Will Humble Social Determinants, Wills Blog

Biden Administration Unravels the Trump Era ‘Public Charge’ Rule

The Biden administration finalized a new public charge rule last week which unravels the Trump-era policies that penalized low-income immigrants seeking health benefits & other services.

The new rule from the Department of Homeland Security rolls back the types of assistance immigration officers can consider when evaluating immigrants for a green card and deciding whether they’ll become a “public charge,” or dependent on government assistance.

The new updated regulations make it clear that Homeland Security can’t consider the use of health care, nutrition, or housing programs when making immigration decisions. The new rule clarifies that a child’s or other family member’s use of federal safety net programs won’t affect the applicant’s immigration application.

The now-repealed Trump administration rule said applicants could be deemed a public charge and denied residence or citizenship if they used noncash public benefits (housing vouchers, food assistance, or Medicaid).

Note: In 2021 President Biden issued an executive order directing the DHS to stop enforcing the 2019 “public charge” restrictions. Last week’s final rule makes that executive order moot.

Any future president that wants to change it back to the way it was during the Trump Administration would need to go through a lengthy rulemaking process (like the Biden administration just did).

See old blog post: Homeland Security Establishes Final “Public Charge” Rules – AZ Public Health Association August 19, 2019

Will Humble Medicaid, Wills Blog

Arizona Community Health Centers Can Challenge AHCCCS Reimbursements

Here’s the Court Ruling

A federal appeals court ordered a new hearing for Arizona community health care centers claiming the state’s Medicaid system is wrongly denying reimbursement for dental, optometric & podiatric care.

A three-judge panel of the 9th U.S. Circuit Court of Appeals on Friday reversed a lower court decision that dismissed the Arizona Alliance for Community Health Centers’ suit against AHCCCS.

The case was filed in 2019 by the FQHC’s successfully argued that they have “…an enforceable federal right to reimbursement including services of its dentists, podiatrists, optometrists and chiropractors (among others).”

The court ruled that AHCCCS improperly limited reimbursement for dental, podiatric and optometric services for adults (during the Betlach-era) all of which are mandated under Arizona’s Medicaid State Plan.

Finally, the appeals court said the lower court wrongly applied “Chevron deference” to the case, a legal principle that requires courts to generally defer to an administrative agency’s interpretation of the regulations it enforces.

Will Humble Disease Control, Vaccination, Wills Blog

Pima County COVID-19 Vaccination Incentives Significantly Reduced Healthcare Costs

Ducey Puts the Kibosh on the Intervention

Last summer Pima County made job offers contingent on being vaccinated against COVID-19. New hires and promotional employees were required to document their vaccination status on the date of hire.

They also implemented a health insurance premium surcharge of $45 per pay period ($1,183 annually) to employees who were unwilling to get vaccinated for COVID-19 (employees with a medical or religious exemption were not subject to the surcharge).

Evaluating the Intervention

Pima County examined healthcare claims from employees during the surcharge period. Health care costs among the 568 unvaccinated employees were compared to the costs among the 4,400 vaccinated employees between October 1, 2021 & July 31, 2022.

The results were profound, but not surprising. The analysis showed healthcare costs among vaccinated team members were 38% lower than among unvaccinated employees. The health care cost to Pima County for unvaccinated staff was $768 per employee/month compared to $475/month for vaccinated employees.

The difference was seen across 7 of 10 categories of health care services and was driven overwhelmingly by differences in in-patient costs and specialty physician services.

See the Pima County Analysis Complete w/ Charts & Graphs

Editorial Note: Evidence-based interventions like this are now a thing of the past. Governor Ducey signed House Bill 2498 on April 25, 2022, which prevents any local government from implementing this type of intervention. The law becomes effective in about 10 days (September 24, 2022) eliminating the ability of all government employers to use this tool to protect their employees or customers.

Will Humble AzPHA Breakfast & Learns, Professional Development, Wills Blog

AzPHA Breakfast & Learn Video: Firearm Violence & Suicide Prevention – Three Evidence-Based Interventions 

In recognition of Suicide Prevention Month, we invited three community groups to discuss interventions they are implementing to prevent gun violence & suicide in Arizona rates. In this hour-long video you’ll learn about these interventions from 3 perspectives:

  • The work of the Everytown Survivor Network to raise awareness through storytelling. A survivor (Carol) will share her story.
  • The work of Moms Demand Action to raise awareness about the prevalence of suicide and the distinct role of guns in making suicide attempts more deadly along with the policy recommendations that could reduce suicide rates.
  • The work of the Be SMART For Kids (besmartforkids.org) which raises awareness of the importance of safe storage in deterring unintentional shootings, suicide, and homicide, especially in children and teens. 

Our advocacy work is unique in that we address multiple roots of violence – including weak gun laws, easy access to firearms, lack of education on safe storage and firearm responsibility, and the intersection of gun violence and suicide.

View the Discussion

Our Speakers:

Carol Bates is a Massachusetts native who is a mother of 3 and grandmother of 2. She has been retired for almost 20 years from a diverse career including being a small business owner and a political consultant. Since retirement, she has been an active community volunteer and activist, volunteering at the Ronald McDonald House and with Moms Demand Action.

She has also been a board member on the Human Rights Project and the National Abortion Rights Action League. As a survivor of gun violence, she shares her son’s story in the hopes that no one else will ever have to endure the pain of losing a child.

_______

RJ Shannon, born and raised in Chicago, has lived in Phoenix, Arizona for 41 years as a mother, musician, health educator, community mobilizer, and social justice advocate. For 30 years, RJ has worked in the areas of community violence prevention; HIV in communities of color; health equity; racial justice; and women’s and LGBTQ2S rights.

She is an active member of AZPHA, serving on the Health Justice committee and previously as a board member when employed by the AZ Department of Health Services. As a member of Moms Demand Action for Gun Sense in

America, RJ proudly represents an organization dedicated to ending gun violence and looks forward to the potential collaborative efforts of AZPHA and Moms.

________

Candace Vodicka is a volunteer with Moms Demand Action for Gun Sense in America and the Phoenix Co-lead for the Be SMART program. She is a former elementary school teacher. As a mother of three young girls, Candace is committed to creating a safer future through outreach and education of gun violence prevention.

Will Humble American Indians, Public Health, Wills Blog

The Inflation Reduction Act & Tribal Communities

The Inflation Reduction Act of 2022 supplies $369 billion to address climate change and domestic energy production in a more sustainable way, sets targets to reduce carbon emissions by 40% percent by 2030, allows for Medicare to negotiate prescription drugs prices on a few drugs and provides $64 billion to extend the Affordable Care Act subsidy for three years (American Indians are eligible to sign up for benefits under the Affordable Care Act on an open enrollment basis). 

Specific provisions in the Act to directly help Tribal nations include:

  • $272.5 million to Native communities for climate resilience and adaptation, including ~ $25 million in targeted climate resilience funding to the Native Hawaiian community for the first time;
  • $12.5 million to mitigate drought impacts for Tribes;
  • $10 million for Tribal fish hatcheries;
  • $150 million for Tribal home electrification;
  • A tenfold increase (from $2 billion to $20 billion) in loan guarantees for Tribal energy development.

Tribal nations will celebrate this historic step in the right directly as the rest of the Country, and Congress begin to understand what AI/ANs have known since time immemorial ~ interdependence with the environment requires respect for the earth as our very existence depend on it. 

The $272 million for Tribal climate resilience over ten years is a substantial increase and will begin to address these climate change challenges. We urge the administration to quickly initiative Tribal consultation to ensure Tribal governments drive how these funds are received.  

Will Humble Public Health, Wills Blog

Barbara Olson, BSN (1935-2022): A Public Health Life Well Lived

Barbara Olson, BSN, a long-time Arizona Public Health Association (AzPHA) member, served as Board President in 1993 and helped with many conferences and public health nursing section activities over the years, passed away on Saturday, August 27, two short weeks before her 87th birthday.

Barbara gained her nursing degree in New York and worked as a public health nurse in New York, California and Arizona. She led an impressive, effectual and caring life, working as a public health nurse, raising two daughters and being an ever present and engaged Grandma to her grandchildren. Barbara believed individuals, families, communities and organizations all could benefit from what Public Health had to offer. During her career, Barbara’s contributions to Public Health, in particular Adolescent Health, were many. Her enthusiasm, energy and visions were endless.

She is the only AzPHA member to date to receive the Arizona Public Health Association’s Harold B Woodward Award twice, first in 1991 and again in 1994 (shared with Bonnie Barclay). This award is given to members for work done for the advancement or betterment of the Association.

In Arizona, she served as the adolescent health consultant with the Arizona Department of Health Services’ Office of Women’s and Children’s Health. Through this role Barbara’s accomplishments included: bringing professionals and organizations that promoted adolescent health together to form the Arizona Adolescent Health Coalition; bringing health education, awareness and resources directly to adolescents through the Adolescent Health Risk Appraisal Project; bringing to Arizona, “Demystifying Adolescence”, a comprehensive training that included Adolescent Physical, Cognitive, Emotional and Social Development and making it available to public health and adolescent educators in the state; and being a co-author on the “Consent & Confidentiality in Adolescent Health Care: A Guide for the Arizona Health Care Practitioner” sponsored by the Arizona Medical Association’s Committee on Maternal and Child Health Care.

Barbara also served as the reproductive health/family planning program manager and adolescent health program manager in the same office. She was also a member of the Society for Adolescent Medicine, American Public Health Association and served as the Chair of the Arizona Collaborative for Adolescent Health, which she spearheaded its formation after her retirement from the Arizona Department of Health Services.

Barbara’s advocacy for public health and adolescent health provided a foundation that many who followed her continued to build on to improve the health of Arizona adolescents and their families. She was a role model for many and a mentor to even more including local health department public health nurses, school nurses and those working with adolescents and at-risk communities throughout Arizona. She is remembered fondly and will be missed for her dedication to public health and her thoughtfulness for so many.

From her family, we are asked to celebrate Barbara’s life in our own way, perhaps raising a glass of our favorite drink in memory or thinking of her as you pass by or visit one of our local casino where she loved to visit for some ‘slot therapy’. Instead of flowers, Barbara’s wish to us is to do an unexpected and unsolicited act of kindness-a familiar Barbara dictum and one that endears her in our heart further.

Will Humble Community Health Workers, Prevention, Wills Blog

Community Health Worker Certification Rules Being Heard by the Governor’s Regulatory Review Council Wednesday

Community Health Workers are frontline public health workers who have a trusted relationship with the community and facilitate access to a variety of services and resources for community members. Building CHWs into the continuum of care has been proven to both improve health outcomes and reduce healthcare costs.

For a picture of how CHWs can fit into a continuum of care, take a look at this report from the NAU Center for Health Equity Research in collaboration with the UA Prevention Research Center (AzPRC) which provides insight into innovative strategies for integrating, sustaining and scaling of the CHW workforce within Medicaid (AHCCCS).

Building CHWs into the healthcare continuum requires that a certification process be in place. The public health community tried for many years to get such a process in place, finally meeting with success 4 years ago with the passage of HB 2324 (sponsored by Representative Carter), which charged the ADHS with implementing a program for the voluntary certification of Community Health Workers.

More than 4 years after the law passed giving the ADHS the responsibility to write rules to provide for the voluntary certification of Community Health Workers – the rulemaking is finally almost finished. The last step is this week’s hearing by the Governor’s Regulatory Review Council – Wednesday September 7 at 10am.

The virtual Council meeting (which is open to the public) will be held on September 7, 2022 at 10:00 a.m.

Google Meet – Join by phone: +1 317-624-2043 PIN: 172 007 846# 

Google Meet – Video Link: https://meet.google.com/ryp-jrrt-xos 

The Council allows time for public comments on each item on the agenda. To address the council, you’re supposed to complete a Request to Address the Council. Please note that this request form doesn’t become active until the start of the meeting.

Here’s the agenda for the meeting- the CHW Voluntary Certification is item number 4 (Title 9, Chapter 16, Article 8). Right now, it’s on the Consent Agenda- which is a good thing.

To view the Article and included Sections you can reference the most recent Notice of Proposed Rulemaking, filed on March 24, 2022.

The final rules on the Administrative Rules webpage.

Will Humble Disease Control, Early Childhood, Vaccination, Wills Blog

MMR Vaccination Rate Continues Its Insidious Decline During the Ducey Administration

Maricopa County Department of Public Health confirmed three related cases of measles. One case is an adult and the other two are kids. Whether these cases transition from an outbreak to an epidemic will depend on how many contacts the cases had with unvaccinated classmates.

MCDPH teams will also be checking the vaccination status of the classmates of the pediatric cases. Vaccination rates at the school attended by the index cases will be a key determinant of whether these initial cases cascade into an epidemic. The downward slide of vaccination rates makes it more likely that we’ll have additional cases coming from the index case school. But why?

As has been the case throughout the Ducey Administration, childhood vaccination rates have continued their insidious decline, with the statewide immunization rate for Kindergarteners now at 91%… well below the community immunity threshold for measles of 95%.

See: Governor: Education parental choice on value of vaccinations by Howard Fischer

State law requires the ADHS to collect data about the vaccination rates for Child Care/Preschool; Kindergarten; and 6th grade. Schools submit the data to the ADHS each fall. In the spring ADHS is required to publish the data by school. Rather than showing the actual vaccination rates, the system records the percentage of exemptions (personal, medical and religious) as a proxy for vaccination rates.

ADHS posted the data in April. There are some aggregate tables but also a big giant spreadsheet with the vaccination rate by school. A clever parent that knows how to sort in Excel could quickly find the vaccination rate for their kid’s school. Here’s the big file with all the school data: Arizona Reporting Schools Coverage

There are also some summary tables with coverage levels for various vaccines by geographic region:

Vaccination rates aren’t uniform across the state. Yuma and Santa Cruz counties continue to enjoy the highest vaccination rates (above 95% for MMR among Kindergarteners). Also as usual… Yavapai had the lowest vaccination rates with MMR coverage at only 74% and nearly 10% of students totally unvaccinated among Kindergarteners.

Another continuing trend… students enrolled in charter schools have vaccination rates much lower than students in district public schools. Also, higher income districts tend to have lower vaccination rates.

There are several evidence-based strategies that can be implemented at a statewide level, but such initiatives require leadership by a state health department director & governor…  something that’s in short supply these days.

Interventions to increase pediatric vaccine uptake: An overview of recent findings

For information on school immunization requirements, review the Guides to Arizona Immunization Requirements for Child Care/Preschool and Grades K-12.

Far and away the most effective (and highest ROI) intervention to improve childhood vaccination rates is to eliminate the ability for parents to exempt their kid from the school vaccine requirement with the ‘personal exemption’. Governor Ducey & the state health directors during his tenure have had zero interest in eliminating the personal exemption.

Editorial Note: Governor Ducey has been hostile to vaccination mandates (e.g., eliminating the personal exemption), even signing several bills eroding public health authority (see PowerPoint). His health directors remained completely silent as he signed those bills – signaling their tacit support for the erosion of public health authority. 

 

Perhaps childhood vaccination will again become a priority when we get a new governor in 118 days (but who’s counting).

Will Humble Disease Control, Vaccination, Wills Blog

Measles Returns to Arizona for the First Time Since 2019

Maricopa County Department of Public Health confirmed three related cases of measles. One case is an adult and the other two are kids. One of them had been hospitalized, but all 3 are recovering.

Whether these cases transition from an outbreak to an epidemic will depend on how many contacts the cases had with unvaccinated folks in their friend groups or at school. No doubt that Maricopa County staff have been busy doing case investigations to figure out just that.

Assuming the cases cooperate, Maricopa will be able to figure out who those unvaccinated contacts are (if any) and urge them to quarantine for the remainder of their incubation period. Cooperation of the cases and contacts and the fidelity to isolation and quarantine are critical to the success of the interventions. They will also likely urge unvaccinated contacts to get the measles vaccine right away. If taken within 3 days of the exposure it can be effective at preventing an infection.

Teams will also be checking the vaccination status of the classmates of the pediatric cases (assuming they’ve been in school). Best practice procedures include excluding unvaccinated contacts from school for at least one incubation period (up to 21 days) and vaccinating susceptible contacts within 72 hours of exposure.

Maricopa County Public Health will be using authority in ARS 36-624 and state communicable disease rules for measles in AAC R9-6-355. Measles (Pages 34-35) which call for:

Determining which measles contacts will be quarantined or excluded (from school), according to R9-6-303, to prevent transmission; and arranging for immunization of each nonimmune measles contact within 72 hours after last exposure, if possible.

R9-6-303 gives the county health department the ability to issue isolation, quarantine and other control measures. The details of that authority and best practice procedures are on pages 20 and 21 of the communicable disease rules.

Because the average incubation period for measles is 11–12 days (range of 7–21 days) this investigation will be ongoing throughout September and most likely beyond. It’ll be at least a couple of weeks before we’ll know how much (or whether) this cascades into an epidemic.

Much will depend on how much contact the cases had with unvaccinated folks before they were symptomatic, how good case and contact cooperation is, and whether folks follow MCDPH recommendations & instructions.

Measles cases in Arizona: What to know about symptoms, vaccine (azcentral.com via Stephanie Innes)

Will Humble Professional Development, Wills Blog

Annual AzPHA Public Health Awards: Accepting Nominations Now!

Each year AzPHA recognizes public health professionals & health care workers across Arizona are performing extraordinary services to our community at our annual awards event. Many of our awards go back decades.

We’re proud to announce that the 2022 awards program will be held on:

Thursday. October 27, 2022
5:00pm – 8:30pm
Outdoor Courtyard at the Maricopa Medical Society
326 E Coronado Rd #101, Phoenix, AZ 85004
This will be an outdoor, happy hour event. Registration begins Monday, September 5, 2022
Please take a moment to view our award categories and submit your entries by September 15, 2022

Nominate Here

Award Categories
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