Striker Bill Targets Eliminating Public Health Emergency Authority

April is often sneaky season for bills – when legislators bring out their ammunition for things they’ve wanted to get done but knew they would go down in flames if they expose the bill too fast or they try to resurrect earlier bad bills and propose them again – but under a deceptive name.

Those are called Strike All Amendments – AKA Striker Bills. A doozie came out of the woodwork this week called HB2545 from Jake Hoffman (Senate). The label on that bill says “Legislators; Unpaid leave of absence”. Sounds boring and unrelated to public health, right?

Wrong.

Despite its fake name, the bill would limit Governors to declaring a public health emergency for only 7 days. To extend the public health emergency declaration, the governor would need to get a supermajority of the legislature (2/3) to extend it – and then only in one-week increments. Each week after that the Governor would need to get another 1-week extension!

Ridiculous, I know. There are other ridiculous limitations in there too: HB2545 Striker Memo.  Why doesn’t he just run a bill to get rid of all public health emergency authority?

This striker bill naturally cleared Hoffman’s Senate Government Committee yesterday. It still needs to pass the full Senate and then succeed in a House committee and then pass the House. If it made it that far, it would meet a sure veto stamp.

Because of the certain veto, the bill really doesn’t post a public health threat. It looks a lot more like a vehicle for Senator Hoffman to build his brand.

UPDATE: HB2545 is up for a final floor vote in the Senate on Tuesday, April 10. Because it’s a strike all amendment it’ll still need to pass the House before it would get to the Governor’s desk – where it would face a certain veto,

Ballot Referral Could Dismantle Arizona’s Emergency Management System

HCR2039 governor; state of emergency is a House Resolution that’s an existential threat to emergency management in Arizona. It poses a huge potential threat to not just public health emergency responses – but to overall emergency management. See: Scottsdale lawmakers want more legislative oversight over emergency declarations.

It would end Governor-proclaimed states of emergency after 30 days (including public health emergencies) unless extended by the Legislature in 30-day increments. It would impact all declared emergencies like floods, fires, chemical spills, and other kinds of disasters – not just public health emergencies.

Here’s why it’s so bad for emergency management:

The 4 pillars of Emergency Management are Mitigation, Preparedness, Response and Recovery. The Response part of many if not most state-declared emergencies (think wildfires) often last more than a month. If this becomes law, all of them would expire after 30 days unless the legislature acts (whether they’re in session or not). If the legislature doesn’t extend the authority, the response would just end. Money flows would likely stop and the people impacted would be out of luck.

The Recovery portion of Arizona emergency responses would be damaged the most. The Recovery phase always lasts a lot longer than the response. The response part of a flood disaster includes things like rescuing people, cleaning up the roads, moving earth and the like. The Recovery phase includes fixing the drainage culverts, roads, and the uphill hazards like loose uphill boulders.

If HCR2039 ends up on the ballot and passes, the Recovery phase of emergency response would basically not happen. The flow of money and authority to do the recovery work would have ended. There is no way to get a quorum & a majority of legislators to keep reauthorizing emergencies – especially when they’re not in session.

Because HCR2039 would change the state constitution, it would need to be approved by the voters at the November 2024 election to be effective. It has already passed the full House (31-28) & the Senate Government Committee. All that remains is the Senate Rules committee and then the full Senate, where it’s likely to pass on a party line vote.

It will then go on the November 2024 ballot (it doesn’t need Hobbs’ signature to get on the ballot).

Would voters put in the time to understand how this would impact emergency management and vote it down? Maybe… but there are also bad actors that might intentionally confuse folks into changing our constitution in a way the permanently disables emergency management in Arizona.

Let’s hope at least one Republican Senator is paying attention and either votes no or ‘takes a walk’ and sinks this before it gets to the ballot.

The Lancet: Arizona Had the Highest Per-capita Standardized COVID-19 Death Rate in the U.S between January 2020 & July 2022

Assessing COVID-19 pandemic policies and economic trade-offs across US: Jan 1, 2020, to July 31, 2022

“Standardized cumulative COVID-19 death rates for the period from Jan 1, 2020, to July 31, 2022 varied across the USA (national rate 372 deaths per 100 000 population, with the lowest standardized rates in Hawaii and the highest in Arizona (581 per 100 000).”

Note: This study adjusts for each state’s age profile and the prevalence of chronic health conditions that put people at higher risk of death from COVID-19 like COPD, diabetes, BMI, and cancer and smoking rates… meaning it more directly measures the quality of a state’s response because it factors out age and health factors outside of a governor or health department director’s control.

“State governments’ uses of protective mandates were associated with lower infection rates, as were mask use, and higher vaccination rate.” 

“US states that mitigated those structural inequalities, deployed science-based interventions such as vaccination and targeted vaccine mandates and promoted their adoption across society were able to match the best-performing nations in minimizing COVID-19 death rates.”

Note: If Arizona were a country, our crude COVID-19 mortality rate would rank among the worst in the world, similar to Russia, Romania, and Belarus and just behind Peru.

Bill Separating the Arizona State Hospital from the ADHS Likely to Get Final House Floor Vote this Week

The needs of patients at ASH can be complex and the patients are vulnerable, so it’s critical to ensure the facility uses best practice treatment and is following a rigorous set of regulations. To achieve fidelity to best practice standards, it’s critical that the governance structure ensures accountability and is free from conflicts of interest.

The existing governance structure is insufficient to ensure quality care is provided at ASH. The fundamental flaw is that ADHS both runs & regulates ASH.

The lack of independent regulation of ASH results in poor accountability and can lead to unchecked substandard care when ADHS leadership soft-pedals oversight to give the impression that the facilities are providing care that meets standards.

SB1710 reforms of the governance structure by removing ASH from ADHS, separating ADHS’ operational and regulatory responsibilities re ASH by creating two separate entities (ASH would no longer be a part of ADHS). 

A 5-member State Hospital Governing Board would be responsible for the oversight of ASH. The Superintendent would report to the Board rather than the ADHS Director. ADHS would then regulate the hospital without an institutional conflict of interest.

I’ve written a summary of how ASH is currently governed and why I believe SB1710 is so important. Here is that summary: Fixing the Governance Flaw at Our Arizona State Hospital: A Primer

I’m confident SB1710 will have the needed votes in the House this week…  but whether the Governor will sign it is an unknown. There are no doubt forces within the executive branch that will do a full court press to urge her to veto this important intervention. Let’s hope commonsense & reason prevail!

Do You Have Events Planned for National Public Health Week?

Many of our members are excited to celebrate National Public Health Week April 3-9, 2023. This year’s theme is “Centering and Celebrating Cultures in Health”. You can find lots of tools to help you commemorate the week on APHA’s NPHW Website!

 The American Public Health Association wants to promote events happening during NPHW. If your organization is planning any events during NPHW, contact our APHA representative to the governing council, Rebecca Nevedale, at Rebecca@frameshiftgroup.com.

Rebecca will collect some information from you and provide to APHA so that they can promote your event too. You can also submit an event to be included on the NPHW website by clicking here.

Fixing the Governance Flaw at Our Arizona State Hospital: A Primer

The Arizona State Hospital is located on a 260 bed 93-acre campus in Phoenix providing inpatient psychiatric care to people with mental illnesses who are under court order for treatment.  Treatment at ASH is considered “the highest and most restrictive” level of care in the state. Patients are admitted because of an inability to be treated in a community facility or because of their legal status.

The Civil portion of the hospital provides services to people civilly committed as a danger to self, danger to others, gravely disabled and/or persistently and acutely disabled. Forensic patients are court-ordered for pre- or post-trial treatment because of involvement with the criminal justice system due to a mental health issue.

The needs of patients at ASH can be complex and the patients are vulnerable, so it’s critical to ensure the facility uses best practice treatment and is following a rigorous set of regulations. To achieve fidelity to best practice standards, it’s critical that the governance structure ensures accountability and is free from conflicts of interests.

The Problem

The existing governance structure is insufficient to ensure quality care is provided at ASH. The fundamental flaw is that ADHS both runs & regulates ASH.

The lack of independent regulation & oversight of the Arizona State Hospital results in poor accountability and can lead to unchecked substandard care when ADHS leadership soft-pedals regulatory oversight to give the appearance that the facilities are providing care that meets standards.

There is evidence that this occurred during the Ducey Administration.  For example, in 2021, ADHS’ licensing division investigated multiple suicides and a homicide and concluded that no operating deficiencies led to those deaths. Suicides and homicides only occur when there are deficient practices.

For context read this article by Amy Silverman: Patient deaths at Arizona State Hospital raise questions about staffing levels, lack of oversight and this piece by Mary Jo Pitzl at the Arizona Republic

The Solution

AzPHA is a supporter of SB1710 because it is a commonsense solution to governance problem that’s jeopardizing care at ASH by separating the operational functions of running ASH from the regulation of ASH by creating two separate entities (ASH would no longer be a part of ADHS).

The bill would establish a 5-member State Hospital Governing Board and transfer operational responsibilities to the Board. Members of the governing board would be appointed by the governor. The ASH Superintendent would report to the governing board rather than the ADHS Director. ADHS would then regulate the facility without an institutional conflict of interest.

[SB1710 passed the full Senate with a vote of 27-2 and has passed all assigned committees in the House. It awaits a final floor vote in the AZ House of Representatives. If it isn’t amended on the House floor and passes, it would go to Governor Hobbs’ desk for a signature.]

ADHS leadership has suggested that there is sufficient independent oversight of ASH, an oft told and misleading statement designed to give the impression that separating ASH from ADHS is unnecessary. To clear things up, we prepared this review of how the Arizona State Hospital is ‘regulated’ under the current model and why SB1710 is so important.

Civil Hospital

The ASH Civil Hospital provides treatment and care for persons that are court ordered to the facility for psychiatric care.  The Civil Hospital at ASH is run and regulated by the Arizona Department of Health Services (ADHS). ADHS’ Licensing Division is responsible for regulating the Civil Hospital which the ASH Superintendent is responsible for its operation.

State law allows healthcare institutions like ASH’ Civil Hospital to enjoy a Deemed Status license from the ADHS. That means that the Civil Hospital can hire an accrediting body to accredit the Civil Hospital. Once accredited, the Civil Hospital turns in the accrediting report to the ADHS Licensing division, and the ASH Civil Hospital receives a License from the ADHS – even though the ADHS doesn’t do an inspection of the facility before issuing the license.

ADHS pays The Joint Commission to accredit the Civil Hospital, which gives the facility a deemed-status license from ADHS. ASH Civil started hiring TJC to do that work when I was Director. I think we paid TJC something like $10K for that service. Here’s a link to the deemed status licensing information about the Civil Hospital: Licensing Statement of Deficiencies.  ADHS accepts the accreditation in lieu of an inspection and issues the state license to operate on that basis.

ADHS doesn’t do any annual inspections of the Civil Unit to ensure compliance with state licensing criteria because of its ‘Deemed Status’.  ADHS’ Licensing division can send out surveyors to investigate complaints about the care at the Civil Hospital when they receive them. If the complaint is substantiated, the ADHS Licensing Division can require corrective action and has some enforcement authority like issuing civil money penalties or placing the facility on a provisional license or even seeking revocation.

During the Ducey administration, ADHS ‘complaint investigations’ seldom substantiated the complaints they receive and seldom find deficiencies (with a few exceptions), even after suicides. Here’s the recent compliance record: Licensing Services Facilities Report

Because Medicare and Medicaid (AHCCCS in Arizona) pay for some of the services at the ASH Civil Hospital, CMS requires ASH’ Civil Hospital to be Certified to their certification standards. However, CMS doesn’t do their own certifications. They contract with the ADHS Licensing staff to conduct the certification surveys.

ADHS licensing staff go out and check at the ADHS ASH Civil Units to see if they’re adhering to CMS’ certification standards (which are a little different from the actual ADHS healthcare Institution regulations). ADHS Licensure then sends their report to CMS Region IX in San Francisco and the report is blocked, copied, pasted, and is sent back to ADHS and ASH on CMS letterhead.

ADHS both runs and regulates the ASH Civil Hospital. ADHS leadership often suggest that there are checks and balances in the regulatory system to send the message that the monitoring of care is rigorous. CMS Certification is not an independent review of care at the Civil Hospital because the work is conducted by ADHS Licensing staff.

While it’s true that The Joint Commission accreditation is separate from ADHS, the agency pays TJC for the accreditation surveys. TJC views ADHS as a customer/client. It is not a regulatory body, and they have no enforcement authority. TJC Accreditation inspections that document deficiencies can sometimes jeopardize their contract with their customer, having a chilling effect on documenting deficient practices.

Forensic Hospital

ASH’ Forensic Hospital provides care for patients that are determined by the courts to be “Guilty Except Insane” or “Not Guilty by Reason of Insanity”.  The Forensic Hospital is also both run and ‘regulated’ by ADHS.

State law allows ASH’ Forensic Hospital to enjoy a Deemed Status license from the ADHS. That means the Forensic Hospital can also hire an accrediting body to accredit the Forensic Hospital. Once accredited, the Forensic Hospital turns in the accrediting report to the ADHS Licensing division and receives a License from the ADHS – even though the ADHS doesn’t do an actual inspection of the facility. ADHS also pays the Joint Commission to accredit the Forensic Hospital.

When ADHS’ Licensing division receives complaints about care at the Forensic Hospital they can send out surveyors to investigate those complaints. If the complaint is substantiated, the ADHS Licensing Division can require corrective action and has some enforcement authority like issuing civil money penalties or placing the facility on a provisional license or even seeking revocation.

During the Ducey administration, ADHS ‘complaint investigations’ seldom substantiated the complaints or identified deficiencies (with some exceptions). Here’s the recent compliance record: Licensing Services Facilities Report (azdhs.gov)

Conclusion

The current governance structure for operating and regulating the Arizona State Hospital is fundamentally flawed because the ADHS both runs and regulates the hospital. The lack of independent regulation and oversight results in poor accountability and can lead to unchecked substandard care when ADHS leadership soft-pedals regulatory oversight to give the appearance that the facilities are providing care that meets standards. There is evidence that this occurred during the Ducey Administration.

SB1710 reforms of the governance structure by removing ASH from ADHS. It would separate the operational functions of ASH from the regulatory responsibilities by creating two separate entities (ASH would no longer be a part of ADHS). A 5-member State Hospital Governing Board would be responsible for the oversight of ASH and the Superintendent would report to the Board rather than the ADHS Director. ADHS would then regulate the hospital without an institutional conflict of interest.

ADHS Justice Reinvestment Grant Applications Open

In November 2020, Arizona voters approved the Smart and Safe Arizona Act legalizing retail marijuana and establishing a Justice Reinvestment Fund for grants to qualified nonprofit organizations that provide justice reinvestment programs in Arizona. 

Last week ADHS opened up the application period for the first set of Justice Reinvestment Grants. The RFGA will remain open and accept applications for the next 6 weeks. Pre-application conferences are being held over the next couple of weeks for folks interested in applying.

Public Comment Period Open for AHCCCS Adult Dental Services

AHCCCS is accepting public comments through March 31 about their dental policies. You can submit a comment to AHCCCS to encourage the expansion of preventive dental benefits to adults over 21 years of age on the site. 

Note: HB2338 which would add a preventive adult dental benefit to AHCCCS is being heard in the Senate Health Committee this Tuesday. Make sure you’ve signed up in support of that bill if you haven’t done so yet.

AzPHA Objects to the Pacific Legal Foundation’s Petition to Throw Out Arizona’s Cage Free Environment Law for Egg Laying Hens

A few years ago, the Arizona Department of Agriculture brokered a compromise among stakeholders interested in protecting the safety of Arizona’s supply of eggs, those interested in more humane treatment of egg-laying hens, and egg producers when they adopted rules phasing out caged environments for egg-laying hens. Arizona joined California, Oregon, Washington, Michigan, Colorado, Nevada, Utah, Massachusetts, and Rhode Island in outlawing the use of cages for egg laying chickens.

Starting on January 1, 2023, all eggs and egg products sold in Arizona are supposed to be from hens that are housed in accordance with the UEP Animal Husbandry Guidelines. The chickens are supposed to have at least one square foot of usable floor space per egg-laying hen. Beginning January 1, 2025, all eggs and egg products sold in Arizona are supposed to be from hens housed in a cage-free manner.

Last month, along came the “Pacific Legal Foundation”, petitioning the Governor’s Regulatory Review Council to throw out the cage free rule. Surprisingly, GRRC is considering the Pacific Legal Foundation’s proposal to throw out the Rule at their upcoming March 28 meeting.

Minimizing foodborne illness is a key component of protecting public health and welfare. When enacting the cage-free regulations, ADA reviewed science-based evidence and concluded that ensuring eggs produced and sold in our state come from cage-free facilities minimizes food safety risks and advance public health goals.

Eggs contaminated with Salmonella and Campylobacter are much less common when produced in cage-free environments

The science related to hen housing has not changed since last year, and the existing policy still better protects public health outcomes.

For these reasons, AZPHA Chicken Egg Cage Rule Comment GRRC AZPHA to the Governor’s Regulatory Review Council urging them to leave in place Arizona’s cage free law (Arizona Administrative Code R3-2-901 – R3-2-907) and reject the Pacific Legal Foundation’s petition at GRRC’s upcoming March 28, 2023 meeting.

If you object to the Pacific Legal Foundation’s meddling in our cage-free environment law, you can email GRRC and ADOA at grrc@azdoa.gov and grrccomments@azdoa.gov and urge them to reject PLF’s ploy at their March 28 meeting (see the agenda)

Planning for the Renewal of ADHS’ Title V Maternal & Child Health Block Grant Underway

Comments on Needs Assessment Open Through March 31

The federal Title V Maternal and Child Health Block Grant Program is a partnership between the federal government and states which supports the health and well-being of all mothers, children, and families.

One of the beauties of the MCH block grant is states have wide guardrails on how they can spend the funds. In Arizona we’ve traditionally developed a plan every 5 years – using stakeholder input – about how to best leverage the money in the block grant.

The block grant is refreshing because so often federal grants come with strict criteria and leave little room for discretion. The Title V block grant isn’t that way. HRSA administers the grants to states.

Funds from the Title V MCH Block Grant help:

  • Assure access to quality maternal and child health care services to mothers and children, especially those with low incomes or limited availability of care;
  • Reduce infant mortality;
  • Provide access to prenatal, delivery, and postnatal care to women, especially pregnant women who are low income and at-risk;
  • Increase regular screenings and follow-up diagnostic and treatment services for children who are low income;
  • Provide access to preventive and primary care services for children who are low income and rehabilitative services for children with special health needs;
  • Implement family-centered, community-based, systems of coordinated care for children with special health care needs; and
  • Set up toll-free hotlines and assistance with applying for services to pregnant women with infants and children eligible for Medicaid

ADHS is seeking input on how to spend the block grant funds via this online survey.  For example, this is a great opportunity to elevate oral health as we know inequitable access to oral health remains a key issue facing Arizona’s children and families. 

The survey will close on March 31, 2023. For more information about the grant program, visit ADHS‘ website.