Author: Will Humble

The U.S. spends far more on medical care than any other nation, yet ranks 26th in life expectancy.  That’s partly because we tend to focus on treating illnesses rather than preventing them in the first place.  Basically, we’re not adhering to wise advice that “a stitch in time saves nine”.

More than 85% of the health care costs in the U.S. are from preventable chronic conditions, yet only 3% of our health care spending is focused on prevention and public health – the key factors that prevent chronic medical conditions before they start. It’s essential that we do a more effective job preventing costly chronic medical conditions to reduce health care costs.

The Affordable Care Act included several initiatives designed to reduce health care costs. One important component was the creation of the Prevention and Public Health Fund, which provides federal, state and local public health resources to reduce long-term health costs. The fund focuses on preventing expensive chronic medical conditions by providing expanded and sustained national investment in public health programs that improve health and restrain the rate of growth in health care costs.

This investment in public health infrastructure to reduce costs is evidence-based. Research suggests that funding for community-based public health has a 5.6 to 1 return on investment. In other words, every dollar invested in evidence-based prevention programs results in a $5.6 in savings in overall health care costs.

Over the last several years, the fund has been used to support an array of evidence-based community prevention and clinical prevention programs that bolster public health infrastructure and workforce and expand public health research and tracking efforts that reduce health care costs. Resources go to programs at the local, state and federal levels to: a) better detect and respond to disease threats; b) increase vaccination rates; c) fight obesity; d) curb tobacco use; and e) increase access to preventive care services.

The fund also provides state and local resources to fight numerous health threats. Vaccination programs supported by the fund ensure access to vaccines that protect the most vulnerable among us from routine diseases like influenza and provide community-based immunity to prevent the widespread circulation of diseases like mumps and measles. The fund supports the ability to track emerging infectious disease outbreaks like Zika or Ebola, as well as foodborne illnesses.

Arizona public health jurisdictions have received more than $52.6 million through the Prevention & Public Health Fund since 2010. This $9.3 million annual investment is at work in Arizona, providing critical resources that support evidence-based, community prevention activities tailored to meet community health needs and preferences.

Evidence-based PPHF investments in Arizona include:

• Prescription painkiller (Opiate) and heroin use prevention;

• Health security funds for bioterrorism, disease outbreaks, and disasters;

• Building immunization services to prevent serious infectious disease outbreaks;

• Promoting better detection and response to disease threats;

• Lead poisoning prevention;

• Reducing tobacco use; and

• Reducing diabetes, heart disease, and obesity.

Astonishingly, the US House of Representative’s “American Health Care Act”, all introduced versions of the US Senate’s “Better Care Reconciliation Act” (and Amendments), and the President’s proposed budget would eliminate the Prevention and Public Health Fund.  

We’re urging our elected representatives in congress and their staff to reflect on the impact that Prevention and Public Health Fund resources are having in Arizona as they consider options for reforming the U.S healthcare system.  Arizona’s public health infrastructure is already stretched thin because of limited state and local investment in public health. Further reductions in capacity by reducing or eliminating the Prevention and Public Health Fund would impair Arizona’s ability to bend the health care cost curve as well as impair its ability to respond to infectious diseases, the opioid crisis, and preventable diseases and chronic conditions.

The Arizona Public Health Association partnered with the Vitalyst Foundation to develop a report that outlines the progress that Arizona is making using existing prevention and Public Health Fund resources. 

The report, entitled The Value of Prevention: How the Prevention and Public Health Fund Invests in Arizona’s Health is geared to inform policy makers and other stakeholders of the potential implications related to eliminating or restructuring the Prevention and Public Health Fund.  The report is also posted on our AzPHA home page at www.azpha.org.

Please take a gander and forward the report to folks that might be interested- especially people and organizations that you know that may be able to influence the outcome of this enormously important national debate about the future of health care and public health in our country.

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“Our Lives on the Line”, Arizona” Rally and Press Event

More than a dozen groups have joined forces to lead a national “day of action” against the plan to drastically cut back Medicaid and public health resources as part of the repeal of the Affordable Care Act. The rally and press event in Arizona is one of many being held simultaneously in numerous other cities around the country that day.

“Our Lives On the Line, Arizona” event — including a flagship rally in Washington — will set the tone for several weeks of action to persuade key lawmakers to focus on evidence-based solutions that will improve health outcomes as they debate changes to the Affordable Care Act  Here’s where you can register for the Arizona event    

 

Time:

Saturday, July 29, 2017 11:00 AM – 12:00 PM AZ Time

Host:

Our Lives on the Line

Location:

Parsons’s Center for Health and Wellness – Southwest Center for HIV/AIDs (Phoenix, AZ)

1101 N. Central Avenue
Phoenix, AZ 85004

There were 2 important actions this week regarding public health & access to care.  The U.S. Senate released their 3rd version of the Better Care Reconciliation Act (BCRA) and House released their Health and Human Services and Appropriations bill for next fiscal year

Let’s start with BCRA.

The Senate released it’s new version of BCRA this week (PDF) but it still hasn’t been evaluated by the non-partisan Congressional Budget Office…  so we won’t know the particulars of what the new version would likely do to insurance coverage and premiums until that evaluation is complete (probably next week). 

We do know that many things are the same as the previous version of the bill- especially when it comes to the troubling changes that would be made to Medicaid:  

• Like the previous version of BCRA, the new bill would still convert federal Medicaid funding to a per capita allotment (or a block grant) and limit growth in federal Medicaid spending beginning in 2020. Medicaid funding per person would go up with the Medical Consumer Price Index from 2020 – 2024 and by just the regular Consumer Price Index after that- which will likely serve to dramatically cut back Medicaid funding.

• Phases out the enhanced federal contribution for the expansion population in states like AZ from 90% in 2020 to regular state match in 2024.  That means that somewhere between 2020 and 2024 Arizona would drop the expansion population from Medicaid coverage (people from 100% to 138% of FPL).

• Marketplace plan premium tax credits would be available down to 100% of FPL in 2020 (because those folks between 100 and 138% of poverty won’t be enrolled in Medicaid anymore).

• Eliminates the individual mandate for everybody to have health insurance.

• Eliminates the requirement that larger employers provide health insurance.

• Would let insurers sell currently “non-compliant” insurance plans – meaning insurance plans with very high deductibles and limited benefits (people that buy these catastrophic plans would be eligible for a tax credit). This would serve to reduce premiums (and benefits) for people that elect these plans- but it would shrink the risk pool for people that want more robust (compliant) plans- meaning that premiums for the more comprehensive plans will go up alot.

• Repeals the mandate to have health insurance and eliminates cost sharing subsidies in 2020.

• Completely eliminates the Prevention and Public Health Fund in FY19, which is used by every state to support vital public health programs that promote health, prevent disease, and allow for rapid response to emerging public health threats.

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The House Labor, Health and Human Services and Education Subcommittee released their FY18 appropriations bill this week too. Here’s a summary of the funding proposals included in the bill:

The bill decreases the US Department of Health and Human Services’ budget by $542M below last year’s level.  It reduces CDC’s budget by almost $200M , which includes $840M in transfers from the Prevention and Public Health Fund (eliminating the fund).  Many if not most of these budget cuts would roll down to state and local health departments.

The bill reduces HRSA funding by about $400M (to $5.8B) including a complete elimination of all Title X Family Planning Funds ($300M).

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We’re encouraging AzPHA members to send messages to our Senators urging them to focus on supporting a Senate bill that: 1) protects future funding for Medicaid; 2) allows folks with pre-existing conditions to be able to continue to have access to affordable health insurance; and 3) protects the Prevention and Public Health Fund.

Senator Jeff Flake
Russell Office Building 413
Washington, D.C. 20510
(202) 224-4521
Twitter: @JeffFlake

Senator John McCain
Russell Office Building 218
Washington, DC 20510
(202) 224-2235
Twitter: @SenJohnMcCain

This week the U.S. Senate had a goal of voting on the “Better Care Reconciliation Act of 2017” – the earlier version of the bill that was passed in the House of Representatives this year.  Fortunately, the Senate decided to chill and not to take the vote this week or next.  Hopefully they’ll reflect over the July 4 break and come back with a more productive approach to improving on the ACA.

The nonpartisan Congressional Budget Office released it’s analysis of the Senate Bill (https://www.cbo.gov/publication/52849), which seems to have had a profound impact on the negotiations.  The report found that the proposal would have increased the number of people who are uninsured. It is estimated that 15 million more people would be uninsured by next year. The increase in the number of uninsured people would reach 19 million in 2020 and 22 million in 2026.

In later years, lower spending on Medicaid and substantially smaller average subsidies for coverage would lead to even more increases in the number of people without health insurance. By 2026, enrollment in Medicaid would fall by about 16% and an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under the ACA.

Another interesting development this week was a new analysis released by AHCCCS concluding that the proposal would cost our state at least $7.1 billion through 2026. Download the full report from the AHCCCS website.            

The analysis shows that the Bill increases costs for Arizona by $2.9 billion between FY 2018 and FY 2026.  It would make changes to the enhanced federal funding provided for the 320,000 Medicaid members that are childless adults with incomes up to 100% of federal poverty, as well as 82,000 adult members with incomes between 100-133% of federal poverty.   

We’re encouraging AzPHA members to send messages to our Senators urging them to focus on supporting a Senate bill that decouples the issues related to the individual health care insurance market from these dramatic changes to federal and state Medicaid programs.

Senator Jeff Flake
Russell Office Building 413
Washington, D.C. 20510
(202) 224-4521
Twitter: @JeffFlake

Senator John McCain
Russell Office Building 218
Washington, DC 20510
(202) 224-2235
Twitter: @SenJohnMcCain

This morning the U.S. Senate released draft healthcare legislation entitled the “Better Care Reconciliation Act of 2017”.  Note that it has a different name than the House version that passed a few weeks ago (American Health Care Act).  In many respects, the two bills are very similar.

They’re calling this a “discussion draft”, implying that it’s possible that the language of the bill could morph before it hits the Senate floor next week.

The non-partisan Congressional Budget Office is still working on an evaluation of the Senate version.  That evaluation will provide a better picture of the practical impacts that the bill would have if enacted, however, here’s what we know from the initial reading of the discussion draft: 

• Like the House version, BCRA would give states either a per capita cap for federal Medicaid contributions or a block grant of funds beginning in 2020. It appears that, unlike the House version, federal funds for kids the elderly and people with disabilities could not be “block granted” (an improvement).  On the down side, the inflation rate used to calculate future per capita contributions would be even lower than the inflation rate in AHCA which will result in less Medicaid spending in 2025.

• Rolls back the Medicaid expansion (to 138% of poverty), but more slowly than the House version. Would creates some kind of state innovation fund for states that didn’t expand Medicaid.

• Eliminates the individual mandate for everybody to have health insurance.

• Eliminates the requirement that larger employers provide health insurance to their employees.

• Insurance companies would still not be allowed to increase premiums or deny coverage based on preexisting conditions.

• States would be allowed to change what qualifies as an essential health benefit for Marketplace plans.

• Completely eliminates the Prevention and Public Health Fund (PPHF) in FY18, which is used by every state to support vital public health programs that promote health, prevent disease, and allow for rapid response to emerging public health threats.

The Century Foundation has a good comparison of the House and Senate Versions as well as the current law under the Affordable Care Act on their website here:  https://tcf.org/content/commentary/heart-comparison-house-senate-health-bills/   ;

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We’re encouraging AzPHA members to send messages to our Senators urging them to focus on supporting a Senate bill that: 1)  protects futue funding for Medicaid; 2) allows folks with pre-existing conditions to be able to continue to have access to affordable health insurance; and 3) protects the Prevention and Public Health Fund.

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

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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There’s has never been a better time to join or renew your membership in AzPHA!

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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