Will Humble Public Health, Vaccination, Wills Blog

AZ Childhood Vaccination Rates Declined During the Ducey Administration: Is it Bad Luck or Bad Policy & Management?

Childhood vaccination rates in Arizona consistently eroded during the Ducey Administration. The conventional wisdom has been that it was because of a general decline in parental enthusiasm for vaccines. However, more and more it’s looking like it’s because of eroding access to vaccines resulting from the actions of ADHS’ Vaccines for Children program. A primer:

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 (deadline is November 15) and in the spring ADHS is required to publish the data by school. ADHS then published that data. See: Childhood Vaccination Rates Continue to Drop In the 2021-2022 School Year

The news isn’t good. Childhood vaccination rates continuously declined during the Ducey administration with the statewide immunization rate for Kindergarteners now at 91%, well below the community immunity threshold for measles of 95%.

The conventional wisdom and talking points from ADHS leadership during the Ducey era were that parental choice was driving lower childhood vaccination rates. But is that true?

No. It’s increasingly looking like the erosion of access to vaccine for lower income kids is a bigger driver of Arizona’s eroding childhood vaccination rates – making it harder for parents to get their kids vaccinated.

Evidence is emerging that vaccination rates among kids who are Medicaid members has been declining while the rates for non-Medicaid member kids has remained stable. Why would vaccination rates be declining among AHCCCS member kids but not the rest?

The decisions and operational behavior of ADHS’ Immunization Office during the Ducey Administration appears to be a big part of why rates are dropping. ADHS’ over-regulation of the Vaccines for Children program has been running doctors’ offices out of the VFC program…  meaning parents of kids who are Medicaid members are having a harder and harder time finding a time and place to get their kids vaccinated, lowering overall vaccination rates.

Here’s a deeper dive into why:

Vaccines for children enrolled in Medicaid come via the U.S. Vaccines for Children Program. States distribute them to physicians’ offices & clinics that take part in the VFC program. The ADHS manages the VFC program in our state.

Doctor’s offices and clinics are required to be enrolled as a VFC provider by ADHS to take part in the Medicaid (AHCCCS) program…  so, the number of providers enrolled in VFC has a direct impact on the adequacy of a state’s care network for kids enrolled in AHCCCS.

Arizona lost 50% of its Vaccines for Children providers during the Ducey administration, going from 1,200 providers to 600…  reducing access to childhood vaccines & harming AHCCCS network capacity

Why the decline? Anecdotally, providers who left VFC over the last few years say they quit because of the administrative hassles imposed on them by the state during the Ducey administration (ADHS not AHCCCS).

At the top of the list of grievances is ADHS’ punitive practice (during Director Christ’s tenure) of financially punishing providers with wastage rates over 5% making participation financially difficult (see this letter to AZAAP members regarding the former ADHS policy).

Arizona now only has 6 VFC providers per 10,000 Medicaid eligible kids, while the national average is 24 providers per 10,000 Medicaid kids… only 25% of the national average.

The Ducey-era ADHS never conducted an analysis to determine why so many providers have stopped participating in VFC during the Ducey administration. Thankfully, the Arizona Partnership for Immunization has been working with the OMNI Institute to figure out why so many have quit so we can right the VFC ship.

We expect the results of this landmark report to be out this summer… ideal timing for the new ADHS to conduct interventions to right the ship like:

1) Reversing Ducey administration VFC policies;

2) Changing ADHS operational procedures;

3) Making leadership changes at ADHS’ Immunization Office; and/or

4) Exploring moving VFC to AHCCCS.

Related:

 

Will Humble Professional Development, Wills Blog

Share Your Talent with Arizona: Consider Serving on a Board or Commission

Perhaps now that we have new leadership in the Governor’s Office you also have a renewed interest in serving on one of the many Boards and Commissions in Arizona? Serving on a board or commission gives you a chance to make a significant contribution to the governance of Arizona by lending your experience, judgment, and ability. Here’s some background about ways you can serve.

Board & Commissions are independent bodies consisting of members who are appointed by Governor Hobbs (there are a few exceptions however). Appointments are created statute enacted in the State Legislature or by an Executive Order.

There Are 220 Active Boards & Commissions in Arizona:
Boards and Commissions List

There are two types of boards and commissions: regulatory and advisory. Regulatory boards oversee the licensing, handle complaints, and enforce disciplinary actions of individuals or industries that fall within the jurisdiction of the board’s authority. For example, a complaint filed by a patient against a physician would be reviewed, investigated, and appropriately acted upon by the Arizona Medical Board.

Advisory boards, develop policy and makes recommendations to public officials on how to address specific issues. For example, the Civil Rights Advisory Board investigates and holds hearings on infringements of Arizona civil rights laws and then advises the civil rights division of the Attorney General’s Office.

Time commitment varies depending on the board. Most boards meet once a month for four to six hours, with some added preparatory work needed. However, there are many boards that meet quarterly or even as little as twice a year. Most Board members serve terms that range from two to seven years for most boards and commissions, while other members serve ‘At the pleasure’ of the Governor.

How to Apply

You can apply online from the Governor Hobbs’ Boards & Commissions Website. In the application you can describe the kinds of boards you’re interested in. A vacancy list is also available on the Governor’s Boards and Commissions Website which is updated monthly with current board positions.

Submit an Application
Will Humble Professional Development, Wills Blog

AzPHA Career Center: An Opportunity to Advance Your Career?

Finding the right talent and candidates seems to be getting harder in today’s competitive job market. Having those open positions in your organization is costing time, energy, and productivity. Posting your open jobs with the AZPHA Career Center is the best solution to get your positions in front of a niche audience, allowing you to create a pipeline of talented and serious candidates.

Posting on the AZPHA Career Center provides exposure to reach over 27,000 members and job seekers. There’s also a national clearing house for public health jobs at www.publichealthcareers.org.  

Will Humble Professional Development, Wills Blog

Deepen Your Public Health Commitment: Become a Civic Health Fellow!

Vot-ER is a nonpartisan, nonprofit organization working to integrate civic engagement into healthcare. 

Vot-ER is accepting applications for its next cohort of Civic Health Fellows. During the seven-month program, fellows train with experts in civic engagement, health equity, and community organizing (including a Nobel-nominated activist!) and work in teams on a voter access project in their community.

The priority application deadline is March 15th and the final deadline is April 1. Financial aid is available. Apply at vot-er.org/fellowship

Will Humble AzPHA Breakfast & Learns, Firearm Safety, Public Health, Wills Blog

AZPHA Breakfast & Learn – Gun Violence in Arizona: Data to Inform Prevention Policies

Friday, March 24, 2023 from 9-10am

Gun Violence in Arizona:
  Data to Inform Prevention Policies
Our Speaker:

Allan N. Williams, MPH, PhD Adjunct Assistant Professor, University of Minnesota School of Public Health Retired, Chronic Disease & Environmental Epidemiology, MN Dept. of Health

______

At a 2022 strategic planning retreat the AZPHA Board of Directors committed to putting resources toward improving community health by advocating for evidence-based policies to stem the tide of increasing firearm injuries in Arizona.

The first step in that process was to develop comprehensive firearm injury epidemiology and an evidence-review of effective interventions.

During this hour-long webinar, our speaker and a primary author of our landmark report Gun Violence in Arizona: Data to Inform Prevention Policies will present the major findings from our report which will:

  • Identify and review the relevant literature on gun violence;
  • Identify and utilize available key data sources for gun violence;
  • Define the human and financial toll of gun violence in Arizona;
  • Characterize the different forms of gun violence including suicide, homicide, police shootings, and unintentional shootings;
  • Characterize the demographics of gun violence by age, gender, race/ethnicity, and urbanicity;
  • Compare gun violence rates in Arizona to rates in other states and the U.S.;
  • Identify gun laws and policies that have been shown to reduce gun violence; and
  • Show where Arizona stands with respect to key gun laws.
View the Webinar Here
Passcode: 5%kfz^tF
View the Webinar PPT Slides
Will Humble State Legislature, Wills Blog

Legislative Update: March 12, 2023

The action in the legislature last week was dominated by floor votes (3rd Read) in the House and Senate. A handful of the bills that we’re in favor of advanced to the other chamber. You can view this updated PowerPoint with the 30 or so bills on our short list and our Excel file bill tracker managed by our interns.

The public health highlight last week was House approval of HB2338 which would provide preventive dental services to adult Medicaid members. Prior to the 2009 recession, Medicaid members (including adults 21 and over) had a dental benefit. All dental services for folks 21 and over were eliminated that year.

Over the last few years we’ve made incremental gains, first by restoring an emergency dental benefit for persons with disabilities and later an emergency benefit capped at $1K/year for all adult members. 

HB2338 still needs to be successful in the Senate and then get baked into the budget for this important public health gain to be realized. JLBC estimates the benefit would increase AHCCCS General Fund formula costs by $3.5M and that the Hospital Assessment match fund would need to go up $3.8M.

Sadly, a floor amendment by Rep. Gress (Ducey’s former budget director) specifies that the Hospital Assessment Fund can’t be used for preventive dental care services, reducing the chances this will end up in the final budget.

Committee Work this Week

Committees are meeting this week including House & Senate Health, but their agendas are pretty thin. See the Senate Health & House Health agendas.

The only bill I’m signed up to speak on this week is HB1710 in House Health (the bill that would extract the Arizona State Hospital from ADHS): Good Bill Moving the AZ State Hospital Out of ADHS to an Independent Governing Board Up in House Health Committee Monday

Will Humble Uncategorized

Legislative Update: Early March

State Legislature Committees didn’t meet again last week as both chambers focused on floor action. Floor action in the House ground to a halt last Tuesday afternoon when the House Republican caucus decided that no bills sponsored by Democrats will be brought to the floor unless a majority of Republicans express support for the bill, essentially requiring a super-majority for any bill sponsored by a Democrat.

In response, the House Democratic caucus began voting NO on every bill brought to the floor, which would stop any bill not supported by every single Republican (and with no absences). The House continued with Committees of the Whole, but it is still unclear how many bills may move to a full floor vote if the Democratic caucus continues to withhold their support for all bills until the process changes.

The Senate cleared quite a few bills this week and sent them over to the House to begin the process all over again before the next deadline of March 24 when bills must be heard in committee in their opposite chamber.

Here our 2023 Legislative Session Working Powerpoint. I’ll update this ppt each week to keep it accurate – a particularly challenging task when the Strike All Amendment gets in full swing. You can also follow public health related bills on this  Excel File tracker.

Will Humble Health Equity, Healthcare, Wills Blog

Valleywise Health Begins Countdown to Opening of New Medical Center

After officially breaking ground on the brand new 673,000 square-foot, 10-story Valleywise Health Medical Center three years ago the public teaching health system is proud to announce the countdown to the grand opening in October. Valleywise Health is a top-level Organizational Member of AZPHA.

The new medical center will replace the more than 50-year-old facility Valleywise Health is currently running in at 24th Street and Roosevelt.  The new building is 75% complete and on budget. The exteriors and infrastructure (power, water, HVAC, medical gasses, etc.) are nearly complete and final trim for the mechanical, plumbing and electrical work is ongoing.  

Over the course of the last three years, Valleywise Health has also constructed and opened five new community health centers in South Phoenix/Laveen, North Phoenix, Peoria, West Maryvale and Mesa. Each center provides access to primary and pediatric care, integrated behavioral health services and on-site pharmacy to for patients in need.

fosemckay Firearm Safety, Wills Blog

Firearm Violence in Arizona: An Avoidable Public Health Crisis

 – Guest blog by Julia Jackman, B.S., B.A., MSc Candidate in Global Health Fulbright Study & Research Grantee, Norwegian University of Science & Technology 

1,265 Arizonans.

1,265 lives cut short.

1,265 families with a missing seat at the dinner table.

1,265 deaths due to firearms in 2020 alone.
A Growing Problem in Arizona: Suicides, Homicides, Police Shootings, Mass Shootings, and School Shootings

Firearm violence is one of the leading causes of death among both adults (11th) and children aged 1-19 (2nd) in Arizona. These deaths are preventable. They are the result of inequality, inadequate and dangerous policies, and a culture deeply concerned with personal rights and individualism.

Contrary to popular belief, aggravated gun violence (i.e., gun homicide/murder) is not the primary driver of firearm mortality in Arizona; in fact, from 1999-2020, 65% of firearm deaths were due to suicide. Homicides made up about 31% of deaths, and police shootings, unintentional, and undetermined deaths made up the remaining 4% of deaths.

View Our Full Report: Firearm Violence in Arizona: Data to Inform Prevention Policies

These deaths don’t come out of nowhere. The U.S. leads the world in gun ownership per capita and household gun ownership is consistently associated with rates of firearm suicides, homicides, and accidental shootings.

Rates of firearm mortality are on the rise in Arizona. Firearm suicides have been increasing by 1.2% per year since 2005; rates of firearm homicides have been increasing by 7.1% per year since 2014; and rates of police shootings have been increasing by 4.0% per year from 2000-2021.

Nationally, school shootings have been increasing by 30% per year since 2011; in Arizona, there have been more school shootings in the first three years of this decade than in any previous decade.

Arizona has witnessed 20 school shootings at 19 schools since 1970, with the majority occurring since 2010. Mass shootings have also been on the rise; nationally, rates have increased by 153% since 2014.

The problem is pervasive and unrelenting, with 2020 bringing an average of 7 nonfatal firearm injuries and 3.5 fatal firearm injuries per day in Arizona. While detailed data on firearm deaths are readily – and freely – available at the state and national level from government and independent sources, there is no comparable complete data source on nonfatal firearm injuries for the U.S.

View Our Full Report: Firearm Violence in Arizona: Data to Inform Prevention Policies

Nevertheless, we found that non-fatal firearm injuries greatly outnumbered fatal injuries in Arizona; without publicly accessible granular data, it is very difficult to determine upon which populations this burden is greatest. This highlights the need for more funding in the area of gun violence research to better understand the distribution of firearm injuries.

A Social Justice Problem

As with nearly every other health outcome in the United States and Arizona, sociodemographic disparities are present in firearm deaths in Arizona.

Homicides disproportionately impact non-Hispanic black people. When compared to the Asian and Pacific Islander population (the least at-risk group in Arizona), non-Hispanic blacks experienced an 8.6-fold increased risk of firearm homicide.

This trend is in line with national data showing that residential segregation and structural violence may contribute to the disproportionately high rates of gun homicide in U.S. Census tracts with a higher proportion of black residents. Disaggregating the data by sex shows that males had significantly higher rates of gun homicide across all racial and ethnic groups.

Suicides, on the other hand, peak in non-Hispanic white males older than 85 years old. Both old age and white race drive this trend; the rate among men over 85 is 24x higher than the rate for females of the same age category, and the rate among non-Hispanic whites was double the rate of every other racial group.

Hispanic Arizonans are also at a much higher risk of firearm mortality when compared to Hispanic Arizonans in all other states—in fact, Hispanic Arizonans have the highest rate of firearm homicide of Hispanic populations in any other state.

Police shootings almost exclusively affected males, who accounted for 94% of all fatal police shooting victims. Both black and indigenous populations were overrepresented in police shootings relative to their percentage of the population.

Financial Costs of Gun Violence in Arizona

The human toll of gun violence clearly paints a dramatic problem; nevertheless, the financial toll of gun violence is also extraordinary. The CDC calculates estimates for the total value of a statistical life (i.e., cost of death prevention) due to firearm mortality.

In Arizona in 2020, this figure was more than $8.03 billion for suicide and $4.45 billion for homicide. Everytown for Gun Safety creates a more comprehensive estimate that also includes non-medical costs like property damage, criminal justice proceedings, and loss-of-work costs. This total societal cost estimated for Arizona in 2019 was nearly $16 billion, which totals about 4.3% of Arizona’s total GDP.

A Path Forward

So, how do we fix this? It won’t be easy, and the road in Arizona is not yet paved, but we can look to the blueprints used in other states and countries that have reduced gun mortality.

View Evidence Based Policy Interventions in Our Full Report:

Firearm Violence in Arizona: Data to Inform Prevention Policies

Based on the evidence outlined in the report, we have selected five evidence-based policies, listed below, which, if implemented, could have a significant impact on gun violence in Arizona.

Notably, many of the above policies are highly supported by the public. A January 2021 memo from Giffords and Everytown found that 93% of those surveyed supported “requiring background checks on all gun sales” (from a national sample of voters in the 2020 election and voters in battleground House districts).

Additionally, according to a 2021 survey of gun owners and non-gun owners, requiring a permit for concealed carry is a popular policy, with only 20% of Americans supporting completely permitless concealed carry. The same study showed that 74% of respondents also agreed that conceal carry permit applicants should also have to “pass a test demonstrating that they can safely and lawfully handle a gun in common situations they might encounter.” The public supports commonsense measures—do our elected state representatives?

Firearm safety legislation has been implemented in states around the U.S., with much success in curbing gun violence mortality. The figures below show that firearm mortality in A-rated states (i.e., states with comprehensive firearm violence prevention legislation) have lower firearm mortality rates among all racial and ethnic groups than F-rated states such as Arizona, which lack firearm safety legislation.
I think of the Swiss cheese model of harm when I think of firearm violence prevention. (A more in-depth explanation of the model can be found here). The idea behind this model, which was widely used to describe COVID-19 precautions, is that multiple layers of protection are vital to address public health concerns and that no single prevention measure will work perfectly. There will never be a panacea to the gun violence public health crisis.

We need many forms of protection, ranging from conversations about gun safety in our families and communities, advocacy for common sense legislative action, and relentless attention to the tragic deaths that occur every single day. As shown in the political cartoon, ending gun violence requires many puzzle pieces which include legislation, community engagement, mental health financing, and research funding, among other interventions.

See Evidence-Based Interventions in Our Full Report

We cannot come to the point where yet another shooting on the nightly news is just background noise. We cannot become complacent. We must mourn the victims and vow to stop the epidemic. Neither policy action nor mortality decreases will happen overnight, but through deliberate, concerted, and committed actions, change is possible, if only we are willing to act. These deaths are not inevitable.

Let’s work together to ensure that 1,265 more Arizona families don’t have to eat around a dinner table with an empty chair next year or any year to come.

Citations for all data can be found in the report, linked here. If you or someone you know is experiencing suicidal thoughts or mental health-related distress, call or text 988 for the Suicide and Crisis Lifeline, a free and confidential support line available 24/7/365. You are not alone.

AZPHA-Gun Violence Presentation
Will Humble Community Health Workers, Medicaid, Wills Blog

Community Health Worker Medicaid Reimbursement Begins April 1

Last week the Centers for Medicare & Medicaid Services approved AHCCCS’ request to begin reimbursing Community Health Workers for services provided to Medicaid members. CHWs are an integral and essential part of the health care delivery system, often at the front lines of the intersection between communities and health care providers.

CHWs often are also known by other names, such as Community Health Representatives, Patient Navigator, Promotores de Salud, Community Health Advisors, and Cultural Health Navigators, to name a few. Approval to reimburse CHWs for services is effective April 1, 2023.

Last week’s action brings full circle to the multi-year effort to build a reimbursement pathway for CHWs in Arizona. Way back in 2016 a group of stakeholders including AZPHA began pressing to give the ADHS the statutory responsibility to certify CHWs, a pre-requisite for reimbursement under Medicaid.

We succeeded in getting that authority in 2018 when the Arizona Legislature passed House Bill 2324, requiring ADHS to establish qualifications, a scope of practice, and core competencies for Certified Community Health Workers. That bill was successful due to the tenacious work be then Representative Heather Carter. See the ADHS Community Health Workers web page.

Starting April 1, 2023, AHCCCS and their contractors will be able to reimburse certified CHWs when their services are recommended by a physician or other licensed practitioner of the healing arts acting within the scope of authorized practice.

Services must be documented in the member’s medical record and may include health system navigation and resource coordination, health education and training, and health promotion and coaching.

AHCCCS has three billing codes for CHW’s: 98960- patient education & training for 1 patient for 30 minutes; 98961- for a group of two to four patients; and 98962- or a group of five to eight patients.

CHW Certification Portal Now Open

Arizona’s Community Health Workers can apply for voluntary certification once they show they meet the standards and have successfully completed an approved training program. Here is the ADHS certification portal. ADHS is using a federal grant to temporarily bring the certification fee down to $1, but that will end when the grant funding ends. Applications are fully electronic and available at azhealth.gov/CHW.

Report: Building Community Health Workers into the Continuum of Care

How to Get Your CHW Training Program Certified

The Tumblers Click: Community Health Workers Entering Arizona’s Care Network at Scale

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