Author: Will Humble

When Arizona expanded our Medicaid program (AHCCCS) to cover people up to 138% of poverty we used a provision in the ACA that allows states to expand coverage with the federal government absorbing all the cost at first.

But that meant we had to first cover all “childless adults” below the federal poverty level- a group that lost AHCCCS coverage during the recession.  We paid for covering the childless adults with an assessment (fee) on hospitals (right now it’s about $264M).

AHCCCS set the assessments using a formula that made sure each hospital chain would be OK with the assessment because their fee would be lower than what they stood to gain by the reduction in uncompensated care.

The bill that authorized the assessment and Medicaid expansion barely passed with just over 50% of the House and Senate.  Many of the lawmakers that voted “no” believe that the bill should have required a supermajority because of a voter approved initiative that requires tax increases to pass by 2/3 of each chamber.

The Executive Branch believes that the assessment is not a tax, but a fee set by an agency director.  That’s the crux of the Biggs v. Betlach suit that challenges our Medicaid expansion.

The Goldwater Institute filed new documents this week with the Arizona Supreme Court, who will ultimately decide if the assessment is a fee or a tax. 

If the Court ultimately agrees with the Plaintiffs, AHCCCS wouldn’t be able to collect $264M hospitals pay and there won’t be enough money to fund the childless adults or the expanded coverage.  Unless the legislature were to vote by a 2/3 majority to fund the program, the only path to keeping the coverage would be via a voter initiative- which just got a lot harder to do with the passage of HB 2404 (preventing signature gatherers from getting paid by the signature) and HB2244 (changing the citizen’s initiative compliance standard from “substantial compliance” to “strict compliance”).

There will be Oral Arguments on the Biggs v. Betlach case on Thursday, October 26 starting at 9 am at the Arizona Supreme Court (Case CV-17-0130-PR).

ADHS’ Bureau ofEmergency Medical Services and Trauma System has been awarded $3.1 million by the Substance Abuseand Mental Health Services Administration for development of a comprehensive first responder opioid/naloxone program in partnership with the University of Arizona and the Arizona Peace Officer Standards and Trainingboard. Naloxone is a medication that can counteract an opioid overdose.

This joint initiative will implement a statewide naloxone delivery system to provideaccess to naloxone for first responders, an acute opioid overdose recognitionand naloxone administration training program for first responders, and addressa targeted first responder opioid screening, brief intervention, and referralto treatment curriculum to instruct first responders how to recognize actual orpotential opioid-related substance abuse and to provide appropriateinterventions and referrals to care.

The budget approved by the Legislature last session provided the funding for AHCCCS to cover emergency dental services for all adult members (over 21) up to $1,000 per year beginning October 1. AHCCCS turned in a plan to the Centers for Medicare and Medicaid fortheir approval a few weeks ago.

The next public health question is “what is the definition of Emergency Dental Services” so folks can know what’s covered. 

AHCCCS posted proposed language that defines what will be covered awhile back (the comment period ended September 21).  In it, they proposed covering dental servicesfor: “…an acute disorder of oral healthresulting in severe pain and or infection as a result of pathology or trauma.”

The proposed language is posted at 310-D1 – Dental Services for Members21 Years of Age and Older and also clarifies what kinds of procedures meet the criteriafor treating an “acute disorder of oral health resulting in severe pain and orinfection as a result of pathology or trauma”. 

I couldn’t tell whether this is going to be the final definition and list ofprocedures or not that will shortly become covered.  I’ll keep my eye out for that.

Children up to age 21 enrolled in AHCCCS have had (and continue to have) access to comprehensive and even preventative oral health coverage under the program.

Last week Senators Hatch and Wyden introduced bipartisan legislation to reauthorizethe Children’s Health Insurance Program (CHIP)- which is the parent ofArizona’s KidsCare program.

The Bill (called S.1827) proposes a 5-year reauthorization of the program and maintaining the current 23% increase in the federal matching funds rate through FY 2019, but reducing thematching rate in FY 2020… and returning to the standard state-federalmatching rate in FY 2021-2022.

While it looks like this reauthorization bill won’t be voted in this week, it’s not dead.  It can still be approved in thecoming weeks.  The lack of a reauthorization introduces some uncertainty to states (all 50 states have a CHIP program) butas long as it gets voted on in the near future most states will probably holdfast and keep the program going for the time-being.

The issue in the long-run is that the Hatch/Wyden bill drops the federal matching rate in FY 2020 below the threshold that’s wired into state law for fundingAZ’s share of the program.  But, that’s something that could be changed in either the 2018 or 2019 AZ Legislative Sessions.

Congratulations to the ADHS and all the Stakeholders that helped the team achieve national accreditation through the Public Health Accreditation Board (PHAB). The national accreditation program improves public health system performance by transforming the quality and performance of the nation’s state, local, tribal, and territorial public health departments.

PHAB Accreditation is a multi-year process that ADHS began in 2010 with the development of an agency strategic plan in 2011 and the first ever State Health Assessment in 2014.  Next was building the Arizona Health Improvement Plan.  Along the way, Accreditation includes developing, reviewing, and submitting documentation that supports the accreditation standards evaluate processes and services, outcomes, and progress toward specific goals and objectives.

The entire public health system including numerous Stakeholders need to be involved to achieve this recognition.  Congratulations to AZ’s public health system for this remarkable achievement.

The state health department joins Maricopa, Mohave, Pima, and Yavapai counties as national accredited public health agencies in Arizona.

The Children’s Health Insurance Program (CHIP) is a program that provides health insurance coverage for uninsured children in families with incomes that are modest but too high to qualify for Medicaid (AHCCCS). To continue operating, the CHIP program needs to be reauthorized by Congress by September 30.

In our state, CHIP is called KidsCare. AHCCCS offers health insurance through KidsCare for kids (under age 19) who aren’t eligible for other AHCCCS health insurance. There are several eligibility criteria- but the basic income criteria is a family income less than 200% of the federal poverty level.  Right now, about 23,000 kids are insured through Kids Care.  AZ also gets CHIP matching funds that covers an additional 73,000 kids via AHCCCS.

Arizona law requires AHCCCS to freeze enrollment if the federal match goes below its current level, meaning that there would be an enrollment freeze if Congress lowers the federal match below 100% as part of a funding reauthorization.

Last week there was an agreement struck in the Senate Finance Committee between Senators Hatch and Wyden on extending CHIP funding for 5 years but with a scaling down of the federal match.  So far, my understanding is that starting in FFY 2020, the federal matching rate would be reduced bump will be reduced and beginning in 2021 the federal match will go back to the regular CHIP match (for Arizona that’s 79% federal and 21% state match). 

Bottom line is that if this amendment goes through with the reauthorization bill, it would probably mean that KidsCare would continue as is through September 30, 2019.  After that, the program would freeze enrollment unless a state law is changed allowing for an alternative federal matching rate.  If the reauthorization doesn’t go through at all I’m not sure what would happen.

Please urge Senators McCain and Flake to reauthorize full funding of the Children’s Health Insurance Program (KidsCare in Arizona) and to keep the federal match rate at 100%.

Contact Senator John McCain and Senator Jeff Flake:

     Sen. John McCain: (202) 224-2235 or (602) 952-2410

     Sen. Jeff Flake: (202) 224-4521 or (602) 840-1891

Senator McCain indicated that he looks to the Governor for guidance. Please contact the governor’s office to urge the governor to support reauthorization of CHIP funding at 100% match.

     Gov. Ducey: (602) 542-4331 or (520) 628-6580

A last-ditch effort is underway in the US Senate to repeal the Affordable Care Act and replace it with an alternative plan.  It’s called the Graham-Cassidy bill. Before October 1 the Bill could pass the Senate with only 51 votes.  After that, it would take 60 votes, meaning that changes to the ACA would need to be bipartisan.

The Congressional Budget Office (CBO) – which evaluates the impact of health bills in terms of cost and impact on private insurance coverage and Medicaid- will need several weeks for it to evaluate the Bill’s impact, so it’s unknown how many fewer people could be insured under it or what the impact on premiums may be.

Even though the bill won’t have a CBO evaluation & its impact on commercial and group insurance and Medicaid as well as the fiscal impact have no objective estimates, the US Senate is poised vote on the bill in the coming days. 

What would Graham – Cassidy do?  In a nutshell, it would:

·       End Medicaid expansion funding, turning the federal funding for Medicaid expansion into a block grant. States would be given a lump sum of money and decide what to do with it (e.g. help enrollees pay their premiums, set up a high-risk or reinsurance pools);

·       Send states a fixed amount of money per Medicaid enrollee (a per-capita cap) starting in 2020.  States could also opt to receive Medicaid funding as a block grant – a fixed amount of federal funding each year- regardless of how many participants are in the program (states couldn’t take a block grant for persons with disabilities);

·       Repeal the ACA individual and employer mandates;

·       Repeal ACA cost-sharing subsidies that lower marketplace premiums by 2020, and roll the funds into a block grant to states;

·       Loosen the ACA’s requirements that plans cover pre-existing conditions;

·       Allow everyone in the individual market to buy catastrophic plans;

·       Repeal ACA taxes on over-the-counter medicine, health savings accounts and medical devices;

·       End federal funding for Planned Parenthood for 1 year; and

·       Double maximum contributions to health savings accounts.

We’re encouraging our members to use APHA’s action alert to let Senator McCain know what you think of the bill itself (especially the profound changes to Medicaid) and the process that’s being used to debate and approve this Bill.  Here’s the text of the short letter that AzPHA sent to Senator McCain yesterday.

Dear Senator McCain:

The Arizona Public Health Association and our members urge you to trust your instincts regarding the process that is being used in the Senate regarding the Graham-Cassidy Bill.

We agree with your previous statements and commitments suggesting that Regular Order is the best policy for debating and passing key legislation, especially legislation that impacts Arizonans in a profound and personal way like access to health care.

As you know, legislation that goes through the time-tested processes of debate and input from all sides is more likely to build buy-in and consensus.  Legislation and public policy built together is much more likely to be successful in the long-run.

Now more than ever, we need solutions to our Nation’s problems that are built together, with input from all.

We thank you for your leadership and your statesmanship.

Sincerely, 

Will Humble, MPH

Executive Director, 

Arizona Public Health Association

The Arizona Supreme Court announced this week that they’ll hear the Biggs v. Betlach case.  The lawsuit was filed by a group of legislators challenging the method used by the legislature to authorize AHCCCS’ hospital assessment.  It’s a charge to hospitals that’s used annually to draw down the federal match required to pay the state’s share for covering “childless adults” under our state’s Medicaid program (covering them was a pre-requisite to expanding Medicaid eligibility to 138% of poverty).

The Plaintiffs basically argue that the assessment is a tax rather than an assessment charged by the Agency.  Raising a tax requires a super majority while authorizing an agency director to, by rule, assess a fee only takes a simple majority.  The hospital assessment used the latter mechanism.

There’s plenty of agency practice history in assessing fees based on authority that came from a simple majority vote…  and some good case law too.  For example, when I was the ADHS Director, we raised the fees (in 2009) for our licensed facilities in order to pay for all of our licensing programs’ operations.  That authorization came via a simple majority vote budget bill.

We’re probably going to be OK, but you never know.  No date has been set for the Hearing.

A final push to “repeal and replace” the Affordable Care Act is underway in the US Senate. Today Senators Bill Cassidy & Lindsey Graham along with Senators Heller and Johnson unveiled a revised version of their legislation to repeal and replace the Affordable Care Act (ACA). A window of opportunity until September 30 is available for the supporters of the Amendment (for this federal fiscal year). 

It’s called the Cassidy-Graham proposal and it’s essentially an Amendment to the Better Care Reconciliation Act that failed awhile back. Here’s a summary of the content of the Bill, it would:

• Eliminate the ACA’s marketplace subsidies and enhanced matching rate for the Medicaid expansion and replace them with a block grant. Block grant funding would be well below current law federal funding for coverage, would not adjust based on need, would disappear altogether after 2026, and could be spent on virtually any health care purpose, with no requirement to offer low- and moderate-income people coverage or financial assistance.

• Convert Medicaid’s current federal-state financial partnership to a per capita cap, which would cap and cut federal Medicaid per-beneficiary funding for seniors, people with disabilities, and families with children.

• Eliminate federal subsidies to purchase individual market coverage;

• Eliminate the ACA’s individual mandate to have insurance or pay a penalty; and

• When the Bill’s block grant period ends in 2026, it would repeal the ACA’s major coverage provisions with no replacement.

At the same time, the Senate Health, Education, Labor and Pensions Committee is trying to develop a bipartisan health bill that likely would focus on marketplace stability, including assuring that health insurers receive the cost sharing subsidies. Because insurers will soon be setting their 2018 insurance rates, there’s interest in trying to finalize legislation this month, but it is not clear whether an agreement will be reached in the Senate—and then with the House.

Depending on what happens in the next couple of weeks we may issue an Action Alert for our members.