  Our Public Health Policy Committee will share information and meet during the session as we prepare our positions and conduct our public health advocacy.

The party balance in the Senate will remain 17-13 while the balance in the House will be 31-29 (a much closer party balance than there has been in recent years).

The President of the Senate will be  Karen Fann (R) LD-1 and House Speaker will be  Rusty Bowers (R) LD-25.   The Senate Health and Human Service Committee will be chaired by Senator Kate Brophy-McGee (Sen. Heather Carter will be Co-chair).  The House Health Committee will be chaired by Representative Nancy Barto (Rep. Jay Lawrence is Vice Chair)

Senate Health & Human Services Committee

The Senate Health and Human Services Committee will meet this Session on Wednesday mornings at 9 am in Senate Hearing Room #1.  The Chair will be Senator Kate Brophy McGee with Senator Heather Carter as the Vice Chair.  Other committee members will be Tyler Pace, Rick Gray, Sylvia Allen, Rebecca Rios, Tony Navarette, and Victoria Steel.

House Health & Human Services Committee

The House of Representatives Health and Human Services Committee will meet this Session on Thursday mornings at 9 am.  The Chair will be Rep. Nancy Barto with Jay Lawrence serving as Vice Chair.  Other members are Representatives John Allen, Gail Griffin, Becky Nutt, Kelli Butler, Pamela Powers-Hannley, Alma Hernandez and Amish Shah.

Intermediate Care Facilities Like Hacienda de los Angeles are Exempt from State Licensing Requirements

By now you’ve heard the disturbing story of a 29-year-old resident of Hacienda de los Angeles who gave birth a couple of weeks ago. What’s troubling about the birth is that the mother was unable to give consent because of the nature of her medical condition. In short, it means she was raped and delivered a baby while under the care of Hacienda de los Angeles.

Quite honestly, it’s astonishing that the facility and its staff apparently failed to detect – or report — the sexual assault or pregnancy until after the baby was born and in medical distress.  Arizona law (ARS 46-464) requires people that have responsibility to care for a vulnerable adult to report any abuse or neglect that they suspect.  Failure to report is a Class 1 misdemeanor.

With such resources now deployed with the various investigations including the Phoenix Police Department, we will eventually most likely learn whether Hacienda staff knew but did not report the pregnancy or whether the care being provided was such that staff did not discover the pregnancy until the woman gave birth.  

Arizona and local law enforcement officials are investigating the matter – but they may be impeded by this troubling fact: Hacienda de los Angeles isn’t required to have a state license (and doesn’t have one).

How is this possible?

Hacienda de los Angeles is classified as an intermediate care for persons with intellectual disabilities. Facilities in this class provide more intensive services than a residential group home for persons with intellectual disabilities but different services than a skilled nursing facility.

When I learned through the media of the assault and birth, I went to the ADHS’ AZ Care Check    website to look at the regulatory compliance record for the facility. I was puzzled when I discovered that the facility didn’t have an ADHS License number. They have an identifying number for their Certification to get paid by the Centers for Medicare and Medicaid Services (CMS) — but no state license.

In digging deeper- I discovered that this class of facility doesn’t require a license from the ADHS.  They are specifically exempt. The exact statutory language is located in ARS 36-591(E) where it states that: “An intermediate care facility for persons with an intellectual disability that is operated by the division or a private entity is not required to be licensed under this section if the facility is certified pursuant to 42 Code of Federal Regulations section 483.400”.

That’s not to say that there’s no oversight of the facility.  There is. ADHS has conducted annual certification inspections under a contract from CMS every year for the last several years, and you can see that there are several deficiencies that have been identified (and corrected) over time.

What’s problematic is that the state has no direct regulatory authority over the facility because they’re not required to have a state license (if they’re CMS certified).  That means there’s no direct mechanism to compel compliance with state care regulations – because there’s no license to suspend, put on provisional status, or to revoke. 

With information that will be discovered in the coming days and weeks, the federal government could elect to decertify the facility and to no longer pay for services provided there, and/or our state Medicaid agency could decide to no longer approve placement of their members at the facility- but the state has no direct authority to compel compliance — again, because there’s no state license to use as leverage to compel compliance with state licensing requirements.

Intermediate care facilities were exempt from state licensing requirements back in 1997 when HB 2247 was passed by the legislature and signed by Governor Hull.

Perhaps this case provides an opportunity for our state elected officials to re-examine the wisdom of exempting intermediate care facilities from having a state license.

New Funding Opportunity Available for Arizona to Explore Strategies to Reduce Maternal Mortality

A couple of months ago (before the government shutdown happened) landmark federal legislation was passed and signed that will provide millions of dollars to help states determine why women are dying from pregnancy and childbirth at troubling rates.  

The new funding is great news because studies have found that at least half of childbirth-related deaths could have been prevented if health care providers had followed best medical practices to ensure complications were diagnosed and treated quickly and effectively.

The bill provides $12M in annual funding to the CDC to pass through to states with maternal mortality review committees and create committees in the 12 states that lack them.  Arizona has a committee in statute because of a law signed in 2011 – here’s a link to the most recent report.

In order to qualify for funding, states need to demonstrate  that their “methods and processes for data collection and review use best practices to reliably determine and include all pregnancy-associated deaths and pregnancy-related deaths, regardless of the outcome of the pregnancy.” All indications are that the ADHS meets these CDC data standards and therefore would qualify for funding.

We and the Arizona Chapter of the March of Dimes will keep an eye out for the grant announcement and offer any assistance that the ADHS needs with their application for this important funding opportunity that can be used to save the lives of Arizona moms.

Maternal Mortality: A Tragic Trend Continues in the US and AZ

The US has the highest maternal mortality rate of any developed country.  Sadly, it’s getting worse each year.  About 800 American women die and 65,000 almost die during pregnancy or childbirth.

The number of deaths in AZ jumped from around 10 in 2015 to about 30 in 2016 (the last year for which ADHS has data posted). The numbers are rounded for statistical reasons (called cell suppression in the public health statistics trade.)

Nationally, back women die from pregnancy-related causes at three to four times the rate of white women, even after controlling for social determinants. Women in rural areas also have higher maternal mortality rates than urban women.  Here’s a story that highlights some of the issues in an easy to read way.

Fortunately, there are public health policy leverage points that can make a difference within state health departments and Medicaid agencies.  Medicaid is a leverage point because it pays for over half of all births each year in 25 states including Arizona.  

All states provide Medicaid coverage for women with incomes up to 133% of poverty during pregnancy and for 60 days after delivery.  But the scope of services covered before and after delivery vary between states.  As a result, some women lose coverage or Medicaid eligibility in certain states after that 60-day period (mostly in states without Medicaid expansion).

In Medicaid expansion states (like AZ) women have more opportunities to achieve better preconception health because they’re more likely to be able to access contraception and plan their pregnancies, receive primary care services to manage chronic conditions prior to and between pregnancies and access prenatal and perinatal care once pregnant.

Evidence-based policy making is a key.  Twenty-nine states (including Arizona) have committees that review maternal deaths and make public policy recommendations.  Back in 2011, Arizona passed, and the Governor signed a bill that amended our child fatality review statutes by adding reviews of maternal deaths.

The statute charges our existing Child Fatality State Teams to review maternal deaths (called the Maternal Mortality Review Subcommittee) and make policy recommendations. The primary goal is to identify preventive factors and make recommendations for systems change. The existing statute doesn’t require an annual report- and the last report was published in 2017. Note: we’ve heard that there may be a Bill this session that will require an annual report of the committee’s work.

Here are some of the recommendations from the most recent ADHS report (published in 2017):

  • All pregnant women should have access to prenatal care;

  • Encourage maternal care professionals, organizations, and health facilities to update their standards of practice and care to include all recommended guidelines for the prevention of medical complications;

  • Promote public awareness of the importance of healthy behaviors and women’s overall health prior to pregnancy;

  • Women should always wear proper restraints when riding in cars;

  • Maternal health-care systems require strengthened, prepared, and educated communities to improve deliveries in health facilities, particularly in rural areas;

  • Increase and streamline access to behavioral health services statewide, including training and education for advanced practice nurses in behavioral health services;

  • Support and implement community suicide prevention and awareness programs, such as Mental Health First Aid;

  • Health care providers should screen frequently for perinatal depression and domestic violence;

  • Institute and follow recommended California Maternal Quality Care Collaborative guidelines (www.cmqcc.org) for the timely transfer and transport to a higher-level care facility for any complications using regional transport services; and 

  • Educate providers on the availability of maternal postpartum resources such as home visiting programs.

Some states have gone further. For example, South Carolina’s Medicaid agency formed the South Carolina Birth Outcomes Initiative to advance reductions in early elective deliveries; incentivize Screening Brief Intervention and Referral to Treatment; promote long-acting reversible contraception; and support vaginal births.  One outcome of the SC initiative was to reimburse for long-acting birth control (LARC) devices provided in a hospital setting. 

Fortunately, Arizona has also included LARC reimbursement in a hospital setting post-partum.  This is an important policy intervention because it provides women with a long-acting and reversible option, so they can better plan future pregnancies – improving opportunities for preconception health, which is a key to improving health outcomes.

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