Will Humble State Legislature, Wills Blog

Legislative Session Finally Ends: Senate Fails to Vet & Confirm Agency Nominees

Hobbs Has Several Possible Work-Arounds

Arizona’s longest ever legislative session ended last week. Despite being in session for a record 7 months, the Senate completely failed in their responsibility to consider, vet, and confirm (or not) Governor Hobbs’ nominees to lead state agencies and other boards and commissions. That dereliction of duty creates very real governance and operational efficiency problems for agencies that have critical responsibilities.

It’s not just the nominees that are left in limbo…  It’s also the rank-and-file staff who suffer because they are unclear about who will be in charge of their agency, what priorities they have, and direction regarding key decision-making and regulatory actions. Recruitment and retention of staff is difficult as it is- and the failure of the Senate leadership to do their job makes matters worse.

Look no further than the scathing Auditor General reports about the nonperformance and misconduct regulating nursing homes during the Ducey Administration to see the very real impacts on everyday Arizonans poor agency leadership can have: Auditor General’s Office Produces Scathing Review of ADHS’ Nursing Home Complaint Investigations During the Director Christ Era

Governor Hobbs has nominated dozens of persons to lead agencies who require Senate confirmation, yet the Senate has only confirmed 6 (Confirmed are: Glover; Ben Henry, Department of Liquor Licenses and Control; Susan Nicolson, Department of Real Estate; Ryan Thornell, Department of Corrections; Thomas Torres, Department of Forestry and Fire Management; and Jennifer Toth, Department of Transportation).

Senate Committee Doesn’t ‘Vet’ Nominees. It Sabotages Them

A big part of the inaction in the Senate is tied to a new committee that was assembled this year called the Committee on Director Nominations (DINO) chaired by Sen. Jake Hoffman. Previously, committees organized by topic area considered nominees (for example, a Senate Health and Human Services Committee would vet the governor’s pick to lead AHCCCS, ADES, and ADHS).

According to reporting done by Stacy Barchenger at the Arizona Republic, Senate President Petersen has promised that: “We’re going to continue nominations, the committee will continue meeting soon. That’ll occur shortly.” He also said there was a possibility of a special session to confirm nominees and said some could be confirmed next year when the Legislature returns to work. AZ Senate confirms DPS director on final day, leaves other nominees in limbo

The DINO Committee chair (Hoffman) has publicly stated that “The Committee on Director Nominations has postponed all further nominations pending this meeting.” Referring to a demand that Hobbs meet with Hoffman et.al. about grievances he (they) have about executive orders Hobbs has made.

Let’s assume the Senate Republican leadership doesn’t change their mind and continue to fail to do their job (e.g. don’t have a special session). What can be done to help out state government and staff? Anything?

Fortunately, the statutes about senate confirmation requirements are sufficiently vague and provide loopholes that could give Team Hobbs some stability and governance options in the absence of Senate feasance. See: 38-211 – Nominations by governor; consent of senate; appointment

You’ve probably heard that agency directors can serve up to one year without being confirmed by the Senate. While that’s true – the reality is that the law ARS 38-211 is more permissive than that. While the Legislature is in session, the ‘one year clock’ doesn’t start until the Governor actually sends the nominee’s name to the Senate. If the Governor doesn’t send the nominee’s name in, then the clock never starts.

If the term of any state office that is appointive pursuant to this section expires, begins or becomes vacant during a regular legislative session, the governor shall during such session nominate a person who meets the requirements of law for such office and shall promptly transmit the nomination to the president of the senate. If the senate rejects the nomination the nominee shall not be appointed, and the governor shall promptly nominate another person who meets the requirements for such office. If the senate takes no formal action on the nomination during such legislative session… the governor shall after the close of such legislative session appoint the nominee to serve, and the nominee shall discharge the duties of office, subject to confirmation during the next legislative session.

For example, Governor Ducey named Don Herrington as the acting ADHS director in the Summer of 2021. Ducey never formally nominated Don nor sent his name to the Senate… meaning the ‘one year time clock’ never started for him & he ended up in the job for more than 18 months despite the time limit in 38-211E: ‘In no event shall a nominee serve longer than one year after nomination without senate consent.’

Why? Because he was never really the nominee according to the statute.

Note: Jennifer Cunico has been the acting ADHS director since January 2, 2023, but hasn’t been formally nominated. As such, her ‘one year’ timeclock has not yet begun.

The Governor has several work-around options I can think of, and there may be more:

Option 1: Replicate the ‘Herrington/Cunico’ Model

Hobbs could also just keep replicating the Herrington/Cunico model. Simply keep naming ‘Acting’ agency directors. Appear to be recruiting a permanent nominee without really doing it. Never formally nominate the person but tell them and their staff and stakeholders that the acting status is permanent. Not an ideal arrangement, but it supplies more stability than the status quo.

Option 2: Recess Appointments

Now that the legislative session is officially over, a different part of the confirmation statute applies:

If the term of any state office that is appointive pursuant to this section… becomes vacant during a time in which the legislature is not in regular session, the governor shall nominate a person who meets the requirements of law for such office and shall transmit the nomination to the president of the senate during the first week of the next regular session. The nominee shall assume and discharge the duties of the office until rejection of the nomination or inaction of the senate.

Now that session is over, when Hobbs nominates folks for posts who require confirmation, the person’s one year time clock won’t start until at least early January – and even then, not until Hobbs actually formally sends the person’s name to the Senate. This could be paired with the Herrington/Cunico model. Simply keep the recess appointment directors “acting’ on paper indefinitely.

Option 3: The Wizard of Oz

Even persons who Hobbs has formally nominated for agency director posts but for whom the Senate took no action (e.g., Carmen Heredia at AHCCCS, Karen Peters at ADEQ etc.) have easy options for staying in their director position indefinitely even without confirmation (their one-year time clock started in February/March 2023)

For example, prior to the one-year time clock running out on an agency nominee (in March 2024) Hobbs could move the nominated director to a Deputy position that doesn’t require confirmation. Hobbs could then name a new ‘Acting Director’ (possibly even the former deputy). The Governor’s Office could make it clear to agency staff and stakeholders that the Deputy is the ‘real’ director, providing governance certainty for stakeholders and staff. The (fake) Acting Director could stay on indefinitely as long as Hobbs doesn’t formally nominate the person to the job. The Governor could even rotate the directors on paper – with the acting director and deputy trading positions after a year. Again, staff and stakeholders could be told exactly who the real decision-maker is Not ideal: but again… better than the status quo that Hoffman has delivered.

Editorial Note: As I noted above, a root cause of the confirmation problem is that Senator Jake Hoffman is thwarting the Senate’s confirmation responsibilities…. but DINO committee nonfeasance may take care of itself before the next legislative session.

Mr. Hoffman is one of 11 ‘fake electors’ who submitted (forged) false slates of electors to the national archives, avowing that he was among Arizona’s “duly elected and qualified electors” (part of the effort to illegally overturn the 2020 election). On Jan. 5, 2021, Hoffman even sent a letter to Vice President Mike Pence asking him not to accept the state’s official electoral votes. The letter was sent on official state letterhead and had a return address of the state Capitol. See: Arizona’s 11 Republican fake electors face state, federal scrutiny

Arizona Attorney General Kris Mayes has launched an investigation into Arizona’s fake electors (including Hoffman), similar to a probe in Michigan which has resulted in state criminal felony indictments. It is entirely possible that serious state criminal charges could be filed against Hoffman prior to the next legislative session, increasing the likelihood that Republican Senate leadership could remove his committee assignments (including as DINO Chair) pending trial, or possibly even expelling him, solving the DINO committee’s nonfeasance.

Will Humble Assurance & Licensure, Behavioral Health, Wills Blog

Arizona State Hospital Needs Independent Oversight, Isn’t Getting It

Arizona State Hospital needs independent oversight, isn’t getting it

Arizona State Hospital fails patients, and oversight efforts are going nowhere

Opinion: The Arizona State Hospital cares for some of the state’s most vulnerable people. Yet a lack of independent oversight is putting their lives at stake.

Senators Catherine Miranda and T.J. Shope

The two-year effort to improve care at the Arizona State Hospital went up in a puff of smoke again this year at the state Legislature.

That’s a bad thing for patients, their families and every Arizonan.

The Arizona State Hospital is located on a 93-acre, 260-bed campus in Phoenix providing inpatient psychiatric care to people with mental illnesses who are under court order for treatment. 

Treatment at the hospital 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.

The needs of patients at the state hospital can be complex and the patients are vulnerable, so it’s critical to make sure the hospital uses best practice treatment and follows a rigorous set of regulations.

A prerequisite to ensuring quality care is having a governance structure that’s accountable and free from conflicts of interest.

Sadly, that’s not what we have.

The Arizona State Hospital is part of the Arizona Department of Health Services — the same agency that’s responsible for regulating the Arizona State Hospital.

That’s a classic example of the fox watching the henhouse.

After suicide, it found ‘no deficiencies’

There is evidence that the lack of independent regulation has resulted in unchecked substandard care.

For example, in 2019, the state health department investigated a homicide at facility under its jurisdiction and concluded it wasn’t doing anything wrong and didn’t need to fix anything — indicating that there were “no deficiencies.” 

And in 2021, a patient was provided scissors and let into a bathroom, where he died by suicide.

The department downplayed its role, as a spokesperson told ABC 15, “There appears to be an inaccurate assumption that every event should automatically result in a citation or a noted deficiency for a health care institution.”

These are not isolated incidents, and as former state health director Will Humble has pointed out, suicides and homicides are almost always the result of a deficient practice, such as a poor treatment plan or medical psych assessment.

State health department won’t regulate itself

We’ve learned a lesson the hard way that we can’t count on the state health department to regulate itself.

We need better institutional controls free from conflicts of interest.

For the last couple legislative sessions, Sen. David Gowan has proposed a commonsense solution to the governance problem that’s been plaguing care: Simply separate running and regulating the Arizona State Hospital.

‘Scary place’: Arizona State Hospital has safety concerns, critics say

Senator Gowan’s bill would have set up a five-member State Hospital Governing Board and transferred operational responsibilities to the board.

Members of the governing board would be appointed by the governor. The Arizona State Hospital superintendent would report to the governing board rather than the state health director.

The Arizona Department of Health would then regulate the facility, just like it does every other hospital, but without a conflict of interest.

It’s time to fix this systemic flaw

There was bipartisan support for this important change — with the bill passing 27-2 in the state Senate, only to be undermined in the House at the 11th hour because the governor’s office had concerns about the “civil rights implications” of the bill.

For the life of us we don’t understand why there would be resistance to this commonsense change.

It’s time to fix this systemic flaw.

We call on Gov. Katie Hobbs to call together lawmakers of both parties and come up with a plan she can support to fix this major conflict of interest that has been jeopardizing patient care.

Fixing the governance structure may not guarantee that the state hospital will be well regulated, but it improves the chances that it will be.

The most vulnerable people in the state are counting on our elected and appointed officials to have their back.

So are their families. So does the public.

Let’s stop disappointing them, shall we?

Sen. Catherine Miranda is a Democrat representing Arizona Legislative District 11 (downtown Phoenix, Laveen, South Mountain, Guadalupe). Sen. T.J. Shope is a Republican representing Arizona Legislative District 8 in Pinal County and is chair of the Senate Health and Human Services Committee. On Twitter: @CatherineSenate and @TJShope

See also:

Will Humble Behavioral Health, Maternal Health, Medicaid, Wills Blog

AHCCCS 101 & How You Can Influence Arizona’s Medicaid Program

Arizona’s Medicaid program is largely run under a ‘managed care’ model. AHCCCS contracts with several managed care organizations or MCOs. Those contracted MCOs are responsible for developing a network of providers and ensuring their enrolled members are able to get the healthcare services they’re entitled to receive.

AHCCCS’ main job is to make sure their contractors (the MCOs) are doing their job and following AHCCCS’ requirements (and to make sure taxpayers are getting their ‘money’s worth’ from AHCCCS’ contractors).

Moneywise, the system is largely a ‘capitated model’ meaning each contractor gets a certain amount of money per enrolled member per month. How much the MCOs get per person per month depends on the category the person is in.

For example, AHCCCS pays a certain amount of money per month to the contractors’ healthy kids without special needs. That would be a pretty low amount per member per month. Kids with special needs like developmental disabilities would come with a lot more money per month.  Healthy adults would come in with a certain amount per month that would be modest…  but that dollar figure is a lot higher for adults that have been diagnosed with a Serious Mental Illness for example.

You can see why regulatory oversight is so important! I mean the contractors get a certain amount per person per month and if they spend less than that per person, they will make a profit.

That would be a good thing if the MCO’s healthcare provider network is doing a good job keeping their enrolled people healthy by catching things early.  But… if the managed care organization is making a profit because their network of providers is really thin, and people can’t find a doctor to make an appointment – that would be bad.

Likewise, if one of their contractors is making a lot of money because they aren’t providing needed services to their adults with a serious mental illness (like supported housing, supported employment etc.) then that would be super bad. After all – AHCCCS is paying them a certain amount per person per month with the expectation they’ll actually be providing those services. It’s also bad because the people entitled to those services unnecessarily suffer.

So you can see why it’s so important for AHCCCS to be a good ‘regulator’ and continually make sure that their contractors are doing their job, providing the required services, contracting with an adequate network of providers and that taxpayers aren’t getting ripped off.

One of the primary regulatory tools AHCCCS has are called Administrative Claims Financial and Operational policies aka “ACOMs”…. which are the things their contractors (MCOs) need to follow as a condition of getting AHCCCS money.

When contractors don’t comply with AHCCCS’ expectations they can impose an “Administrative Action” like a Notice of Concern, Notice to Cure, a mandate for a Corrective Action Plan, or financial sanctions. Here’s a summary of the various Administrative Actions takes to regulate their contractors.

See Guides & Manuals for Health Plans and Providers

From time-to-time AHCCCS makes changes to the expectations they have for their contractors. They do that by changing those ACOMs. Those changes can be very significant. Think about it. When AHCCCS changes the contractual expectations, it can affect the care that all 2.5 million persons enrolled in AHCCCS. Why? Because those changes affect the expectations AHCCCS has for their contractors – and those contractors will then change the expectations they have for their provider network – and ultimately the experiences AHCCCS members have.

Right now, AHCCCS has 27 of their ACOMs out for public comment. Here’s the website with the open ACOM modification proposals: AHCCCS ACOM Comment Portal. Five of the ACOM changes have comment deadlines this Thursday including changes in expectations for maternal and child health, services for folks with a serious mental illness (including eligibility determination), waste fraud and abuse and how they’ll assign new members to contractors (MCOs)

It’s important for people who are ‘in the know’ to keep up with the proposed changes and provide comments to AHCCCS – as some of the changes to these ACOM expectations can have profound impacts on how services are provided and the quality of care that AHCCCS members get.

If you’re a subject matter expert – or an advocate for persons who receive services, please take the time to check out AHCCCS’ proposed changes and comment on them! Even minor changes to some of these policies can have a huge impact on real people.

Here’s a quick summary of the proposed changes that have a comment deadline this week:

AMPM EXHIBIT 400-3 – Maternal & Child Health

This one makes changes in the expectations AHCCCS has for their contractors for members who are pregnant.

ACOM POLICY 103 – Fraud Waste and Abuse

This one completely overhauls AHCCCS’ auditing expectations for the contractors and changes reporting expectations and the way contractors are expected to interact with AHCCCS’ Office of the Inspector General.

AMPM POLICY 320-O – Behavioral Health Assessments, Service and Treatment Planning

This ACOM change makes massive changes to behavioral health services planning, including very different expectations for AHCCCS’ ‘fee-for-service’ programs (American Indian Health Plan). Note: It looks like some of these changes are geared to prevent the fraud perpetrated during the Ducey Administration in the AIHP.

AMPM POLICY 320-P – Eligibility Determination for Individuals with a Serious Mental Illness

This ACOM policy change proposed big changes in the way eligibility determinations are made for persons with a Serious Mental Illness.

ACOM POLICY 314 – Auto Assignment Algorithm

When people newly qualify for AHCCCS they can pick the managed care organization they want to manage their care. If people don’t pick a health plan then AHCCCS picks one for them (called auto assignment). This ACOM change shifts the way AHCCCS makes those decisions by rewarding health plans who have good results on their provider and member surveys.

Will Humble Professional Development, Wills Blog

8th Annual Rural Women’s Health Symposium! August 17 & 18: Prescott Resort and Conference Center

This year’s theme for the 8th Annual Rural Women’s Health Symposium is Supporting Rural Communities: Resilient & Refocused.

Rural communities have faced many challenges in the past few years. The Symposium hopes to strengthen your efforts by bringing people back together in person and focusing on supporting rural communities to overcome these hardships. The goal is to explore ways we can support providers, healthcare workers, and community members in serving rural women. The Symposium is a chance to learn from each other and share best practices as leaders, advocates, and experienced community members.

More information and registration here: 2023 Rural Women’s Health Symposium – AACHC
Will Humble Behavioral Health, Wills Blog

New Opportunities for Schools to Provide Behavioral Health & Other Services

Schools have been able to bill AHCCCS for medically necessary services they provide in schools if the child is a Medicaid member, and the services are included in the kid’s individualized education plan or IEP. IEPs are a set of goals and expectations that are individually developed for kids in schools.

A couple of years ago AHCCCS developed a State Plan Amendment that would allow schools more flexibility and dropped the requirement that kids have an IEP or 504 plan.

An 504 plan allows the school to give accommodation to students who may have a disability affecting their learning. It’s unlike an IEP because you can have any disability. In order to have an IEP, students need to qualify for the services under specific categories.

 

Under the new rules, services can be documented in “… any other documented individualized health or behavioral health plan or as otherwise determined medically necessary.”

See the State Plan Amendment

The new State Plan Amendment is a potential game-changer for schools that want to augment the behavioral health (or other services) they want to provide for their students. The services can be provided to any student that’s an AHCCCS member – even if they don’t have an IEP… opening up possibilities to meet behavioral health needs of students even if they don’t have a disability.

The list of potentially covered services are:

  1. Speech-Language Pathology Services
  2. Occupational Therapy Services
  3. Physical Therapy Services
  4. Nursing Services
  5. Specialized Transportation Services
  6. Behavioral Health Services
  7. Personal Care Services
  8. Audiology Services
  9. Physician Services
  10. Nurse Practitioner Services

To get reimbursed the school provides need to meet AHCCCS’ service definitions and at document the ‘other documented individualized health or behavioral health plan’.

Schools are reimbursed the lesser of AHCCCS’ fee-for-service schedule or the amount billed by the school minus an AHCCCS administrative fee. 

I’m not sure how many schools are taking advantage of the new flexibilities built into the new State Plan Amendment provisions. I’ve pitched the idea of doing a story to a couple journalists- so we’ll see if anybody follows up and sheds some light on this.

I don’t expect Superintendent of Public Instruction Tom Horne to pay any attention to this or to encourage public schools to participate. Let’s just say he has other priorities like eliminating nonexistant critical race theory, encouraging even more participation in the private and homeschool voucher program and ‘classroom discipline’.

Arizona Medicaid School Based Claims FAQs
Will Humble Maternal Health, Reproductive Health, Wills Blog

FDA Approves First Nonprescription Daily Oral Contraceptive

Last week the AZ Board of Pharmacy’s rules allowing Pharmacists to Dispense Contraceptives w/o a Physician Prescription became effective. This week brought a potentially bigger change- FDA’s approval of Opill (norgestrel) – a tablet for nonprescription use to prevent pregnancy. This is the first time FDA has approved a daily oral contraceptive approved for use without a prescription.

Approval of this progestin-only oral contraceptive pill supplies a choice for consumers to buy oral contraceptive medicine without a prescription at drug stores, convenience stores and grocery stores, as well as online.  

From the FDA’s Decision Memo: The potential benefits of an increase in the ability for consumers to prevent unintended pregnancy (with its attendant medical, economic, and societal harms) outweigh the potential risks of the product in the nonprescription setting.

The manufacturer hasn’t identified a launch price – and how big of a deal this is will in large part be tied to the price consumers would pay over the counter for the product.

Decision Memo

Opill Consumer Information

Will Humble Climate Change, Wills Blog

Arizona Joins US Climate Alliance

Governor Hobbs has used her authority as Governor to join the U.S. Climate Alliance. The Alliance is a bipartisan coalition of governors committed to reducing greenhouse gas emissions consistent with the goals of the Paris Agreement. Smart, coordinated state action can ensure that the United States continues to contribute to the global effort to address climate change. 

US Climate Alliance Fact Sheet

Each member state, including Arizona has to commit to:

  • Reduce collective net greenhouse gas emissions 26% by 2025 and 50% by 2030 and achieve overall net-zero GHG emissions by 2050.
  • Accelerating new and existing policies to reduce greenhouse gas pollution, building resilience to the impacts of climate change, and promoting clean energy deployment at the state and federal level.
  • Centering equity, environmental justice, and a just economic transition in their efforts to achieve their climate goals and create high-quality jobs.
  • Tracking and reporting progress to the global community in proper settings, including when the world meets to take stock of the Paris Agreement.
Will Humble Disease Control, Wills Blog

Did the SARS CoV2 Virus Have a Natural or Laboratory Origin? Here’s What the ‘Intelligence Community’ Says:

The COVID-19 Origin Act of 2023 told the U.S. Intelligence Community to declassify information relating to potential links between the Wuhan Institute of Virology and the origin of the COVID-19 pandemic. A summary of that information was recently released by the US government. It came from the Intelligence Community rather than scientists…  so take that into consideration as you read the report.

Report on Potential Links Between the Wuhan Institute of Virology-& COVID-19

There are several sources of Intelligence in the report including the FBI, CIA and many others. Each agency takes a different take on the origins of the COVID-19 pandemic. Those differences “… stem from differences in how agencies weigh intelligence reporting, scientific publications, intelligence and data gaps.”  

The FBI & the Department of Energy think the virus originated via a laboratory-associated incident. The National Intelligence Council and four other intelligence agencies think SARS-CoV-2 was most likely caused by natural exposure to an infected animal.

The CIA was “… unable to determine the precise origin of the COVID-19 pandemic, as both hypotheses rely on significant assumptions or face challenges with conflicting reporting”.

Almost all the intelligence agencies assessed that SARS-CoV-2 was not genetically engineered and that “… both a natural and laboratory-associated origin remain plausible hypotheses to explain the first human infection”.

We’ll probably never really find out the real answer as to the origin of the virus in part because the Chinese Government has been unwilling to fully cooperate with a full investigation of the origin of the virus.

Will Humble Public Health, Wills Blog

AZ Public Health Journalism this Week:

Raising Phoenix: Mind Games – PHOENIX magazine

Antibiotic shortages expected to worsen syphilis epidemic – NYT –

Arizona joins US Climate Alliance after lull in climate efforts (azcentral.com)

Peer-to-peer program supports Arizona teens after suicide attempts (azcentral.com)

Launch of community health worker training program – Arizona PBS (azpbs.org)

Media’s right to private records – Arizona PBS (azpbs.org)

Will Humble Professional Development, Public Health, Wills Blog

Consider Your Public Health Wins

Kelli Donley Williams – AZPHA President

I had the opportunity to sit down with AzPHA member Gordon Jensen and board member Dr. Kara Geren for coffee recently. We came together to discuss AzPHA’s priority in improving firearm safety statewide. While we visited and shared our interest in the work, we also shared the reality that working in public health can often feel thankless. We batted around small wins over the years and how to be personally satisfied with this field, you have to have the ability to celebrate the small joys and recognize when they become big wins.  

Gordon shared with us a quote from Dan Gross, President of the Brady Campaign to Prevent Gun Violence, which ran in “The Nation’s Health in May 2015: “Our goal is not to ban guns any more than the goal of automobile safety is to ban cars. It’s simply to make the products as safe as possible and keep them out of the hands of the wrong people.”  

This comparison brought the three of us to discussing ashtrays as a standard feature in American-made vehicles. We laughed realizing ashtrays in cars are longer the norm. There wasn’t a parade for this design update, or likely even a press release. But it came after decades of public health officials crying for national changes to discourage tobacco use. Think of the countless community coalitions, neighborhood groups, voters, and more who came together to say smoking is a smelly, puking habit.*   

This isn’t a small joy, but a huge win. If you want to smoke in your car today, it is nowhere near as convenient as it once was.  

Whether you’re early in your career in public health, looking at retirement, or like me and somewhere in between, I hope you’ll take a moment to consider your public health wins. You are part of a bigger whole working every day to make our communities stronger, healthier, and better places to live. We’re going to keep banging on the drum and working to build new partnerships to come up with solutions. It may feel thankless somedays, but I’m grateful you’re here.  

*High fives to all Arizona kids who saw these commercials in junior high like I did and immediately swore off ever trying cigarettes. And higher fives to those at ADHS who made that statewide campaign a reality, hopefully forever reducing tobacco rates in Arizona.

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