Will Humble Medicaid, State Legislature, Wills Blog

House Passes Budget Bill with Big Tax Cuts for the Wealthy: Medicaid & SNAP Likely on the Chopping Block

This week the U.S. House of Representatives narrowly passed a budget bill that extends and expands the massive tax cuts for wealthy individuals first implemented in 2017. At the same time, the bill mandates $880 billion in spending cuts over the next decade.

While the legislation does not specify which programs will be cut, it assigns the House Energy & Commerce Committee the task of deciding where the axe will fall.

The House of Representatives Energy & Commerce Committee oversees Medicaid, Children’s Health Insurance Program, Medicare Part B & Part D, Public Health Programs (including the CDC, NIH, and HRSA), the FDA and the Substance Abuse and Mental Health Services Administration.

One thing is clear: Medicare is off the table. That leaves programs like Medicaid (AHCCCS) and the SNAP as the most likely targets for the committee. If history is any guide, House leadership will fall back on a familiar strategy—forcing states to cover a greater share of Medicaid expansion costs.

For Arizona, that would be bad. As outlined in our recent Arizona Public Health Association blog post, shifting more of the Medicaid costs to the states will result in Arizona’s Republican-controlled legislature refusing to pick up the tab.

That would mean the end of Medicaid coverage for 550,000 Arizonans, including low-income childless adults and people earning between 100% and 138% of the federal poverty level.

Interestingly, the parts of the state that voted for Mr. Trump by the widest margins are in the very areas that stand to lose the most if these cuts happen. Thirty-six percent of working-age Arizona adults who live in rural Arizona are covered by Medicaid versus 17% who live in urban areas (according to data from Georgetown University’s Center for Children and Families).

The House has acted, but the Senate has yet to vote on a budget plan. That means there’s still time for advocacy. If these cuts move forward, Arizona—and states across the country—will see big (and bad) consequences for public health.

Stay tuned.

Will Humble Vaccination, Wills Blog

Public Health Journalism this Week

Why Musk cuts could affect AZ public health | 12news.com

4 Arizona counties have lower vaccination rates than Texas measles epicenter

This Arizona health expert weighs in on the measles outbreak — and how contagious it is

Measles symptoms include a high fever, cough and runny nose

Here’s why Arizona is at high risk for a measles outbreak

Map: Where Medicaid Enrollment in the U.S. Is the Highest – The New York Times

Will Humble Vaccination, Wills Blog

Measles Outbreaks & Wildfires: The Importance of Early Intervention

Measles outbreaks are like wildfires: both get out of control fast if they’re not immediately detected and managed. The surge of measles cases across nine counties in Texas (originating from a single first case in a community with low vaccination rates) highlights the critical need for immediate detection of early case(s) and immediate and effective interventions.

Public health has several tools that can help stop a measles outbreak once – but only if they all work in tandem and happen fast.  The core control measures are:

  1. Robust Surveillance and Early Detection: The first case of measles needs to be found right away. Having relationships with front line clinicians and laboratories are key to finding that critical first case. Healthcare providers need to recognize early symptoms and quickly report suspected cases to the county health department.
  2. Immediate Contact Tracing: Once a case is confirmed, county epidemiologists need to quickly do contact tracing to find everyone who may have been exposed – with a focus on unvaccinated contacts – especially in school settings. Having immediate access to the vaccination status of the kids in a school or preschool is key to knowing which contacts are unvaccinated.
  3. Exclusion of Unvaccinated Contacts: County health officers need to exclude unvaccinated student contacts from in-person schooling for two incubation periods (approximately 42 days) to curb potential spread within schools and day cares.  County staff also need to ensure good isolation of exposed unvaccinated contacts from unvaccinated people (including family members). As kids under 1 year old are all unvaccinated – health officials need ensure infants don’t have contact with unvaccinated contacts.
  4. Accelerated Vaccination Campaigns: Counties also need to deploy immunization teams to administer the MMR vaccine to unvaccinated contacts (and hopefully newly motivated unvaccinated community members).

AzDHS Measles Control Measures

What Happens if Measles Gets into Arizona Schools or Childcare?

Many areas of Arizona are at risk of a measles epidemic running out of control because of our poor vaccination rates.

New CDC Report: Arizona Has Among the Lowest Childhood Immunization Rates in the U.S.

During the 2023-24 school year, only two counties—Santa Cruz and Yuma— had the 95% herd immunity threshold necessary to prevent measles outbreaks. The increasing number of personal belief exemptions (and the paucity of places where families can get their kids vaccinated) have significantly reduced vaccination rates, leaving communities vulnerable to outbreaks like the one in Texas.

Here’s why Arizona is at high risk for a measles outbreak

County health departments need to treat measles outbreaks with the urgency of a wildfire. Immediate detection, fast & thorough contact tracing, strategic exclusion policies, and proactive vaccination efforts are key to preventing small sparks from igniting into an uncontrollable epidemic.

Of course- public health is really all about prevention – and the most effective intervention is to have and keep high childhood immunization rates – something that will be more and more difficult in the coming years given the new leadership at HHS.

RFK Jr. as HHS Secretary? Why It Could Mean the End of Evidence-Based Public Health Policy

Will Humble Vaccination, Wills Blog

RFK Jr. Already Taking Actions to Undermine Immunizations

Just days into his tenure as Secretary of Health and Human Services Robert F. Kennedy Jr. is already backtracking on ‘assurance’ he gave during his Senate confirmation.

Despite pledging to uphold the integrity of the Advisory Committee on Immunization Practices and not to interfere with childhood immunizations, Kennedy has already taken action to destabilize ACIP and evidence-based vaccine policy.

The ACIP, a panel of independent experts, is instrumental in developing vaccine recommendations in the US. These guidelines inform healthcare providers and influence insurance coverage, as most health plans must cover vaccines recommended by the ACIP. Those that aren’t on the schedule are generally not covered.

On his first day in office, Kennedy postponed a scheduled ACIP meeting set for late February. This meeting was slated to discuss critical updates on vaccines, including Gardasil, the human papillomavirus vaccine that prevents cervical cancer.

Kennedy has a history of opposing Gardasil, having represented individuals claiming injury from the vaccine and alleging that its manufacturer, Merck, overstated HPV risks to promote mass vaccinations.

Beyond canceling the meeting, reports indicate that Kennedy plans to overhaul the ACIP by removing members he perceives as having conflicts of interest.

RFK Jr. prepares shake-up of vaccine advisers – POLITICO

The ACIP’s recommendations are foundational to public health, guiding vaccine schedules that have significantly reduced the prevalence of infectious diseases. Insurance coverage for vaccines is often contingent upon these recommendations, meaning alterations could lead to decreased coverage and higher out-of-pocket costs for patients

During his confirmation, Kennedy assured senators that he would respect scientific analyses and uphold existing immunization practices. His recent actions, however, indicate a (predictable) departure from these commitments.

As these developments unfold, we will continue to raise the alarm and do what we can to educate the public about the real consequences of Mr. Kennedy’s decisions and actions.

I have no delusions that we will get him to change his mind about anything – but it will at least feel good to tell the public the truth in our small little way.

Will Humble Public Health, Public Health Law, Wills Blog

Legal Remedies when the Trump Administration Ignores Federal Court Orders

Over the past several years, state attorneys general and nonprofit organizations have filed many lawsuits against Trump administration officials, challenging the legality and constitutionality of various agency and DOGE bro decisions and actions.

In many cases, federal judges have issued preliminary injunctions or temporary restraining orders to halt abrupt policy changes and actions, like cuts to research funding or the withholding of grants and contracts.

But what happens when Mr. Trump or his staff ignore or don’t follow these court orders? What legal remedies are available to plaintiffs, and who’s responsible for enforcing the judicial rulings if the administration blows them off?

The Role of U.S. Marshals in Enforcing Court Orders

Federal court orders are typically enforced by the U.S. Marshals Service, which is responsible for carrying out court directives, including serving subpoenas, making arrests, and ensuring compliance with judicial rulings.

In cases where a government official defies a court order, a judge can hold them in contempt of court, leading to potential fines or even jail time. The Marshals may be directed to act against those in defiance, ensuring that court mandates are upheld.

However, U.S. Marshals report to the President. If the Trump administration were to direct federal law enforcement to delay or refuse enforcement of a court order, plaintiffs could face significant hurdles in ensuring compliance.

Contempt of Court and Sanctions

If the Trump administration ignores judicial rulings, courts have another tool: contempt proceedings. Judges can impose escalating fines, sanctions, and even imprisonment for officials who refuse to comply.

Courts can also seek intervention from Congress or escalate matters to the Supreme Court to resolve constitutional crises.

At that point, it would be up to the 9 judges on the US Supreme Court to decide whether they care about the constitution and the republic or not.

Can State Law Enforcement Step In?

In cases where federal marshals fail to act to enforce court orders (or contempt of court findings), courts can turn to state and local law enforcement agencies.

Federal judges have the authority to deputize state law enforcement officers to carry out federal court orders, particularly in cases of contempt or defiance by federal officials. State attorneys general, governors, and local sheriffs can be called upon to enforce judicial rulings.

The use of state law enforcement to enforce federal court orders has happened before. In high-profile cases involving civil rights enforcement and desegregation orders, federal courts have relied on state and local law enforcement—sometimes even deploying the National Guard.

While the Trump administration could try to resist enforcement, state and local officials committed to the rule of law (in blue states) may still have tools at their disposal (and the will) to ensure compliance.

Bottom Line

When Trump administration officials (and the DOGE bros) ignore or fail to follow court orders, enforcement will depend on the willingness of law enforcement agencies—both federal and state—to uphold the rule of law.

While the U.S. Marshals Service is the primary enforcer, if (when) the administration obstructs enforcement, state law enforcement can be deputized to ensure compliance.

The rule of law and our republic are only as strong as our institutions’ ability to uphold it. If federal officials refuse to comply with judicial rulings, the courts need to be prepared to use every tool at their disposal to enforce their decisions and maintain the integrity of the judicial system (and the republic).

Legal Remedies when the Trump Administration Ignores Federal Court Orders

Will Humble Public Health, Public Health Law, Wills Blog

The Judicial Branch: Public Health’s Best Friend for the Next Few Years

Attorney General Kris Mayes attended the Arizona Center for Rural Health Policy Forum last week and talked about how she and the other 22 democratic attorney generals are fighting the parts of the Project 2025 agenda now being implemented by the Trump Administration that they believe are unlawful or unconstitutional.

As policy decisions are made by the federal agencies or a DOGE bro – the staff at the state attorney general offices examine the decisions, prepare research, and build & file lawsuits to challenge those that conflict with existing federal law or that are unconstitutional.

That work has already bore some fruit. Several lawsuits have been filed about various policy decisions, with several judges issuing preliminary injunctions or temporary restraining orders halting those decisions – at least temporarily.

Here are a few examples:

  • Challenge to Birthright Citizenship Executive Order: Multiple federal judges have issued preliminary injunctions blocking the enforcement of President Trump’s executive order aimed at ending birthright citizenship. These rulings assert that the order likely violates the Fourteenth Amendment.
  • Lawsuit Against Federal Funding Freeze: A coalition of 23 states, filed motions resulting in a federal judge issuing a temporary restraining order against the Trump administration’s freeze on federal grants and loans. The court found the funding freeze to be potentially unlawful and issued a TRO.
  • Legal Challenge to “Fork in the Road” Directive: A federal judge extended a temporary restraining order against the Trump administration’s “Buy Out, Fork in the Road Directive,” which aimed to alter government procurement processes. The extension prevents the directive’s implementation pending further legal review.
  • Opposition to DEI and Gender-Related Executive Orders: Civil and human rights organizations filed a lawsuit challenging executive orders targeting Diversity, Equity, and Inclusion initiatives and gender identity policies. The plaintiffs argue these orders violate constitutional rights, leading to ongoing legal proceedings (no judge decision as of yet).
  • Litigation Over USAID Funding Freeze: A federal judge has ordered the administration to release frozen USAID funds, but the Trump administration has been ignoring that Order leading to ongoing legal challenges and calls for enforcement of the court’s directive (more on this process in the next blog).
  • Case Involving Special Counsel Dismissal: Hampton Dellinger, obtained a temporary restraining order preventing his firing by Trump. The case challenges the president’s authority to remove certain federal officials, and has already been escalated to the U.S. Supreme Court for resolution.

The judicial branch of government will be crucial in potentially mitigating some of the dangerous and harmful public health and healthcare decisions being implemented by the Trump Administration.

Some of those cases will ultimately be successful and some won’t – but until the mid-term elections the judicial branch is our most important tool for mitigating the damage.

But…  what if Mr. Trump, his secretaries or the DOGE bros ignore those court orders? What’s the remedy?

That’s the topic for my piece tomorrow: Legal Remedies when the Trump Administration Ignores Federal Court Orders

Will Humble Uncategorized

Register Today: AzPHA 2025 Conference – Modernizing Public Health Practice

Building an Innovative & Inclusive Infrastructure for the Future

View Our Agenda

Thursday, April 3, 2025

Desert Willow Conference Center

Phoenix AZ

We’ll have innovative thinkers, practitioners, and researchers to share insights and strategies that drive transformative changes in public health: 

  • Engaging Keynote Presentation from Jyoti Pathak, PhD Inaugural Dean, ASU School of Technology for Public Health
  • Sixteen (16) breakout sessions with 30 participants in the areas of:

Data Infrastructure & Informatics

Public Health Workforce

Using AI to Enhance PH practice

  • Closing Panel Discussion: Innovative Methods & Techniques in Public Health Implementation Science

View Our Agenda

 Register Here

View Our Sponsorship Opportunities

 

Will Humble State Legislature, Wills Blog

Legislative Update: February 22, 2025

This was the last week for bills to be heard in assigned committees in their house of origin – so all the bills that failed to get a committee hearing are now dead (although there are resurrection pathways). Next week will be dominated by floor votes (called 3rd Read).

Bills that successfully get approved on the floor votes then move over to the other chamber.

It’s really hard to predict which bills will get floor votes next week – because the floor vote calendar is often posted just beforehand – not much tome to prep. 

Here is a list of the public health related bills that have advanced out of their chamber last week:

  • SB1019 photo enforcement; traffic (AzPHA opposes)
  • HB2001 behavioral health temporary licenses (AzPHA Supports)
  • HB2291 opioids, red cap packaging (AzPHA Supports)
  • HB2130 claims; prior authorization (AzPHA Supports)
  • HB2175 claims; prior auth; company conduct (AzPHA Supports)

There will no doubt be several of the bills that we’re for or against advance to floor votes next week. I’ll do my best to keep track of them and provide a more thorough update next week.

We’ll have better clarity about which bills have advanced to the other chamber (e.g. adult preventive dental; parental rights bills; secure behavioral health facilities; produce purchase incentives; etc.) and I’ll be able to provide a more comprehensive update. 

Will Humble Medicaid, Wills Blog

AHCCCS Seeks Public Input on Proposed Medicaid Work Requirements & 5-Year Lifetime Limit on Benefits

Back in 2015, the Arizona Legislature passed & Governor Ducey signed SB1092, mandating that AHCCCS ask for federal approval to limit lifetime eligibility to 5 years for all ‘able-bodied’ adults (regardless of income).

The law also requires them to ask permission to implement work requirements for all “able-bodied adults” receiving Medicaid.  

AHCCCS is supposed send their request to CMS each April. AHCCCS first submitted the plan and got the green light back in 2019 – but they didn’t implement it because of an ongoing court case challenging the legality of the plan.

The COVID-19 Public Health Emergency put things on hold throughout the rest of 2020.  In February 2021, the Biden Administration’s CMS rescinded approval for the AHCCCS Works program.

As April approaches, AHCCCS is getting ready to submit the request again – and launched their draft proposal, which they plan to submit to CMS in a couple of months.

What they put in their final plan is super important as Dr Oz (the CMS Administrator) is certain to approve the plan (unless he thinks it’s not harsh enough).

According to the draft plan released this week, able bodied adults can be exempt from the work requirements by doing the following things for at least 20 hours per week:

  • Be employed;
  • Attend school; or
  • Attend an Employment Support programs like:
    • English as a 2nd language courses;
    • Parenting classes;
    • Disease management education;
    • Courses on health insurance competency; and/or
    • Healthy living classes.

Not everyone will be subject to these proposed rules (including the 5-year lifetime limits on eligibility) as AHCCCS’ draft proposal exempts the following populations from the definition of ‘able bodied’:

  • People over 55
  • American Indians
  • Pregnant women up to 90 – 120 days post-delivery
  • Former foster youths up to age 26
  • People with a serious mental illness
  • Those receiving temporary or permanent long-term disability benefits
  • Individuals deemed medically frail
  • Full-time students in high school, college, or graduate school
  • Victims of domestic violence
  • Individuals experiencing homelessness
  • Those recently affected by certain events (e.g. death of a household family member)
  • Parents, caretaker relatives, foster parents, and caregivers of family members enrolled in the Arizona Long Term Care System

AHCCCS wants to hear from you about their draft proposal. They’re encouraging the public to review the proposal and share their thoughts.

You can send your comments via email to [email protected]. There are also some public forums about their proposal at AHCCCS Works 1115 Waiver Amendment Request.

Please take some time to look at their proposal and let them know if you have ideas to make it more palatable. All comments are due by March 20, 2025. 

Remember – it’s still important to comment if you think AHCCCS has done a good job identifying the exempt populations and providing a broad interpretation of how members can meet the work (community engagement) requirements!

Editorial Note: How AHCCCS implements the program will be critical to minimizing the number of people who are thrown off of AHCCCS coverage once this is approved and implemented.

In other states that have implemented a similar work requirement lots of people met the community engagement/work requirements but weren’t able to successfully document their service or work – or didn’t know how to – and were thrown off Medicaid even though they were doing what was required of them.

Will Humble Public Health, Wills Blog

What is DEI & Why is it Important in Public Health Practice?

You’ve no doubt heard that the White House recently issued an Executive Order directing federal agencies to stop any and all “Diversity Equity and Inclusion’ policies, personnel positions and activities.

You can read that Executive Order here: Ending Radical And Wasteful Government DEI Programs And Preferencing – The White House

Interestingly, but not surprisingly, the EO doesn’t define exactly what DEI is. There’s no definition in the Executive Order. It refers to the term over and over but doesn’t define it.

So, what is DEI? Diversity, Equity, and Inclusion are foundational principles in public health management that ensure public health policies serve all individuals fairly and effectively.

By integrating DEI into public health strategies, leaders can create more fair health outcomes, reduce health disparities, and improve the overall health & well-being of diverse communities.

  • Diversity encompasses the broad range of differences in race, ethnicity, gender identity, age, disability status, sexual orientation, socioeconomic background, and cultural identity within a population or workforce. A diverse public health workforce reflects the communities it serves, improving cultural competency and responsiveness, and is more likely to develop and effectively implement interventions that improve health outcomes among diverse populations.
  • Equity focuses on cutting systemic barriers to healthcare access and ensuring that resources are distributed based on need rather than equality alone. Unlike equality, which assumes everyone benefits from the same resources, equity acknowledges historical and social disadvantages and looks to address them to level the playing field.
  • Inclusion ensures that diverse voices are actively engaged in decision-making, creating policies and programs that are both representative and effective. An inclusive public health system values different perspectives and fosters a sense of belonging for all individuals.
The Importance of DEI in Public Health Management

Reducing Health Disparities Structural inequalities have long contributed to disparities in healthcare access and health outcomes.

For example, racial and ethnic minorities, low-income individuals, and rural populations often have higher rates of chronic diseases, maternal mortality, and infectious disease exposure. By embedding DEI principles into public health strategies, leaders can tailor interventions that address these specific challenges and reduce disparities.

Enhancing Cultural Competency A diverse and inclusive public health workforce is better equipped to understand and address the unique needs of various communities. Culturally competent care and policies need to consider language barriers, traditional health beliefs, social contexts, and improve healthcare engagement among marginalized populations by fostering trust and credibility.

Improving Public Health Communication Effective health communication requires an understanding of diverse populations. Messaging about vaccination, disease prevention, and health promotion need to be culturally sensitive and linguistically accessible. Without DEI considerations (and diverse staff), public health campaigns are less likely to succeed.

Building Community Trust Marginalized groups have faced discrimination and mistreatment in healthcare, leading to distrust in medical institutions. By prioritizing DEI, public health leaders are better able to rebuild trust through transparent policies, fair resource allocation, and community involvement in decision-making.

Strengthening Public Health Policies Inclusive policymaking that involves diverse stakeholders leads to more effective and sustainable health interventions. Policies that consider the needs of all communities create healthier, more resilient populations and reduce long-term healthcare costs.

By prioritizing DEI, public health management can create fairer, more effective systems that improve health outcomes for all individuals, ensuring that no community is left behind.
Despite the President’s executive order (which applies to the federal government) I expect that many local and state health departments will continue to implement policies and make staffing and hiring decisions using DEI principles.

Why? Because using DEI principles to inform public health policies and staffing decisions is a best management practice.

Besides – many people in the public health profession recognize that structural racism is real – that it has real-life public health consequences and is fundamentally unfair.

Those things alone should be sufficient to sustain grass-roots DEI principles through the next 3.9 years.

DEI Literature

Understanding the Dynamics of Diversity in the Public Health Workforce – PMC

Addressing Health and Health-Care Disparities: The Role of a Diverse Workforce and the Social Determinants of Health – PMC

Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care – PMC & 04/PHR118-4/Betancourt/et al

Structural Interventions to Reduce and Eliminate Health Disparities – PMC

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