State-Level Interventions to Address Social Determinants of Health Catching On

Will Arizona Join the Chorus Next Legislative Session?

The 6th Annual Arizona Health Equity Conference was held last week at Desert Willow in Phoenix. It was a super interesting conference with more than 50 speakers who discussed a whole series of innovative interventions happening in Arizona that advance health equity. Many (actually most) of the presentations focused on the social determinants of health (things like housing, food security, and transportation) which drive the majority of health outcomes in the US.

You can check out the Conference Brochure if you weren’t able to be one of the more than 330 folks that were at the conference.

Along those lines- I thought this week I thought I’d focus on things that other states are doing build healthy environments that improve health and ensure equitable opportunity for wellness.


Perhaps the most acute social determinant of health in many communities these days is access to affordable housing. An individual’s housing impacts his or her wealth, health, and job opportunities. Lack of access to affordable housing can cause a host of bad health outcomes.

Some states and local jurisdictions are using their decision-making authority to incentivize the construction of affordable housing via something called opportunity zones.  ‘Opportunity Zones’ are part of the new federal tax law and can provide incentives to investors to put their money into areas designated by states as low income or underdeveloped. 

The law lets investors defer (or eliminate) their capital gains tax obligation when they invest the money in a designated ‘Opportunity Zone’. If they hold the investment for 7 years, 15% of their capital gains liability can be written off.  If they hold the investment for 10 years, then their entire capital gain tax liability can be written off.

There are few conditions that are put on the program in terms of what is a qualifying investment, except that the investment must be within a state designated Opportunity Zone.  Developers must make a substantial improvement on the property in the first 30 months.  Investors need to show that 70% of their capital is in the opportunity zone and 50% of their activities.

The governor of each state decides where the Opportunity Zones are (they can name 25% of the qualifying low-income Census tracts as Opportunity Zones).  Our Governor delegated that decision to the Arizona Commerce AuthorityHere’s the map of the Opportunity Zones that the Arizona Commerce Authority selected.

Sadly, few guardrails exist for what kinds of developments qualify for the tax deferral- and no doubt there will be some good things (affordable housing) and bad things (investments that don’t improve conditions) in Opportunity Zone communities in the coming years.

Hopefully our Legislature and Executive Branch will do some research to figure out ways that the Opportunity Zone provision can be leveraged to incentivize and facilitate the contruction of affordable housing- a critical (and sorely needed) intervention that will improve health status of vulnerable Arizonans.

Healthy Food Access

Access to affordable healthy foods directly correlates with improved health– and conversely- eating processed foods are associated with chronic conditions such as cancer, heart disease, diabetes, obesity, and high blood pressure. Food deserts, areas of the country with limited access to foods that make up a salubrious diet, compound barriers to accessing nourishing foods.

Earlier this year New Jersey enacted a law implementing the Healthy Corner Store Program, which increases the availability and sales of fresh produce and nutritious foods by small food retailers in rural and urban low-income and moderate-income areas. The program is funded by their Healthy Small Food Retailer Fund operated out of their state health department.

Washington state recently implemented their Fruit and Vegetables Incentives Program which provides fruit and vegetable incentives and food vouchers for low-income shoppers that can be used in grocery stores and farmers markets.

New York passed a law incentivizing increased fresh fruit and vegetable production through community gardens.


California recently passed a budget that prioritizes improvements to their infrastructure and roadway safety focusing on providing increased access to transportation for under-resourced communities including an evaluation component that report on performance measures related to projects that prioritize and implement safe and connected facilities for pedestrians, bicyclists, and transit users.

2019 Nobel Prize in Economic Sciences &  Recognizes Research Helpful to Public Health

One of the Nobel Prize awards caught my eye because it has such a direct link to the social determinants of global health.  It’s a great example of the importance of doing and using solid research to inform public health interventions.  

The Royal Swedish Academy of Sciences awarded the Nobel Prize in Economics to researchers Abhijit Banerjee, Esther Duflo and Michael Kramer for their work to build the evidence base for methods to reduce global poverty.

The primary driver of bad health outcomes is poverty (not just globally- here too).  More than 700 million people have extremely low incomes and 5 million kids under 5 die of diseases that could often have been prevented or cured with inexpensive interventions.

The researchers that won this year’s economics award developed a new way to identify evidence-based strategies to fight global poverty- and improve public health outcomes. 

Much of their research involves breaking down research questions into smaller pieces. Their research (and others that have followed in their footsteps) are having a big influence on organizations that are implementing interventions to fight poverty by measuring the effectiveness of interventions in the areas of health care and prevention, education, agriculture and gender issues. For example: 

  • One of their studies found that immunization rates for children in rural India jumped dramatically (from 5% to 39%) when their families are offered incentives like lentils.

  • Their work in rural Kenya and in India found that providing more textbooks, school meals and teachers didn’t do much to help students learn more.

  • They found that providing free health care makes a big difference… only 18% of parents gave their children de-worming pills for parasitic infections when they had to pay for them (even though the price was less than $1). But 75% gave their kids the pills when they were free.

These are just a few examples of how this new research has already helped to alleviate global poverty. It also has great potential to further improve the lives of the worst-off people around the world.

What caught my eye about this award and their work is how important it is to connect academic and executive public health and public policy!

You can learn more about Research to help the world’s poor in this 7-page paper on the Nobel website

AHCCCS’ Work/Community Engagement Requirements Temporarily Delayed

By now, you’ve probably heard that AHCCCS will be temporarily delaying the implementation of “AHCCCS Works” their community engagement program for able-bodied adults who receive Medicaid benefits.

In their statement, AHCCCS said they remain committed to implementing the community engagement/work requirement waiver granted by CMS several months ago. Implementation had originally been scheduled for no earlier than January 2020. 

The implementation is being temporarily delayed as court cases play out, “to avoid disruptions to Arizona’s vulnerable population served by the Medicaid program”.  Federal courts have issued stays (holds) on the implementation of work requirement/community engagements in states with programs similar to Arizona’s (Arkansas, Kentucky and New Hampshire).

More information will be posted on the AHCCCS Works web page as it becomes available.  Here’s a link to one of my earlier blog posts with more details about the AHCCCS Works program. 

AzPHA’s 91st Fall Conference & Annual Meeting is Tuesday

Many of you will be attending our (sold out) Fall Conference and Annual Meeting on Tuesday.  We look forward to your participation!  For those of you that can’t make it- here’s a link to the Conference Brochure (give it time to load- it’s a big file). 

Our AzPHA Annual Meeting will begin immediately after the conference- at 4pm.  We’ll be holding our annual awards ceremony at the beginning of the Annual Meeting.  

Here’s a link to our Annual Members Meeting Packet.  In it you’ll see the Members Meeting agenda as well as the winners of our annual awards. We’ll be recogninzing Superintendent of Public Instruction Kathy Hoffman with our Policymaker of the Year Award for her commitment to using evidence based public policy to keep kids healthy in Arizona schools.

We’ll also be thanking our outgoing Board Members: Marcus Johnson, Eddie Sissons, Lauren Savaglio Battles, and Adrienne Lent for their service to AzPHA.

We’ll also be recognizing our new Board Members: 

  • Kim Van Pelt: Vice President

  • Eric Tomlon: Professional Development

  • Carolyn (Carly) Camplaign: Student Representative

  • Zaida Dedolph: Director of Public Policy

Thanks to all of you that voted and approved this year’s Resolution: Preventing Firearm Violence in the Community and Schools

We look forward to your participation at the Annual Meeting!

Note about AzPHA Resolutions:

Many of AzPHA’s  public health priorities are driven by Resolutions that are approved by our members.  AzPHA has dozens of Resolutions in place dating back to the 1930s.  They are all available on our Members Only site

Early resolutions focused on the importance of food safety regulations, tuberculosis control, family planning, and other contemporary public health issues.

More recent Resolutions have focused on support for addressing the Opioid epidemic, certifying community health workers, and addressing electronic cigarettes.  Our Resolutions are important to us because they set our public health advocacy priorities.

AzPHA Resolutions stay in place until and unless the Members vote to remove or update a Resolution. There is a process for developing new Resolutions.  Resolutions are developed by AzPHA Members and are forwarded to the Board for review. 

The Board reviews the Resolution and votes whether to forward the Resolution to the Members for approval.  Proposed Resolutions can be voted on electronically before the Annual Meeting or they can be voted on in-person at the Annual Meeting.  After approval of the resolutions, final copies are posted on the members only portion of our website.

Maricopa County Hepatitis A Outbreak Slowing Because of Quick & Effective  Interventions

Maricopa County has 320 hepatitis A cases with 4 deaths predominantly affecting those experiencing homelessness, substance use and/or recent incarceration. A few months ago, Maricopa County Public Health activated its incident command system and have had all hands on deck with not only members of the County Epi team but also contracted staff and many, many volunteers.

Selecting and Executing an Intervention

After reviewing the data and learning from other jurisdictions around the country, the team determined that the most impactful and cost-effective intervention for quelling the outbreak was to focus on a vaccination campaign among high risk folks.

Of course- that means that they would need some funding to support the intervention. Team MCDPH built a proposal and went to the County Board of Supervisors and were able get a $600K appropriation last fiscal year for the intervention. They were also able to get an additional $1.7M for the current fiscal year. 

The intervention has been focusing on 3 main strategies to vaccinate those at highest risk to prevent further spread including 1) Vaccinating everyone who enters the Maricopa County jail system by hiring temporary staff; 2) Providing vaccine to partners who work with those at risk; and 3) Deploying field teams in partnership with cities to vaccinate people where they are.

AHCCCS stepped in to help as well- facilitating reimbursement to Maricopa County for the vaccinations given to Medicaid members.

By working with healthcare, community, faith-based and local government partners, the public health system has vaccinated over 14,000 residents at risk for hepatitis A. The results have been impressive. They have achieved a 66% reduction in the number of new cases since the peak of the outbreak. Vaccination efforts will continue until they can confirm that the outbreak is over.

Return on Investment

Each prevented hospitalization because of Hepatitis A saves about $25K. Emergency Department visits from Hepatitis A cost less but are still expensive- a few thousand dollars.

Persons experiencing homelessness are at much higher risk for hospitalization when they become infected with the Hepatitis A virus. For example, more than 71% of the 1,521 persons involved in a 2017 Hepatitis A outbreak were hospitalized (1,073) and 41 died.

Kentucky had a similar outbreak but they didn’t jump on it nearly as quick as Maricopa County Department of Public Health (MCDPH) and KY ended up with 4,000 cases. MCDPHs quick response likely prevented hundreds, if not thousands of cases- and untold hospitalization costs to say nothing of the lives saved.  BTW- the Hepatitis A Vaccine is $36 per dose.

Partnerships are Key

There are several keys to the success of this response including doing research to determine the most effective evidence-based interventions to use, working community, government and private partners on solutions, and making a compelling case to the Board of Supervisors to invest county funds on the proposed interventions.

Well done! This is a good example of an effective and targeted response to an important public health problem that has been causing bad health outcomes among a very high-risk population- and causing expensive downstream costs for Arizona’s healthcare system.

FY 20/21 State Agency Budget Requests

Each Fall state agencies turn in their official budget requests to the Governor’s Office. In my experience while I served in the executive branch, there are usually conversations between the agency directors and governor’s office staff before the official requests are turned in- and there was usually governor’s office support for the requests 

The AZ state agencies turned in their requests a couple of weeks ago. Below is what they asked for:

Department of Health Services:

  • Asks for an increase of $1.4 M (GF) from their Emergency Medical Services Fund for:

  • Support Operatins within the Bureau of Emergency Medical Services & Trauma System;

  • Enhance funding to the 4 regional Emergency Management Services Councils;

  • Sustain contracted transportation services for high-risk expectant mothers and for physicians that provide follow-up services for uninsured newborns in intensive care centers;

  • Requests one-time funding of $200,000 from the state general fund (not the Newborn Screening Fund) to address aging equipment and ongoing increase of $56,000 for increased costs of reagents.

  • Seeks additional funding for Nursing Care Institution Resident Protection Revolving Fund to allow the agency to relocate residents to other facilities, maintenance of operation of a facility pending corrections of deficiencies or closure and reimbursement of residents for monies lost. The funds would go toward:

  • $100,000 to address pressure ulcers in nursing homes and training for nursing home staff;

  • $70,000 to provide evacuation tracking and staff tracing system to the 148 skilled nursing facilities in AZ; and

  • $25,000 for an annual conference on best practices on infection prevention in a skilled nursing facility.

Department of Economic Security:

  • Asks for an increase of $15M from the General Fund and $35M (Title XIX) to fund a DDD HCBS provider rate increase that emphasizes quality of direct care worker and service delivery;

  • Asks for $30.5 M (CCDF fund) to increase child care assistance rates to serve low income families in quality settings & continue suspense of the child care waiting list;

  • Seeks a $48.9 M (GF) and $116.1 (Title 19) funds to cover growth for 42,800 members of the DD ALTCS program for targeted case management, state-only case management & AzEIP populations this is based on a projected growth of 5% for ALTCS cases, 2% for targeted case management; 5% growth in state-only case management; 3% growth in AzEIP caseload, a 2% growth in ALTCS capitation & a 5% growth in state funded long term care room & board costs; and

  • Requests additional expenditure authority in the DD line items to use federal Title XIX funds for the DD populations.


Requests an overall increase of $15.15B (Total Funds) of which $1.9B is state general fund (GF), $324.6 M in other appropriated funds, $1.8B in other non-appropriated funds & $11 in federal funds.

Changes driven by Caseload Growth in the population:

  • Increases in the ALTCS-EPD population by 4.8% in FY 2020 & FY 2021 by 3.72%

  • Forecasts for the Traditional T-19 growth to be flat;

  • Estimates growth in Prop 204 Population to increase by 4.14% in FY 2020 and decline in FY 2021 by 3.40%;

  • Changes in the Newly Eligible Adults to grow by 3.84% in FY 2021

  • Declines in the CMDP program are slightly for FY 2020 of -0/09% and increase by 0.43% in FY 2021; and

  • Adds KidsCare growth in FY 2021 of 14.83%.

  • Growth in the baseline Capitation Rate for all programs 3.0% due to a rebasing, changes in utilization, savings from pharmacy, provider increases, adjustments to assure actuarial soundness, and other factors;

  • Adjustment in the FMAP (federal match rate) going to 70% and making adjustments for KidsCare & the childless adults FMAP (match);

  • Seeks authorization or $10.5 M (Federal Funds) for the Medicaid School-Based Administrative Claiming Guide;

  • Reduces the hospital assessment fund to $78.8 M which is being used for the restoration of Prop 204 (childless adults, expansion population) populations in FY 2014;

  • Increases $43.1 (Federal Funds) for non-appropriated federal for regular and supplemental Prescription Rebates;

  • Continues expansion of the Graduate Medical Education program by moving forward the allocation from the FY 2020 appropriations act; and,

  • Seeks $11.9 M (GF) to cover federally mandated IT projects of Asset Verification System, Electronic Visit Verification & Provider Management System.

Department of Child Safety:

  • Increases funding for Adoption Services by $16.4 M (GF) due to increases in the caseload by a growth of 7%; reduce the Adoption Incentive funding due to a structural shortfall due to changes in federal computations; and provide incentive pays of a daily rate of $75 for families who adopt a child with a developmental disability or serious mental health issue;

  • Retains the current appropriation for CMDP in the AHCCCS budget but allocate 4 Single Line Items to manage expenditures and provide transparency with these SLIs: Health Service Request, Higher Level of Care, Care Management & Quality, & Administration and adds 104 FTE which is a 33 FTE increase over current CMDP allocation;

  • Enhances by $5.0 M (GF) to continue and Support the Field Structures within DCS;

  • Reauthorizes $5.0 M (Automation Projects Fund) to continue development & implementation of the Guardian (child welfare information system);

  • Requests $2.6 M (GF) for Legal Costs associated with defending DCS in the class action child welfare case;

  • Makes technical adjustments that provide for Extended Foster Care line item for costs of youth aged 18-21; &, consolidate special line item of Records Retention, Overtime, and General Counsel; and,

  • Asks for $5.4 M (Child Care Development Funds) to increase the Child Care Assistance Rates for low income and foster families to assure children are in quality settings and suspends the child care waiting list.

Federal Judge Issues Preliminary Injunction on the new DHS Public Charge Rules

A federal judge in New York on Friday temporarily blocked the Trump administration’s “public charge” rule linking immigrants’ legal status to their use of public benefits.

Judge George Daniels of the U.S. District Court for the Southern District of New York issued a nationwide Preliminary Injunction which temporarily stops the implementation of the recently filed “public charge” rules promulgated by the US Department of Homeland Security. The new framework would have become effective on Tuesday Oct. 15.

Remember, this is just a Preliminary Injunction, it’s not a final ruling on the merits of the case (PI’s are just that, preliminary).  Because the application of the law cannot be a state by state thing, it is a nationwide PI. 

The bottom line is that the new Rules would (if implemented) change the criteria the federal government uses to make decisions about legal permanent resident applications. The final rules will block legal immigrants from extending their temporary visas or gaining permanent residency if the government decides the applicant is likely to rely on public benefits in the future.

Under the new rule, any immigrant who receives at least one designated public benefit— including Medicaid, food stamps (SNAP), or public housing vouchers for more than 12 months within any three-year period will be considered a “public charge” and will be more likely to be denied a green card (legal permanent resident) by immigration officials.

The Feds already consider whether applicants for legal permanent residency receive Temporary Assistance for Needy Families or Supplemental Security Income (SSI) when they evaluate applications for permanent resident status.

Importantly, the final Rule won’t consider whether benefits were used by an applicant’s children. Likewise, if lawfully present kids receive benefits (e.g. Medicaid) that fact won’t be considered against them if the child later applies for legal permanent residency (a “green card”).

Public health note:  We know from both national reports and from assistors and community organizations working in Arizona, that families are afraid and withdrawing from or reluctant to participate in benefits for which they or their children are legally eligible. Nationally, nearly one in four children have an immigrant parent, and almost 90% of them are US citizens.  Missing out on safety net programs for which folks are entitled can result in bad health outcomes because of social determinants that won’t be addressed and missed doctor’s appointments which could result in missed developmental screenings and interventions.

States Increasingly Implementing Innovative Policy Approaches to Quell the E-Cigarette Use Epidemic Among Kids

Will Arizona Join In?

Electronic cigarette use among kids is a growing concern among some state and federal elected officials, appointees and other policymakers.  E-cigs are the most commonly used tobacco products among kids and young adults.  Nationally, e-cigarette use has grown 900% among middle and high school students from 2011 to 2015.

It’s happening in Arizona too.  Last year’s Arizona Youth Survey found that e-cig use was up dramatically across all three age groups:

  • 8th -graders: 21% reported using e-cigarettes in 2016- that’s up to 28% now

  • 10th-graders: 29.4% 2016, now it’s 39%

  • 12th-graders: 35% 2016, now it’s nearly half- at 46%.

Flavored e-cigs are far and away the most popular kind of e-cig for kids- and the data are clear that flavored e-cigs are attracting (and addicting) kids.  The data are striking.  

According to FDA, 96% percent of kids who started using e-cigs between 2016 and 2017 started with a flavored e-cig. The 2018 National Youth Tobacco Survey data found that 68% of current high school e-cig users used a flavored e-cig.

Those data are compelling- and it’s easy to see why some elected officials and appointed public health officials see regulating the sale of flavored e-cigarettes as  an important strategy to reduce youth e-cigarette use.

Regulating Flavored E-Cigarettes

As I mentioned in my policy update a few weeks ago, the HHS issued a press release announcing that they “intend” to remove all flavored e-cigarette products from the market until manufacturers of those products file premarket tobacco product applications with FDA.

Some Governors and state health officials have also taken executive and regulatory action to regulate flavored e-cigarettes. Last month Michigan became the first state to announce a ban on the sale of all flavored e-cigarettes. She based her decision on leadership from their state health department with their issuance of an emergency finding, and Governor Whitmer directed the agency to issue emergency rules banning the sale of vaping products.

New York‘s Governor Cuomo has instructed their state health department to convene an emergency session of their Public Health and Health Planning Council to consider banning flavored e-cigarettes. The Council adopted rules banning sales of most flavored e-cigarettes.

In Massachusetts, Governor Baker declared a public health emergency, and their state health department commissioner issued an order prohibiting the sale or display of all vaping products.

Some state legislatures are taking action on flavored e-gigs as well.

North Dakota’s governor signed HB 1477 prohibiting the sale of any flavored e-cigs.  Maine’s governor signed LD 1190 which penalizes the sale of flavored tobacco products, including e-cigarettes and flavoring, to anyone under 21.

The California legislature is considering matching bills (AB 739 and SB 38) that would prohibit tobacco retailers from selling flavored tobacco products including e-cigs.  

A similar Illinois bill (HB 3883) would create the Flavored Tobacco Ban Act which would prohibit the sale of any flavored tobacco product.

Massachusetts introduced companion bills (H 1902 and S 1279) that would prevent the sale of flavored cigarettes (and e-cigs).

Public Health advocates like ourselves can play an important role in building the evidence base and conducting the advocacy necessary to move elected and appointed officials to take action. 

Our administrative advocacy can take several forms- from collaborating with elected officials to develop legislation to take action- to working within state and county health departments to urge appointed officials to take action.  State health departments play a key role in catalyzing a response as well, if they take action.

So far, our Governor doesn’t appear to be supportive of banning the sale of flavored e-cigs in AZ.  He’s quoted in this article in the Arizona Capitol Times as saying “What I don’t want to do is take someone who is addicted (to nicotine), restrict them from finding a product and push them to the black market, so we’re going to have a measured approach.”

Perhaps if he knew that 96% percent of kids who started using e-cigs start with a flavored e-cig and that 68% of current high school e-cig users used a flavored e-cig  it would change his mind?

Please Promote Participation in the Title V Needs Assessment Survey

The 2020-2025 Maternal and Child Health Title V Needs Assessment Survey is underway, and they need your help to make sure they good data from the Assessment! 

This needs assessment is done every 5 years and is super important because the needs assessment results drive decision making and resource allocation for the next 5 years.  Getting good data from the needs assessment can make the difference between getting great public health results and getting just mediocre or even no result.

The Federal Title V MCH Block Grant is a key source of support (including funding) for promoting and improving the health and well-being of mothers, children, adolescents, including children/youth with special needs, and their families.  

In order to accurately identify the needs of Arizona’s women and children, a needs assessment is conducted every five years. The results of the survey help to develop the priorities for the next five years. 

The survey is available in English & Spanish and should take about 20 minutes to complete. The survey data collection period will end on December 31, 2019. All Arizona residents including service providers and families are welcomed to take the survey. 

Please participate in the survey and promote it with your partners and families. They have created two flyers, in English and Spanish that can be shared and distributed. In addition, they can mail printed copies of the flyer to your organization for waiting rooms. Printed flyers can be ordered through here.

Anyone with questions about the survey can contact the ADHS Office of Assessment and Evaluation at 602-542-2233 or at

Member Vote: Proposed New AzPHA Board Member Slate

The AzPHA Board of Directors is pleased to propose a slate of incoming Board Members to replace the folks that will be transitioning off the Board at our Annual Meeting on October 29, 2019.  The Board has interviewed the candidates and is recommending that you (our members) approve their recommended slate of candidates. Please take a few minutes to vote on the recommended slate by October 14, 2019

AzPHA Board Recommendations

Vice President: Kim Van Pelt

Chief Regional Officer, First Things First CV

Dir. of Professional Development: Eric Tomlon, FACHE, MBA/MSHA

VP/Chief Operating Officer for Dignity Health Medical Group CV

Student Representative: Carolyn (Carly) Camplaign, JD

Sr. Program Coordinator, Center for Health Equity Research, NAU CV

Director of Public Policy: Zaida Dedolph

Director of Public Policy, Children’s Action Alliance. CV

A Big Thank You to our outgoing Board members- they have served AzPHA for many years and have done a lot of hard work for our organization- than we thank you!

Please take the time to thank our outgoing Board members!  We appreciate your service to AzPHA and to the people of Arizona!

  • Marcus Johnson: Immediate Past President

  • Eddie Sissons: Director of Public Policy

  • Lauren Savaglio: Director of Professional Development

  • Adrienne Lent: Student Representative