Will Humble Assurance & Licensure, Behavioral Health, Prevention, Public Health, Wills Blog

Abuse & Neglect Prevention Task Force Report Released

A few months ago (after the discoveries at Hacienda Healthcare) the governor issued an executive order directing AHCCCS, ADES and ADES to convene a working group and make recommendations to better protect vulnerable adults (including folks with disabilities) from abuse and neglect.

A task force was put together and did some pretty diligent work. Last week the task force published their report which included 30 detailed and fairly measurable recommendations.  Each recommendation has a lead agency and many provide well-defined implementation deadlines.

The recommendations include sensible reforms, practices, resources, policies, and some commitments that would, if implemented, improve and sustain safety and security for vulnerable individuals. The report (w/o appendices) is 19 pages long- and is quite readable.  I encourage you to take a look. It really is some impressive work.

Of course- the key is really implementing the recommendations.  Some are contractual changes that AHCCCS can make within their managed care contracts.  Some are agency and inter-agency process recommendations. Others involve implementing modifications to computer systems. Some will require changes to state law (like modifying the definition of abuse).  All have a lead agency (almost all are AHCCCS and ADES) and most have an implementation date goal.

Some of the recommendations will require additional funding.  For example, Recommendation #21 states that…  “The State should also provide a level of funding for the APS (Adult Protective Services) program that takes into account annual growth in the number of reports, fair market wages for investigators, outdated technology across the program, and lack of available service referrals in certain areas of the state.”

This is an important report that clearly involved a lot of work.  Let’s keep our eye on the document and the implementation progress (including the important funding that APS needs).  If implemented, the recommendations provide an opportunity to better protect vulnerable adults across AZ.

Will Humble Medicaid, Return on Investment, Wills Blog

New Research Finds Medicaid Expansion Has Saved at Least 19,000 Lives Nationally

Back in 2013- via a lot of hard work by public health advocates, solid support from many legislators, funding via an assessment on hospitals, and with the urging of Governor Brewer, Arizona restored Medicaid coverage to “childless adults” (who has previously been frozen out of the state’s Medicaid program) and extended coverage up to 138% of the federal poverty level. 

Those decisions have extended access to healthcare to hundreds of thousands of Arizonans (400,000 folks in the expansion population alone)- and have been a big reason why Arizona’s uninsured rate has dropped so precipitously.

A new study published this week (using national data) found that the states (like Arizona) that expanded Medicaid have saved lives in their states.  Likewise, the study found that the policy decision states made to not expand has led to premature deaths.  The new study compares mortality rates among 55- to 64-year-olds likely eligible for Medicaid in expansion states to mortality rates among similar older adults in non- expansion states.

The study found that Medicaid expansion from 100% of FPL to 138% saved the lives of at least 19,200 adults aged 55 to 64 from 2014 to 2017.  Conversely, 15,600 older adults died prematurely because of state decisions not to expand Medicaid.  Remarkably, there was an estimated 39 to 64% reduction in annual mortality rates for older adults gaining coverage. 

If all states had expanded Medicaid, the number of lives saved just among older adults in 2017 would roughly equal the number of lives that seatbelts saved among the full population.

Other studies have found similar results, so this week’s results aren’t surprising, since a large body of research has already documented mechanisms by which Medicaid expansion could be preventing premature deaths, and other studies have found reductions in mortality from pre-ACA coverage expansions. 

For example, other studies have found that Medicaid expansion resulted in:

  • Large increases in prescriptions filled for heart disease, diabetes, mental health conditions, and other chronic conditions.

  • Large increases in the share of low-income adults getting regular check-ups and other preventive care, and large decreases in the share without a personal physician or usual source of care.

  • Large decreases in the share of low-income adults skipping medications due to cost.

  • Decreases in the share of low-income adults screening positive for depression.

  • An increase in the share of people getting surgical care consistent with clinical guidelines, for example less invasive surgical techniques where feasible.

  • Increases in cancer screenings and early-stage cancer diagnoses.

  • A decrease in one-year mortality rates for patients diagnosed with end-stage renal disease.

How is Medicaid Funded?

Medicaid is financed by both the federal government and the states using a formula that is based on a state’s per capita income. The federal share (FMAP) varies by state from a floor of 50% to a high of 74% with exceptions for certain services or populations. The Affordable Care Act (ACA) expanded Medicaid eligibility for adults under age 65 and provided the states that chose to expand with an Enhanced FMAP of 100% federal funding through 2016 for the newly eligible adults. The federal share for the expansion population phased down to 95% in 2017 and to 90% by 2020 and beyond.

HERE is the Kaiser breakdown of Medicaid expansion spending by state.

Will Humble Affordable Care Act, Disease Control, Medicaid, Wills Blog

Community Health Centers File Lawsuit Challenging AHCCCS Reimbursement Practices

Federally Qualified Health Center Primer

Federally Qualified Health Centers occupy a special place in America’s healthcare system.  Better known as FQHC’s, they operate under a mandate to provide comprehensive community-based health care in underserved areas- basically in areas where there’s a shortage of healthcare providers (often in rural and lower income urban areas).   

FQHCs are often also called Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Health Centers for Residents of Public Housing.

FQHCs are a super-important part of the healthcare network because they provide access to healthcare in areas that would otherwise likely have very few providers. Much of their mission focuses on primary care- which as I’ve written about many times is critical to improving public health outcomes and reducing costs.

In addition to funds from HRSA- federal law provides some financial incentives like special reimbursement programs which keep FQHC’s business models afloat.  Without these special incentives their business models would be in jeopardy- risking already thin networks in rural and under-served areas.

In order to qualify for the financial incentives they receive, FQHC’s have to meet stringent requirements like providing care on a sliding fee scale based on ability to pay (e.g. for uninsured folks), providing a full array of services including primary care and preventive services as and operating under a governing board that includes patients. 

Many FQHCs integrate access to pharmacy, mental health, substance use disorder, and oral health services and are often the only truly accessible place to get care in a community.

The ADHS website has easy to use tools to find FQHCs and Sliding-Fee-Schedule Clinics including ones for Primary Care Providers, Behavioral Health Providers and Oral Health Providers.  One can also download a mobile app to find federally-funded health centers on the go.

The Lawsuit Filed this Week

This week the Arizona Alliance for Community Health Centers- a nonprofit group that represents many of Arizona’s FQHCs – filed a lawsuit (in the 9th Circuit Court of Appeals) on behalf of Arizona FQHCs challenging some of AHCCCS’ reimbursement practices with respect to FQHCs (mostly for adult dental services but more on that in a bit). 

The case is called Arizona Alliance For Community Health Centers v. Arizona Health Care Cost Containment System.  The named Plaintiffs are Sunset Community Health Center, North Country Healthcare, Sun Life Family Health Center and others And the Defendant is Jami Snyder, the Director of AHCCCS.

There are several areas in the lawsuit that challenge the way AHCCCS is reimbursing for (or not reimbursing for) services in FQHCs…  but after reading the complaint (which isn’t posted on the court’s website yet) and talking to a few folks this week – the core issue seems to be that AHCCCS hasn’t been paying for adult dental services the way the 9th Circuit has previously ruled that they should (in CA).  

The FQHCs that have been providing adult dental services say they’ve been forced to pay for those services with other funds (like sliding fee scale funding) rather than the funds that they argue should be coming back from AHCCCS.  Other grievances in the Complaint argue that AHCCCS hasn’t been reimbursing for podiatry, optometry and chiropractic services the way the 9th Circuit has previously ruled that they should (again in CA).

A few months ago, the Federal 9th Circuit ruled that state Medicaid programs need to reimburse for adult dental services even if the state’s Medicaid program doesn’t cover adult dental services (or they limit them to emergency dental only or caps the services like Az does). 

So, at the core it looks to me like the suit is geared to leverage the previous 9th Circuit ruling that health centers are entitled to reimbursement when providing dental services to Medicaid members (and not limited to the existing $1K or $2K annual financial cap).

It’ll be awhile before it’s all settled, but if the suit is successful it will likely result in a more robust oral health network for adults covered by Medicaid as well as improve oral health outcomes.

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

AZ Kids Health Insurance Coverage Lagging

The number of uninsured children in Arizona rose dramatically more than 10% between 2016 and 2018 and the state jumped to the third highest in the country for percentage of uninsured kids, according to a new report released by the Georgetown University Center for Children and Families.  The report is full of very interesting data.

Arizona does not fare well in the report- ranking near the bottom in terms of the percentage of kids that have some kind of health insurance. In Arizona, 146,000 children (8.4%) lacked coverage in 2018. 

The states which have lost statistically significant ground are Alabama, Arizona, Florida, Georgia, Idaho, Illinois, Indiana, Missouri, Montana, North Carolina, Ohio, Tennessee, Texas, Utah, and West Virginia.

Nationally, the loss of coverage is most pronounced for kids under age 6, and children in families who earn between 138 percent and 250 percent of poverty ($29,435 – $53,325 annually for a family of three)- basically the CHIP or Kids Care population.

The report finds a number of factors have contributed to the rise in uninsured children, including a chilling effect caused by a shifting immigration policy landscape and parents not enrolling their eligible children in Medicaid or Children’s Health Insurance Program (CHIP or KidsCare); confusion over the Affordable Care Act’s individual mandate and open enrollment dates; and added red tape to the Medicaid enrollment process.  

Children’s health coverage has long had broad bipartisan support in Congress and in Arizona. It’s time to double-down on our efforts to let families know quality health coverage options are here! One thing you can do is to let families know that the ACA Marketplace (or Obamacare) open enrollment begins tomorrow, November 1st. You can find out more by visiting CoverAZ.org. Marketplace Open Enrollment info is happening right now with enrollment and other info at https://www.healthcare.gov/.

Will Humble Affordable Care Act, Federal Budget, Federal Public Health Bud, Prevention, Wills Blog

Progress on Federal Health Funding Remains Elusive (and an Advocacy Ask)

The federal government funded this fiscal year (which started October 1) through Nov. 21 under a continuing resolution (all of the health agencies in the HHS family are finded under the current CR).

The Senate continues to struggle to complete action on its version of the FY 2020 Labor-HHS-Education Appropriations bill. While the House of Representatives has passed 10 of the bills to date, the full Senate has not passed any, though several have been reported out of the Senate Appropriations Committee.

The continuing resolution also includes an extension of funding for several other important health care programs that were set to expire on Sept. 30, including the Community Health Centers and National Health Service Corps programs. 

Under the Senate draft, funding for the CDC would increase by nearly $180 million above FY 2019 levels, with most programs receiving level funding. One controversial provision in the Senate bill is the proposal to completely eliminate funding for the agency’s Racial and Ethnic Approaches to Community Health program – a proposal strongly opposed by APHA and many other health partners.

The House bill would provide a more than $929 million increase for CDC programs, including a $16 million increase for the REACH program, $25 million in funding for CDC to undertake gun violence prevention research and a $5 million increase in funding for CDC’s Climate and Health Program, among many other important increases.

HRSA would get an $85 million increase under the Senate bill compared to a more than $472 million increase under the House version of the bill.

On Oct. 23, 120 members of the CDC Coalition, led by APHA, and other supporting organizations sent a letter to House and Senate Appropriations Committee leaders urging them to include the higher House funding levels for CDC in any final FY 2020 appropriations bill. The Friends of HRSA, also led by APHA, sent a letter to House and Senate Appropriations Committee leaders on Nov. 1 urging the higher House levels for the agency in any final FY 2020 spending bill.

We’re urging our members to contact their members of Congress and ask them to prioritize strong funding for public health programs in FY 2020.

Will Humble Prevention, Public Health, Social Determinants, Wills Blog

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.

Housing

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 Authority. Here’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.

Transportation

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.

Will Humble Prevention, Public Health, Wills Blog

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

Will Humble Health Insurance, Medicaid, Wills Blog

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. 

Will Humble Uncategorized, Wills Blog

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.

Will Humble Disease Control, Prevention, Public Health, Return on Investment, Wills Blog

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.

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