Will Humble Medicaid, Public Health Law, State Legislature, Wills Blog

CMS Puts Medicaid Block Grants on the Table

A couple of days ago CMS released guidance encouraging states to ask for Medicaid waivers that would block grant the services “able bodied adults”.  The block grant would come with increased flexibility about how to spend those federal dollars and what services to provide- but would cap federal funding for that portion of the program. They’re branding the initiative the Medicaid Healthy Adult Initiative.

Here’s the letter that CMS sent to the State Medicaid Directors and their ”Fact Sheet”.

It’s an optional program, so governors will have a choice whether to take the bait or not. I haven’t seen any media responses from our governor about whether he’s interested in such a new block grant waiver. The Oklahoma governor already directed his state health department to begin the waiver application work.

Also, as is standard operating procedure these days it seems, it’s likely that a state or group of states will sue CMS in federal court challenging their authority to approve such waivers – likely arguing that CMS doesn’t possess the authority to do this under the existing law.

Will Humble Medicaid, Public Health Law, State Legislature, Wills Blog

CMS’ New Medicaid Fiscal Accountability Rule Expected this Spring

The new regulation could blow a $2B hole in the AHCCCS Budget & undo Medicaid expansion

CMS is proposing a set of new wide-ranging regulations that would change the way states can pay for their share of Medicaid costs including supplemental payments. The proposed “Medicaid Fiscal Accountability Rule” will have profound implications for the ways in which States finance Medicaid programs and pay for Medicaid services.  It basically changes the ways states can finance the state share of Medicaid costs (including provider taxes like our hospital assessment that pays for Medicaid expansion).

AHCCCS put together a Summary Document that details how the proposed new regulations could impact Arizona’s Medicaid program. Their comment letter is 4 pages long and outlines the challenges the new rule would pose in Arizona.

CMS says that they’re proposing the new rule to “address states’ increasing reliance on donations, taxes, or other financing strategies that CMS perceives mask or circumvent current Medicaid rules regarding how states are permitted to generate the state portion of the Medicaid match.”  

In my opinion, CMS (Seema Verma) wants to force states to finance their match with unpopular taxes so states can’t raise that match and instead cut eligibility and/or services.

One thing is certain with the proposed new Rules…  it’ll be a game changer in terms of how states are able to finance their portion of Medicaid programs (likely including our hospital provider assessment which pays for the state match for our Medicaid expansion). CMS even concedes that they don’t know how the new Rule will play out in states or how it will affect the real people that rely on Medicaid services.

The comment period ended yesterday (we turned in comments) and the final rule will be announced in the coming months.

Will Humble Immigration Policy, Social Determinants, Wills Blog

US Supreme Court Temporarily Allows Homeland Security to Enforce their New ‘Public Charge” Rule

Last week the US Supreme Court granted the president’s request to immediately begin enforcing the Department of Homeland Security’s new “public charge” rule which overhauls how DHS makes decisions about granting legal permanent resident applications. The final rules block legal immigrants from extending their temporary visas or gaining permanent residency if DHS decides the applicant is “likely to rely on designated public benefits in the future”.

The implementation of the new public charge” final rule now has the green light while it’s under judicial review in the lower courts. The SCOTUS issued this Order (which is different from a full on opinion). The Order stayed the temporary injunction issued by the district court.  If DHS gets the result they want in the lower courts, then the Plaintiffs (NY etc.) will appeal to the supreme court.  As is often the case these days, it was a 5-4 decision with the usual cast of characters on each side of the issue.

DHS will now begin considering whether applicants for legal permanent status have received Medicaid (AHCCCS), the Supplemental Nutrition Assistance Program (food stamps), or Section 8 Housing assistance in the past.  The definition of a “public charge” in the new 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”. 

Medicaid 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.

Fortunately, the new Rule doesn’t consider whether benefits were used by an applicant’s kids. So, lawfully present kids that are receiving benefits (e.g. Medicaid) won’t have that used against them if the child later applies for legal permanent residency (a “green card”).  The public charge rule will use a “totality of the circumstances” test for applicants, which means that DHS will use the statutory factors and now the new factors laid out in the final rule.

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 and a couple of smaller exempt groups.

However, this issue is still not resolved. A group of states are still challenging the new DHS regulations arguing that the new rules are inconsistent with the law passed by congress a couple of decades ago (on which the new rules rest).  The district court ruling from a few months ago agreed with the challengers that they were likely to win, and temporarily blocked DHS from implementing the new regulations.

Public health note: 

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.

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 fate of the new regulations are in the hands of the Judicial branch and to some extent in the hands of the voters this fall.

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 Disease Control, Prevention, Wills Blog

WHO Declares the new Coronavirus a Public Health Emergency of International Concern

Last Thursday the WHO declared the international Coronavirus outbreak a Health Emergency of International Concern.  WHO defines a public health emergency of international concern as “an extraordinary event” that constitutes a “public health risk to other States through the international spread of disease” and “require a coordinated international response.”  

The most important words there are the require an international response words.  Declaring the Coronavirus a public health emergency of international concern allows the WHO to better coordinate the international response and hold countries accountable if they don’t implement certain standards regarding things like travel, trade, quarantine or screening.  The declaration can also free up additional resources to implement interventions.

There’s still a chance that a combination of public health interventions can slow or stop the spread of this new virus – but the chances of that happening are decreasing in my opinion because of that fact that it has now spread to some countries with less mature public health systems.  Much will depend on whether persons are truly communicable before they have symptoms- a key indicator for how effective isolation interventions can be.  Other key information that’s still not complete includes how virulent (serious) and how communicable the virus is.

If it begins circulating in the US at some point, we will have advantages that China doesn’t have right now- a better understanding of the etiology of the disease and the most effective treatment options.   

However, it has to be said that the Chinese have advantages that the US public health system won’t have – in that they’re able to implement public health interventions that we could never do because of civil liberty constraints. 

Will Humble State Legislature, Wills Blog

Legislative Update

This Policy Update is already pretty long…  so I don’t think I’ll list all the bills we’re tracking again here- but here’s a link to last week’s update that has the core bills we’re tracking and our positions on them.

However there are a few new bills that have been proposed since last week’s update- so I’ve included those below:

SB1472  Maternal Health; Postpartum Visits – AzPHA Supports

This is a terrific bill from Senator Carter that would direct AHCCCS to require their contracted health plans to increase post-partum visits by new moms and increases the appropriation that would be required to pay for this important initiative.  There are a ton of important physical and behavioral health reasons to implement this important initiative.

1493 Dispensing Hormonal Contraceptives – AzPHA Supports

This is a bill we support from Sen. Ugenti Rita which would allow a pharmacist to dispense a self-administered hormonal contraceptive to a person 18 or over under a standing order. There are checks and balances in this statute to ensure that best practices are used. This is a net public health benefit as teen births are the number one cause of inter-generational poverty and the bad health outcomes that result.

HB2535 Preventive Dental Care (AHCCCS) –  AzPHA Supports

This bill from Representative Shah would boost the adult oral health coverage for Medicaid members to include two regular cleanings, fluoride 15 treatment, and one set of X-rays annually.  We are in support of this common-sense bill.

SB1397 Health Insurance; Preexisting conditions

This bill provides a partial backstop in case the US Supreme Court strikes down the Affordable Care Act. It would prohibit health insurers from offering health insurance plans that exclude people with preexisting conditions from coverage. It’s silent on whether people with preexisting conditions could be charged higher premiums (in other words – yes – they could)

This Week’s Member Action Item:

HB 2608  Overdose; Disease Prevention (syringe services) will be heard in the House Health and Human Services Committee at 9 am on Thursday January 30.  Please sign in to the azleg system and express your support for this important bill.  It will decriminalize syringe services programs in Arizona. 

It’s currently a felony to provide syringes to injection drug users via a syringe access program even though these programs are evidence-based programs that reduce the spread of Hepatitis C, HIV and other blood-borne pathogens and engage injection drug users in treatment.  We have supported bills like this for the last several years, but they have yet to be successful.

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