August 22, 2025
Via Electronic Submission
Thomas Salow, Assistant Director
Public Health Licensing
Arizona Department of Health Services
150 N. 18th Ave., Suite 500
Phoenix, AZ 85007
Stacie Gravito, Office Chief
Administrative Counsel and Rules, Director’s Office
Arizona Department of Health Services
50 N. 18th Ave., Suite 200
Phoenix, AZ 85007
Re: Notice of Proposed Rulemaking for Title 9, Chapter 10, Health Care Institutions: Licensing
Dear Mr. Salow and Ms. Gravito,
On behalf of the Arizona Public Health Association (AzPHA), I am writing in support of the Department’s Notice of Proposed Rulemaking to increase licensing fees for health care institutions.
AzPHA agrees with ADHS that by leaving fees unchanged since January 2010 (when I began my tenure as Director), the Department has not had the necessary financial resources to fulfill its licensing and oversight duties.
For more than 15 years, the revenue generated from health care institution licensing fees has been inadequate to support the staffing, oversight, and enforcement functions that protect the health and safety of patients and residents.
Indeed, when I was Director and we set the licensing fees in 2009–2010, we neglected to include agency indirect in the fee calculation. That omission meant the fees were insufficient even then, and the gap has only widened over the past 15 years.
The revenue shortfall has been unsustainable for nearly a decade, and AzPHA has consistently urged the Department to increase its licensing fees since 2017. Sadly, Directors Cara Christ and Don Herrington ignored our pleas.
These proposed fee increases will allow the licensing division to maintain adequate staffing levels, accommodate inflation and rising technological costs, and prepare for future legal & legislative demands.
Without these changes, the Department’s ability to meet compliance and enforcement responsibilities will continue to erode, impairing financial stability and lead to unaddressed neglect of some of Arizona’s most vulnerable residents.
The consequences of underfunding licensing have been severe. Multiple reports by the Arizona Auditor General from 2019 through 2022 documented gross underperformance by the Department in responding to complaints and inspecting skilled nursing and other care facilities.
Faced with insufficient resources (or because former Director Christ & Assistant Director Colby Bower were unwilling to concede that the Auditor General found gross shortcomings in the Department’s performance), Christ & Bower chose to reclassify more than 95% of high-risk complaints as “low risk,” allowing the agency to delay investigations by up to a year, an indefensible decision that contributed to tragic and lethal outcomes for vulnerable Arizonans.
While those choices were largely the result of unethical leadership decisions during the Ducey Administration, it’s also clear that inadequate funding contributed to the Department’s failures.
AzPHA also commends the Department for preparing an objective and thorough economic impact evaluation as part of this rulemaking. By assessing the financial implications for providers and the Department, ADHS has provided stakeholders with clear, evidence-based justification for these fee adjustments.
This is precisely the kind of data-driven approach AzPHA has long urged the Department to adopt. Since 2017, we consistently advocated both higher fees and transparent economic analyses to prove their necessity.
The fact that ADHS has now conducted such an evaluation reflects a welcome shift toward evidence-based decision-making and accountability… actions that will strengthen both the agency and the public’s trust over time.
This rulemaking will finally provide the financial resources necessary for ADHS to meet its licensing responsibilities. While adequate funding cannot by itself ensure that future administrations will always prioritize health and safety, it does provide the Department with the means to do so.
Importantly, AzPHA now has confidence in the Department’s current leadership. With Mr. Salow as Assistant Director for Licensing and Interim Director Sheila Sjolander on board, we are now assured that the agency has ethical and talented leaders who are committed to restoring public trust and improving agency performance.
We applaud ADHS leadership for advancing this rulemaking and for your commitment to correcting the licensing division’s deficient performance during the Ducey administration.
These fee increases are not only long overdue, but also absolutely essential, and AzPHA strongly supports their adoption.
Sincerely,
Will Humble, MPH
Executive Director, Arizona Public Health Association
Director, Arizona Department of Health Services (2009–2015)
