Will Humble Affordable Care Act, Wills Blog

Group Gathering Signatures for the “Healthcare Quality Improvement Act”

A group called Healthcare Rising Arizona filed the paperwork with the AZ Secretary of State with language for a voter initiative called “Arizonans Fed Up with Failing Healthcare” that would make some changes to healthcare law and provide a backstop for consumers in case the Affordable Care Act is overturned by the US Supreme Court now that the tax penalty for not having health insurance has been removed from the ACA by the 2017 major tax law overhaul.

Here’s a link to the voter initiative language.  The folks running the campaign still need almost 238,000 valid signatures by July 2, 2020 to get on the ballot- no easy feat given the new requirements passed by the Legislature and signed by the Governor which make getting things on the ballot harder. There are 4 basic components to the measure:

Consumer Protections for Health Insurance

Some consumer protections for Arizonans in case the Supreme Court overturns the ACA now that the tax penalties for not having insurance are gone.  This initiative would prevent commercial health insurance companies in Arizona from doing the following things (if the ACA is overturned):

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.

Hospital Associated Infections

Requires private hospitals to meet national safety standards regarding hospital-acquired infections and gives the Arizona Department of Health Services the authority to impose civil penalties if hospitals fail to meet those standards.

Surprise Billing

Protects Arizona consumers against surprise medical bills from out-of-network providers and requires refunds if patients are overcharged.

Raises for Direct Care Workers

Gives direct care hospital workers a 5% wage increase each year for four years. Direct hospital care workers include nurses, aides, technicians, janitorial and housekeeping staff, social workers and non managerial administrative staff. Physicians are excluded.

The fly in the ointment on this one is that last bullet. My guess is that there wouldn’t be a whole lot of organized opposition to the measure without that last piece- requiring raises for hospital direct care workers. 

Honestly, I think the provisions that require raises for direct care workers is what will make the Initiative fail, and along with it the opportunity to provide consumer protections in the health insurance market in case the US Supreme Court overturns the ACA now that the tax penalties for not having health insurance have been eliminated.

We’ll continue to review the language and evaluate whether to take a position on this and other voter initiatives that are I the works like the retail marijuana initiative and the Voter’s Right to Know Amendment.

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

Doula Services Improve Maternal and Child Health Outcomes

Medicaid Programs Increasingly Reimbursing for Doula Services

Doulas are professionals who provides physical, emotional, and informational support to a woman throughout pregnancy, childbirth, and postpartum. Doula’s act as a facilitator between the laboring women and her physician by ensuring that mom and dad get the information they need in a way that they understand so they can make informed decisions. 

Evidence suggests that support from doulas is linked to lower c-section rates and fewer complications. Medicaid finances more than half of all births each year in 25 states, indicating that Medicaid reimbursement policy can be a particularly effective lever to improve maternal health outcomes. Two states have enacted legislation to provide reimbursement for care by doulas as a way to improve maternal health outcomes and address existing maternal mortality disparities.

Currently, Minnesota and Oregon take advantage of the fact that doulas can reduce healthcare costs while improving outcomes in their state Medicaid programs. In the 2018 budget, Minnesota increased the reimbursement rates for doulas.  The new law also requires Oregon’s coordinated care organizations (which deliver Medicaid services) to provide information about how to access doula services online and through any printed explanations of benefits. The law tasked Oregon Medicaid with facilitating direct payments to doulas, which was addressed through rulemaking.  

New Jersey recently enacted legislation to improve maternal health among disproportionately affected groups of women by permitting the state to seek a state plan amendment or waiver that establishes Medicaid reimbursement for doula services. The legislation follows a recently piloted state doula program aimed at reducing health disparities in communities with high infant mortality rates.

Indiana also enacted legislation ensuring that pregnancy services covered by Medicaid also include reimbursement for doulas. The law incorporates doula services into the state’s obstetrician navigator program through the department of health, as well as the family and social services administration, allowing Medicaid reimbursement for services provided by doulas. Like in New Jersey, this legislation allows the state to apply for a state plan amendment or waiver necessary to implement doula reimbursement in Medicaid.

There’s growing momentum to conduct comprehensive reviews of maternal mortality data, which could help better understand the underlying causes of health disparities. Using a health equity lens to develop policy and design clinical interventions could also prove valuable by ensuring that services are culturally competent, affordable, and accessible by populations who need them most. 

Twenty-nine states (including Arizona) have committees that review maternal deaths and make public policy recommendations.  Arizona took a big step forward this last legislative session with the passage of SB 1040 Maternal Mortality Report which establishes a Maternal Fatalities and Morbidity Advisory Committee to explore public health policy interventions to improve maternal outcomes.

Perhaps the Advisory Committee, which meets on Friday August 30 from 9:30am to 12:30 pm at the Arizona State Laboratory, will explore the role that Doulas can play in improving birth outcomes and make some evidence based recommendations to better use their services in Arizona’s care network (our Board President Mary Ellen Cunningham will be representing AzPHA on the committee).

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

Addressing Postpartum Depression with Public Health Policy

As Arizona embarks on an in-depth look at maternal mortality in the coming months no doubt that postpartum depression will be part of the discussion.  

Moms with postpartum depression can have feelings of sadness, anxiety, and exhaustion that may make it difficult to care for themselves and their kids.  Data from the CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS) show that one in nine U.S. women experience symptoms of postpartum depression.

While there’s not a single cause of postpartum depression—it likely results from a combination of physical and emotional factors—women are at greater risk for developing postpartum depression if they have one or more of the following risk factors:

  • Symptoms of depression during or after a pregnancy.

  • Previous experience with depression or bipolar disorder.

  • A family member who has been diagnosed with depression or other mental illness.

  • A stressful life event during pregnancy or shortly after giving birth.

  • Medical complications during childbirth.

  • Mixed feelings about pregnancy.

  • Lack of strong emotional support from a partner, family, or friends.

  • Alcohol or other drug use problems.

Legislative approaches to address maternal mental health conditions and postpartum depression include increasing awareness of risk factors for and effects of postpartum depression, increasing access to prenatal and postpartum screening for these risk factors, and increasing access to treatment and support services for women at high risk for postpartum depression.

Below is an overview of state legislative activity in 2019 to address the screening and treatment for maternal mental health conditions and postpartum depression.

Texas passed 2 bills addressing postpartum depression. One (HB 253) requires their health and human services commission to develop and implement a five-year strategic plan to improve access to postpartum depression screening, referral, treatment, and support services.  The other bill (SB 750) instructs the commission to develop and implement a postpartum depression treatment network for women enrolled in the state’s medical assistance program.

In Oklahoma, SB 419, directs the state licensing boards to work with hospitals and healthcare professionals to develop policies and materials addressing education about and assessment of perinatal mental health disorders in pregnant and postpartum women.

Illinois passed HB 2438 which requires that mental health conditions occurring during pregnancy or postpartum be covered by insurers.  HB 3511 (the Illinois Maternal Mental Health Conditions, Education, Early Diagnosis, and Treatment Act) requires their department of human services to develop educational materials for health care professionals and patients about maternal mental health conditions and requiring birthing hospitals to supplement the materials with relevant resources to the region or community in which they are located.

Virginia passed HB 2613, which adds information about perinatal anxiety to the types of information licensed providers providing maternity care must provide to each patient (including postpartum blues and perinatal depression).

Arizona will be exploring strategies to improve maternal health outcomes as part of the implementation of SB 1040 Maternal Mortality Report – which established a Maternal Fatalities and Morbidity Advisory Committee to explore public health policy interventions to improve maternal outcomes.

Perhaps the Advisory Committee, which meets on Friday August 30 from 9:30am to 12:30 pm at the Arizona State Laboratory, will explore the role public policy can play in reducing the public health impact of post-partum depression. Our Board President Mary Ellen Cunningham will be representing AzPHA on the committee.

Will Humble Oral Health, Wills Blog

AHCCCS Accepting Public Comments on their Oral Health Policy Manual

These Polices are Important in Reducing Health Disparities

AHCCCS is in the process of accepting comments on their oral health policy manual for their EPSDT program- so this is your opportunity to do some administrative advocacy and provide them with your insight and comments.

Here’s a link to the Manual and comment page: AMPM 431 – Oral Health Care for Early and Periodic Screening, Diagnosis and Treatment Aged Members

A Stakeholder group organized by First Things First staff (and AzPHA members) Kavita Bernstein and Vince Torres met last week and developed some priority recommendations that would improve children’s oral health.  Those recommendations are listed below.

You can use This Link to get to their comment page. Below are some of the recommendations for you to consider submitting.  Please use your own voice and incorporate your own perspective.  Personalized comments have more impact than block-copy-paste ones.

The sample comments below state the page number in the Manual that the comment goes with. Please ensure to include the Policy Page Number relating to each comment.

Remember that our collective voice is stronger than one…  so please take some time to submit your comments in the next couple of weeks.  The comment period ends right after Labor Day.

Page 2

Recommendation for AHCCCS to expand provider types who can provide oral health screenings within pediatric settings to include RN, RDH and APDH. This would allow for co-location models, as well as, more flexibility for pediatric clinics in service delivery.

Page 3

Recommendation for AHCCCS to consider the use of the definitions for ‘urgent’ and ‘routine’ from the Association of State and Territorial Dental Directors (ASTDD). This would allow for a consistent approach to screening and referral across health plans and providers.

Recommendation that AHCCCS consider a tighter timeline for urgent referrals given that three business days could span over a weekend and may be too long for a child exhibiting signs of pain, infection and swelling.

Recommendation for AHCCCS to expand provider types that can apply fluoride varnish within a pediatric setting, to include MAs.

Page 4

Recommendation for AHCCCS to consider allowing reimbursement for nutrition counseling by a dental home to align with the requirement to provide this specific service.

Page 5

Recommendation for AHCCCS to consider stronger, clarifying language that defines ‘medical necessity’.

Recommendation for AHCCCS to consider language that permits and reimburses for sealants on primary teeth as evidenced by positive outcomes seen by IHS and would be in alignment with the AAPD Dental Sealant Policy and Recommendation.

Recommendation for clarity on the definition of a dental provider – in addition, there is no definition in AMPM 100 to which health plans and providers can align.

Page 7

Recommendation for AHCCCS to consider the impact of a two tiered consent process on dental mobile clinics

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Recommendation for AHCCCS to clarify who ‘all providers’ are in new bullet point #7. In addition, recommendation for AHCCCS to assess the feasibility of pediatric clinics (and families) scheduling a child to come into the clinic solely for a dental screening. Recommendation for AHCCCS to consider language that indicates that providers should schedule the dental screening within the next EPSDT visit (if at a primary care clinic) or at the next dental visit (if at a dental home)

Will Humble Health Insurance, Immigration Policy, Social Determinants, Wills Blog

Homeland Security Establishes Final “Public Charge” Rules

Here’s my Best Shot at Explaining What the New Rules Will Do

I’m sure you’ve the flurry of reports about the Department of Homeland Security (DHS) “public charge” final rule. There will be lawsuit(s) challenging the new rules, but for now the new regulations are scheduled to kick in October 15, 2019.

The bottom line is that the new regulations will 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.

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.

When the new Rules take effect on October 15 they’ll also consider whether applicants receive Medicaid (AHCCCS), the Supplemental Nutrition Assistance Program (food stamps), or Section 8 Housing assistance. 

The definition of a “public charge” in the final Rule is: “an individual who receives one or more designated public benefits for more than 12 months in the aggregate within any 36-month period”.

The draft rules released last year had included criteria that would have applied these standards to kids and adults. 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”).

Here are some things to remember about this new Rule

  • This is an issue of legal immigration- unauthorized migrants are largely ineligible for public assistance;

  • This doesn’t directly impact current legal permanent residents (current green card holders). The public charge test won’t be applied to legal current residents (green card holders) applying for citizenship;

  • The new rule isn’t retroactive – meaning public benefits received before 10/15/19 won’t be counted as a public charge; and

  • The new rules don’t apply to refugees. Existing statute prevents DHS from using these criteria for refugees.

Even though the final Rule excludes benefits received by children, this policy will still have a significant impact on children’s health as well as the health of their families and our communities.

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.

The US government has made their decision – and the new policy will be implemented unless overturned by the courts. There’s nothing short suing that will undo this decision for now.

What we can do is to get the word out to families in this category that signing up their kids for safety net benefits to which they’re entitled won’t count against them when they apply for legal permanent status- nor will it count against their kids if they eventually apply for a green card. We can minimize the public health impact of this decision if the public health system is effective in ensuring that families know this important information! 

Will Humble Prevention, Social Determinants, Wills Blog

Immigration Status, Public Benefits & Access to Care

Medicaid generally limits eligibility (for immigrants) to qualified legal immigrants with refugee status, veterans, and people lawfully present in the US for 5 years or more. State Medicaid programs can elect to provide coverage to legally present immigrants before the 5-year waiting period ends (Arizona does not).

States get matching funds from CMS when they choose to provide Medicaid coverage to legally present immigrants who are children or pregnant before the end of the 5-year waiting period.  33 states have elected to cover lawfully residing immigrant children and 25 states cover legally present pregnant women (Arizona does not).

The Affordable Care Act made it possible for the legally present immigrants who are ineligible for Medicaid (due to being in the five-year waiting period) to qualify for commercial coverage and subsidies on the Federal health insurance marketplace.

Immigrants eligible for Medicaid or employer-sponsored insurance face several coverage and service barriers.  As I mentioned above, immigration officials consider the likelihood of individuals and families becoming a “public charge,” which can result in denied admission to the US or status as a lawful permanent resident. 

The criteria that will be considered beginning 10/15/19 will include whether applicants receive Medicaid (AHCCCS), the Medicare Part D Low Income Subsidy, the Supplemental Nutrition Assistance Program (food stamps), and Section 8 Housing program. The existing Rule only considered participation in Temporary Assistance for Needy Families.

Fear that using safety net services will mean that they’ll be considered a public charge contributes to some families of mixed immigration status avoiding use of services like TANF, Medicaid, SNAP etc.  Some eligible immigrants avoid services because they think family members will become involved in immigration enforcement actions.

Research findings by the Kaiser Family Foundation found that changes in healthcare use and decreased participation in Medicaid and the Children’s Health Insurance Program because of this immigration policy.

Anyway, it’s a complicated system but I hope this makes it a little clearer.

Will Humble Immigration Policy, Social Determinants, Wills Blog

History of Considering Public Benefits

The term “public charge” as it relates to admitting immigrants has a long history in immigration law, appearing at least as far back as the Immigration Act of 1882.  In the 1800s and early 1900s “public charge: was the most common ground for refusing admission at U.S. 

Those immigration laws have evolved over the history of the country, with the most recent overhaul being the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (often referred to as PRWORA or welfare reform).  That’s the law that created Medicaid’s “qualified immigrant” standard.

In 1999, the Immigration and Naturalization Service (DHS didn’t exist yet) issued Rules to “address the public’s concerns about immigrant fears of accepting public benefits for which they remained eligible, specifically medical care, children’s immunizations, basic nutrition and treatment of medical conditions that may jeopardize public health.”

Here’s that final Rule from 1999, which didn’t include Medicaid our housing benefits in the public charge definition. The new DHS Rules will consider whether adult applicants receive Medicaid (AHCCCS), the Medicare Part D Low Income Subsidy, the Supplemental Nutrition Assistance Program (food stamps), or Section 8 Housing assistance.  

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”).

Will Humble Return on Investment, Tobacco, Wills Blog

FDA Finally Proposes Updated Cigarette Warning Labels

In 2009 the Congress directed the FDA to create more graphic warning labels and mandate them on packs of cigarettes. In 2012, the FDA proposed 9 new more graphic labels. The tobacco industry sued the FDA arguing that the proposed new warning labels violated their 1st Amendment rights to free speech. Astonishingly, a 3 judge panel agreed because the propoised labels were crafted to evoke a strong emotional response rather than to educate consumers.

So it was back to the drawing board. Over the next few years the FDA didn’t propose new labels, so some health groups sued the FDA in 2016 because they still hadn’t complied with the 2009 law (now 10 years old). The health groups won, and the court ordered the FDA to come out with new draft warning labels by August with final ones in March of 2020.

You can read more about the new labels and look at them on the FDA website. Perhaps the new labels will be finally on packs of cigarettes next spring- more than 10 years after the law was passed and signed.

Will Humble Family Planning, Social Determinants, Wills Blog

National Family Planning Program in for a Major Shake-Up

Title X is a super important public health program that provides folks with comprehensive family planning and related preventive health services. It’s designed to prioritize the needs of low-income families or uninsured people. The overall purpose is to promote positive birth outcomes and healthy families by allowing individuals to decide the number and spacing of children.

The services provided by Title X grantees (the funding comes from the federal government) include family planning and contraception, education and counseling, breast and pelvic exams, breast and cervical cancer screening, screenings and treatment for sexually transmitted infections and HIV.  It also focuses on counseling, referrals to other health care resources, pregnancy diagnosis, and pregnancy counseling. Title X funding does not pay for abortions.

Back in March of this year, the US Department of Health & Human Services published in the Federal Register a final rule making changes to the federal regulations governing the Title X national family planning program. The final rules dramatically change the existing Title X family planning program nationally and in AZ.  The changes include:

  • Eliminating Title X’s long-standing legal and ethical requirement for non-directive pregnancy options counseling; and

  • Requiring a “bright line” of physical and financial separation between the provision of family planning and abortion services.

Numerous provider groups, state attorneys general and non-profit organizations sought an injunction after the new Rules were announced (seeking an injunction to stop the rule from taking effect while the courts decide the legality of the rule). 

Legal History of the Case

Multiple federal district court judges blocked the new restrictive rules from going into effect. On June 20, 2019, a three-judge panel of the 9th Circuit Court of Appeals granted the Administration’s request to lift the preliminary injunctions, allowing the new Title X rules to be enforced. In early July, the 9th Circuit court ordered the cases be reheard en banc (meaning by all the judges on the 9th circuit versus a three-judge panel).

On July 11, the en banc court refused to block the new Title X rules from taking effect.

So, what’s the bottom line then?  For now- the new April Title X Rules that eliminate Title X’s long-standing model of offering non-directive pregnancy options counseling, and requiring a “bright line” of physical and financial separation between the provision of family planning and abortion services stand. 

Title X grantees including the Arizona Family Health partnership received notice from HHS that they must certify that they comply with the new regulations by September 18.  The plans for how they intend to comply were due Friday August 18.

What remains to be seen is what happens to the family planning network after September 18.  If Planned Parenthood decides to no longer provide Title X because of the new Rules, there would be a big gap in the network and folks that usually get their family planning services via Title X would need to find other places to go for these services. Since other providers are likely booked up- that means there cojld be some pretty significant delays in getting appointments for family planning services.

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