Arizona Abortion Statistics & Clinic Regulations

Back in 2010 the state legislature passed a bill (SB1304) that required clinicians that provide abortion services to report certain data points to the ADHS and talked the agency with writing an annual report. Ever since, the agency has been developing annual reports. Here is the 2020 Arizona Abortion Report, the last report for which data are available.

The report contains more than 15 tables with various statistical and demographic characteristics of abortions performed in Arizona. For example, about 95% of abortions are performed at less than 15 weeks gestation, and important statistic considering that if the territorial law is dismissed by the courts, abortions will be limited to those less than 15 weeks because of the signing of SB1164.

Other meaningful charts in the report document the marital status of the women seeking the abortion as well as the self-disclosed reasons for seeking the abortion. About 4% of abortions were to protect the health of the mother, and Table 7 documents the various maternal characteristics for that category.

Arizona’s 2020 abortion report found that 1,218 of the 13,186 abortions provided in 2020 were among teens (9.3% of the total).  By contrast, 1,512 of the 11,438 abortions provided in 2010 were among teens (13.2%).

The Arizona Department of Health Services regulates the 9 clinics that provide abortion services. They – of course – haven’t said anything about what they intend to do with the clinics. Will they send them threatening letters telling them to immediately cease providing abortion services? Will they say nothing? Perhaps Mr. Herrington will disclose more about their intentions this week, but I doubt it.

An Evidence Review: Does Withholding Abortion Services Harm Public Health?

In A Word, Yes

Now that the U.S. Supreme Court has stricken the longstanding constitutional right to abortion services, abortions will be severely restricted or no longer available at all in about ½ of the states in the U.S. Whether abortion remains legal in Arizona will be determined by the Arizona Supreme Court’s interpretation of conflicting abortion laws on the books in Arizona. See: U.S. Supreme Court Scraps Roe: Sends Abortion Rights Decisions to the States

From now on, decisions about whether women have the right to abortion services will be made at the state level.

Lawmakers who are in favor of restricting abortion rights are unlikely to be persuaded that their decision harms public health outcomes. Nevertheless… it’s important that we, as public health professionals, present the evidence base regarding the public health consequences of eliminating abortion services.

The most comprehensive analysis done to date is the ‘The Turnaway Study’ which is a longitudinal study examining the effects of unwanted pregnancy on women’s lives.

The Turnaway Study: Ten Years, a Thousand Women, and the Consequences of Having or Being Denied an Abortion

The major aim of the study is to describe the mental health, physical health, and socioeconomic consequences of receiving an abortion compared to carrying an unwanted pregnancy to term. Among the study’s top-level findings is that receiving an abortion does not harm the health and wellbeing of women, however, being denied an abortion results in worse financial, health and family outcomes.

The Turnaway Study found serious consequences are more likely to occur when women are denied a wanted abortion including a 400% increased risk of living below the Federal Poverty Level, which causes a cascade of bad health outcomes and intergenerational poverty.

Beyond a 400% increase in the risk of living in poverty, the Study found that women denied an abortion also are:

  • More likely to experience serious complications from the end of pregnancy including eclampsia and death;
  • More likely to stay tethered to abusive partners;
  • More likely to suffer anxiety and loss of self-esteem (in the short term) after being denied abortion;
  • Less likely to have aspirational life plans for the coming year; and
  • More likely to experience poor physical health for years after the pregnancy, including chronic pain and gestational hypertension.

The study also finds that being denied abortion has serious implications for the children born of unwanted pregnancy, as well as for the existing children in the family.

The study also found that many of the common claims about the detrimental effects on women’s health of having an abortion are not supported by evidence. For example, women who have an abortion are not more likely than those denied the procedure to have depression, anxiety, or suicidal ideation. Their findings suggest that 95% of women report that having the abortion was the right decision for them over five years after the procedure.

Here are some resources that make the results of the Turnaway Study more digestible:

Issue briefs on the mental health and socioeconomic consequences of having an abortion versus carrying an unwanted pregnancy to term are also available.

More than fifty scientific papers in peer-reviewed journals have used the findings of the Turnaway Study. Here’s a bibliography that provides a complete list of publications. Research categories include:

  • Socioeconomic consequences of abortion and abortion denial
  • Effect of abortion and abortion denial on romantic relationship
  • Consequences of abortion for women’s life plans and education
  • Effect of abortion and abortion denial on mental health and wellbeing
  • Physical Health after Abortion and Abortion Denial
  • Consequences of abortion and abortion denial for alcohol, tobacco and drug use
  • Effect of abortion and abortion denial on women’s existing and future children
  • Why women in the U.S. seek abortions
  • Who seeks later abortion and who is denied because they are beyond gestational limits?
  • Women’s experiences with paying for abortion, counseling, ultrasound viewing and protesters
  • Emotions and Decision Rightness
  • Consideration of adoption among women seeking abortion
  • Effect of abortion on attitudes toward abortion rights and morality
  • Contraceptive use and subsequent pregnancies
  • Pregnancy intentions

For a deep dive into the Turnaway Study including the study’s design, methods, analysis, results, and conclusions visit The Turnaway Study | ANSIRH (Advancing New Standards in Reproductive Health).

I’m not naïve to the fact that most politicians who support ending abortion services are unlikely to be persuaded that their position does harm. Nevertheless… it’s important that we, as public health professionals, present the evidence base regarding what happens when abortion services are withheld to inform politicians about the evidence base. We will continue to engage in the evidence debate, even as our state health department refuses to do so.

U.S. Supreme Court Scraps Roe: Sends Abortion Rights Decisions to the States

It’s Unclear Whether Abortion Will Remain Legal in AZ Up to 15 Weeks or Whether It Will Be Forbidden In All Cases Except When the Life of the Woman Is At Risk

Now that the U.S. Supreme Court has removed constitutional protections for abortion rights and sent the decision about whether abortion is legal to the states the question becomes…  what’s going to happen in Arizona?

The answer to that question hinges on whether the newly signed SB1164 (restricting abortions to the first 15 weeks gestation) is the law of the land, or whether a territorial-era law [ARS 13-3603] takes precedence. Here’s the old law still on the books from the territorial days:

13-3603. Definition; punishment

A person who provides, supplies or administers to a pregnant woman, or procures such woman to take any medicine, drugs or substance, or uses or employs any instrument or other means whatever, with intent thereby to procure the miscarriage of such woman, unless it is necessary to save her life, shall be punished by imprisonment in the state prison for not less than two years nor more than five years.

If the Arizona Supreme Court determines that the new statute that Ducey just signed (limiting abortions after 15 weeks but not outlawing them before 15 weeks) (SB1164) has precedence [Chaptered Version] over the territorial law then abortion services will still be available in Arizona (at less than 15 weeks gestation). Because about 95% of abortions in Arizona occur at less than 15 weeks gestation, there will be little change for the majority of women seeking an abortion.

The thing is that SB1164 also says:

This act does not: Repeal, by implication or otherwise, section 13-3603, Arizona 20 Revised Statutes, or any other applicable state law regulating or restricting abortion.

While I’m not a lawyer, it looks to me like SB1164 makes it clear that the territorial era law would take precedence making all abortions illegal unless it is necessary to save the woman’s life (punishable by 2 to 5 years in ADOC).

Here is today’s U.S. Supreme Court Decision

19-1392 Dobbs v. Jackson Women’s Health Organization

DOBBS, STATE HEALTH OFFICER OF THE MISSISSIPPI DEPARTMENT OF HEALTH, ET AL. v. JACKSON WOMEN’S HEALTH ORGANIZATION ET AL.

CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE FIFTH CIRCUIT No. 19–1392.

Argued December 1, 2021—Decided June 24, 2022 Mississippi’s Gestational Age Act provides that “[e]xcept in a medical emergency or in the case of a severe fetal abnormality, a person shall not intentionally or knowingly perform . . . or induce an abortion of an unborn human being if the probable gestational age of the unborn human being has been determined to be greater than fifteen (15) weeks.” Miss. Code Ann. §41–41–191.

Respondents—Jackson Women’s Health Organization, an abortion clinic, and one of its doctors—challenged the Act in Federal District Court, alleging that it violated this Court’s precedents establishing a constitutional right to abortion, in particular Roe v. Wade, 410 U. S. 113, and Planned Parenthood of Southeastern Pa. v. Casey, 505 U. S. 833.

The District Court granted summary judgment in favor of respondents and permanently enjoined enforcement of the Act, reasoning that Mississippi’s 15-week restriction on abortion violates this Court’s cases forbidding States to ban abortion pre-viability. The Fifth Circuit affirmed.

Before this Court, petitioners defend the Act on the grounds that Roe and Casey were wrongly decided and that the Act is constitutional because it satisfies rational-basis review.

Held: The Constitution does not confer a right to abortion; Roe and Casey are overruled; and the authority to regulate abortion is returned to the people and their elected representatives. Pp. 8–79.

Legislature Passes a Bipartisan Budget for 1st Time in 14 Years: Here’s A Summary Top Line Health & Human Service Line Items

As you know, the state legislature passed a bipartisan budget early this morning. There are dozens of various bills to go through to get a comprehensive view of this legislative session – but I thought I’d go through and give a quick budget summary before my more comprehensive session review this weekend… so here’s a teaser blog post:

Maternal Health

Postpartum physical and behavioral health care for pregnant women will be expanded to 12 months after the child is born (up to 150% of the federal poverty level).

The Medicaid pregnancy provider rate will increase by 88% for certain pregnancy care provider codes (procedure codes 59400, 59510, 59160, and 59618).

Access to Care

KidsCare members will be able to remain eligible for 12 months ($3M).

There will be a new AHCCCS chiropractic care benefit (when ordered by a primary care physician or primary care practitioner). Up to 20 visits/year.

Behavioral health providers will be added to the ADHS’ student loan repayment program (for those that agree to work in public or non-profit BH hospitals, BH residential facilities, and secure BH facilities including the Arizona State Hospital.

There will be $105M invested in various programs to enhance the nursing workforce, including:

  • Nurse education programs for universities and community college districts to supplement their existing nurse education programs;
  • Money for institutions that provide clinical training to nurses;
  • Transition to practice program – this is intended to provide access to a “nurse residency” program for new graduate nurses for hospitals and facilities that do not already have such a program;
  • Behavioral health technician training programs; and
  • ‘Accelerated’ nursing programs ($6 million to Creighton, $44 million to other universities)
Behavioral Health

A new general fund appropriation was established ($25M) developing secure BH residential facilities. The goal is to develop 3 facilities in central AZ, and 1 each in northern and southern AZ. Priority populations are persons with SMI diagnoses who are chronically resistant to treatment and have been court ordered to a secure facility.

The Arizona State Hospital can give out up to $700,000 in hiring bonuses this fiscal year. ASH will also enjoy an additional $7M appropriation for upgraded video and audio capabilities.

Human Services & Housing

ADES’ Adult Protective Services will receive an increase in funding so hire an additional 95 staff ($11M). Note: This has been badly needed for many years.

Development Disabilities providers will receive a 9.7% rate increase. The reimbursement rate for Elderly and Physically Disabled providers will increase by 11% (for both home and community-based services and skilled nursing facilities). Note: This appears to be over and above the more than $1B AHCCCS Home & Community Based Services Action Plan funded with American Rescue Plan Act money.

There is an increase in the Independent Living Stipend for youth aging out of foster care to “not less than $1200”. There is an increase in the kinship stipend to $300 per month per child.

‘Food Banking’ will get an additional $500M. No real detail on the guardrails for those funds yet.

Housing

The Housing Trust Fund (administered by the Arizona Department of Housing) will receive an additional $60M next fiscal year.

Another $15M is earmarked for ‘homelessness’ but with few details about how that can be used (at least there will be a new administration for half of the fiscal year).

Alternatives to Law Enforcement Responses to Mental Health & Substance Abuse Improves Outcomes & Reduces Crime

Police officers often serve as first responders to mental health and substance abuse crises even though they’re often poorly trained or professionally and emotionally unequipped to manage such incidents. The inefficient response by law enforcement staff has high costs and often results in poor outcomes.

Alternatives to Law Enforcement Responses to Mental Health & Substance Abuse Improves Outcomes & Reduces Crime

The evidence base is building showing that alternative “community responses” to 911 calls involving mental health or substance abuse reduces costs, improves outcomes and reduces overall crime.

For example, this new study entitled A community response approach to mental health and substance abuse crises reduced crime documents how a pilot in Denver that directed targeted 911 calls to health care responders instead of the police.

The authors found robust evidence that the program reduced crimes like trespassing, public disorder, and resisting arrest by 34%. The sharp reduction in targeted crimes reflects the fact that health-focused first responders are less likely to report individuals they serve as criminal offenders and the spillover benefits of the program (e.g., reducing crime during hours when the program was not in operation).

Another essay in Scientific American: Sending Health Care Workers instead of Cops Can Reduce Crime makes a compelling argument that non-police-centered strategies not only are better at reducing crime; they’re less expensive & don’t come with the negative lateral consequences associated with policing.

In part, that’s because law enforcement is poorly equipped to resolve mental health or substance abuse issues in the field and tend to default to transport to emergency departments and arrests, both of which are extremely expensive and not associated with good outcomes.

HBO has captured the San Antonio Police Department’s pioneering crisis intervention approach in an Emmy Award-winning documentary, and Vitalyst is pleased to be offering free virtual screenings.

Ernie, Joe, and Behavioral Health Crisis Best Practices

By region, the Zoom-based “Ernie & Joe Crisis Cops” events will span the month of June, starting with Maricopa County’s screening on June 3. The screenings are open to leaders and individuals from law enforcement, the fire service, emergency medical services, emergency dispatch, and behavioral health services. The abridged, 35-minute screening will be followed by a live panel Q&A.  

As communities reckon with the behavioral health impacts of the pandemic and more, the work modeled by Ernie and Joe in this documentary is more important than ever. All Arizonans are encouraged to view the full documentary via HBO, and our first responders are urged to click here to register today for their free regional screening events

Tempe Implementing an Innovative Approach

The City of Tempe recently funded a pilot project that uses this alternative approach by triaging calls in the dispatch area and sending more appropriate staff like social workers on certain calls. The project is being done in partnership with AzPHA member organization Solari Crisis & Human Services. Hopefully more city managers and councils will recognize this promising new model and begin reforming how they deal with 911 calls.

Tempe partners with Solari to divert some crisis calls from police

Maricopa County Department of Public Health Accepting Applications for Fellowship Program

The Maricopa County Department of Public Health has created a new Fellowship Program and is now accepting applications on the Maricopa County Government Jobs website.  This two-year program will connect recent graduates of advanced degrees with practical, hands-on learning experience. Fellows will:

  • Work with multiple layers of government to plan and execute initiatives combating substance misuse and abuse
  • Be placed in one of Maricopa County’s largest cities or at Maricopa County Correctional Health Services to support local efforts
  • Have support from other’s working on similar initiatives in other parts of the country
  • Gain exposure to city and county operations while supporting impactful, evidence-based plans and activities

Arizona State Legislature Increasingly Concerned About Abuse and Neglect of Nursing Home Residents Due to ADHS’ Neglect of Regulatory Duty During the Director Christ Era

A couple of weeks ago we wrote about the scathing Auditor General’s report about ADHS’ neglect of duty to follow up on nursing home complaints during the Director Christ era. Last week the legislature followed up on that report with a joint meeting of the House and Senate Health Committees.

The legislators heard first-hand from the Auditors about how terribly behind the department was in following up with nursing home complaint investigations from 2019 to 2021. They were very upset when they also learned that, instead of catching up and implementing recommendations from the Auditor, ADHS leadership simply reclassified the vast majority of high-risk complaints to low and medium to give the appearance that they were improving. Most formerly high-risk complaints were simply closed out with no investigation.

  • Between 7/1/19 and 4/21/21, under the leadership of former Director Christ and Assistant Director Colby Bower, ADHS lowered the priority level of 98% of their open high priority complaints, giving them months more time to investigate and giving the appearance they were making improvements (high risk complaints need to be done in 10 days vs months for the others).
  • ADHS leadership CLOSED 79% of those former high priority complaints without ever doing an investigation.
  • ADHS leadership CLOSED 82% of high priority facility self-reports after changing them to medium and then closing without an investigation.
  • In the second half of 2019 (before the 1st auditor general report) ADHS had classified 42% of nursing home complaints as high risk. After the report was published – the percentage of complaints classified as high risk dropped to only 4% (July – Dec. 2020).
  • ADHS did not post complaints on AZCARECHECK (the public disclosure site) unless there was an investigation…  but because they closed out the vast majority of complaints without an investigation, thousands of those complaints never made it to their website- further greatly limiting the ability of family members to make informed decisions.

The interim joint committee of reference is asking for quarterly reports from ADHS, told ADHS to be transparent about how they classify complaints, legislature will make sure CMS knows about the audit reports, the ADHS is supposed to fully cooperate with the auditors on follow ups. Sadly, there was no mention of urging state or county law enforcement or prosecutors to investigate the disturbing and potentially illegal findings in the Auditor General’s Report.

See our previous blog post: Auditor General’s Office Produces Scathing Review of ADHS’ Nursing Home Complaint Investigations During the Director Christ Era

Note: The unprofessional conduct documented by the Auditor General occurred while Director Christ was in charge of the agency and while Colby Bower was in charge of licensing. Both have left state government and now enjoy well-paid positions at Blue Cross Blue Shield of Arizona.

For a summary of what happened at the hearings and the damning findings of the auditor general’s report read these articles:

The entire 3+ hour hearing is posted here: Joint House Senate Nursing Home Complaint Hearing. To be honest, I’ve never seen a hearing quite like this in all of my 30+ years following state government.

This Thursday, the House Ad Hoc Committee on Abuse and Neglect of Vulnerable Adults will be meeting at 1:00 in HHR 1 to learn more about the disturbing findings.

Legislative Roundup

The state’s constitution gives one primary performance measure to the Arizona State Legislature: to develop a budget before the end of the fiscal year (June 30 at 11:59pm). This year that’s a week from Thursday.

I presume that there are negotiations happening behind the scenes – but nothing has leaked out since last Monday – when a draft budget that was supposedly negotiated by House and Senate (R) leadership & the governor’s office was circulated among legislators (see our previous blog post).

There were no budget hearings last week, and as of right now there’s nothing posted on www.azleg.gov to suggest there will be hearings this week.

The only real thing that happened last week at the legislature was a joint meeting of the House and Senate Health Committee to go over the Auditor General’s report about how ADHS (while Director Christ was in charge) fell terribly behind in nursing home complaint investigations from 2019 to 2021.

Instead of catching up and implementing recommendations from the Auditor, they simply reclassified the vast majority of high risk complaints to low and medium to give the appearance that they were improving. Many high risk complaints were simply closed out with no investigation. See our previous blog post: Auditor General’s Office Produces Scathing Review of ADHS’ Nursing Home Complaint Investigations During the Director Christ Era

Note: All the unprofessional conduct documented by the Auditor General occurred while Director Christ was in charge.

For a summary of what happened at the hearings and the damning findings of the auditor general’s report read these articles: 

The entire 3+ hour hearing is posted here: Joint House Senate Nursing Home Complaint Hearing. To be honest, I’ve never seen a hearing quite like this in all of my 30+ years following state government.

Should AZPHA Support the Upcoming Predatory Debt Collection Protection Act?

The Predatory Debt Collection Protection Act is a Voter Initiative effort that is currently collecting signatures with a goal of being on the ballot in Arizona this fall. The goal of the Initiative is to revise Arizona law to protect more assets from being sold to pay off debt collectors, ensuring Arizonans keep more of their bank accounts and wages and limiting interest rates that trap families in an unending cycle of debt.

Because the ability to earn a living wage and have access to sufficient resources to provide a sturdy family environment and ensure that families can make healthy choices, the Arizona Public Health Association Board of Directors is urging our members to vote to support the initiative.

Below is excerpted language from the Grand Canyon Institute’s Predatory Debt Collection Protection Initiative Policy Paper. We urge you to read the full policy paper and the voter initiative language before you vote whether to affirm the Board’s recommendation.

We Need Your Vote by 6/30/22 In Order to Submit Language to the Voter Guide

Go to AZPHA member poll page

Across Arizona, 30% of people with a credit file have debt in collections. This tracks closely with the national average of 29%. How these consumers experience the collections process can vary widely, due to minimal protections afforded by federal and state Unfair and Deceptive Acts and Practices laws. The absence of greater protections puts consumers at risk of predatory collection practices that can be financially devastating due to low thresholds for income and property protected against being seized by debt holders.

Medical debt stands out in the discussion of consumer debt. It is estimated to be the largest source of bankruptcies in the United States and exceeds $140 billion. Medical debt generally arises out of necessity, due to a medical emergency or persistent healthcare needs. Sixteen percent (16%) of Arizonans with a credit file have medical debt in collections, with a median amount of about $1,000 according to the Urban Institute based on an analysis of consumer credit files.

However, this understates medical debt, since it is not reported to credit agencies until it is 180 days past due and it is not always immediately moved into collections and debt moved to a collection agency is not always reported to credit agencies. Further, some medical debt is also disguised as credit card debt.

Further exacerbating the precarious situation that some debt holders find themselves in, an analysis of the civil court system finds that debtors almost never have legal representation, while creditors do, creating a legal imbalance. This is a growing concern given findings by the Pew Charitable Trust in 2020 of an alarming increase in the use of courts to collect on debts by businesses since the early 1990s. According to one study from 1993 to 2013, the share of civil claims for debt in state courts more than doubled from less than 12% to 24% of claims.

The protections in the Predatory Debt Collection Protection Act will provide greater protections for the issues raised above, bringing Arizona much more in line with the recommendations provided by the National Consumer Law Center to enable those in debt to pay off what they owe without placing them in a position where their ability to meet their daily living needs are not impacted by the loss of housing, transportation, or other resources. The Act also provides low asset Arizonans by limiting the ability of landlords to withhold security deposits and folk’s paycheck to paycheck by limiting the amount of wage income that can be garnished. The formula is calibrated to protect wages, so the person doesn’t get pushed below the federal poverty level.

The Predatory Debt Collection Protection Act initiative along three themes:

  1. The Initiative’s Impact on Arizona Law and Comparisons to Other States
  2. The Initiative’s Impact on Medical Debt
  3. The Initiative’s Impact on Debt Collection through the Courts

Because defendants owe money normally, their primary protection is the strength of the law that protects their earnings and assets. The Predatory Debt Collection Protection Act will significantly limit the occurrences of wage garnishment and when it occurs the amount will be less. The Predatory Debt Collection Protection Act will act as a de facto lawyer to help limit access to wage garnishments or direct removals from bank accounts.

Summary of Enacted & Pending Bills Limiting Public Health Authority

Arizona isn’t the only state in the U.S. where state legislatures and governors are hostile to public health. Many states have enacted harmful new laws damaging public health authority, just like Mr. Ducey.

AZPHA PowerPoint: Laws Signed by Ducey So Far this Year Preempting Public Health Authority

In their regular 2021 legislative session, many states introduced or passed laws that restricted the ability of state and local public health officials, governors, and others to respond to the immediate threat of COVID-19, as well as future public health threats.

A second wave of similar legislation began in regular and special sessions in the fall of 2021 and has continued into the 2022 regular session. The table below details COVID-19-related laws and pending legislation, and broader enacted and proposed limitations on public health authority in all 50 states (and the District of Columbia) from January, 2021 through mid-May, 2022 for enacted laws and from September, 2021 through mid-May, 2022 for pending legislation.

This Report from the Network for Public Health Law identifies enacted laws and current state bills and identifies how they would limit public health powers (if enacted) to respond to natural disasters, disease outbreaks, and other health threats. These limitations are categorized within specific columns as follows:

1. Emergency Orders (providing authority to address a public health emergency);

2. Shifts in Authority (between levels of government and away from public health agencies and the executive branch); and measures related to public health interventions including:

3. Vaccines;

4.Testing;

5. Masks; and

6. Places (including, but not limited to business, schools, places of worship).

See the Full Report: Enacted & Pending Bills Limiting Public Health Authority

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