Will Humble Affordable Care Act, Public Health, Wills Blog

University of Arizona Creating a Primary Care Tuition Waiver Program!

Great news. The UA Colleges of Medicine in Tucson and Phoenix are creating a new tuition waiver program for medical students specializing in primary care fields that agree to work in rural under-served areas in Arizona.  Up to 94 students who attend the UA Colleges of Medicine in Phoenix or Tucson can receive free tuition if they agree to practice in a rural area for at least 2 years after they graduate.

Kudos to the UA Administration for making the decision to spend a big chunk of the $8M that had appropriated to the medical schools in last year’s state budget for this innovative and badly needed intervention. 

In addition to the $8M appropriation to those medical schools, last year’s budget included an additional $750,000 for the State Loan Repayment Program (to make a total of $1.75M/year) and $12.5M more for Graduate Medical Education ($7M rural and $4.5M urban).

The new UA tuition waiver program will be a new resource to help carry some of the additional load already carried by the state’s loan repayment program.  That program was enhanced back in 2015 with the success of Senate Bill 1194 which enhanced Arizona’s State Loan Repayment Program by expanding the types of providers who can receive loan repayment assistance, increasing the award amounts for the initial and succeeding commitment years, and removing the 4-year service cap.  

The list of practitioners that can qualify for the state loan repayment program now include primary care physicians, dentists, advanced practice providers like nurse practitioners, physician assistants, nurse midwives, mental health providers, pharmacists and geriatrics. 

The AZ loan repayment program makes up to $65,000 available (for a 2-year commitment) for physicians and dentists.  Advanced practice providers can qualify for up to $50,000.  The incentives even get better as providers stay longer in the program. 

For each year of continued service in the under-served area after the first two years, physicians and dentists can receive up to $35,000.  Actually the loan repayment funds are worth even more than these figures because it is loan relief that isn’t counted as income for tax purposes.

Will Humble Affordable Care Act, Medicaid, Prevention, Wills Blog

AZ Center for Rural Health Workforce Reports

The UA Center for Rural Health (AzCRH) recently release healthcare workforce data briefs on Maternal Health and the Obstetrician and Gynecologist Physician Workforce in Arizona.  Access to timely and high-quality women’s health and primary care services is an essential component of a supporting maternal health. In the report, you’ll see that Greenlee and La Paz counties are maternal care deserts and Cochise, Graham Pinal, and Santa Cruz counties have limited access to maternal care.

Women in rural Arizona face barriers to maternal health care including a lower ratio of Ob-gyn providers per population. In general, women in rural areas have additional barriers like longer drive-times and fewer facilities offering obstetric services. 

Reports like this are important as they can be used to inform and influence both elected officials in the legislature and appointed officials in state agencies and universities.  Thoughtfully used- this kind of data can help inform legislative and administrative policy initiatives that can help improve the system of care for women (like the new tuition waiver program mentioned above).

Will Humble Early Childhood, Maternal Health, Nutrition, Prevention, Wills Blog

Good News about Childhood Obesity in new MMWR Report

We got some good news from the childhood obesity public health front this week!  This week’s Morbidity and Mortality Weekly Report  found that the obesity rate among WIC participants aged 2–4 years went down in most states between 2010 and 2016 in most states including Arizona.  Arizona’s rate went from 15% in 2010 to 12% in 2016.  The study  looked at kids between 2 and 4 years old that participate in WIC between 2010 and 2016  obesity.  Very encouraging.

Here’s an news article that summarizes the Arizona results.

A big factor was undoubtedly a public health policy initiative from back in 2009 which revised the content of the foods that qualify under the program- to better align with nutrition research and practice guidelines of the American Academy of Pediatrics.  The revised food packages included a broader range of healthy food options and promotes fruit, vegetable, and whole wheat product purchases; support breastfeeding; and gave states more flexibility to accommodate cultural food preferences.

The study was among WIC participants- but WIC interventions are likely not the only intervention at play here.  Other state initiatives were under way in Arizona during the 2010 – 2016 study period, including:

  • Working with the county health departments to implement the Health in Arizona Policy Initiative. This initiative focused on school health, worksite wellness, healthy community design, procurement of healthy foods (like having healthy alternatives in vending machines), preventive clinical care, and inclusion of children with special health care needs.

  • The implementation of the CDC public health prevention grant in 2013, which, like the Health in Arizona Policy Initiative, which made healthy living easier by supporting healthy environments in workplaces, schools, early childhood education/child care, and in the community. Arizona was one of 32 states to be awarded enhanced funding that year and received $2M per year for 5- years. That grant resulted in a host of statewide interventions.

  • Arizona’s county health departments implemented Health Impact Assessments, action plans, and initiatives during the study period aimed at increasing healthy eating and active living by using tools like the Arizona Health in Policy and Practice Resources and the Urban Land Institute’s Community Plan, both of which help local officials to focus on a holistic approach to land use planning, zoning, transportation, economic development, real estate development and finance.

  • School Health Advisory Councils were started in 2012 which helped schools to identify and incorporate best practices for obesity prevention including standards that promote healthy eating and physical activity, like focusing on serving fruits and vegetables, limiting sugary beverages, and providing more opportunities for physical activity, and reducing screen time- like the ADHS’ 2010 nationally-recognized Empower program does.

  • State level legislative policy also may have been a factor. Back in 2013 we were able to pass ARS 33-1551 which addresses liability concerns of schools when opening outdoor facilities to the public outside of the school day- making it easier for schools to open playgrounds to the public so children have more places to play and be physically active.


WIC at a Glance

As a federal grant program inside the USDA, WIC is administered by states, territories, and Indian Tribal Organizations to provide supplemental nutritious foods, breastfeeding support, health care referrals, and nutrition education for low-income children aged <5 years and pregnant, postpartum, or breastfeeding women. WIC PC is a biennial census in even years of all participants certified to receive WIC benefits.

To be eligible for WIC, participants must live in the states in which they apply, have gross household income ≤185% of the federal poverty guidelines or be eligible for other programs (e.g., Supplemental Nutrition Assistance Program, Medicaid, and Temporary Assistance for Needy Families), and be at nutrition risk. Children’s weight and height are measured by WIC staff members during certification and recertification clinical visits.

Will Humble Federal Budget, Wills Blog

Congress Passes Temporary Continuing Resolution- Keeping the Federal Government Open until December 20

This year’s federal fiscal year started October 1, but there’s still not a budget for this year.  At least there’s a new continuing resolution.  Last week the US House and Senate passed a continuing resolution that temporarily funds the federal government through December 20.  It’s called the Further Continuing Appropriations Act, 2020 and Further Health Extenders Act of 2019, and it continued current funding levels through December 20, 2019.

The previous continuing resolution had expired last Thursday.  Here’s a section-by-section summary of the bill can be found funding bill and here’s the full text.  Public health programs will continue to be funded at the current level, for now. Congress now has 3 weeks to continue work on FY20 (current year) budget negotiations.

Will Humble Affordable Care Act, Health Insurance, Public Health, Wills Blog

Is the AZ Attorney General Contemplating Legislation to Protect Health Insurance Coverage for Folks with Pre-existing Conditions?

I was surprised to see an article in the AZ Capitol Times this week  reporting that Attorney General Brnovich along with Senator Mesnard abd Rep. Weninger and  are contemplating putting together a bill  that would provide a backstop for folks with pre-existing conditions to continue to be able to buy health insurance in case the Affordable Care is stricken down by the US Supreme Court in 2020 – which by the way is a real possibility. 

Arizona, via Brnovich, has signed on to the lawsuit trying to overturn the ACA in its entirety.

In December 2018 a judge in Texas (O’Connor) ruled that the Affordable Care Act is unconstitutional now that the individual mandate has effectively been eliminated (by the large tax cut bill last year). In July of this year, the 5th US Circuit Court of Appeals heard the Texas v Azar case. That ruling could come out any day now.

Whatever the 5th Circuit rules, the ACA will probably once again be in front of the US Supreme Court- perhaps as early as this spring.

Protections at Risk

At risk if the ACA is overturned are core health insurance coverage provisions like expanded Medicaid eligibility from 100% to 133% of the poverty level, coverage for childless adults under 100% of federal poverty (made possible via the AZ hospital assessment), subsidized Marketplace Plans, and a host of health insurance reforms like protections for folks with pre-existing conditions. 

The idea floated by Brnovich et.al. really focused on one of the insurance regulation measures in the ACA – the pre-existing conditions exclusions- which is one of the consumer protection components in the ACA that prevent insurance companies from: 

1) denying someone health insurance because they have a preexisting condition -called the “guaranteed issue” requirement;

2) refusing to cover individual services that people need to treat a pre-existing condition- called “pre-existing condition exclusions”; and

3) charging a higher premium based on a person’s health status – called the “community rating” provision.

Prior to the ACA, standards to protect people with preexisting conditions were determined at the state level.  Most states including AZ had very limited protections. Before the ACA, many insurers maintained lists of up to 400 different conditions that disqualified applicants from insurance or resulted in higher premiums.  35% of people who tried to buy insurance on their own were either turned down by an insurer, charged a higher premium, or had a benefit excluded from coverage because of their preexisting health problem.

Several states already have their own state laws that incorporate some or all the ACA insurance market protections. Could it be that Senator Mesnard, Rep. Weninger and Attorney General Brnovich want to do the same? 

And if so, what about the other things like expanded Medicaid eligibility from 100% to 133% of the poverty level (FPL), coverage for childless adults under 100% FPL (made possible via the AZ hospital assessment), and subsidized Marketplace Plans? 


Background on the 2012 Ruling Upholding the ACA

In the 2012 Ruling that upheld the ACA, Chief Justice Roberts wrote that: “… the Affordable Care Act’s requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax… because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.” 

Roberts rejected the Obama Administration’s argument that the federal government’s authority to regulate interstate commerce provides the authority needed for the ACA to be constitutional (the Court struck down that argument 5-4).  Fortunately, the court held (5-4) that the ACA was constitutional based on the federal government’s taxing authority (and that tax has now been eliminated).

Supreme Court Forecast

Because of the makeup of the 5th Circuit Court of Appeals they will likely uphold O’Connor’s decision to invalidate the ACA…   and the case will probably end up with the US Supreme Court, which has a different cast of characters than it did when the ACA was originally upheld back in 2012 by a 5-4 vote.

Since the 2012 decision upholding the ACA, Gorsuch has replaced Scalia.  Kavanaugh replaced Kennedy.  Both Scalia and Kennedy voted to overturn the ACA- so not much on that score has changed.

Chief Justice Roberts voted with the majority that upheld the law. His argument rested on the ACA’s link to the financial penalties for not having health insurance. But remember, those financial penalties f were removed from the IRS tax codes in last year’s federal tax overhaul, pulling out the structure that Roberts used in his argument.

The bottom line is that the ACA, including its protections for folks with pre-existing conditions, and all of the coverage through Medicaid and the subsidized Marketplace plans are in jeopardy if Roberts views the ACA as fundamentally different now that the financial penalties are gone.

Basically, the fate of the US’ health care system and all the protections that it provides will likely rests with one person, Chief Justice John Roberts.

And while it’s nice that AG Brnovich is contemplating doing something about the pre-existing condition exclusions- it’s really just focusing on a fraction of the chaos that would result from the overturning the ACA.

Will Humble Affordable Care Act, Public Health, Wills Blog

CMS Files Hospital Price Transparency Rule (But Penalties for Noncompliance are Negligible) 

Last Friday CMS filed final rules requiring hospitals to make public their gross charges, payer (health plan) specific negotiated charges, minimum and maximum negotiated charges, and their discounted prices. The data is supposed to be displayed in electronic format. The rule will apply to all US hospitals.  The rules kick in on January 1, 2021. 

Hospitals will be required to make public standard charges for at least 300 “shoppable services” (including 70 CMS-specified and 230 hospital-selected) the hospital provides in a “consumer‑friendly” manner.  

A sweeping rule indeed, until you look at the penalty for noncompliance.  If CMS thinks a hospital is noncompliant they can fine the hospital up to $300/day (total). That’s about $110K per year.

This fact sheet discusses the provisions of the final rule (CMS-1717-F2), which can be downloaded from the Federal Register at: https://www.hhs.gov/sites/default/files/cms-1717-f2.pdf.

Will Humble Affordable Care Act, Assurance & Licensure, Health Insurance, Return on Investment, Wills Blog

Transparency in Coverage Proposed (Rule CMS 9915 P)

HHS proposed a “Transparency in Coverage” this week.  It’s just a proposed (not a final rule by any means). The proposed rule would require group and individual health insurance plans to disclose  personalized out-of-pocket cost information for all covered health care items on line. Plans would also be required to disclose in-network negotiated rates with their network providers.  The proposed rule is at here: https://www.hhs.gov/sites/default/files/cms-9915-p.pdf.

Will Humble Public Health, Social Determinants, Wills Blog

Help the Maricopa County Department of Public Health with their Community Needs Assessment

Every three years, the Maricopa County Department of Public Health conducts a community health needs assessment that includes a survey of our community partners on the effectiveness of the Local Public Health System.

Here’s a link to their survey asking about the functioning of our public health system.  This is not an assessment about the department, but of the greater public health system in Maricopa County.  All responses are anonymous.

Please complete the survey by November 30th. You can start the survey and come back to it- your responses will be saved.  The findings will be published with the 2020 Maricopa County Coordinated Community Health Needs Assessment next year.  Please help with the Local Public Health System Assessment Maricopa County 2019

Will Humble Affordable Care Act, Medicaid, Wills Blog

Steward Health Care to be Bought by Blue Cross Blue Shield

Steward Health Care System announced this week they they’re selling their Medicaid and Dual Special Needs Medicare Health Plans to Blue Cross Blue Shield of Arizona. The sale won’t be final until approved by AHCCCS.  They expect to complete the sale in early 2020.  Steward’s Medicaid health plan serves the northern part of the state and covers about 200,000 AHCCCS members.  Their network includes about 17,000 healthcare providers.

Blue Cross Blue Shield is currently not in Arizona’s Medicaid program, so this will be a new entry into the Medicaid market for them in Arizona.  The press release said that providers won’t need a new agreement with BCBSAZ Health Choice Arizona and Medicaid members can keep their current providers as well.  Members will be getting new ID cards after the transition.

Will Humble Assurance & Licensure, Prevention, Wills Blog

What’s Up with the ADHS Sunset Review?

Every 10 years AZ state agencies come up for what’s called a Sunset Review. It’s a process by which the legislature reviews agency performance and their mission. The legislature generally reauthorizes the agency for a 10 year period after the review. We’re currently in the fiscal year in which the ADHS is up for review.

There are several pieces to the process including some agency Auditor General reports, a review of that report by a selected legislative committee, and finally a bill that will re-authorize the agency (usually but not always for 10 years).   

ADHS Auditor General Reports

The sunset review starts with a report written by the Arizona Auditor General.  They pick a few areas of the agency to examine and put forward their findings. The Arizona Auditor General is in the legislative branch is supposed to serve as an “independent source of impartial information concerning state and local governmental entities and provides specific recommendations to improve [their] operations”.

A few weeks ago, the Auditor General published some findings on the ADHS as part of the sunset review.  The reports are published on the Auditor General’s website which include their findings and also recommendations for improvements in areas that are found deficiencies.

They published 2 reports about the agency last month.  One of the reports found that the ADHS licensing division “failed to investigate or timely investigate some long-term care facility complaints, didn’t  comply with some conflict-of-interest requirements, and has some gaps in IT security.” 

A 2nd report focused on the Arizona State Hospital (which is part of ADHS) and found that they hadn’t fully “evaluated assault-reduction strategies but has established processes for patient admission, ensuring patients receive prescribed treatment, and reporting incidents.”

The Auditor General’s website posts the reports and the agency responses to the report.  Those responses state whether the agency leadership agrees with the findings or not and whether and how they intend to change practices to improve on the report findings. 

ADHS leadership disputed many of the findings about the nursing home complaints- but nevertheless agreed to partially implement some of the auditor recommendations. Their leadership also stated that additional funding will be needed to timely follow up on nursing home complaints.

On page 6 of their response, ADHS leadership states that will need an additional 44 staff and $3.3M to do timely follow on the 2,500 nursing home complaints that they get each year. 

Legislative Review of the Auditor General Report

Once the Auditor General Reports are completed, a committee of the state legislature meets (before the legislative session starts) and has a hearing about the findings and votes whether to recommend to the full legislature that the agency be re-authorized for another 10 years.

The Senate Health & Human Services Committee met last week to talk about the findings and vote on the recommendation to reauthorize the agency. 

You can read more about what happened in this article from Stephanie Innes at the Arizona Republic …  but basically 3 of the Senators on the committee voted “no” on the motion to recommend reauthorizing the ADHS for another 10 years because they wanted to learn more about how the agency intends to change their processes and timely follow up on nursing home complaints.  The vote was still 4-3 to reauthorize…  but it’s kind unusual to have “no” votes like that.

There still needs to be a successful bill next legislative session in order to reauthorize the agency. 

Licensing Division Funding

Before the recession, the ADHS received state general fund appropriations to perform their licensing functions (hospitals, skilled nursing, assisted living, childcare, residential behavioral health facilities, outpatient treatment clinics etc.). 

As part of the budget cuts in 2009, all of the general fund dollars were discontinued and the agency was given rulemaking authority to charge a fee to licensed facilities to satisfy their regulatory responsibilities.  The licensing fees were authorized to go into a new ADHS Licensing Fund.  

We estimated the resources that we’d need to do our work and published the final fee structure in 2009. However, we forgot to add in overhead (called Indirect in state government speak) to the fees, and the final fees that we ended up charging (and therefore our revenue) was about 20% lower than they should have been – and we basically had to live with that.  My bad.  And remember- those fees were set in 2009 – and no adjustment for inflation is in the fee structure.

I don’t know is how much money is in the Licensing Fund right now… but there are a couple of possibilities when it comes to getting the additional $3.3M that the agency says they need to timely follow up on nursing home complaints. 

If there’s enough money in the Licensing Fund, they could ask the legislature to appropriate that money to hire the staff they need to adequately follow up on nursing home complaints (and other functions).  If the funds aren’t available in the Licensing Fund, then they could ask permission to raise the licensing fees and raise the needed revenue that way.

I suspect that when the Executive Budget is released in January it’ll propose an appropriation from the Licensing Fund to cover the need (although this was not included in the agency’s budget request). 

If the funds aren’t available in the Licensing Fund, then I suspect there may be a proposal to raise licensing fees. It’s just hard for me to believe that if it’s really true that $3.3M more is needed to do the job right that the money won’t be found.

After all, inspecting and following up on complaints in nursing homes is a core government function that’s necessary to ensure the health and safety of some of the most vulnerable folks in Arizona.

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