Will Humble Family Planning, Maternal Health, Prevention, Wills Blog

Federal Court Decision Allows Implementation of the New Title X Family Planning Rules

The new regulations eliminate Title X’s long-standing requirement for non-directive pregnancy options counseling and requires a “bright line” of physical and financial separation between the provision of family planning and abortion services

Title X is a super important public health program that provides folks with comprehensive family planning and related preventive health services. It’s designed to prioritize the needs of low-income families or uninsured people. Its overall purpose is to promote positive birth outcomes and healthy families by allowing individuals to decide the number and spacing of children.

The services provided by Title X grantees (the funding comes from the federal government) include family planning and contraception, education and counseling, breast and pelvic exams, breast and cervical cancer screening, screenings and treatment for sexually transmitted infections and HIV.  It also focuses on counseling, referrals to other health care resources, pregnancy diagnosis, and pregnancy counseling. Title X funding does not pay for abortions.

Back in March of this year, the US Department of Health & Human Services published in the Federal Register a final rule making changes to the federal regulations governing the Title X national family planning program. The final rules dramatically change the existing Title X family planning program nationally and in AZ.  The changes include:

  • Eliminating Title X’s long-standing legal and ethical requirement for non-directive pregnancy options counseling; and

  • Requiring a “bright line” of physical and financial separation between the provision of family planning and abortion services.

Numerous provider groups, state attorneys general and non-profit organizations sued and sought an injunction after the new Rules were announced in March (seeking an injunction to stop the rule from taking effect while the courts decide the legality of the rule). 

Legal History of the Case

Multiple federal district court judges blocked the new restrictive rules from going into effect. On June 20, 2019, a three-judge panel of the Ninth Circuit Court of Appeals granted the Trump Administration’s request to lift the preliminary injunctions, allowing the new Title X rules to be enforced. In early July, the 9th Circuit court ordered the cases be reheard en banc (meaning by all the judges on the 9th circuit versus a three-judge panel).

On July 11, the en banc court refused to block the new Title X rules from taking effect, rejecting 20 states, the District of Columbia, and reproductive right advocates request to impose an emergency stay (indefinitely or temporarily suspend or stop proceedings).

So, what’s the bottom line then?  For now- the new April Title X Rules that eliminate Title X’s long-standing legal and ethical requirement for non-directive pregnancy options counseling, and requiring a “bright line” of physical and financial separation between the provision of family planning and abortion services stand.  There have been mixed signals from HHS whether Title X grantees will be contractually required to immediately comply with the new rules or not. 

Earlier last week, published accounts suggested that HHS would be requiring immediate compliance with the new rules by their Title X contractors (including the Arizona Family Health Partnership).  Later in the week, journalists quoted anonymous HHS sources suggesting that Title X grantees wouldn’t be immediately required to adjust their business processes. Late Saturday night grantees got a letter saying the HHS “does not intend to bring enforcement actions against clinics (grantees) that are making good faith efforts to comply” with the new rules. Perhaps grantees (including the Arizona Family Health Partnership) will hear something more specific this week.

Most likely there will be an appeal and rehearing of the challenge to the April Rules in the coming weeks.

A big thanks to AzPHA members Hannah Fleming, Leila Barraza and James Hodge for helping to straighten out this complicated legal case!

Will Humble Prevention, Vaccination, Wills Blog

Sign on to this Letter to Support Policies that Encourage Vaccination

We invite you to express your support for immunization requirements for public school attendance, vaccine education and informed use of appropriate vaccine exemptions by signing a letter of support to the Governor. The letter includes the Arizona Medical Association Resolution adopted in 2015. Practicing physicians, nurses and pharmacists from across the State of Arizona believe vaccine education is essential to the health of our children and our communities.

CLICK HERE and add your name to the growing list of Arizonans that believe that we must protect Arizona children against vaccine preventable diseases and protect community immunity that protects the most vulnerable among us.  Here’s a copy of the letter you’d be signing on to:

Dear Governor Ducey,

We, the undersigned, want to express our full support for this resolution adopted by the Arizona Medical Association (ArMA):

“ArMA supports adopting requirements that parents (or guardians) who do not wish to have their children vaccinated receive public health-approved counseling that provides scientifically accurate information about the childhood diseases, the available vaccines, the potential adverse outcomes from catching diseases, the risks unvaccinated children pose to children who cannot be vaccinated for medical reasons, the risks of vaccine side effects, and the procedures that are implemented to exclude unvaccinated children if an outbreak of disease occurs in the area administered by the local or state public health agency.

ArMA also supports adopting requirements that parents annually sign an affirmative statement that acknowledges the risks they are accepting for their own children and the children of others by claiming a personal exemption from mandatory vaccination requirements.”

As residents of Arizona, we actively support and encourage you to work with the Arizona Department of Health Services (ADHS), all County Health Departments, and longstanding partners of The Arizona Partnership for Immunization (TAPI) to maintain high levels of immunization coverage rates in our schools and our communities…to keep your constituents safer and healthier.

Respectfully,

A.D. Jacobson, M.D.
Steering Committee Chair
The Arizona Partnership for Immunization

Will Humble Disease Control, Prevention, Wills Blog

WHO Declares the DRC Ebola Outbreak a Public Health Emergency

Decision will Amplify Intervention Efforts

The WHO declared the Ebola virus disease outbreak in the Democratic Republic of the Congo a Public Health Emergency of International Concern this week. The declaration follows several decisions in the last few months to not make that call. 

The WHO cited recent developments in the outbreak in making its recommendation, including the first confirmed case in Goma (a city of almost 2M and a major transportation hub).  The outbreak has been underway for more than a year now and there have been insufficient resources including funding to fight the outbreak – impairing the effectiveness of the public health interventions. 

Policy interventions for controlling Ebola are dicey because of the need to protect livelihoods of the people most affected by the outbreak by keeping transport routes and borders open. Interventions that effect travel and trade can have negative economic consequences, but not implementing some restrictions can impair the public health response.

The WHO made the following recommendations that relate to the declaration:

Strengthen community awareness, engagement, and participation, including at points of entry to identify and address cultural norms and beliefs that are barriers to the response.

Improve cross-border screening and screening at main internal roads to ensure that no contacts are missed and enhance screening through improved sharing of information with surveillance teams.

Enhance coordination with the UN and partners to reduce security threats to enable public health operations.

Strengthen surveillance and reduce the time between detection and isolation and implementing interventions.

Optimal vaccine strategies that have maximum impact on curtailing the outbreak should be implemented rapidly (they are using a ring-vaccination strategy).

The public health tools are available to eliminate the transmission of Ebola in the DRC. The challenge is really getting the resources deployed and implementing the proven intervention methods. Plus, and important new tool- an Ebola vaccination- is now available (it was not widely available during the 2014 West African epidemic). Security concerns, local and regional infrastructure, cultural practices and access to care are all important factors that need to be addressed in order to stop the on-gong transmission of the virus.

In an example of what the Declaration can do- the Congolese government this week tasked the military and policy with enforcing hand-washing and fever checks in Kivu Province.

Will Humble Uncategorized, Wills Blog

AHCCCS to Begin Covering Pre-Exposure Prophylaxis for HIV

Last month the United States Preventive Services Task Force (USPSTF) listed Preexposure Prophylaxis for the Prevention of HIV Infection (PrEP) as a Category A Preventive Health Service.  That’s an important designation because it means that PrEP will now be included (at no cost to consumers) in all Qualified Health Plans during the next contract year. The final recommendation statement can also be found in the June 11 issue of JAMA.

The task force found convincing evidence that PrEP is of substantial benefit in decreasing the risk of HIV infection in persons at high risk of HIV acquisition.  They conclude that PrEP is associated with small harms, including kidney and gastrointestinal adverse effects and that (with high certainty) the benefit of PrEP (with oral tenofovir disoproxil fumarate–based therapy) is substantial.

Pre-exposure prophylaxis (or PrEP) lowers the chances of getting infected with HIV even if the person otherwise engages in risky sexual behavior.  PrEP can stop HIV from taking hold and spreading through the body and is highly effective for preventing HIV if used as prescribed (but it is much less effective when not taken consistently).  Daily PrEP reduces the risk of getting HIV from sex by more than 90%. Among people who inject drugs, it reduces the risk by more than 70%.

This week AHCCCS announced that they’ll be covering PrEP medications as a benefit for their members beginning on October 1, 2019…  a solid public health move that will lower the transmission of HIV in Arizona. The move will likely produce a positive return on investment also, as preventing HIV is much less expensive than treating persons infected with the virus. PrEP (Truvada) will be on their preferred drug list without Prior Authorization starting 10/1/19.

Will Humble Disease Control, Medicaid, Prevention, Public Health, Vaccination, Wills Blog

Maricopa County Seeking Hepatitis A Intervention Strike Team Volunteers 

AHCCCS Policy Change Assisting the Response

Maricopa County is part of a statewide hepatitis A outbreak mostly affecting folks experiencing homelessness, substance use and/or recent incarceration. 229 people have been reported with the disease and more than 80% have been hospitalized. The Maricopa County Department of Public Health is working with community partners to vaccinate the people at highest risk…  both to protect them from getting sick and to stop the disease from spreading further.  

The public health response consists of: 1) vaccinating everyone in the county jail system for the next 8 months; 2) deploying vaccination and service strike teams (with other organizations); and 3) partnering with cities and parks to go to homeless encampments and offer vaccination in Strike Teams.

They’re recruiting volunteer healthcare providers and screeners (no healthcare experience needed) for the vaccine outreach events. If you’re interested in volunteering, please contact [email protected].

In addition, AHCCCS now covers medically necessary covered immunizations for people 19 years of age and up when the vaccines are administered by AHCCCS registered providers through county health departments. Immunizations are covered even if the AHCCCS registered provider isn’t in the member’s health plan network. The list of covered vaccinations includes (but isn’t necessarily limited to) Hepatitis A & B and Measles.

Policy changes like this make a big difference in the effectiveness of public health interventions like the ones associated with this Hep A outbreak – and they also sets up a system that will be better able to prevent future outbreaks.

Will Humble Affordable Care Act, Medicaid, Wills Blog

Federal 5th Circuit Court Signals New Threat to the ACA

Health Care Increasingly Looking Like a Major Campaign Topic for 2020

Background on the 2012 Ruling Upholding the ACA

In the 2012 Ruling that upheld the ACA, Chief Justice Roberts wrote that: “… the Affordable Care Act’s requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax… because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.” 

Roberts rejected the Obama Administration’s argument that the federal government’s authority to regulate interstate commerce provides the authority needed for the ACA to be constitutional (the Court struck down that argument 5-4).  Fortunately, the court held (5-4) that the ACA was constitutional based on the federal government’s taxing authority.

The Texas v Azar Challenge

Last week the 5th US Circuit Court of Appeals heard the Texas v Azar case which, once again, challenges the constitutionality of the Affordable care Act. Arizona is a party to the case and is supporting the suit (to overturn the ACA).

This latest challenge essentially argues that the ACA is no longer constitutional because the tax penalty for not having health insurance has been eliminated. 

All the media reports that I found about the questions they were asking and the statements they were making suggest that the appellate court may rule that the ACA is unconstitutional (now that the tax penalties for not having insurance are gone) – which would send the case up to the Supreme Court.

Protections at Risk

In addition to the coverage that the ACA provides through Medicaid expansion and the availability of Marketplace Plans with subsidies, the ACA has a ton of health insurance reform measures including preventing commercial health insurance companies from:

1) denying someone health insurance because they have a preexisting condition -called the “guaranteed issue” requirement;

2) refusing to cover individual services that people need to treat a pre-existing condition- called “pre-existing condition exclusions”; and

3) charging a higher premium based on a person’s health status – called the “community rating” provision.

Supreme Court Forecast

Because of the makeup of the 5th Circuit Court of Appeals (and the signals they sent through their questions at the hearing this week) the Court will likely uphold O’Connor’s decision to invalidate the ACA and the case will probably end up with the US Supreme Court…  which has a different cast of characters than it did when the ACA was originally upheld back in 2012 by a 5-4 vote.

Since the 2012 decision upholding the ACA, Gorsuch has replaced Scalia and Kavanaugh has replaced Kennedy.  Both Scalia and Kennedy voted to overturn the ACA- so not much on that score has changed.

Chief Justice Roberts voted with the majority that upheld the law. His argument rested on the ACA’s link to the financial penalties for not having health insurance. But remember, the financial penalties for not having health insurance were removed from the IRS tax codes in last year’s federal tax overhaul, pulling out the structure that Roberts used in his argument.

The bottom line is that the ACA, including its protections for folks with pre-existing conditions, may very well be in jeopardy if Roberts views the ACA as fundamentally different now that the financial penalties are gone.

Healthcare’s Link to the 2020 Election

If a decision comes from the 5th Circuit in the next couple of months (as is likely) the US Supreme Court could be hearing the case during their October 2019 – April 2020 schedule…  making access to healthcare a sentinel issue in the November 2020 election.

Pre-existing exclusion exemptions, community rating, guarantee issue of health insurance, the availability of Marketplace plans with subsidies, and Medicaid expansion will all be front and center with the electorate. All very personal issues.

Social science suggests that people feel a loss of a benefit much more acutely than a missed opportunity.  In other words, it’s a lot harder to take something away than to not give it in the first place. 

With the American people now accustomed to the benefits that the ACA provides, there could be a backlash against those that take those benefits away.  Just sayin’.

Will Humble Affordable Care Act, Medicaid, Public Health Law, Wills Blog

AZ Can Prepare for a Post ACA Arizona

It’s easy to see how the ACA could end up being struck down once this case gets to the highest court. Gone would be the health insurance market reforms like protection for folks with pre-existing conditions, community rating pricing and guarantee issue as well as Medicaid expansion and the health insurance marketplaces.

Prior to the ACA, the standards to protect people with pre-existing conditions were determined at the state level.  Most states including AZ had very limited protections. Many insurers maintained lists of up to 400 different conditions that disqualified applicants from insurance or resulted in higher premiums.  35% of people who tried to buy insurance on their own were either turned down by an insurer, charged a higher premium, or had a benefit excluded from coverage because of their preexisting health problem.

Fortunately, Arizona is partially in control of our own destiny if the ACA is struck down. We couldn’t do much about Medicaid rolling back to pre-ACA levels or the loss of subsidies on the Marketplace, but we could have some control over the market reforms like pre-existing condition exclusions, community pricing, and guarantee issue.

Several states have enacted their own laws to be consistent with the ACA market reforms. Several states already have their own laws that incorporate some or all the ACA insurance market protections. Arizona could do the same.  Also, CMS released new resources to support states with improving their health insurance markets and making coverage more affordable through section 1332 waivers.

The good news is that we have time before the Texas v. Azar case makes it to the Supreme Court. A good 1st step would be for the Governor to ask our state agencies to generate (or commission) a report outlining the real-life impact in Arizona in the event that the Texas v. Azar suit is successful. The report would put forward options for state-based health insurance market reform laws to require things like prohibiting pre-existing condition exclusions.

Such a report would give the Arizona State Legislature an analysis to evaluate public policy options for state-based market reforms.

I know what you’re thinking, it’s impossible to pass these kind of market reforms in Arizona.  Maybe, but many thought Arizona’s expansion of our Medicaid system back in 2013 was impossible.  That case study shows that with the right kind of leadership on the 9th floor, anything is possible.

Will Humble Medicaid, Wills Blog

Medicaid Work/Community Engagement Requirements May Be Phased In

Back in January CMS approved Arizona’s request to include work requirements and/or community engagement and reporting requirements as a condition of Medicaid enrollment beginning on January 1, 2020.  

The work requirement/community engagement Waiver request was filed back in 2018 and is mandated by Senate Bill 1092 (from 2015) which requires AHCCCS to ask CMS’ permission to implement new eligibility requirements for “able-bodied adults”.  Folks that are exempted from the upcoming requirements include:

  • Pregnant women up to the 60th day post-pregnancy

  • Former Arizona foster youth up to age 26

  • Members of federally recognized tribes

  • Designated caretakers of a child under age 18

  • Caregivers who are responsible for the care of an individual with a disability

  • Members determined to have a serious mental illness (SMI)

  • Members who are medically frail

  • Members who have an acute medical condition

  • Members who are in active treatment for a substance use disorder

  • Members with a disability recognized under federal law and individuals receiving long term disability benefits

  • Full-time high school, college, or trade school students

  • Survivors of domestic violence

  • Individuals who are homeless

At last week’s State Medicaid Advisory Council meeting, AHCCCS announced some changes that they hope to make in order to make the transition easier for their members that don’t qualify for exemptions when implementation begins. 

They’re hoping to gradually phase in the AHCCCS Works program by geographic area (subject to CMS approval). If approved, the program will be implemented in three phases- beginning no sooner than 1/1/20:

Phase 1: Most Urbanized Counties: Maricopa, Pima, and Yuma

Phase 2: Semi-Urbanized Counties: Cochise, Coconino, Mohave, Pinal, Santa Cruz, & Yavapai

Phase 3: Least Urbanized Counties: Apache, Gila, Graham, Greenlee, La Paz, & Navajo

The idea behind the phase in is to:

  • Establish community engagement supports for members in regions with limited employment, educational and training opportunities, accessible transportation, and child care services;

  • Give the State time to assess the availability of community engagement resources in rural areas and address gaps; and because 

  • Counties with a higher percentage of urban populations are likely to have sufficient community engagement supports compared to counties with a higher percentage of rural populations. 

Will Humble Affordable Care Act, Health Insurance, Public Health Law, Wills Blog

States Lowering Marketplace Premiums with 1332 Waivers

One of the successes of the Affordable Care Act was the development of the health insurance Marketplace.  States can have can have a significant impact on what the premiums are on their state’s Marketplace plans by using some of the policy tools available in the ACA. 

For example, Section 1332 waivers in the ACA allow states to implement innovative market driven solutions to lower premiums and protect coverage at the same time.  The goal of Section 1332 waivers is to allow states to experiment with alternative payment and delivery models. 

Recent CMS guidance changed several components of the 1332 waiver processes including allowing executive orders or state regulations to pursue 1332 waivers.

Many states have recently taken administrative action to lower the Marketplace premiums in their states by implementing reinsurance waivers.  Reinsurance programs allow states to reimburse insurers for certain high-cost claims, allowing them to lower premiums overall. In essence, reinsurance (insurance for insurance) creates a backstop for insurers for super-expensive claims – which makes insurance for everybody more affordable. 

So far this year, CMS has approved Section 1332 reinsurance waivers in Alaska, Hawaii, Maine, Maryland, Minnesota, New Jersey, Oregon, and Wisconsin. There are reinsurance waiver applications pending in Colorado (following their passage of HB 19-1168) and North Dakota (following their enactment of HB 1106).

More 1332 waiver applications are on the way too.  Delaware, Montana, and New Mexico enacted legislation authorizing reinsurance 1332 waiver applications – so those waiver applications should be on the way in the near future.   Maryland passed HB 1098 which authorizes (but doesn’t require) their state to submit a 1332 reinsurance waiver by January 1, 2020.

Basically, 1332 waivers offer states the opportunity to implement reinsurance waivers that have a direct and beneficial effect on Marketplace premiums that benefit their residents. Seems like a no-brainer in terms of smart public policy. 

Will Arizona be next in line to seek a reinsurance waiver to help reduce Marketplace premiums in AZ? 

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