Doula Care Reduces C-sections, Pre-term Birth & Cuts Birthing Costs by a Net $1,000

AHCCCS Actively Working Toward Incorporating Doula Care as a Covered Service but ADHS Still Hasn’t Developed the Certification Regulations

Those of you that attended the health equity conference last week were treated to a terrific late morning panel discussing a range of reproductive health topics including: 1) maternal mortality interventions; 2) local health policies that promote access to care for birthing people and infants; 3) overcoming barriers to care for birthing people and infants in Arizona, and 4) opportunities for cross-sector collaborations.

Several of the speakers (DeShawn Taylor, MDJennifer Piatt, JDZaida Dedolph Piecoro,Sara Salek, MD, and Jacqueline Badine) mentioned the role that Doula care can play in improving birth outcomes (especially Ms. Badine). Their discussions inspired me to take a deeper dive into Doula care this week, so here goes.

A doula is a trained professional who provides physical, emotional, and informational support to a woman throughout her pregnancy, childbirth, and postpartum period. Doulas act as a facilitator between the laboring women and her physician by ensuring that the mother gets the required information to make informed decisions.

Several studies have shown that moms who have doula services during their pregnancy and delivery have fewer cesarean sections and epidurals, reduced premature births, higher rates and a longer duration of breastfeeding, while substantially reducing birthing costs

In March 2014, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal medicine issued a consensus statement which explicitly stated that published data has indicated better labor and delivery outcomes when continuous support personnel such as doulas are used. In addition to improving birth outcomes, doula care has a high return on investment.

Doula care reduces healthcare costs by lowering the rate of pre-term and C-section deliveries to the tune of about $1,000 per doula-supported birth

Fortunately, the word that doula care improves health outcomes while reducing healthcare costs has struck a chord- and Arizona policy is slowly moving toward integrating doula care into the network, including AHCCCS coverage.

The strategy for building doula care into the network is much like the model we used for Community Health Workers…  build a professional certification process, followed by amending AHCCCS’ waiver with CMS to provide for reimbursement for the services.

Back in 2021, the legislature passed, and the governor signed a new law [ARS 36-766.01-09charging the ADHS with developing rules to certify doulas including a scope of practice, qualifications, standards for education and training programs and compliance criteria. The law gave ADHS ‘exempt’ rulemaking authority- which is essentially the diamond lane for writing rules (there’s no excuse for slow-walking them).

While ADHS hasn’t made any tangible progress on that rulemaking yet, they’ve at least published a ‘Notice of Public Information‘ with the Secretary of State.

The slow pace of the rulemaking shows that finishing the rule isn’t a priority for the current ADHS director, but it might be a higher priority for whoever is appointed to that post a few months from now.

At the Health Equity Conference last week, AHCCCS’ Chief Medical Officer (Dr. Sara Salek) mentioned that the agency is in the process of preparing an amendment to their state plan to incorporate doula care as a covered service. Hopefully the next ADHS director will get on the stick and finalize the doula certification rules in time for certification to be available by the time AHCCCS is able to complete their paperwork with CMS. 

Also See:  Doula Coverage to Help Minimize Arizona’s Birth Woes

Message from AzPHA Member Dr. Leonard Kirschner: Nine Big Lies & One Big Truth

Ken Burns gripping documentary, “The U.S. and the Holocaust” brought back memories of my own family. My four grandparents immigrated from eastern Europe in the 1890’s and settled in New York. My parents were born in New York, met, married and had two children in the city. My father and his sister were orphaned and raised by cousins. My father got his college degree from City College, his Master’s in Business from NYU, and became the Chief Operating Officer of an international textile corporation with headquarters in New York.

My aunt moved to Paris in the 1920’s to study at the Sorbonne. When the war started, she joined the OSS (the precursor to the CIA). She served in North Africa and Europe. A true immigrant story. At the end of the war, my aunt returned to Europe to search for the cousins she had met in her years living in Paris. They had all perished in the Holocaust. My own history makes me reflect on big lies that have had horrific consequences.

The Big Lie #1. When Adolph Hitler rose to power in 1933, he propagated the big lie that the Jews of Germany had caused the country to lose World War 1. He added to that lie by saying the Jewish population was the cause of all the problems the country faced in the Great Depression. Joseph Goebbels, his Minister of Propaganda, said it well: “A lie once told remains a lie, but a lie told 1000 times becomes the truth.” My dear friend Sue was born in Stuttgart, Germany, in 1937, into a family that had lived in the country for centuries. Her father served in the German Army in World War 1 but that did not matter because he was a Jew. They escaped to the United States in 1938. I met Sue when we were in high school. Those big lies led to the death of millions of innocent people.

The Big Lie #2. For hundreds of years witchcraft was believed to exist. There are estimates that tens of thousands of people (mostly women) were convicted of witchcraft and hung, drowned or burned at the stake. The American colonies were not immune to this big lie with the most infamous being the Salem witch trials of 1692-1693 in which 19 individuals were executed. This event has been described as a case of mass hysteria. In the 1950’s, the Massachusetts Legislature passed legislation exonerating the people who had been executed.

The Big Lie #3. Joseph McCarthy was a United States Senator from Wisconsin, serving from 1947 to 1957. He propagated the big lie that the United States was the target of widespread communist subversion. He claimed to have lists of communists in the State Department, the administration of President Truman, the U.S. Army and other government agencies as well as in Hollywood. There were no lists. Eventually Senator Margaret Chase Smith called him out and the Senate censured McCarthy. Today the term, “McCarthyism” stands for a demagogue who makes reckless and unsubstantiated accusations.

The Big Lie #4. “Separate but Equal” was a legal doctrine employed in the years after the Civil War. It included segregation in housing, education, health care, transportation and many other services. The fact is that these services were separate but definitely not equal. The Supreme Court decision in Brown v. Board of Education in 1954 started the dismantling of this noxious practice. The passage of the Civil Rights Act of 1964 was historic. In 1963, I was a newly commissioned USAF Captain stationed at Gunter AFB in Mongomery, Alabama. I was living in a motel in the city when I heard the screech of tires. I went out in the street to find a man who had been hit by a hit and run driver. I gave first aid and called for an ambulance. When the driver arrived, he looked at the injured Africa-American and said we had called the wrong ambulance. We needed to call the “Black Ambulance.”

The Big Lie #5. American Indian boarding schools were established in the United States to “civilize” Native American children. One of the largest schools was in Phoenix, and we still drive on Indian School Road.  The schools were usually harsh as the children were forcibly removed from their families, had their hair cut and were not allowed to speak their native language. Many of the children died, and we are still finding evidence of unmarked graves. Eventually, through court action and legislative victories, the system was shut down.

The Big Lie #6. Following the Japanese attack on Pearl Harbor, President Roosevelt issued Executive Order 9066, that led to the incarceration of some 120,000 people of Japanese ancestry in concentration camps in the western part of the country. That included camps in Arizona. Some two thirds of those incarcerated were United States citizens. The big lie was that they were a threat to the country. That was false. Many volunteered to serve in the military and their units were among the highest decorated combat units in the war. In 1988, President Reagan signed the “Civil Liberties Act” which apologized for the incarceration. My friend Judy was born in Los Angeles in 1938, to Japanese parents. In 1942, she and her entire family were deported to the Poston War Relocation Center on the Colorado River Indian Reservation. At its height, the camp had 17,000 inhabitants and was the third largest city in Arizona. When Judy and family were released in 1945, they returned to Los Angeles but had lost their home and business.

The Big Lie #7. In 1964, the United States and North Vietnam were engaged in a limited confrontation in Southeast Asia. On August 4, 1964, the USS Maddox, an American destroyer, was patrolling in the Gulf of Tonkin between China and North Vietnam. The commander of the Maddox reported that the ship was being attacked by North Vietnamese boats. Later evidence proved that there were no hostile ships in the area. The outcome of this error was the passage of the “Gulf of Tonkin Resolution.” That gave President Johnson the authority to deploy US troops to South Vietnam and commencement of open warfare against North Vietnam. Marines were deployed to DaNang in early 1965, and I arrived there on Labor Day of that year.

The Big Lie #8. Immigration has been a contentious political issue for centuries and remains so today. The term was coined in the 17th century referring to non-warlike population movement. It has been a constant in our country since the landing of the passengers on the Mayflower. They were immigrants fleeing religious intolerance. We, however, have spent time and resources limiting new immigrants. In 1882, Congress passed the first of many immigration laws; “The Chinese Exclusion Act.” In the 1920’s, Congress passed several laws that put quotas on immigration from certain countries. Ken Burns chronicles how those quotas kept scores of people from escaping Nazi Germany death camps. The last comprehensive immigration law was signed by Ronald Regan in 1986. There are any number of big lies concerning immigrants. They won’t assimilate. FALSE! They don’t pay taxes. FALSE!  They are here to get government benefits and won’t work. FALSE!  Today we have a border wall, DACA immigrants, transport to northern cities and other political issues. It is time for Congress to perform its function and act.    

The Big Lie #9. November will be the third anniversary of the start of the Covid pandemic in Wuhan, China. Since then, the disease has ravaged the world with over one million deaths in the United States. One of the great scientific efforts has been the development of vaccines that are safe and effective. That has also led to an avalanche of big lies concerning the vaccines. Let me mention a few. When you get the shot, you will have a microchip injected into your arm, FALSE! The vaccine is made with fetal tissue. FALSE! The shot will alter your DNA. FALSE! The vaccine will make you unable to have children. FALSE! And more big lies.

The Big Truth #1. Joseph Robinette Biden Jr. won the 2020 presidential election.

An Evidence Review: Does Outlawing Abortion Care Harm Public Health?

In a Word, Yes. Here’s How

Laws regulating abortion care in Arizona are very close to fully settled now that Pima County Superior Court Judge Kellie Johnson the lifted the injunction in the Nelson v. PP case. In her decision she dismissed the relevance of the new law limiting abortions to those at less than 15 weeks of gestation because the state legislature included in the session law that the 15-week gestation age limitation does not “… repeal by implication or otherwise Section 13-3603 or any other applicable state law regulating or restricting abortion.”

Women’s Reproductive Rights in Arizona: 1864–2022

Planned Parenthood of Arizona has appealed but given the makeup of the AZ Appellate & Supreme Courts, there is little chance of being overturned. Abortion care will be illegal in Arizona through at least December of 2024, when a voter initiative may change the landscape, repealing ARS 13-3603 and substituting it with alternative regulations.

Abortion Care Now Largely Illegal in Arizona

Pregnant persons of means will be able to travel to clinics in Las Vegas and Southern California for abortion care…  (see this clinic locator) but many with fewer resources will not be able to… begging the question:

What will the public health impact be from the ending of abortion care in Arizona?

The most comprehensive analysis done to date is the ‘The Turnaway Study’ which is a longitudinal study examining the effects of unwanted pregnancy on women’s lives.

The Turnaway Study: Ten Years, a Thousand Women, and the Consequences of Having or Being Denied an Abortion

The major aim of the study is to describe the mental health, physical health, and socioeconomic consequences of receiving an abortion compared to carrying an unwanted pregnancy to term. Among the study’s top-level findings is that receiving an abortion does not harm the health and wellbeing of women, however, being denied an abortion results in worse financial, health and family outcomes.

The Turnaway Study found serious consequences are more likely to occur when women are denied a wanted abortion including a 400% increased risk of living below the Federal Poverty Level, which causes a cascade of bad health outcomes and intergenerational poverty.

Beyond a 400% increase in the risk of living in poverty, the Study found that women denied an abortion also are:

  • More likely to experience serious complications from the end of pregnancy;
  • More likely to stay tethered to abusive partners;
  • Less likely to have aspirational life plans for the coming year; and
  • More likely to experience poor physical health for years after the pregnancy.

The study also finds that being denied abortion has serious implications for the children born of unwanted pregnancy, as well as for the existing children in the family.

The study also found that many of the common claims about the detrimental effects on women’s health of having an abortion are not supported by evidence. 

For example, women who have an abortion are not more likely than those denied the procedure to have depression, anxiety, or suicidal ideation. Their findings suggest that 95% of women report that having the abortion was the right decision for them over five years after the procedure.

Here are some resources that make the results of the Turnaway Study more digestible:

Issue briefs on the mental health and socioeconomic consequences of having an abortion versus carrying an unwanted pregnancy to term are also available.

More than fifty scientific papers in peer-reviewed journals have used the findings of the Turnaway Study. Here’s a bibliography that provides a complete list of publications. 

For a deep dive into the Turnaway Study including the study’s design, methods, analysis, results, and conclusions visit The Turnaway Study | ANSIRH (Advancing New Standards in Reproductive Health).

Register Today! AzPHA’s Annual Awards Event: Thursday, October 27, 2022

AzPHA’s 2022 Annual Awards Event

Celebrating Excellence & Integrity In Arizona’s Public Health System


Join us for AzPHA’s annual award event as we recognize public health leaders with integrity & who support evidence-based public health policy!
Thursday, October 27, 2022
5:00pm – 8:30pm
Outdoor Courtyard at the Maricopa Medical Society
326 E Coronado Rd #101, Phoenix, AZ 85004

Tickets only $60 and includes a full taco bar from Senor Taco with taco fillings, beans, rice, guacamole, chips, tortillas & additional pre-rolled tacos. Open Hosted Bar service by Top Shelf Bartenders includes wine, beer & soft drinks

View Our Program Brochure

Register Today!

2022 Awardees

Senator Andy Nichols Award

Doug Campos Outcalt, DO – UArizona

Policy Maker of the Year

Laura Conover – Pima County Attorney 

Pete Wertheim Public Health Leadership Award

Loni Anderson – Pima County Health Department

Cele Cohen Nursing Award

Tascha Spears, RN – Pinal County Public Health Service District

Elsie Eyer Commitment to Underserved People Award

Andy Shanks – Southern Arizona Hospital Alliance

Harold B Woodward Award

Allan Williams, PhD – University of Minnesota

Health Education Award

Maricopa County Dept of Public Health – Ryan White Program

Public Health Research Award

Frank LoVecchio, MD, MPH – Valleywise Health

Corporate Public Health Service Award

Salt River Project for the Implementation of their COVID Management Plan

Predatory Debt Collection Protection Act Policy Paper

The protections in the Predatory Debt Collection Protection Act will provide greater protections for the issues raised above, bringing Arizona much more in line with the recommendations provided by the National Consumer Law Center to enable those in debt to pay off what they owe without placing them in a position where their ability to meet their daily living needs are not impacted by the loss of housing, transportation, or other resources.

This from the Grand Canyon Institute provides an analysis of the Predatory Debt Collection Protection Act initiative along 3 themes:

  • The Initiative’s Impact on AZ Law & Comparisons to Other States 
  • The Initiative’s Impact on Medical Debt
  • The Initiative’s Impact on Debt Collection through the Courts
Predatory Debt Collection Protection Act Policy Paper

Arizona’s Electric Vehicle Infrastructure Deployment Plan Approved

Arizona is one of the first states in the nation to have its Electric Vehicle Infrastructure Deployment Plan given the stamp of approval from the Federal Highway Administration

The Arizona Department of Transportation submitted its draft proposal in August and with the federal approval this week, $11.3 million will be made available immediately with another $16.3 million coming in October to begin implementing the plan. This is a portion of the overall $76.5 million allocated for this program in Arizona over the next five years through the recently enacted federal Infrastructure Investment and Jobs Act

The next step for ADOT is to solicit and award the contracts to upgrade existing stations as well as develop new locations along designated alternative fuel corridors. Advertising for bids to upgrade existing stations will begin in Spring of 2023 followed by bid solicitations in autumn 2023 for new construction. The plan calls for stations to be no more than 50 miles apart wherever possible. 

Currently, the alternative fuel corridors are identified as all five of the federal Interstate Highways throughout the state. These are Interstates 8, 10, 15, 17, and 19, which account for more than 20% of all the vehicle miles traveled in Arizona. 

The specific goals of the plan are reducing electric vehicle drivers’ “range anxiety” by closing gaps in the charging network along the designated corridors and ensuring the network is resilient, equitable, accessible, and reliable. Also the plan aims to identify new charging locations as part of an ongoing public outreach process and will use data to evaluate the system and make improvements. 

A copy of the plan, more information, and contact information to leave feedback are available here: azdot.gov/evplan

Abortion Care Now Largely Illegal in Arizona

View Our Newly Updated Report: Women’s Reproductive Rights in Arizona: 1864-2022

Ever since the territorial days, Arizona has had a history of severely restricting women’s reproductive freedom. From territorial era laws passed in 1864 to the laws restricting both abortion and contraception passed in 1901 (called the Comstock Laws), Arizona lawmakers and governors have actively sought to restrict women’s reproductive rights.

When the U.S. Supreme Court announced their decisions in the 1960s and 1970s (Griswald v Connecticut Roe v Wade) Arizona finally began to allow more reproductive freedom (including the right to have an abortion), but only because the courts had forced their hand.

Arizona law regarding abortion care was again thrown into flux in the summer of 2022 when the U.S. Supreme Court overturned Roe v. Wade once again allowing states to decide how they regulate or prohibit abortion care. Throughout the summer of 2022 it was unclear whether and what kind of abortion care was legal in Arizona.

Arizona had laws on the books from the territorial days limiting abortion to only those cases when it was necessary to save to life of the patient, to a new 2022 law that generally allowed abortions as long as it was before 15 weeks’ gestation.

That confusion was resolved on September 23, 2022, when Pima County Superior Court Judge Kellie Johnson ordered the lifting of the injunction in the Nelson v. PP case. In her decision she dismissed the relevance of the new law limiting abortions to those at less than 15 weeks of gestation because the state legislature included in the session law that the 15-week gestation age limitation does not “… repeal by implication or otherwise Section 13-3603 or any other applicable state law regulating or restricting abortion.”

Women’s Reproductive Rights in Arizona: 1864 – 2022

September 23, 2022, any clinician in Arizona who performs an abortion (whether medication or surgical) that is not necessary to save the life of the patient can be charged with and convicted of a violation of ARS 13-3603 and if found guilty, punished with between 2 and 5 years in the state penitentiary.

Planned Parenthood of Arizona is likely to appeal the lifting of the injunction on the 1973 ruling to the Arizona Supreme Court, where is stands little chance of being overturned. The Arizona Supreme Court was recently increased in size from 5 to 7 justices, giving Governor Douglas A. Ducey an opportunity to fill the court with his preferred appointees. Governor Ducey is a well-established foe of abortion services and presumably ensured that his appointees share is values in that regard.

Unless the election in November 2022 drastically changes the makeup of the Arizona State Legislature and the Democratic candidate for Governor (Katie Hobbs) is elected, abortion services will remain illegal to perform in Arizona through at least 2024 with no exceptions unless the clinician establishes that the procedure is necessary to save the life of the patient.

A voter initiative changing the Arizona Constitution to guarantee the right to abortion services will likely be initiated in 2024. If the effort can collect the more than 300,000 valid signatures needed to qualify for the ballot, and if the initiative survives the inevitable legal challenges to keep it off the ballot, Arizona voters will have an opportunity to again make abortion services legal beginning in late 2024.

At a practical level, Arizona women will be forced to seek abortion services in neighboring states like California, Nevada, New Mexico, or Colorado, all of which allow abortion services. Several resources exist to help women that are living in states with restrictive abortion laws such as I need an abortion. However, many women who can’t afford to or are unable to travel will be forced into motherhood in a state with little commitment to safety net services.

Disappointing News: Director Snyder Will Be Leaving Her Post as AHCCCS Director at the End of the Year

Disappointing news today out of AHCCCS. Director Snyder announced that she’ll be leaving AHCCCS at the end of the year. I’ve been a state government aficionado for many years, and Jami is the best and most thoughtful AHCCCS Director in a long time.

As we have all observed and can attest to, most state agencies have been starved for talent in the agency director position. Not so at AHCCCS, where Jami has been a shining star among Ducey appointees.

We thank Jami for her service & leadership over the last 4 years even as we remain disappointed that she won’t be here when the next administration begins 100 days from now.

Below is the letter Director Snyder addressed to stakeholders earlier today:

 

__________________

Dear Stakeholder Partners – 

I am writing today to let you know that I will be leaving AHCCCS at the end of the year. 

I’ve been honored to serve as the director of AHCCCS for the last four years. During that time, your partnership and advocacy have been essential to our success in spearheading delivery system transformation, navigating through the COVID-19 pandemic, and advancing the agency’s nationally recognized work related to whole person care. I am incredibly proud of what we have accomplished together. 

As you know, we have an outstanding team at AHCCCS. I will be working with them over the next three months to ensure a smooth transition, including beginning to lay the groundwork for the exciting initiatives outlined in our 1115 demonstration waiver currently under review with the Centers for Medicare and Medicaid Services (CMS) and slated for approval in October.  

Again, thank you for your guidance and unwavering support over my tenure. It has served as the foundation of our continued progress as a Medicaid program and as a tremendous source of strength for me personally. 

Sincerely,

Jami

HHS Proposed New Rule Streamlining Enrollment in Federal Healthcare Programs

Last week the US Department of Health and Human Services proposed a new rule that would reduce red tape and streamline administrative processes to help children, older adults, people with disabilities, and others from underserved communities connect to health care coverage through Medicaid and CHIP. 

This proposed rule follows President Biden’s executive orders in April 2022 and January 2021 directing federal agencies to take action to expand affordable, quality health coverage, including by strengthening Medicaid and the Affordable Care Act.

This rule would standardize eligibility and enrollment policies like limiting renewals to once every 12 months, allowing applicants 30 days to respond to information requests, requiring prepopulated renewal forms, and establishing clear, consistent renewal processes across states.

The proposed rule also removes some administrative hurdles for people who do not have – but are eligible for – Medicaid (AHCCCS) and CHIP (KidsCare).

It also simplies enrollment for Medicare Savings Programs, which permit Medicaid to pay Medicare premiums or cost sharing for Medicare beneficiaries with lower incomes. 

There will be a 60-day comment period, and comments on the notice of proposed rulemaking must be submitted to the Federal Register no later than November 7, 2022. For more information on how to submit comments or to review the rule in its entirety, visit the Federal Register.

Applications for Vitalyst System Change Grants Open

The Vitalyst Health Foundation is now accepting applications for their Systems Change grants. These are three-year awards for up to $175,000 in total. You can View the Slide Deck here that explains more about the System Change grants.

  • Applicants are welcome to discuss their Systems Change Grant proposal with a Vitalyst team member. You can complete the Discovery form and note interest in Systems Change Grants, and they’ll schedule a 30-minute conversation via phone call or Zoom with you.
  • LOIs are due by 5pm on Friday, October 28th to this Vitalyst online portal and refer to these instructions for portal submission.
  • Notifications of invitation to submit a full proposal will be made on Friday, December 9th.