Shelby Behavioral Health

SAHMSA to Distribute $3 Billion in American Rescue Plan Funding for Substance Abuse and Mental Health

ARIZONA’S (AHCCCS’) SHARE WILL BE ROUGHLY $80M

SAHMSA’s Community Mental Health Services Block Grant Program and Substance Abuse Prevention and Treatment Block Grant Program will be dispersing $1.5B  billion each to states. This supplemental funding is an addition to the usual $2.5B award. Here’s a press release and information on the supplemental awards.

Back in the day, these SAHMSA substance abuse funds were managed by the ADHS. These days they’re managed by AHCCCS’ Substance Abuse Prevention and Treatment Block Grant.: FY 2021 Substance Abuse Prevention and Treatment Block Grant Program American Rescue Plan Supplemental Awards

Yet another pot of money for the system to keep their eye on to ensure that it is used in evidence-based ways.

Shelby Community Health Workers

Voluntary Certification Rules for Community Health Workers

Community Health Workers are frontline public health workers who have a trusted relationship with the community and are able to 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 3 years ago with the passage of HB 2324, which charged the ADHS with implementing a program for the voluntary certification of Community Health Workers. After 3 years of anticipation (and advocacy trying to get the ADHS to write the rules) the agency finally released draft rules for the voluntary certification of community health workers last week.

HB 2324 was very prescriptive so the rulemaking by ADHS is pretty straightforward and there isn’t that much discretion or decision-making involved in the Rule. The draft rule package (open for public comment through June 6 includes:

The scope of practice and the core competencies of certified community health workers;

  • Qualifications for certified community health workers;

  • Requirements for community health worker’s education and training programs;

  • Standards and requirements for continuing education courses;

  • Education, training, experience and other qualifications for trainers;

  • Criteria for granting, denying, suspending, and revoking a certificate; and

  • Certification application fees.

The draft rules are open for public comment through June 6.

Shelby Disease Control

Dr. Gerald’s Final COVID-19 Epidemiology & Hospital Capacity Report

Ever since the beginning of the pandemic, Dr. Joe Gerald at the UA’s Mel and Enid Zuckerman College of Public Health has been writing weekly reports that have been super-valuable for hospital systems, county health departments, clinicians, schools, nursing homes and assisted living centers, other university researchers, journalists and the general public.

ADHS senior leadership appears to have taken little heed of his important findings each week – but the rest of the public health system eagerly awaited each weekly epidemiology and hospital capacity report.

This weekend Dr. Gerald published his final weekly report. I personally want to thank Dr. Gerald for his incredible work over the last year as he helped all of us to understand where we were and where we were likely going (epidemiologically). He also frequently provided sound advice for mitigating spread.

Here is Dr. Gerald’s summary of this week’s report. As always, we encourage you to view the full report and Appendix for details and context.

Arizona continues to chug along with COVID-19 case rates >50 cases per 100,000 residents per week (looking at you Maricopa County). As mentioned last time, the ASU COVID-19 Modeling group estimates the doldrums to continue for most of the summer before materially improving. This is the result of continued normalization of behavior, more prevalent highly-transmissible variants, and slowing vaccination rates.

Even though too many Arizonans are not fully vaccinated as we would like, another summer resurgence seems off-the-table. That doesn’t mean though we won’t experience thousands more COVID-19 cases and hundreds more COVID-19 deaths over the summer. So, please get vaccinated if you haven’t already.

As mentioned last time, this is my last regularly scheduled COVID-19 update. If something unforeseen develops, I’ll be sure to let you know. I would like to thank you to everyone who has been reading these reports and dropping me notes of encouragement!

If you would like to show your appreciation, please feel free to send an e-mail to my Department Chair, Dr. Kelly Reynolds (reynolds@arizona.edu) letting her know how these reports have been valuable to you or your organization.

I hope you have a safe and enjoyable summer!

Shelby Federal Public Health Bud

Arizona Has Received More than $1B in Pandemic Response Funding

WHERE HAS IT ALL GONE?

Congress has allocated unprecedented funding to state health departments to respond to the pandemic. Most of that money was allocated to CDC who then passed those funds to state governments (mostly state health departments). State agencies then decide how much of those funds to keep for themselves and how much to pass through to the county health departments and other stakeholders and entities.

This week the CDC posted a new tool that discloses how much each state has received from each funding category. You can search the new tool by state, congressional act, name of the funding award, and funding category. Under each of those categories, you can drill down more deeply into the programmatic areas that have received the money.

Of course, CDC doesn’t tell you the ultimate destination of the money in each state. Because our individual state agencies have not been transparent about how these funds have been spent (little is available on the ADHS or other state agency websites about the uses of these funds), one would need to search the ADOA’s State Procurement Office website to find out who has received these funds, what the funds were spent on, and how many of the contracts were ‘no-bid’ (like this multi-million dollar ADHS no-bid ‘competition impractical’ contract to Diaz and Associates).

So far, state government (mostly the ADHS) has received more than one billion dollars ($1,000,000,000) from the CDC from various supplemental funding initiatives. State government and the ADHS have received this funding through:

  • The Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 ($485,000,000);

  • American Rescue Plan Act of 2021 ($362,000,000);

  • Paycheck Protection Program and Health Care Enhancement Act ($151,000,000);

  • Coronavirus Aid, Relief, and Economic Security Act ($24,000,000); and

  • Coronavirus Response and Relief Supplemental Appropriations Act, 2021 ($24,000,000).

As I mentioned, we don’t know how these funds were used, what entities received them, and how much of the money has been allocated and spent.

However, an enterprising journalist interested in government accountability could become an expert in the state’s procurement website and shed some light on this important topic for the people of Arizona.

Shelby Marijuana

Adult Use Marijuana Dispensary “Social Equity” License Rules In the Home Stretch

SEE OUR POWERPOINT SUMMARIZING THE RULE PROCESS AND THE NEW DRAFT RULES

The authors of the Smart and Safe Arizona Act (aka Adult Use Marijuana) included an opportunity for persons “ from communities disproportionately impacted by the enforcement of previous marijuana laws” to be able to compete for 26 new licenses to own and operate a “marijuana establishment”.

The statutory language that the voters approved was very open-ended and gives wide discretion to ADHS to decide how to allocate those licenses including developing the specific criteria. A couple of weeks ago the ADHS released their initial draft rules fleshing out what criteria they will use to decide who qualifies to apply for these new coveted licenses. After a brief comment period, they released a new draft set of rules yesterday, with a comment period that ends on Monday.

In a nutshell, the newest draft rules set forth the criteria for who qualifies to apply for the licenses. Applicants must be a resident of Arizona for 3 of the last 5 years and meet 3 of the following 5 criteria:

  1. Had a household income in at least 3 of the previous 5 years less than 400% of the federal (HHS) poverty level;

  2. Convicted of and eligible for expungement of eligible for possession of marijuana conviction under A.R.S 36-2862 (less than 2.5 oz of Cannabis);

  3. Have a spouse, surviving spouse, parent, child, sibling or legal guardian who was convicted of a violation of federal or state laws related to marijuana or marijuana paraphernalia;

  4. Have lived for at least 3 of the last 5 years in a “community that has been disproportionately affected by the enforcement of Arizona’s previous marijuana laws” (These criteria are still being developed and will be added in a subsequent iteration of the rules prior to September 1, 2021); and/or

  5. Completed an ADHS approved educational training course.

Principal officers & board member applicants cannot have had an “A.R.S. § 36-2801 felony offense (with some exceptions – see the PowerPoint) and must be eligible for a Level I fingerprint clearance card under A.R.S. § 41-1758.07.

Additionally, applicants must show that principal officers and board members cannot be removed from their position without the written consent of the principal officer or board member or a court order for removal of the principal officer or board member.

No principal officer or board member can be a principal officer or board member on any other marijuana establishment license application.

Applications would be accepted during the first 2 weeks of this December and would be awarded by the end of the year.

The comment period ends Monday and the agency will release the final rules by June 1. The ADHS Draft Rules for Social Equity are posted and comments are being accepted through Monday, May 24, 2021. Here’s a link to the Online Survey.

The Marijuana Industry Trade Association will be holding a webinar this afternoon from 3-5pm to explain the latest draft regulations. It’s free and you can join here.

SEE OUR POWERPOINT SUMMARIZING THE RULE PROCESS AND THE NEW DRAFT RULES

Shelby Federal Public Health Bud

American Rescue Plan Act Begins Providing Resources to Address Health Disparities

TREASURY DEPARTMENT RELEASES FUNDING DETAILS FOR STATE AND LOCAL RELIEF FUNDS

The American Rescue Plan Act is landmark legislation that will provide significant resources with which to address the social determinants of health and to reinforce the public health workforce.

The mere fact that there are additional resources being provided doesn’t mean that we will see improvements in the field. That will only happen if our elected and appointed officials that will control these funds use them in evidence-based ways that have a high return on investment. Whether that will happen in Arizona remains to be seen.

The Joint Legislative Budget Committee made some estimates based on the finding formula. They estimate that Arizona will receive about $12B.

State government will receive $4.8B between now and December 31, 2024 (much of the funding will be available to the next governor as Governor Ducey will be gone in January 2023).

The $4.8B (spread out over 4 years) can be used “… to respond to COVID-19 or its negative economic impacts, premium pay to essential workers, lost revenues, and broadband infrastructure.”

On Monday, the U.S. Treasury Department released details on how states and cities can spend the money. Here’s is a link to the Treasury Department’s guidance and their proposed interim final rule.  The Treasury Department began accepting applications this week from states and cities for $350B in relief funds. There are 4 broad categories that Treasury says the money can be used for:

  • Address systemic public health and economic challenges that have contributed to the unequal impact of the pandemic.

  • Support urgent COVID-19 response efforts to continue to decrease spread of the virus and bring the pandemic under control.

  • Replace lost revenue for eligible state, local, territorial, and Tribal governments to strengthen support for vital public services and help retain jobs; and

  • Support immediate economic stabilization for households and businesses.

Specifically, Treasury’s new interim rules say states and cities can use the money to:

  • Support public health expenditures, (for example, funding COVID-19 mitigation efforts, medical expenses, behavioral healthcare, and certain public health and safety staff);

  • Address negative economic impacts caused by the public health emergency, including economic harms to workers, households, small businesses, impacted industries, and the public sector;

  • Replace lost public sector revenue, using this funding to provide government services to the extent of the reduction in revenue experienced due to the pandemic;

  • Provide premium pay for essential workers, offering additional support to those who have and will bear the greatest health risks because of their service in critical infrastructure sectors; and

  • Invest in water, sewer, and broadband infrastructure, making necessary investments to improve access to clean drinking water, support vital wastewater and storm water infrastructure, and to expand access to broadband internet.

Key documents from the Treasury Department’s Coronavirus State and Local Fiscal Recovery Funds webpage include:

Editorial Note: County health departments and even the ADHS have developed state and county health improvement plans that outline resource and intervention priorities to reduce health disparities. We urge the ADHS to USE those county and state health improvement plans to guide decision-making as they apply for these funds.

We sincerely hope that Director Christ will (over the next 19 months) prioritize Rescue Act resources based on the needs identified in county health improvement plans.

It would be a huge missed opportunity if the ADHS were to allocate Rescue Act funds to reward obedient stakeholders or political allies of the governor rather than resource the objectives outlined in the state and county health improvement plans.

Shelby Health Equity, Prevention, Social Determinants

AzPHA Support Letter for AHCCCS Draft Housing Waiver

AHCCCS is in the process of requesting an amendment to Arizona’s  1115 “Research and Demonstration Waiver” to enhance and expand housing services and interventions for AHCCCS members who are homeless or at risk of becoming homeless. The goals are to:

  • Increase positive health and wellbeing outcomes for target populations including the stabilization of members’ mental health conditions, reduction in substance use, improvement in the utilization of primary care and prevention services, and increased member satisfaction,

  • Reduce the cost of care for individuals successfully housed through decreased utilization of crisis services, emergency department utilization, and inpatient hospitalization, and

  • Reduce homelessness and improve skills to maintain housing stability.

The waiver is too involved to summarize here, but you can read the full draft proposal on the AHCCCS website. I just submitted AzPHA’s support for the waiver. You can read our support letter here.

The proposal is thoughtful and evidence-based. In our letter, we commended the AHCCCS leadership team for embracing new opportunities to improve the health of your members.

Shelby Community Health Workers

White House Announces $7.4 Billion Investment in Public Health Workforce

VARIOUS PROGRAMS TO PROVIDE SUBSTANTIAL RESOURCES TO SUPPORT ARIZONA’S PUBLIC HEALTH WORKFORCE

The White House released a fact sheet and statement to announce a significant immediate and long-term investment in the public health workforce. The $7.4 billion in funding is split into two parts. About $4.4B of the $7B will be targeted toward state and county health departments to hire staff “to support COVID-19 response efforts”

The other $3B will be used to create a new grant program that will “facilitate federal investment in the people and expertise needed at the state and local levels to expand, train, and modernize the public health workforce for the future.”

With a nod to health equity, the CDC stated that “All awardees of this American Rescue Plan funding will be asked to prioritize recruiting individuals from the communities they will serve and from backgrounds underrepresented in critical public health professions. Here’s the fact sheet released by the White House about the initiative.

FUNDING TO HIRE PUBLIC HEALTH WORKERS

The top line announcement says that $4.4B These programs are divided into support for state and county health departments, money to hire school nurses, creating a Public Health AmeriCorps, boosting the Epidemic Intelligence Service, and enhancing the public health laboratory workforce.

Public Health Department Staffing

$2B of the $4.4B is targeted toward programs “to expand the public health workforce to support vaccinations, testing, contact tracing, and community outreach”.  CDC’s announcement specifically identifies contact tracing, case management, and support outbreak investigations as core uses for those funds. Arizona’s 2-year allocation is $43,570,409.

This summary by the Association of State and Territorial Health Officials (ASTHO) says that the goals are to establish, expand, train, and sustain the public health workforce to support jurisdictional COVID-19 prevention, preparedness, response, and recovery initiatives, including school-based health programs. CDC expects public health agencies to use the money to recruit, hire, and train personnel to address projected jurisdictional COVID-19 response needs over the performance period, including hiring personnel.

CDC recommends that states use CDC’s Social Vulnerability Index data and tools to inform jurisdiction COVID-19 planning, response, and hiring strategies. CDC expects that at least 25% of the jurisdictional award will support school-based health programs, including nurses or other personnel.

Of the remaining 75% CDC expects that at least 40% will support local hiring through local health departments or community-based organizations.

The allowable costs, deliverables, metrics, and allowable activities are all presented by ASTHO in CDC’s Crisis Response Cooperative Agreement: COVID-19 Public Health Workforce Supplemental Funding Guidance.

Editorial Note: Ideally, Arizona would elect to do something creative with these funds that would have a longer lasting impact that just short-term hiring of public health staff. For example, we could potentially make changes to the Arizona Loan Repayment Program to add public health workers to the list of qualifying professions. These federal funds could be used to finance a new loan repayment program in exchange for a commitment by new MPH graduates to work in a rural county health department for a few years. There are probably other good ideas- my point is I’d love to see something more creative then just shoveling out money for short-term staff (especially when you consider that the waning days of the pandemic are here and the need for contact tracing and the like are becoming less acute).

School Nurses

CDC is also targeting an additional $500M “… to hire school nurses to help schools safely reopen and remain open for in-person instruction”. Arizona’s proportionate share of those funds would be about $10M, which would be enough to hire about 150 school nurses for one year. It’s unclear whether that money would go to the Arizona Department of Education or the ADHS.

Public Health AmeriCorps

About $400M of the $4.4B will go toward creating a Public Health AmeriCorps. This will be a partnership between CDC and AmeriCorps. The goal is to “… build a diverse pipeline for the public health workforce and provide direct service to communities across the country”. AmeriCorps says this will fund 5,000 Public Health AmeriCorps positions over the next 5 years. Grants will be awarded through a competitive process with the first competition this fall.

Epidemic Intelligence Service

CDC is allocating $245M of the $4.4B to increase funding for the Epidemic Intelligence Service, the Undergraduate Public Health Scholars Program, and the Emerging Infectious Diseases RISE Fellowship, which offers students from underrepresented background the opportunity to study infectious diseases and health disparities.

Public Health Laboratory Workforce

About $337M will be used to strengthen the public health laboratory workforce pipeline by expanding fellowship programs and implementing a new program for undergraduate students to gain experiences in public health laboratory settings.  These funds don’t look to me like they will be flowing directly to state health department labs.

GRANTS TO EXPAND THE FUTURE PUBLIC HEALTH WORKFORCE

The other portion of the $7.4B is a $3B allocation to “… create a new grant program that will facilitate federal investment in the people and expertise needed at the state and local levels to expand, train, and modernize the public health workforce for the future”.

This new (and large) grant program will “… provide under-resourced health departments with the support they need to hire staff and build a strong public health workforce”.  This grant program will offer community health workers and others hired for the COVID-19 response an opportunity to continue their careers beyond the pandemic as public health professionals.

CDC will be convening federal, state, local, and territorial public health experts to inform the design and focus of this new grant program. CDC says the goal of the program is to support the nation’s public health infrastructure, particularly in lower-income and underserved communities.

Shelby Air Quality, Climate Change

Clean Energy Rules Go Down the Drain

The Arizona Corporation Commission voted down the clean energy rules last week. Those rules, had they been adopted by the Commission would have required state-regulated utilities to get 100% of their power from carbon-free sources by 2050.

Back in April, the Administrative Law Judge presiding over the formal rulemaking issued her recommended opinion and order which recommended approving the rules.

At the May 5 meeting, Commissioner Olson proposed amendments that would have changed the Rule’s requirements for carbon-free electricity, energy efficiency, peak demand reduction, and distributed storage into voluntary goals. The amendment was supported by Chairwoman Marquez Peterson and Commissioner Jim O’Connor.

Once that amendment passed, Commissioners Sandra Kennedy and Commissioners Anna Tovar voted with Olson against the full Rules package (which had become meaningless really) and the entire package failed by a vote of 3-2.

AzPHA, environmental organizations, utilities, industry, and consumer advocates had all aligned  in support of the Rules as originally drafted and we all expressed their disappointment with the Commission outcome on social media.

This very disappointing outcome came after years of work, multiple public meetings and workshops, dozens of supportive studies, and thousands of public comments all in support of the Rules as originally drafted.

Before the Commission’s vote took place,~30 diverse public commenters including large businesses, faith leaders, and more urged the Commission to move forward with the Rules expeditiously and without amendment.

This isn’t the end. The good work that all the stakeholders did to get this going still exists. The question becomes what strategy to use next.

Shelby Healthcare

Landmark Telemedicine Bill Big Boost to Access to Care

In some ways Arizona has been leading the way in terms of leveraging telehealth as a means of improving access to care. The UA Telemedicine program was established 25 years ago and has successfully built infrastructure and partnership agreements that has laid groundwork to bring telehealth to the next level.

COVID-19 provided a big push to use telehealth in a more widespread way, including within AHCCCS. Executive orders early on pushed health plans to pay for appropriate telehealth services. A new law passed and signed last week (HB 2454) locks in telehealth services for the future, expanding statewide use of virtual video and audio doctors visits.

It’s a long bill – but the opening line gives you a sense of what it does:

All contracts issued, delivered or renewed on or after 7 January 1, 2018 in Arizona must provide coverage for health care services that are provided through telehealth if the health care service would be covered were it provided through an in-person consultation encounter between the subscriber and a health care provider and provided to a subscriber receiving the service.

The new law:

  • Ensures doctors receive equal compensation from insurance companies for telehealth services.

  • Allows out-of-state health care providers to practice telehealth in Arizona.

  • Ensures payment parity for audio-only medical visits for patients without internet access.

  • Prohibits health care boards from enforcing any rule that requires a patient to visit in-person before being prescribed most medications.

Importantly, there are no exemptions for our Medicaid program, so telehealth can become an increasingly important way to reduce health disparities especially in rural and underserved areas with thin network access.

Perhaps Dr. Ronald Weinstein (founding director of the University of Arizona’s Arizona Telemedicine Program and a president emeritus of the American Telemedicine Association) said it best in this article from the Arizona Republic yesterday:

The UA’s Arizona Telemedicine Program is 25 years old, but telehealth has been around even longer, Weinstein said. Until the pandemic, efforts to get telehealth more widely used have been hindered by regulations and reimbursement challenges, he said.

“It’s really been held with a brake on it for 50-plus years and waiting to be proven,” he said. “COVID came along, and social distancing and so forth, and within a month the amount of telemedicine being done in the United States went up about 3,000%.”

The rapid removal of the regulations and fragmented payments that had been holding telehealth back is what Weinstein calls an interesting example of innovation acceleration.

“What are the major things that are innovation acceleration? Natural disasters, pandemics and wars,” Weinstein said. “Digital medicine has moved ahead 10 years within the period of a month.”

One of our breakout sessions at our August 26 AzPHA Annual Conference will focus on the future of telehealth in Arizona’s Medicaid program AHCCCS.

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