Author: Will Humble

There’s been a promising increase in public health policy focus in recent weeks regarding Arizona’s ongoing opioid epidemic. 

A few weeks ago the Arizona Department of Health Services (ADHS) released the 2016 Arizona Opioid Report which found that there were 790 deaths in 2016 in Arizona from opioids, a 16% increase from 2015 and a 74% increase since 2012.  More than half of the increase in the last two years have been heroin deaths (heroin increased from 11% of opioid deaths in 2007 to 39% in 2016).

Shortly after the report was released, the Governor declared a Public Health State of Emergency charging the ADHS with developing: 1) an enhanced opioid surveillance protocol; 2) new emergency regulations for prescribing opioids among licensed healthcare institutions; 3) additional provider practice guidelines; 4) Naloxone use guidelines for law enforcement; and 5) a report of findings that include possible additional legislative action by September 5, 2017.

Last week the ADHS launched an opioid website at www.azhealth.gov/opioid which houses information about the opioid epidemic including information for those required to report data, and resources for law enforcement and EMS and  clinicians as well as standing orders for naloxone dispensing.

These latest administrative actions are just the latest in a string of interventions in Arizona regarding the opioid epidemic.  In October 2016 the Governor issued an Executive Order charging AHCCCS with limiting  Initial Opioid prescriptions to 7 days.  On January 9, 2017 he signed an Executive Order that establishes a substance abuse program for people leaving prison at risk for opiate abuse.

Last legislative session, the Legislature passed HB 2493, which will set 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 that will:

• 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, recommend policies to decrease drug overdose fatalities; and
• Educate the public regarding drug overdose fatalities.

In addition to all of these interventions, AHCCCS has received a  State Targeted Response Grant ($24M over the course of 2 years) from the Substance Abuse and Mental Health Services Association to increase access to medication assisted treatment, care coordination for high risk individuals, recovery support services and prevention activities to reduce opioid use disorders and deaths.  The project will also develop and support state, regional, and local level collaborations, build capacity and infrastructure and service enhancements in high need areas.

The proposed activities within the Arizona Opioid State Targeted Response project will: 1) create a new streamlined data-driven decision-making process to target and tailor treatment and prevention resources where they are most needed in the state; 2) expand training for prevention and treatment providers; 3) expand law enforcement access to Naloxone kits; 4) expand access to MAT and integrated treatment; and 5) expand peer support services, recovery homes and recovery supports to pregnant and parenting women. 

We’ll continue to track the policy interventions that are underway and update our AzPHA members on the latest surveillance and intervention activities.

Last week the Nevada State Legislature handed Governor Sandoval an opportunity to provide the U.S. Senate a template for modifying the Affordable Care Act.

The Nevada Legislature approved a bill and sent it to the Governor’s desk that would allow any Nevadan to “buy in” to their state’s Medicaid program.   If the Governor signs the bill (and if the Centers for Medicare and Medicaid Services – or CMS –  approves the plan) any Nevadan would be allowed to buy managed care health insurance through their state Medicaid program.  The bill would allow the purchase regardless of income. Nevada residents that qualify for their current Medicaid program would continue to receive services as-is.                  

The actual Bill is called Assembly Bill 374.  If it’s signed, the new law would direct the Nevada Department of Health and Human Services to ask CMS for a Waiver allowing their Medicaid agency let Nevadans buy health insurance through their Medicaid managed care program.  If the law is signed by their Governor (and if the approach is approved by CMS) the Medicaid insurance would be available for purchase on the “Silver State Health Insurance Exchange”.  The plan calls for folks who qualify for tax credits under the Affordable Care Act to be able to use their credits to help pay for the coverage. 

Nevadans would need to pay an annual premium “… representing 150% of the median expenditure paid on behalf of a Medicaid recipient during the immediately preceding fiscal year“.   The coverage would be the same as the coverage for NV Medicaid recipients except it wouldn’t cover emergency medical transportation (e.g. ambulance rides).  The measure is written to ensure that no federal funds would be used.

The plan has several advantages that cover many of the consensus areas that most Americans agree with… that folks should have access to reasonably priced health insurance regardless of whether or not they have a pre-existing condition. This relatively simple plan would accomplish that without a complicated overhaul of the healthcare system since all states have existing Medicaid programs. 

I often hear people arguing that a solution to the healthcare debate is to adopt a “Medicare for All” plan…  and I’ve wondered why there’s never been much discussion of a Medicaid buy-in option.  It solves a lot of the issues that the exchanges struggle with because the risk pool is larger and the rate negotiation much bigger than in the individual market today.  That means lower costs and less volatility.

Arizona would be in a good position to lead the way with such a plan.  Our state Medicaid program (called AHCCCS) is widely recognized as an efficient and cost-effective model for providing Medicaid coverage. In addition, AHCCCS’ legislation already provides the enabling statutory language to allow state employees to buy into Medicaid- so the buy-in concept isn’t entirely foreign. 

To make it work, the actuarial rates would need to be calculated in order to set the premium levels for buying in to AHCCCS.  With ACA tax subsidies and cost sharing reductions, the out of pocket costs per person would be competitive or less expensive than plans currently offered in Arizona’s Marketplace, with less year-to-year volatility in pricing.

Sometimes solutions to complicated problems are staring you right in the face.

Last week the President released the Executive Branch’s FY18 proposed budget… called“A New Foundation for American Greatness.” The proposal outlines the administration’s funding priorities for the upcoming fiscal year… but it’s Congress that has the authority to actually set the budget.  

In a nutshell, the President’s budget requests an additional $54B in military spending next federal fiscal year (about a 9% increase) and proposes paying for the increase with cuts to other domestic discretionary programs (including core public health programs) by the same amount ($54B). 

Obviously, if it were to be enacted by congress as proposed, it would mean pretty substantial reductions in public health spending at the national, state and local level as the cuts would significantly impact public health grant funds to state (and local) health departments here in Arizona. 

Below is a breakdown of the proposed cuts to the CDC & HRSA and here’s a link to the President’s proposed budget:

https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/budget/fy2018/budget.pdf 

Centers for Disease Control & Prevention

The executive budget proposes cutting the CDC’s budget by 17% (from $7.2B to $5.9B) with large specific cuts to several programs.  I’ve broken down the proposal by public health service category below.

Chronic Disease Prevention and Health Promotion

The proposal completely eliminates several line items in the CDC’s budget including:

• tobacco prevention and cessation ($204M cut);
• nutrition, physical activity and obesity ($50M cut);
• heart disease ($103M cut);
• diabetes ($140M cut); and many other line items.

The proposed budget reduces the CDC’s Immunization and Respiratory Disease program by 10%; from the current $782M to $701M.

The proposal calls for cut by 17% funding for HIV/AIDS, Viral Hepatitis, STIs and TB Prevention programs; from the current $1.1B to $934M. In addition, the budget calls for decreases HIV/AIDS Prevention and Research Program by $147M.

A cut of 11% is proposed for Emerging and Zoonic Infectious Diseases; going from $579M to $514M.

The Executive budget completely eliminates the Preventive Health and Health Services Block Grant. Arizona currently over $1.85 million in FY16 from this Block grant, which allows AZ to address our unique public health needs in innovative and locally defined ways.

The budget does propose the creation of a $500M fund called the America’s Health Block Grant to provide flexibility for each state to implement specific interventions to address its population’s unique public health issues. States could theoretically use this funding to support interventions such as tobacco prevention and control; diabetes; heart disease and stroke; nutrition, physical activity and obesity and arthritis.  However, this new Block Grant is slated to be funded via the Prevention and Public Health Fund, which is completely eliminated by the American Health Care Act as passed by the House of Representatives.

Birth Defects, Developmental Disabilities, Disability and Health

The proposed budget eliminates 18 current categorical programs in the birth defects center and directs the CDC to focus its birth defects and developmental disabilities portfolio on core public health activities that “align with CDC’s mission and have proven interventions to make an impact on America’s health.”  It calls for 26% cut to the total programs in this category going down from the $135M to $100M.

Public Health Scientific Services are slated to be cut by $30M to $460M from the current $491M; Occupational Safety and Health is slated for a dramatic 41% cut to $200M from the current $338M.  Public Health Preparedness and Response is slated for a 9% cut ($136M), bringing preparedness funding down to $1.2B including a cut of $107M to the Public Health Emergency Preparedness Cooperative Agreement.

Environmental Health

The budget proposes eliminating the Amyotrophic Lateral Sclerosis Registry and reducing the Environmental and Health Outcome Tracking Network by $9M.  Environmental programs are slated to be cut to $157M, a decrease of $59 million from the current $217M.    

Injury Prevention and Control

Eliminates the elderly falls program and the injury research control centers. It does plan for level funds for opioid abuse and overdose prevention at $74M but cuts total injury prevention by 8% going from to $216 million from the current $235M.

Health Resources & Services Administration (HRSA)              

The executive budget proposes cutting HRSA’s budget to $5.5B from the current $6.15B with large specific cuts to several programs among rural health and primary care.  I’ve broken down the proposal by public health service category below.

Primary Health Care

The budget proposes the elimination of HRSA primary care programs for area health education centers; training diversity; training in primary care medicine; oral health training; public health and preventive medicine programs and other workforce programs.

HRSA workforce programs would be cut by 33% from $1.15B to $771M. I couldn’t tell from the line item whether this represents the match funding for state loan repayment programs for primary care incentives in rural areas or not.

Overall, this category of the HRSA budget would be $5B. There are proposed increases in mandatory funding for Community Health Centers by $89M.

Rural Health

The proposed budget eliminates the rural hospital flexibility (FLEX) grants and the state offices of rural health grants (like our Arizona Center for Rural Health). The Rural Hospital Flexibility Grants and State Offices of Rural Health are discontinued “to prioritize programs that provide direct services”. 

The total HRSA rural health budget would be cut by 50% with whatever funding remaining targeted toward the Rural Health Outreach Network and Quality Improvement Grants, Rural Health Policy Development, and Telehealth.

Maternal and Child Health Bureau

The proposed budget envisions cutting this Bureau within HRSA by $35M to $1.2B. It increases funding for the Title V Maternal and Child Health Block Grant by $30M and increases funding for the Healthy Start program by $10M but eliminates the sickle cell demonstration program; autism and other developmental disorders; heritable disorders; universal newborn hearing screening and emergency medical services for children.

Ryan White HIV/AIDS Program is slated for a $59M cut from the current $2.3B; eliminating the AIDS Education and Training Centers Part F and the “special projects of national significance”

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Remember, these proposed FFY 18 budget cuts by the President are just that, proposed.  Congress is the branch of government that’s authorized to set spending levels, so it’ll be important for us to continue to follow the budget conversations over the coming months and add our voices to others that will be advocating for the protection of important public health programs.

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107 years ago Arizona’s founders protected ordinary voters with a state constitution that guaranteed AZ residents the power of referendum, recall and initiatives.

Many of the bold moves to improve public health policy have come via citizens initiatives. A few examples are:

• The Smoke Free Arizona Act;
• The TRUST Commission for tobacco education and prevention;
• First Things First;
• Proposition 204 (from 2000) which extended Medicaid eligibility to 100% of federal poverty

This legislative session, Arizona’s legislative and executive branches passed and signed two bills (HB2244 and HB2404) that will impair our ability to use voter initiatives to improve public health in the future.

• 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 be a barrier to getting the large number of signatures needed to put citizens initiatives on the ballot in the future.

• HB2244 changes the citizen’s initiative compliance standard from “substantial compliance” to “strict compliance” with the requirements for putting initiatives on the ballot. This new law will make it easier to reject petitions if there are any errors on the document.

Fortunately, a new non-partisan political committee called The Voters of Arizona www.votersofarizona.com is challenging these new limits on voter initiatives. Their goal is to collect 75,000 signatures by August 12 in an effort to keep these new laws on hold (called a referendum) until the Arizona voters have an opportunity to weigh in during the November 2018 election.

As an ordinary Arizona citizen, you can help preserve the current voter initiative process. To learn more about the referendum effort or to collect signatures visit www.votersofarizona.com

If you’d like to help gather signatures for this important effort you can click here.

“This is part of what Arizona is supposed to be about, what we always have been about. The people serve as a check on the government and in particular, the Legislature. It’s pretty clear to me that this Legislature is doing what it can to try to take that power away from the public so we’re not going to let them get by with it.“

– Grant Woods, Co-Chair, Voters of Arizona