Will Humble State Legislature, Wills Blog

Legislative Budget Negotiations Underway & Several Public Health Initiatives in the Mix

All signs are that the Legislature is focusing on building a budget for next fiscal year.  The Republican leadership in the House and Senate met with representatives from the Governor’s Office over the weekend to come up with a budget proposal.  Here’s a link to the proposed budget worksheet.

It’s still unclear whether they have a plan that’ll pass. Several issues stand in the way – including a dispute about the statute of limitations for sexual assault victims and other specific priorities that some lawmakers are linking to their support of a budget.  Committee hearings on the spending plan won’t occur until Wednesday at the earliest (if they happen this week at all).

Some of our priorities are included in the weekend proposal (e.g. KidsCare funding & an appropriation for federal funds for child care subsidies), but several other priorities aren’t included (increases in the AZ primary care and loan repayment program and for additional primary care residencies).  Also not included is preventative dental services for pregnant Medicaid members.

Now would be a really good time for you to use any relationships you have with legislators to let them know that you support the encouraging portions of the initial proposal (e.g. KidsCare) but you believe more needs to be done to support access to care in rural and underserved areas by investing in the state’s loan repayment program and through increased residency opportunities (GME), as well as preventative dental care for pregnant Medicaid members.

Here’s the subset of the budget proposal related to public health and human services:

Medicaid

  • Fully funds KidsCare and eliminates the risk of an enrollment freeze by paying the increased state match requirements that are coming up (FY20 = $1.6M, FY21 = $9.4M, FY22 = $9.4M) 

  • Makes last year’s one-time $13M increase for providers that serve persons with developmental disabilities (because of the Prop 206 minimum wage increase) ongoing.  The proposal also includes a $6.7M cap rate increase for the current year for those providers.  Proposes an additional $13M in provider funding for the upcoming fiscal year.

  • Provides new Prop 206 (minimum wage increase) funding for Elderly Long-Term Care (for persons with developmental disabilities) of $4.8M

Child Care Subsidies

  • Appropriates $56M Childcare Block Grant funding (this is entirely federal funding- but the feds still require a state appropriation to draw down the funds)

Arizona State Hospital

  • Provides $2.8M in pay raises for AZ State Hospital staff 

  • Provides $300K for AZ State Hospital for a temporary staffing contract increase

Miscellaneous Health Items

  • Increases Alzheimer’s funding by $2M ($1M base)

  • Proposes $1M for rural prenatal equipment

  • Proposes $700K for Colorado City primary care clinic

  • Proposes $1.5M for Benson and Northern Cochise critical access hospitals

  • Continues $3M annual appropriation for TGEN for 3 years

  • Provides $10M to the Housing Trust Fund for programs related to homelessness

  • Provides an additional $15M for an Arizona Department of Education school safety grant program for School Resource Officers, behavioral health counselors and social workers

  • Provides $1.6M for Veteran’s Suicide Prevention (includes $450K for trauma training)  

This part of the legislative session is very fluid and things can move quickly or completely stall out at any time.  

Now would be a really good time for you to use any relationships you have with legislators to let them know that you support the encouraging portions of the initial proposal (e.g. KidsCare) but you believe more needs to be done to support access to care in rural and underserved areas by investing in the state’s loan repayment program and through increased residency opportunities (GME), as well as preventative dental care for pregnant Medicaid members.

To find your Senator and Representative go to: https://www.azleg.gov/findmylegislator/

Will Humble EMS, Injury Prevention, Wills Blog

Arizona Research will Change EMS Brain Injury Care

Traumatic brain injury is involved in about 1/3 of all injury-related deaths… it’s clearly a public health issue.  That’s why back in 2013 Arizona created the Excellence in Pre-hospital Injury Care (EPIC) project- which has been aimed at improving brain injury outcomes in AZ. 

Back in 2013 the National Institutes of Health chose AZ as the only state to evaluate the national standards for pre-hospital emergency care of brain injury (under a grant application led by AZPHA member Ben Bobrow, MD). 

EPIC has been a unique partnership between state government, the U of A and more than 130 fire departments and ground/air ambulance companies.  Together they implemented a series of pre-hospital traumatic brain injury treatment interventions and measured the effectiveness of the results.

The interventions included: 1) prevention of hypoxia by early oxygen administration; 2) airway interventions to optimize oxygenation; 3) prevention of hyperventilation; and 4) quickly treating low blood pressure by infusing fluids.

Participating EMS agencies sent treatment information to the ADHS and the UA College of Medicine for tracking and evaluation. An early donation from the Ramsey Justice Foundation made it possible for the agencies to receive special breathing devices to implement the new protocol and assist in the treatment patients at no cost.

More than 5 years of work by literally hundreds of Arizonans resulted in the publication of the results this week in JAMA Surgery entitled Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines with Patient Survival Following Traumatic Brain Injury.

Remarkably, the team found that implementation of the protocol doubled the chances of survival among persons with a critical traumatic brain injury and improved neurological outcomes. Doubling the chances of survival is no small thing for a public health intervention, so this is really a landmark study.

This Arizona study will change the way EMS providers treat traumatic brain injury in the field around the globe. That shows the importance of publishing. When hard work like this with dramatic results is published in reputable journals- people take note. It won’t be long before the Arizona protocol becomes a global EMS standard for traumatic brain injury care. For more info go to www.epic.arizona.edu.

A huge public health thank you to the entire research team including Dan Spaite, MD; Ben Bobrow, MD; Sam Keim, MD, MS; Bruce Barnhart, RN, CEP; Vatsal Chikani, MPH; Joshua Gaither, MD; Duane Sherrill, PhD; Kurt Denninghoff, MD; Terry Mullins, MPH, MBA; P. David Adelson, MD; Amber Rice, MD, MS; Chad Viscusi, MD; and Chengcheng Hu, PhD.

Will Humble Affordable Care Act, Health Insurance, Wills Blog

Washington Passes Medicaid Buy-In Law

This week Washington Governor passed the nation’s first Medicaid buy-in law.  The new law will offer a new health insurance option to people who make too much money to qualify for Medicaid but not enough to afford private health coverage. 

Washington’s new law directs their state Medicaid agency to contract directly with at least one private health insurer to offer a “qualified health coverage” plan that meets Affordable Care Act standards on the state’s marketplace. It will expand subsidies to people making up to 500% of the federal poverty line, or $62,450 a year, for a single person.

The tiered public plans are expected to be up to 10% cheaper than comparable private insurance, in part because of savings from a cap on rates paid to providers. The WA public plans are set to be available to all residents regardless of income by 2021.  Here’s more info in a Time Magazine article from this week.

In addition to Washington, legislation to study or start a public option or Medicaid buy-in program is currently pending in Colorado, Connecticut, Maine, Massachusetts, Minnesota, Missouri, New Hampshire, New Jersey and Oregon.

The basic idea is to leverage the buying power of state Medicaid programs to negotiate better premium rates that offer a lower-cost alternative to the health-care marketplace and spur competition which would lower premiums overall.

Will Humble Prevention, Vaccination, Wills Blog

Washington State Eliminates the Personal Exemption for MMR

Washington’s Governor also signed a new law this week that will eliminate the “personal exemption” that parents can sign to exempt their kids from school and pre-school vaccination attendance requirements. 

Interestingly, the new law just eliminates the personal exemption for the MMR (measles, mumps, rubella) vaccine.  The personal exemption option will still be available for the other school-required vaccines.  The new law will be effective before the start of this year’s school season.

Washington lawmakers overcame strong lobbying by anti-vaccine groups who mobilized hundreds of supporters, who telephoned and sent emails to lawmakers, and turned out in large numbers for the hearings.

As is often the case, a protracted outbreak created the political will to pass the measure.  Earlier this year Washington declared a  state of emergency after officials reported 25 measles cases. The cases continued to climb – and so far 78 measles cases have been confirmed in Washington and neighboring Oregon.

As is the case in AZ, Washington has seen a consistent increase in the number of kids whose parents have exempted them from vaccination school enrollment requirements.  In fact, Washington’s exemption rate for Kindergarteners is 4.7%.  Arizona’s exemption rate is even worse than Washington’s- as the exemption rates for Kindergarten went up this year to 5.9%.

It’s only a matter of time before Arizona has a Washington/Oregon style outbreak.  Most likely it’ll be in a place like Yavapai County- which has the state’s lowest immunization rates.  There’s a good chance it’ll start when an unvaccinated Arizonan returns from Europe with measles and spreads it within their community.

Will Humble Opioids, Wills Blog

AzPHA Letter to AHCCCS Urging them to Consider Adding Additional Opioid Use Disorder Medications

AzPHA sent the following letter to AHCCCS’ Pharmacy & Therapeutics Committee (which meets next Thursday), urging them to consider expanding the MAT Preferred Drug List for treating AHCCCS members with an opioid use disorder.  This work fits under the Administrative Advocacy portion of our mission.

I write on behalf of the Arizona Public Health Association – one of Arizona’s oldest and largest membership organizations dedicated to improving the health of Arizona citizens and communities. An affiliate of the American Public Health Association, our members include health care professionals, state and county health employees, health educators, community advocates, doctors, nurses and students.

Thank you for the opportunity to comment on the Pharmacy & Therapeutics Committee’s recommendation regarding the Preferred Drug List for Medication-Assisted Treatment (MAT) for opioid use disorder.

As Governor Ducey correctly declared, opioid addiction and abuse constitutes a public health emergency in Arizona.  While the Arizona Opioid Epidemic Act passed last year included several evidence-based interventions that will have an impact on the public health crisis over time, we believe that additional measures are necessary to improve MAT options for clinicians and patients.  In the area of medication options, we believe that more should be done to improve the therapeutic options available to clinicians as they treat patients for opioid use disorder. 

Buprenorphine products have demonstrated clinical efficacy in treating individuals with opioid addiction. There are now several FDA approved medications which each work differently and exist in several forms, strengths, and routes of administration.  Physicians treating AHCCCS members with opioid use disorder should be able to take advantage of the growing number of therapeutic options and be able to select the optimal medication in consultation with their patient.

The current PDL for AHCCCS members provides one buprenorphine treatment option: Suboxone film. While this medication may be the best currently available FDA approved option for many patients, evidence suggests that other patients may respond more positively to some of the other alternatives that are now FDA approved.

While “non-preferred” MAT options can be obtained by physicians via pre-authorization for Medicaid members, the process represents an unnecessary barrier to treatment. Time is of the essence when treating patients with opioid use disorder, and delays between when an individual decides to seek treatment and begins his/her regimen can reduce the likelihood of treatment success.

In summary, we ask that the Pharmacy & Therapeutics Committee recommend that AHCCCS open the Preferred Drug List to additional FDA-approved MAT medications.  When evaluating the list of FDA approved medications for the Preferred Drug List, we urge the Committee and AHCCCS to take into consideration the various FDA approved forms, strengths, and routes of administration as well as individual medication risks for diversion and accidental poisoning. 

Using those criteria, we believe the Committee can responsibly recommend an expansion of the MAT Preferred Drug List for treating AHCCCS members with an opioid use disorder that would improve outcomes for Medicaid members with an opioid use disorder.

We commend the Governor, our state legislators, and the staff at the ADHS and AHCCCS for recognizing the public-health threat posed by opioid abuse and taking concrete steps to implement evidence-based interventions to save lives.  Expanding options for MAT would be an additional concrete step toward that end.

Will Humble State Legislature, Wills Blog

Legislative Update

Not a ton news since last week. I’m beginning to sound like a broken record.

On the e-cigarette and smoking front, the good bill (HB 2357) remains in limbo- as it’s passed the full Senate and got through it’s Conference Committee- but wasn’t called to the floor of the House for a vote again this week.

The competing- not so good bill- SB 1147 passed on a voice vote through the Committee of the Whole in the House- but didn’t make it to a floor vote this week. 

Other than that, legislators are mostly focused on the budget negotiations.  There are a few items we’ll need to ask you to press for in the next couple of weeks with the legislators in your district including:

1) preventative and comprehensive oral health services for pregnant Medicaid members;

2) increased investment in funding for the state loan repayment program and health profession residencies (especially for primary care); and

3) funding Kids Care.

In addition, there’s an important $65M appropriation of federal funds that needs to be made to provide additional subsidies for child care services for folks that qualify- along with a needed increase in reimbursement rates. No state dollars are needed- simply an appropriation of the federal funds that have been allocated to AZ.

Will Humble Tobacco, Wills Blog

A Tale of 2 Vape Bills

This week featured a dual between bills that say their goals are to address the vaping epidemic.  One does and one doesn’t.

The Good Bill

This week the Senate approved (29-0) a bill from Senator Carter (a strike amendment HB 2357) that would classify vaping products in the same category as tobacco.

That means vape pens and the like would be subject to the same laws and rules that govern sales and where you can use them (e.g. vaping would be covered under the Smoke Free Arizona Act). It would also continue to allow cities and towns to impose their own stricter regulations.   HB 2357 would continue to keep the sale age at 18 (rather than 21 which would be ideal) but it would still allow communities to adopt and keep their own ordinances which have raised the age for the purchase of tobacco and vaping products to 21.

After passing the Senate unanimously (as the e-cig version) it went to a Conference Committee a couple of days ago and passed through unanimously. Looks like it’ll be up for a floor vote on Monday in the House.

Now would be a great time to get with your 2 Representatives and let them know you support 2357 because it’s a common-sense bill that defines e-cigarettes as a tobacco product and would remove vaping from public spaces, workplaces and schools.

The Not Good Bill

The tobacco bill dualing for attention is SB 1147 (a different striker bill) which I blogged about last week.  It would set the minimum age statewide for tobacco possession at 21 but it would override lots of other local ordinances about how tobacco and vaping products could be sold and would allow only “reasonable” zoning regulations about where sales can take place.

Another bad thing about SB 1147 is that e-cigs would be in a separate legal category from tobacco meaning it would specifically exempt vaping products from the Smoke Free Arizona Act (vaping didn’t exist when the Smoke Free AZ Act passed in 2006).

This one will likely see a House floor vote next week too.  If it passes it would also need a conference committee because the original Senate version was completely different (about city development). If it gets through the conference committee- it would need another Senate floor vote.

Will Humble Affordable Care Act, Behavioral Health, State Legislature, Wills Blog

Legislative Update

Not a ton news since last week. The main thing that happened this week is that the Governor signed a good bill on suicide prevention (more info below). He also signed a bill that will make Association Health Plans more available in AZ. Info on that below too.  Last week’s  Legislative Update covers things pretty well so far.

Other than that, we’re moving full force into the budget negotiations process now. By all accounts it looks to be a more deliberative process than in years past because of the tight party affiliation margins and the disconnect between the executive budget priorities and those of the legislature. It’s likely that we’ll have at least a few more weeks before a final budget is complete- and it might even go into June this year. 

SB 1468 Suicide Prevention Training

It will require school districts, charter schools, and Arizona teacher training programs to include suicide awareness and prevention training in their continuing education curricula.  It’ll require AHCCCS to make suicide awareness and prevention training available (fortunately some evidence- based tools curricula already exist).

Starting in the 2020 school year, school districts and charter schools would need to provide training in suicide awareness and prevention to school personnel in grades 6 to 12.  The bill also establishes requirements for suicide awareness and prevention training and specifically says that the training use evidenced-based training materials and instruct participants on how to identify the warning signs of suicidal behavior in adolescents and teens.

SB 1085 Association Health Plans (AzPHA Opposed)

This bill was passed by the House this week and is awaiting the Governor’s signature.  He’s sure to sign it. It basically provides a regulatory structure at the state level to regulate AHPs in AZ – serving to make them more available in Arizona. A primary concern for folks interested in public health and consumer protection is that AHPs don’t need to cover the essential health benefits, they can charge differently depending on gender and age. 

Additionally, we’re concerned that if an employer offers a “skinny” benefit plan that barely meets the definition of minimum value (and doesn’t include important essential health benefits) families could be prevented from benefitting from the subsidies that would otherwise be available to them on the Marketplace.

Back in August (at the direction of the President) the US Department of Labor issued a final rule that established criteria for determining when employers can join in an association and be treated as an employer sponsor of a group health plan.  The federal regulation loosens the rules for additional plans to come onto the market, allowing more small businesses including individuals who work for themselves to join these plans.  This bill will make these plans more available in AZ.

Will Humble Medicaid, Social Determinants, Wills Blog

Leveraging Managed Care Contracts to Address Social Determinants

Medicaid programs across the country and our own Medicaid agency (AHCCCS) are increasingly considering how best to address the social factors, such as housing, healthy food, and economic security, that can affect health and medical expenditures (social determinants).

That’s because social determinants of health drive as much as 80% of population health outcomes.  It’s easy to see why there’s such an interest in addressing social determinants as Medicaid program administrators look for ways to contain costs.

Many Medicaid programs including ours have focused much attention on the social determinants that drive costs in expensive or high needs populations (e.g., people with disabilities or a mental illness or HIV/AIDs)… but as the knowledge about how profound social determinants are in terms of costs overall, many are now thinking about how they can address social determinants across the general Medicaid population.

An organization called State Health and Value Strategies has developed an Issue Brief that explores practices states are using to address social factors using Medicaid 1115 waivers and in their managed care contracts The issue Brief also includes steps states can take to implement these practices.

The issue brief includes a review of Medicaid managed care contracts in 17 states and Medicaid 1115 provisions in 6 states.  There are quite a few examples in the report- so I’ve just picked a couple to give examples:

Aligning financial incentives to support SDOH interventions.  States are deploying a range of tools to strengthen the financial incentive for plans to address SDOH. These include the use of withhold payments linked to SDOH-sensitive outcomes and allowing plans to count investments in high-impact social services toward the numerator of their medical loss ratio (MLR).

Creating opportunities for affordable housing. Medicaid does not directly pay for housing, but states are increasingly identifying new ways to connect people to housing resources; providing housing-related services that can be covered via Medicaid; and encouraging their Medicaid managed care plans to participate in broader, cross-sector initiatives to address the affordability and safety of housing.

Building a stronger network of community-based organizations and collaboration with providers. Recognizing that many community-based organizations operate on tight budgets and lack experience contracting with health care plans and providers, states are investing in community-based resources and fostering stronger working relationships between such organizations and health care plans/providers.

Will Humble Medicaid, Social Determinants, Wills Blog

Coding the Social Determinants

ICD-10 diagnosis codes that relate to the Social Determinants of Health can be a valuable source of information to improve health outcomes.  Social Determinants of Health codes can identify the conditions in which people are born, grow, live, work, and age like education, employment, physical environment, socioeconomic status and social support networks- data that can provide managed care organizations information with which to improve outcomes and reduce costs.

AHCCCS is recommending that providers routinely screen for and document the presence of social determinants (as appropriate within their scope of practice) and to document them in claims data. They began monitoring claims for the presence of the codes about a year ago.  You can review the Social Determinant ICD-10 Codes on the AHCCCS website.

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