President Scraps Marketplace CSRs- but the Sky Isn’t Falling

Late last week the President announced that HHS won’t make any more subsidy payments to insurance companies that offer plans on the Marketplace.

The subsidy payments (cost-sharing reductions or CSRs) are payments to insurers to reimburse them for discounts they give policyholders with incomes under 250% of the federal poverty line (about $30,000 in income a year) for an individual. The discounts shield lower-income customers (that buy insurance in the Marketplace) from out-of-pocket expenses, like deductibles or copays.

Cutting off these payments to insurers doesn’t mean the policyholders won’t get help. The ACA and insurance company contracts require those discounts be granted by Marketplace insurers.

The decision does mean that insurance companies on the Marketplace will have to figure out how to recover the money they were promised under the ACA.  The two Marketplace insurers in AZ (Blue Cross Blue Shield and Centene Corp’s Ambetter by HealthNet) announced that they’ll have stable premiums next year. They apparently had already assumed that the CSRs wouldn’t be paid because they don’t expect this decision to impact their 2018 rates.

Remember, the cost-sharing reductions are separate from the tax credit subsidies (called advance premium tax credits) that help millions of people pay their premiums.  The premium tax credit is a refundable credit that helps eligible individuals and families cover the premiums for their health insurance purchased through the Health Insurance Marketplace.

People with income between 100-400% of the Federal Poverty Level still qualify for the tax credits, which are calculated depending on income, and help (and will continue to help) families pay their Marketplace health insurance premiums.

 

Integrated Health Plan for Children in AZ Foster Care?

AHCCCS & Mercer are conducting an analysis of an integrated health plan for children/youth involved in Arizona’s foster care system (e.g. a plan that would cover both acute care and behavioral health services).

Mercer is holding a series of stakeholder sessions – two with providers and two with family members (foster, adoptive, kinship and biological) and youth/young adults currently or previously involved with Arizona’s foster care system to solicit input about the concept. The goal is to gather feedback about the future of AZs health care system for kids in the foster care system

Tuesday, October 24

1 N. MacDonald, 3rd floor Mesa, AZ

Providers:                              10:00 a.m. – 11:30 a.m.

Family/Youth/ Young Adults:   3:30 p.m. – 5:00 p.m.

Wednesday, October 25

400 W. Congress Room 444, 4th floor Tucson, AZ

Providers:                              10:00 a.m. – 11:30 a.m.

Family/Youth/ Young Adults:   3:30 p.m. – 5:00 p.m.

To attend any session by phone, call 1-877-820-7831 and use guest code 679145.

 

200 Stories: Tucson Healthcare Forum Sunday, October 29

·        Are you concerned about the future of healthcare and health insurance?

·        What will the Affordable Care Act, Medicare and Medicaid look like in the future?

·        Have you had problems accessing affordable medical care, insurance, or medication?

Legislators from Legislative Districts 9 and 10 are hosting healthcare a forum in Tucson on Sunday, October 29.  Senators David Bradley & Steve Farley & Reps. Kirsten Engel, Randy Friese & Pamela Powers Hannley will be there to listen to your concerns and hear your stories about Medicare, Medicaid, the Affordable Care Act, insurance, medical care, drugs, cost and related topics.

Sunday, October 29, 2017 1:30 – 3:30 p.m. Unitarian Universalist Church of Tucson 4831 E. 22nd St.  Here’s the Eventbrite Link to sign up.

 

WV Medicaid Waiver Could Bode Well for AZ Opioid Treatment

CMS recently approved West Virginia’s proposal to expand Medicaid coverage for substance abuse treatment by lifting a restriction on Medicaid payments for inpatient treatment at large residential facilities. This waiver also allows the state Medicaid program to cover naloxone, peer support services, and methadone.

This approval could be important for Arizona because it signals that CMS is receptive to these kinds of waiver requests- and a similar recommendation was made in ADHS’ September 5 Opioid Action Plan.

 

2018 Public Health Law Conference

The Network for Public Health Law will be holding next year’s national Public Health Law Conference in Phoenix on October 4 – 6, 2018. They’re already accepting abstracts for panels and individual presentations.

They’re soliciting abstracts related to this year’s Conference theme,Health Justice: Empowering Public Health and Advancing Health Equity, as well as abstracts on other timely public health law topics. Deadline for abstract submission is December 15, 2017.  Here’s theSave-the-Date and Call for Abstracts.

 

Retail Marijuana & Opioid-Related Deaths in Colorado, 2000–2015

Researchers in Colorado did an interesting study recently that was published in the November American Journal of Public Health. They looked to see whether Colorado’s legalization of recreational cannabis had an impact on deaths from opioids in CO.

They used what’s called an interrupted time-series design (2000–2015) to compare monthly opioid-related deaths before and after Colorado stores began selling retail marijuana.  creational cannabis.

Interestingly, they found that opioid related deaths were reduced by 0.7 per month after retail sales of marijuana became legal. This is not a huge reduction by any means, but it was statistically significant.  Here’s what the authors described in the section labeled Public Health Implications:

“Although we found an apparent public health benefit in a reduction in opioid-related deaths following recreational cannabis legalization in Colorado, we note that expanded legalized cannabis use is also associated with significant potential harms. For policymakers to balance the potential beneficial and deleterious effects of these laws, researchers must continue to examine the full range of health effects in both clinic- and population-level research.”

A couple of weeks ago he nonpartisan Congressional Budget Office (CBO) released its final analysis of the House Republican’s American Health Care Act (AHCA) which was passed by the US House of Representatives by a vote of 217-213 on May 4.  The Vote in the House came before the CBO evaluation of the Bill.

CBO’s new analysis of AHCA estimates that 14 million Americans would lose health insurance in 2018.  By 2026 they estimate that 23 million would lose health insurance under the House version of AHCA. 

The measure would convert federal Medicaid (AHCCCS) funding to a per capita allotment and limit growth beginning in 2020 (using 2016 as a base year).  States could also choose to receive Medicaid funds as a block grant instead of the per-capita allotment. These are troublesome provisions that shift financial risk to AZ from the federal government …  setting up an environment that increases the likelihood that we would have future reductions in eligibility and covered services for Arizonans that get their health insurance through Medicaid (including vulnerable populations).

The Bill would also shift more of the cost of care to consumers through higher out-of-pocket expenses. Premiums could go down for some people, but premiums for low-income Americans and seniors would increase.  Subsidies would shift from income-based to age-based, with subsidies increasing with age.

It would also eliminate the Prevention and Public Health Fund beginning in 2019, block Planned Parenthood from receiving Medicaid reimbursements for services (for one year).

The Kaiser Family Foundation has a very helpful set of resources on their website that helps explain the differences between the current health care law and what would happen if the AHCA were enacted as passed by the US House of Representatives.

The Bill as passed by the US House of Representatives would:

• Convert federal Medicaid (AHCCCS) funding to a per capita allotment and limit growth beginning in 2020 using 2016 as a base year and provide states the option to get a block grant instead of the per-capita allotment. 

• Editorial comment: this provision (in my opinion) the most problematic proposal in AHCA as it would shift financial risk to AZ from the federal government and set in motion a sequence of events that would likely result in reductions in eligibility and covered services for vulnerable Arizonans. 

• Sunset the federal funds that paid for Medicaid expansion (to 133% of federal poverty) on January 1, 2020 except for people enrolled in the expansion population on 12/31/19 and who don’t have a break in eligibility of more than 1 month.

• Replace the current income-based tax credits with flat tax credits adjusted for age. Eligibility for new tax credits phases out at income levels between $75,000 and $115,000.

• Impose late enrollment penalty for people who don’t stay continuously covered.

• Repeal the Prevention and Public Health Fund at the end of Fiscal Year 2018.

• Encourage use of Health Savings Accounts by increasing annual tax- free contribution limit and through other changes.

• Establish a fund ($115 billion over 9 years available to all states), and additional funding of $8 billion over 5 years for states that elect community rating waivers (let insurance companies charge more for people with pre-existing conditions). States could use the money to provide financial help to high-risk individuals, promote access to preventive services, provide cost sharing subsidies, and for other purposes.

Our parent organization, the American Public Health Association,issued a statement highlighting the CBO’s findings and urging the Senate to work in a bipartisan manner that builds on the strengths of the Affordable Care Act.

We’re encouraging AzPHA members to send messages to our Senators urging them to focus on supporting a Senate bill that, first and foremost, protects Medicaid and that also allows folks with pre-existing conditions to be able to continue to have access to affordable health insurance.

Senator John McCain

Washington, DC Office:        202.224.2235

Phoenix Office:                    602.952.2410

Senator Jeff Flake

Washington, DC Office:        202.224.4521

Phoenix Office:                    602.840.1891

The Arizona State Legislature’s 2017 Regular Legislative Session ended yesterday.  We had some solid gains in terms of public policy that influences public health.  We also had some missed opportunities and some losses (especially when it comes to future voter initiative possibilities), but on the whole, lots of good things happened.

A big thank you to Eddie Sissions and all of the members of the AzPHA Public Policy Committee for their work tracking and advocating for and against bills this session.  Thank You!

Access to Care

Emergency Dental Care

The biggest public health win came inside the Budget.  Arizona will shortly be providing all of the matching funds needed to ensure that all adult Medicaid members have access to emergency dental services (up to a cap of $1,000 per person per year).  Adult Medicaid members that are members of AHCCCS’ Arizona Long Term Care System had emergency dental services restored last year, so this year’s action fills the last gap in dental emergency care for adults.  Kids that have their insurance through AHCCCS have comprehensive dental coverage that includes preventative services. 

Primary Care Loan Repayment

The state budget authorized an additional $350K per year to go into the state’s loan repayment program, bringing the total funds to $1M per year… which will potentially qualify Arizona for up to an additional $1M in federal funds.  These new resources are timed perfectly to take advantage of the revamping of the program over the last few years.  In a nutshell, this program gives primary care and other front line health practitioners an opportunity to get significant relief for their student loan debt by practicing in rural and underserved AZ.

Newborn Screening

The state budget includes a measure allowing the Arizona Department of Health Services to increase their newborn screening fees by $6 per test so the AZ State Lab can afford to test babies for Severe Combined Immune Deficiency syndrome.  Babies born with Severe Combined Immunodeficiency look normal at birth but they can’t fight infections. They often die before 1 year of age without medical treatment.  But if SCID is caught at birth (before the onset of infection) a bone marrow transplant can successfully treat the disorder.  It’s especially important to test for SCID in Arizona because the disorder is much more common in certain populations in Arizona: 1/2,000 among Navajo’s and Apache’s and about 1/20,000 among Latinos.

Clarifying Certified Registered Nurse Anesthetist Practice

Nurse anesthetists are a kind of registered nurse who is skilled in the administration of anesthesia and pain management.  They are a key practitioner all across Arizona, especially in rural areas.  Some disconnects with respect to the supervision of nurse anesthetists and prescribing and administration authority had been causing access to care problems especially in rural AZ.

In a nutshell, SB 1336 outlines medication orders and prescribing authority for nurse anesthetists and makes it clear that a physician isn’t liable for anesthetic administration by a nurse anesthetist.  It also modifies the definition of “presence” (relating to supervision) of these folks, and outlines medication orders and prescribing authority.  This new law got through the process with some hard work and compromise by folks who kept their eye on the access to care ball in AZ.

Outpatient Occupational Therapy for Adult Medicaid Members

AHCCCS currently provides coverage for occupational therapy services in an inpatient hospital setting to all of their members (when medically necessary), for outpatient members under 21, and for adults that are enrolled in the Arizona Long Term Care System portion of AHCCCS.  The state budget funds AHCCCS so that it can start providing coverage for occupational therapy as an outpatient health service for all their enrollees (when it’s medically necessary).

Involuntary Commitment Procedures

Existing state law has procedures for civil commitment of a person for mental health treatment if a court finds enough evidence that the person (as a result of mental disorder), is a danger to self or others, or has a disability in need of treatment but won’t or can’t accept voluntary treatment.  The court can then order the patient to undergo treatment.

Last year, the State Supreme Court amended the rules for enforcement of Tribal Court Involuntary Commitment Orders to allow the enforcement of tribal court orders upon the acceptance by the clerk of the filing of the tribal court order rather than upon the certification of the order.  In other words- some tribal members had delays in getting treatment because of the new rules. 

HB2084 will allow a mental treatment facility to admit a patient for involuntary treatment for a mental health disorder pending the filing of a tribal courts involuntary commitment order, providing a mechanism for a more smooth access to care- especially for tribal members. 

Tools for Schools

Asthma Management

Schools will be better able to help kids with asthma to manage their symptoms next school year thanks to the passage of HB 2208.  It will let trained school staff to administer (or help administer) an inhaler for a student in respiratory distress.   The new law also outlines the training required and provides immunity from civil liability (lawsuits).

The old statute allowed kids to have & use inhalers if it was prescribed by a doctor and the school had an annual written documentation from the parent or guardian authorizing the student to have and self-administer their inhaler.  The new law will let trained school district and charter school staff to help the child to use their inhaler. 

UA’s Western Region Public Health Training Center has Stock Albuterol Inhaler Training for School Personnel available on their website already… and the e-learning course provides the training needed for schools to implement this new law. 

Sunscreen Use at Schools & Camps

Schools, parents and kids will be better able to protect children from damaging UV rays as a result of the passage of HB 2134 which will make it clear that kids can take and use sunscreen at school and camps… and that school, preschool and camp staff can help them put it on. 

Why was this needed, you ask?  The FDA regulates sunscreen as an over-the-counter drug.  School districts set their own policies concerning the administration of “medication” (including over the counter sunscreen) to kids.  Some school districts and camps prohibit the administration of “over-the-counter drugs” (e.g. sunscreen) unless a parent provides written consent and an order from a physician.  This new law will make it clear for schools, camps, and day cares that it’s OK for kids to have and use sunscreen.  It’ll also give schools, camps and day cares protection from lawsuits.

Injury Prevention

Distracted Driving

Arizona will shortly join the 47 other states that have laws on the books restricting the use of smart phones while driving.  SB 1080 will ban brand-new teen drivers from using their smart phone while driving for the first 6 months of their license (if they’re under 18).  Using the phone in an emergency will still be OK.  Tickets can only be issued if the driver committed another violation.  The new law allows sound only smart phone functions under specified conditions.  Prior to this, the only other limitation in AZ to this kind of distraction was for school bus drivers. 

Drug Overdose & Poisoning Prevention

HB 2493 sets up a drug overdose review team at the ADHS (much like the child fatality review team).  It’ll be a 21-member consisting of nine heads of various government entities (or their designees) and 12 members appointed by the ADHS Director to:

• Develop a data collection system regarding drug overdoses;
• Conduct an annual analysis relating to drug overdose fatalities;
• Develop standards and protocols;
• Provide training and technical assistance to local Teams;
• Develop investigation protocols for law enforcement and the medical community;
• Study state and local laws, training and services in order to recommend policies to decrease drug overdose fatalities; and
• Educate the public regarding drug overdose fatalities.

Looks like a good opportunity to get some better surveillance, standards, protocols, and explore new laws that could help with the ongoing opioid painkiller epidemic.

Safety Net

HB2091 was passed at the very end of the Session and will (assuming it’s signed) remove the requirement that SNAP (food stamp) recipients file fingerprints prior to becoming eligible for benefits.  This had been a barrier for seniors to participate in the program because of perceived stigma.

HB2372 was also passed in the waning minutes of the Session and (if signed) will extend the Temporary Assistance for Needy Families program to 2 years lifetime participation from the current 1 year.

New Laws Posing Public Health Challenges

Changes to the Voter Initiative Process

Many of the bold moves to improve public health policy have come via the citizens initiative process that’s written into Arizona’s constitution.  A few examples are the Smoke Free Arizona Act; the Tobacco, Revenue, Use, Spending and Tracking Commission (Proposition 303 from 2002) for tobacco education and prevention; First Things First; and Proposition 204 from 2000 which extended Medicaid eligibility to 100% of federal poverty for childless adults and creating the AZ Area Health Education Centers.  Future citizens initiatives geared to improve public health will be more difficult to get on the Arizona ballot as a result of the passage of 2 new laws:  HB 2404 & HB 2244.

• HB 2404 prevents signature gatherers from getting paid by the signature (for voter initiatives), making it more difficult to provide the work incentive needed for gatherers to be efficient.  This will make it more difficult to get the large number of signatures that are needed to get citizens initiatives on the ballot in the future.

• House Bill 2244 changes the citizens initiative compliance standard to “strict compliance” with all of the requirements regarding the entire process of getting on the ballot.  The previous criteria meant that citizens initiatives needed to be in “substantial compliance” with the requirements.  This new law does require the Secretary of State generate a rule handbook with the requirements. 

A group of folks will be organizing to collect 75,000 signatures by August 12 in an effort to keep these new laws on hold (called a Referendum) until the voters of Arizona have an opportunity to weigh in during the November 2018 election.  We’ll stay in touch with the groups organizing this effort and we’ll keep our AzPHA members informed regarding how they can participate in the signature gathering process.

Family Planning

One component of the state budget requires the Arizona Department of Health Services to apply to become the Title X family planning grantee in Arizona. Federal Title X funds provide about $5M in family planning resources statewide.  When I was the ADHS Director we never applied to be the Title X grantee because the Arizona Family Health Partnership (an Arizona nonprofit) did such a good job administering the grant.

The challenge that this new law poses is that if ADHS is successful becoming the Title X grantee, they’dbe prohibited by state law (ARS 35-196.05) from contracting with Planned Parenthood of Arizona to provide the family planning services- and many many Arizonans rely on Planned Parenthood a their access point for family planning.

Missed Opportunities

There were several missed opportunities to improve public health that were proposed but failed to get through the legislative process:

• Voluntary Certification for Community Health Workers
• Comprehensive oral health coverage for pregnant Medicaid members
• Requirements for recess time for physical activity in schools
• Requirement for hospitals to offer influenza vaccines to seniors in hospitals
• Regulation of tanning bed studios
• Changing the age at which folks can but tobacco products and e-cigarettes to 21 from 18

_________________________________________________________________________________

Note: according to state law, most of these changes won’t come into effect until 90 days after the end of the legislative session- which is in mid August.  

I’ll be doing a webinar at 12 noon on May 25 summarizing this year’s legislative session.  Tiffany has sent out a couple of notices inviting people to register- and we’ll send out a couple more.

_________________________________________________________________________________

Our Public Policy Committee will continue to meet over the phone on an ad-hoc basis the rest of the year to talk about policy at the federal level and issues that may relate to AHCCCS waiver requests.  We will also be following efforts to collect signatures to suspend implementation of the voter initiative laws until voters have an opportunity to approve or deny the laws at the ballot box in November 2018.  Our materials will continue to be posted on Basecamp.  For information about participating in the committee activities contact [email protected]

From all indications, it looks like this year’s legislative session is about to wrap. Most of the bills besides the budget bill have been through the legislative process and either have been passed and signed or have died. The last bolus of work is to pass and sign a state budget for the next fiscal year.  That will happen in the next few days- maybe even before the end of the week.  

We’re still hopeful that the budget will include funding for adult emergency dental services for all Medicaid members. Right now kids that have their insurance through AHCCCS get comprehensive dental coverage- which is a good thing.  

Adult Medicaid members that are part of the Arizona Long Term Care System have coverage for emergency dental treatment up to $1,000 per year, but other adult Medicaid members don’t have any dental care coverage- which leads to poor oral health outcomes.  We’re crossing our fingers that the financial match will be provided for this in the final state budget.

Here’s a summary of where we are with the various bills that relate to public health this legislative session:

Good New Public Health Laws

Asthma Management

HB 2208 was passed and signed a few weeks ago.  Once it becomes effective later this summer, it will authorize trained school districts and charter schools to administer (or help administer) an inhaler for a student in respiratory distress.   The new law also outlines the training required and provides immunity from civil liability (lawsuits).

The old statute allowed kids to have & use inhalers if it was prescribed by a doctor and the school had an annual written documentation from the parent or guardian authorizing the student to have and self-administer their inhaler.  The new law will let trained school district and charter school staff to help the child to use their inhaler.  The new law will also protect the school from lawsuits.

Lucky for Arizona, we’re ready to implement this already thanks to AzPHA members Dr. Lynn Gerald at the UA’s Mel and Enid Zuckerman College of Public Health and Dr. Doug Taren at the UA’s WesternRegion Public Health Training Center. The Training Center has Stock Albuterol Inhaler Training for School Personnel available on their website already.  

The e-learning course provides the training needed for schools to implement this new law.  Thank you Dr.’s Gerald & Taren for your leadership in this area of public health!

Sunscreen Use at Schools & Camps

HB 2134 will become law 90 days after the end of the legislative session. It’ll  make it clear that kids can take and use sunscreen at school and camps… and that school, pre-school and camp staff can help them put it on. 

Why was this needed, you ask?  Well, the FDA regulates sunscreen as an over-the-counter drug.  School districts set their own policies concerning the administration of “medication” (including over the counter sunscreen) to kids.  Some school districts and camps prohibit the administration of “over-the-counter drugs” (e.g. sunscreen) unless a parent provides written consent and an order from a physician.  
 
This new law will make it clear for schools, camps, and day cares that it’s OK for kids to have and use sunscreen.  It’ll also give schools, camps and day cares protection from lawsuits.  Hooray.

Involuntary Commitment Procedures

The Governor signed HB2084 which will allow a mental treatment facility to admit a patient for involuntary treatment for a mental health disorder pending the filing of a tribal courts involuntary commitment order.  We advocated for this bill because it provides a mechanism for a more smooth access to care- especially for tribal members.  Now that it’s been signed, it’ll become law 90 days after the legislative session ends.

State law already has requirements and procedures for civil commitment if a court finds enough evidence that the person (as a result of mental disorder), is a danger to self or others, or has a disability in need of treatment but won’t or can’t accept voluntary treatment.  The court can then order the patient to undergo treatment.

Currently, an order from an Arizona tribal court is recognized by the other courts in AZ and enforceable by any court of record in this state, subject to the same procedures, defenses and proceedings for reopening, vacating or staying as a judgment of the court. 

Current statute says a patient committed to a state mental health treatment facility by a tribal court order is subject to state jurisdiction.  Last year, the State Supreme Court amended the rules for enforcement of Tribal Court Involuntary Commitment Orders, to allow the enforcement of tribal court orders upon the acceptance by the clerk of the filing of the tribal court order rather than upon the certification of the order.  In other words- some tribal members had delays in getting treatment because of the new rules. 

This new law will fix that delay in treatment, which is a good thing for public health we think.

Nurse Anesthetists  

SB 1336 was passed and signed a couple of weeks ago.  In a nutshell, the new law outlines medication orders and prescribing authority for nurse anesthetists and ill make it clear that a physician isn’t liable for anesthetic administration by a nurse anesthetist.  It also modifies the definition of “presence” (relating to supervision), and outlines medication orders and prescribing authority for a nurse anesthetis.  

AzPHAsupported this Bill and submitted information to the committee providing information about how this bill would be good for access to care in rural AZ- which had been facing challenges as a result of the existing laws.

Teen Texting & Driving

SB 1080 was signed by the Governor last week and will ban brand-new teen drivers from using their smart phone for the first 6 months of their license – if they’re under 18.  Using the phone in an emergency will still be OK.  Tickets can only be issued if the driver committed another violation.  It allows anaudible tool like Mapquest under specified conditions.

The only other limitation in AZ to this kind of distraction is for school bus drivers.  Arizona will now join 48 other states that restrict smart phone use!

Drug Overdose Review Team

HB 2493, which sets up a drug overdose review team at the ADHS (much like the child fatality review team) will also become law later this summer.  The new law sets up a21-member consisting of nine heads of various government entities (or their designees) and 12 members appointed by the ADHS Director.

The Mission for the Team is to:

• Develop a data collection system;
• Conduct an annual analysis relating to drug overdose fatalities from the preceding year;
• Aid in the development of local Teams;
• Develop standards and protocols;
• Provide training and technical assistance to local Teams;
• Develop investigation protocols for law enforcement and the medical community;
• Study state and local laws, training and services in order to determine if changes are needed to decrease drug overdose fatalities and, as appropriate, take steps to implement these changes; and
• Educate the public regarding drug overdose fatalities.

Looks like a good opportunity to get some better surveillance, standards, protocols, and explore new laws that could help with the ongoing opioid painkiller epidemic.

Good Public Health Bills Not Yet Passed

Emergency Dental Coverage for Medicaid Members

We’re still hopeful that the budget will include funding for adult emergency dental services for all Medicaid (AHCCCS) members. Right kids that have their insurance through AHCCCS get comprehensive dental coverage- which is a good thing. 

Adult Medicaid members that are part of the Arizona Long Term Case System have coverage for emergency dental treatment up to $1,000 per year, but other adult Medicaid members don’t have any dental care coverage at all- which has led to all sorts of bad oral health outcomes among adult Medicaid members (they had emergency dental coverage before the Recession- but that funding was a casualty of the recession).  We’re crossing our fingers that the financial match will be provided for this in the final state budget.

Newborn Screening for SCID

SB 1368, which would authorize the ADHS to collect the newborn screening fees needed to add Severe Combined Immune Deficiency syndrome to the list of newborn screening tests passed through the Senate and the was unanimously approved by the House Health Committee. 

Babies born with Severe Combined Immunodeficiency look normal at birth but they can’t fight infections. They often die before 1 year of age without medical treatment, but if caught at birth,  before the onset of infection, a bone marrow transplant can successfully treat the disorder.  It’s particularly important to test for SCID in Arizona because the disorder is much more common in certain populations in Arizona: 1/2,000 among Navajo’s and Apache’s and about 1/20,000 among Latinos. 

Bills Good for Public Health that Died

Community Health Workers

Sadly, HB 2426, which would have set up a pathway for Community Health Workers in AZ, appears to be dead for this year.  Had it passed, it would have set up a pathway for Community Health Workers in AZ to voluntarily become certified… which would be a big step forward for this important health profession.  It would have  expanded  the use of CHWs in Arizona’s healthcare system in part by making it easier to get reimbursement for their services.

The Arizona Community Health Workers Association did a great job of organizing and is in a solid position to keep the momentum going next legislative session.  

Influenza Vaccines in Hospitals

HB 2090 which would have required hospitals to offer influenza vaccines to seniors during the cold and flu months appears dead for whatever reason.  It would’ve provided an additional access point for getting a flu vaccine among a high risk population- but alas- it won’t become law this year (although hospitals could of course elect to offer the vaccines if they want).

Physical Activity

HB 2082, which would have required that schools have some recess time went down in flames.  To be honest, I think it would have passed but didn’tbecause of a heated remark made by the Bill’s sponsor made on social media about the school voucher bill that the Governor signed.  Here’s the story about it in the AZ Republic.   Lesson: relationships are important.

Tanning Beds

HB 2194 which would have prohibited kids under 18 from using tanning beds and prevents studios from claiming that tanning beds are risk-free is effectively dead for this year, again. 

Bills Bad for Public Health that Luckily Died

Traffic Safety Cameras

Let’s face it. Getting a ticket in the mail for speeding or running a red light is no fun.  But evidence suggests that photo enforcement of red lights is an effective public health intervention, which is why we advocated against HB2525.  It would have banned traffic safety cameras in AZ.  While it passed out of the House, it stalled and died in the Senate. 

It’s sure to be back next year.  My advice to some towns that are over-using photo enforcement is to tone it down- or you’ll end up ruining it for everybody.

AHCCCS Waiver Request

AHCCCS received several hundred comments regarding their proposed waiver request as required by Senate Bill 1092.  The law requires AHCCCS to annually apply the Centers for Medicare and Medicaid Services (CMS) for an Amendment to their Demonstration Waiver that would implement the following requirements for “able-bodied adults” receiving Medicaid services:

• Limit lifetime AHCCCS coverage for all able-bodied adults to 5 years except for certain circumstances.
• Require all able-bodied adults to become employed or actively seeking employment or attend school or a job training program and require them to verify on a monthly basis compliance with the work requirements and any changes in family income.
• Ban eligible persons from enrolling in AHCCCS for 1 year if the person knowingly failed to report a change in family income or made a false statement regarding compliance with the work requirements.

AzPHA submitted our response letter on the waiver application back in February.  Several hundred people and organizations turned also in comments regarding the waiver request.  More than 90% of the commenters expressed concerns about the various items in the waiver including the 5 year limitation on benefits, monthly income reporting and other proposed requirements.  Five percent (5%) of the commenters expressed support for the waiver request.

Here are links to the: 

• Individual Comments
• Organization Comments
• Tribal Stakeholder Comments

CMS will now consider whether or not to approve the request (CMS has the final say regarding whether to approve any or all of the pieces of the waiver).  My guess is that the discussions will be on-going between CMS and AHCCCS this Summer.  

CMS denied a similar request last year, but for obvious reasons many of us in the public health world are concerned that this year’s request may be approved – given the changes in leadership at CMS in the last few months.

State Legislative Update

Activity at the Arizona State legislature is pretty much just focused on the development of a budget for the next fiscal year.  We’re still hopeful that the budget will include funding for adult emergency dental services for all Medicaid (AHCCCS) members; authorization to raise the fees needed to add Severe Combined Immune Deficiency (SCID) to Arizona’s Newborn Screening Panel; added funds for state’s loan repayment program which would enable the state to qualify for a full $1M in matching funds.

Nurse Anesthetists  

SB 1336 was passed and signed last week, clarifying the scope of practice for nurse anesthetists.  We’ve been in support of the bill because it will be good for access to care in rural AZ.  Hospitals have had increasing difficulty recruiting physicians due in part to a lack of clarity in Arizona law that leads doctors to believe they’ll be held liable for the work of  nurse anesthetists. At a time when we already face a shortage of nurses and physicians – particularly in rural and underserved communities, our focus should be eliminating red tape and empowering these health care professionals to do their jobs 

Teen Texting & Driving

SB 1080, which would ban brand-new teen drivers from using their smart phone (for the first 6 months of their license – if they’re under 18) continued it comeback last week.  It passed through the House Rules Committee and the full House and is headed back to the Senate for a final approval before going to the Governor for consideration.

Between 2012 and today the US has been conducting a natural experiment on herself.  The US Supreme Court ruling on the Affordable Care Act allowed states to decide whether or not to expand Medicaid to 133% of federal poverty.  Some stated did it and some didn’t….  so we have a kind of case control study.  Now that it’s been several years, let’s look at the data and see who made the better decision.  

The Kaiser Family Foundation recently conducted a comprehensive review of the scientific literature and found that states that expanded Medicaid under the ACA had did better than their peers that didn’t expand.  In a nutshell, the report found that the states that expanded Medicaid improved healthcare insurance coverage, access to care, utilization, and health care affordability.  Interestingly (for me at least) was the fact that states that expanded had better economic outcomes than those that didn’t… including positive effects on state budgets, employment and the labor market.

Additionally, a New Health Affairs article found that there were no significant increases in spending from state funds as a result of expanding Medicaid (in the states that expanded).  The Health Affairs study found that “… expansion states did not experience any significant increase in state-funded expenditures, and there is no evidence that expansion crowded out funding for other state priorities.”  

Statistically, states that expanded Medicaid had budget savings, revenue gains, and higher overall economic growth when compared to their peers that didn’t expand Medicaid.  Studies also found that expansion states had lower Medicaid spending per enrollee for the new ACA adult eligibility group compared to per-enrollee spending across all groups.

Medicaid expansion resulted in health insurance coverage gains among the low-income folks including specific vulnerable populations.   Most research found that Medicaid expansion improved access to care, utilization of services, the affordability of care, and financial security among the low-income population (just as you’d expect). 

The report is really well referenced.  It’s a great resource for folks looking for a one stop shop for data on the impact that Medicaid expansion has had over the last few years.  

Above all, it’s great information for policy makers as it provides objective evidence regarding the impact that Medicaid expansion had in states that expanded v those that chose not to expand.

Take a look and bookmark these two studies.

The big news this week is really about the changes to the voter initiative that were passed and signed last week.  The reason why we consider these bills as laws that impact public health is that the voter initiative process is sometimes the only real vehicle to get through policy based public health interventions.  

For example, the Smoke Free Arizona Act was passed by Initiative in 2006.  Prior to that, there had been no traction in the legislature to pass a statewide smoke free law.  Another really important voter initiative that had a big impact on public health (access to care) was Proposition 204 about a dozen years ago- which brought Arizona’s Medicaid eligibility threshold up to 100% of federal poverty.  Without that pre-existing intervention- it would have been much harder to expand Medicaid eligibility back in 2013.  

Here’s a summary of what’s been happening to the voter initiative process lately:

• Last week, the Governor signed into law HB 2404 which will prevent signature gatherers from getting paid by the signature (for voter initiatives- not for candidate signatures).  This will make it more difficult to get the large number of signatures that are needed to get citizens initiatives on the ballot in the future.

• The Governor also signed House Bill 2244 over the weekend, which will change the compliance standard for voter initiatives to “strict compliance” with standards from the previous (judicially determined) “substantial compliance”.  It also requires that the Secretary of State generate a rule handbook with the requirements.  This new law will make it harder to get initiatives on the ballot (including future initiatives with public health policy implications).

• Senate Bill 1236 is almost completely through the legislative process but hasn’t been totally signed off on yet as it hasn’t had a final vote yet in the Senate (it passed the House last week).  It’s complicated- but it basically puts in a series of regulations regarding who can be a petition circulator (e.g. no felony convictions) and the regulates how they keep and submit their records plus alot more.  Here’s the latest Fact Sheet on the latest amended version. 

Teen Texting & Driving

SB 1080, which would ban brand-new teen drivers from using their smart phone (for the first 6 months of their license – if they’re under 18) came back to life last week!  It had been looking good until it hit a roadblock in the House Rules Committee- as Rep. Phil Lovas had decided that he wasn’t going to hear it in committe.  But last week, he accepted a job in the Trump administration and the new Rules chair (Rep. Mesnard) put it on the agenda today (Monday 4/17) at 1 pm in HHR1.  

We’ve signed in support and I’ve sent this NHTSA summary document to the members that shows that teens are the largest age group reported as distracted at the time of fatal crashes and have the highest prevalence of cell phone use while driving.  One of the nice things about SB 1080 is that the bill hits the mark on the highest risk population – and at a time when their driving habits are developing.

Physical Activity

HB 2082 is in trouble I think.  It would have required that schools have some recess time to help them get some physical activity.   To be honest, I’m a little worried about this one now because of a heated remark made by the sponsor on social media about the school voucher bill that the Governor signed.  Here’s the story about it in the AZ Republic.   Sometimes things like this can derail bills. Lesson: relationships are important.

Nurse Anesthetists  

SB 1336 is waiting for the “Final Read” in the Senate.  Still looking OK though.  AzPHA is in support and submitted information to the committee talking about how this bill would be good for access to care in rural AZ.

Newborn Screening for SCID

SB 1368, which would authorize the ADHS to collect the newborn screening fees needed to add Severe Combined Immune Deficiency syndrome to the list of newborn screening tests still needs House Rules Committee approval, but isn’t on the agenda again this week.  We have no reason to believe that it’s in trouble.  

There are only 3 states left that don’t test for it or don’t have plans in place to test for it (including AZ), and with Arizona having so many high risk folks (American Indians of Askabathan descent) we clearly need to get this done.  Like I said though, no signs of trouble.

Sunscreen Use

HB 2134 would make it clear that kids can take sunscreen to school and camps… and that school and camp staff can help them put it on.  It’s basically in the process of getting concurrence between the Senate and House versions. No sign of trouble really.

Drug Overdose Review Team

HB 2493 would set up a drug overdose review team at the ADHS (much like the child fatality review team).  It  passed the Senate Health & Human Services Committee last week but still needs to get through the Committee as a Whole and then the full Senate, but it will need to go back to the House because it was amended slightly to clarify an issue related to naloxone administration (a rescue drug for opioid poisoning).  No signs of trouble, really.

Arizona Budget

Not much public news about the AZ budget this week….  but when the tumblers click – they click fast!   

We’re in support of proposals in the (executive) budget to: 

1) fund adult emergency dental services for all Medicaid (AHCCCS) members – up to $1,000 annually (this had been a benefit prior to the Great Recession); 

2) add Severe Combined Immune Deficiency (SCID) to Arizona’s Newborn Screening Panel;  and 

3) increase funding to the state’s loan repayment program by $350K (potentially allowing the state to qualify for a full $1M in matching funds from HRSA).   

We believe that these are all important proposals that will improve public health in Arizona. Our Public Policy Committee will be paying close attention to the budget process and will advocate for these important initiatives.

Teen Texting & Driving

SB 1080, which would ban brand-new teen drivers from using their smart phone (for the first 6 months of their license – if they’re under 18).  It passed the Senate and passed the House Transportation and Infrastructure Committee on March 1 but has been stuck in the House Rules Committee ever since.  There was a public statement in the Capitol Times by the Committee Chair (Rep. Phil Lovas) that he doesn’t intend to hear the bill in the House Rules Committee (which would kill the bill).  

Through my years in public health I’ve always been sensitive to make sure that our policies and interventions are careful not to infringe on civil liberties.  It’s pretty clear to me that this proposal would improve public safety by imposing a reasonable behavior expectation for new drivers. The only other limitation in AZ to this kind of distraction is for school bus drivers- this seems like a modest bill that will help set a good expectation for new drivers.  We’re encouraging AzPHA members that live in Rep. Lovas’ district to reach out and encourage him to hear the bill in the House Rules committee.  I sent a note to him and other committee members last week and will do another one this week. 

Physical Activity

HB 2082 which would enhance recess time in Arizona is looking good but still has a ways to go.  It passed its hearing in the Senate Education Committee (but was amended to eliminate the 50 minute per day requirement).  The Bill was heard in Senate Rules on 3/27 but still needs to go back to the House since it was amended to just require the recess period without the 50 minute time requirement.

Nurse Anesthetists  

SB 1336 passed the Senate last week and, after a compromise amendment, passed through the House Health and Rules Committee but still awaits a floor vote in the House.  AzPHA is in support and submitted information to the committee talking about how this bill would be good for access to care in rural AZ.

Newborn Screening for SCID

SB 1368, which would authorize the ADHS to collect the newborn screening fees needed to add Severe Combined Immune Deficiency syndrome to the list of newborn screening tests passed through the Senate and the was unanimously approved by the House Health Committee.  It still needs House Rules Committee approval and then would go to a house floor vote.  It wasn’t on the Agenda for today’s House Rules Committee.  We haven’t heard that there is any trouble with the bill, but we’re keeping our ears to the ground.  

Sunscreen Use

HB 2134 would make it clear that kids can take sunscreen to school and camps… and that school and camp staff can help them put it on.  It passed the full Senate last week but was transmitted back to the house on 4/4/17 because it was amended in the Senate.  No sign of trouble really.

Drug Overdose Review Team

HB 2493 would set up a drug overdose review team at the ADHS (much like the child fatality review team).  It  passed the Senate Health & Human Services Committee last week but still needs to get through the Committee as a Whole and then the full Senate, but it will need to go back to the House because it was amended slightly to clarify an issue related to naloxone administration (a rescue drug for opioid poisoning).

Arizona Budget

Not much public news about the AZ budget this week.  Much of the work happens behind closed doors in meetings among folks that are appointed to important positions in the Executive Branch and members of the legislature- especially those in the Appropriations Committees.

We’re in support of proposals in the (executive) budget to: 1) fund adult emergency dental services for all Medicaid (AHCCCS) members – up to $1,000 annually (this had been a benefit prior to the Great Recession); 2) add Severe Combined Immune Deficiency (SCID) to Arizona’s Newborn Screening Panel;  and 3) increase funding to the state’s loan repayment program by $350K (potentially allowing the state to qualify for a full $1M in matching funds from HRSA).   

We believe that these are all important proposals that will improve public health in Arizona. Our Public Policy Committee will be paying close attention to the budget process and will advocate for these important initiatives.

Trump Administration Budget Proposal & Call to Action

A few weeks ago the President submitted his FY 2018 budget blueprint.  If the proposal were approved as-is, it would have a significant impact on public health resources in Arizona.  The proposal calls for cutting more than $15 billion from the Department of Health and Human Services (HHS) which is an 18% decrease from 2017 levels.  Many of the Agencies that provide grant funds to Arizona’s public health system are located in HHS.

While the budget doesn’t provide specific funding levels for the Centers for Disease Control and Prevention (CDC) or the Health Resources and Services Administration (HRSA), spending reductions of this magnitude would certainly force significant cuts to many if not all public health programs if the proposal moves forward as it stands.  The proposed budget also would cut 31% from the Environmental Protection Agency’s current budget- which could have implications for clean air/water/waste assurance.

The APHA issued a statement opposing the budget proposal and also issued a statement opposing proposed cuts to FY 2017 public health and prevention programs.  APHA-led coalitions, the Friends of HRSA and the CDC Coalition, sent letters to House and Senate Labor-HHS-Education appropriations subcommittee leaders urging support for adequate funding for HRSA and CDC in the FY 2018 appropriations process. 

We’re encouraging AzPHA members to send a message to their members of Congress opposing the proposed budget cuts by visiting APHA’s action alerts page.

Not much has changed with respect to individual health-related bills since last week…  with a couple of exceptions, so you can read last week’s update for the most part to find out where things stand.  The Governor did sign a couple of health-related bills last week- so I’ll touch on those and then transition to the state budget.

Involuntary Commitment Procedures

The Governor signed HB2084 which will allow a mental treatment facility to admit a patient for involuntary treatment pending the filing of a tribal courts involuntary commitment order.  We advocated for this bill because it provides a mechanism for a more smooth access to care- especially for tribal members.  Now that it’s been signed, it’ll become law 90 days after the legislative session ends.

Deliveries

The Governor also signed  SB 1367 (abortion; live delivery; report; definition).  It’ll become law 90 days after the end of session as well.  Under already existing law, when a baby is “delivered alive” during an abortion, doctors are required to ensure that “all available means and medical skills are used to promote, preserve and maintain the life” of the baby.  But, the existing law didn’t specifically provide a definition of the words “delivered alive” leaving room for professional judgment.  The bill that was just signed specifically defines “delivered alive” as showing one or more of these signs of life: breathing, a heartbeat, umbilical cord pulsation or definite movement of voluntary muscles.

Now that it will become law later this year, the Arizona Department of Health Services will be required to set policies that clinics, hospitals and physicians will need to follow to care during a procedure or delivery thatfits the new definition of “delivered alive”.  The requirements will include having neonatal emergency equipment and trained staff in the room for all abortions performed at or after 20 weeks of pregnancy.  Many people expressed concerns that it will require doctors to perform unproductive medical procedures on a fetus born early because of fatal abnormalities.  Healthcare providers represented by the Arizona Medical Association and the AZ Chapter of American College of Obstetrics and Gynecology also expressed these concerns. 

State Budget

Each year the Governor of AZ submits a proposed budget for all the activities of state government including the operation of all the state agencies.  The budget process and outcome is is always very important in terms of public health- because so much of the budget directly and indirectly impacts things that influence public health.

Much of the real action on the budget happens behind closed doors in meetings among folks that are appointed to important positions in the Executive Branch and members of the legislature- especially those in the Appropriations Committees.

AzPHA is in firm support of proposals in the (executive) budget to: 1) appropriate the funding needed to bring back adult emergency dental services among all Medicaid (AHCCCS)  members – up to $1,000 annually (this had been a benefit prior to the Great Recession); 2) add Severe Combined Immune Deficiency (SCID) to Arizona’sNewborn Screening Panel;  and 3) increase funding to the state’s loan repayment program by $350K (potentially allowing the state to qualify for a full $1M in matching funds from HRSA).   

We believe that these are all important proposals that will improve public health in Arizona. Our Public Policy Committee will be paying close attention to the budget process and will advocate for these important initiatives.

Last week was an important one in terms of public health policy to say the least!

All of you know by now that the American Health Care Act didn’t attract enough support in the US House of Representatives to pass (it didn’t come to the Floor because the Speaker knew the votes weren’t there).  

AHCA would have fundamentally changed the Medicaid funding by switching it to a block grant or per capita cap. AHCCCS has an easy to read 2-page summary of how AHCA would have impacted Medicaid in Arizona.  The proposal also would’ve eliminated the Prevention and Public Health Fund, a critical resource for protecting Arizonans from dangerous infectious diseases and other crucial public health issues like the opioid poisonings. 

A big THANK YOU to all of our members that reached out to the AZ delegation last week in response to our Action Alert.  Adding your voice as an independent advocate for public health is important!

Nobody really knows what’s going to happen in the future regarding prospective efforts to modify or repeal the Affordable Care Act.  Our Public Policy Committee team will continue to be vigilant – and we’ll update you here is we hear anything. On to things at the State Legislature:

Health Bills Passed

Asthma Management

HB 2208 will let school staff administer or help a student self-administer an inhaler for things like asthma episodes when it becomes law later this year (under certain circumstances).  It passed both houses & has been signed by the Governor.  Well done Dr. Lynn Gerald at the UA Mel & Enid Zuckerman College of Public Health for informing this debate.

Tribal Courts & Involuntary Commitment

HB2084 which would allow a mental treatment facility to admit a patient for involuntary treatment pending the filing of a tribal courts involuntary commitment order has passed both houses of the legislature and has been sent to the Governor.  Looking good.
 

Health Bills in the Final Stretch

Physical Activity

HB 2082 which would enhance recess time in Arizona is looking good.  It passed its hearing in the Senate Education Committee (but was amended to eliminate the 50 minute per day requirement).  We’re pleased that the Bill appears to be headed to the Governor’s desk (although it needs to complete the Senate Rules Committee & go back to the House since it was amended).

Nurse Anesthetists  

SB 1336 passed the Senate last week and, after a compromise amendment, passed through the House Health Committee but still awaits the House Rules Committee hearing before going to the House floor.  AzPHA is in support and submitted information to the committee talking about how this bill would be good for access to care in rural AZ.

Newborn Screening for SCID

SB 1368, which would authorize the ADHS to collect the newborn screening fees needed to add Severe Combined Immune Deficiency syndrome to the list of newborn screening tests passed through the Senate and the was unanimously approved by the House Health Committee.  It still needs House Rules Committee approval and then would go to a house floor vote.   

Sunscreen Use

HB 2134 would make it clear that kids can take sunscreen to school and camps… and that school and camp staff can help them put it on.  It passed the Senate Education Committee last week but still needs approval of the Senate Rules Committee before going to a final Senate floor vote.

Drug Overdose Review Team

HB 2493 would set up a drug overdose review team at the ADHS (much like the child fatality review team).  It  passed the Senate Health & Human Services Committee last week but still needs the Rules Committee hearing before a final vote of the Senate. 

Teen Texting & Driving

SB 1080 would ban brand-new teen drivers from using their smart phone (for the first 6 months of their license (if they’re under 18).  It passed the Senate and passed the House Transportation and Infrastructure Committee on March 1.   Still waiting for the Rules Committee hearing.

Health Bills that look Dead for Now

Influenza Vaccines in Hospitals

HB 2090 which would require hospitals to offer influenza vaccines to seniors during the cold and flu months was assigned to Senate Health and Human Services Committee.  No hearing date is set yet… so this one is on a pretty short leash right now. 

Traffic Safety Camera Prohibition

HB2525 passed the House last week but was never heard in the Senate Transportation and Technology Committee, so it’s effectively dead for this year (for now).   

Tanning Beds

HB 2194 which would have prohibited kids under 18 from using tanning beds and prevents studios from claiming that tanning beds are risk-free is effectively dead for this year.  

On to the Budget…

Now that most of the House and Senate work on bills is winding up- full attention will turn to the budget negotiations.  We’ll focus some time on next week’s update on the budget and our related public health priorities- like restoring adult emergency dental as a benefit under Medicaid.  

If you’re interested in joining our Public Policy Committee, you can contact [email protected] and she’ll get you on our list.  We have a weekly call every Monday at11 am and someone from the committee is always down at the Legislature for key hearings.