Arizona Legislative Policy Updates
Kids Care Included in the AHCCCS Budget Request
AHCCCS’ 2020 budget request includes a general fund request of $7.9 million for KidsCare. The request was made under the assumption that the KidsCare trigger law will be amended this coming legislative session, preventing a freeze to CHIP enrollment.
There’s a trigger in state law that automatically freezes the Arizona KidsCare program if FMAP (the federal contribution) drops below 100%. Under current federal law, the match rate is scheduled to go down to about 90% (9 federal dollars for every state dollar) on October 1, 2019. So, if the current law isn’t changed during this next legislative session then we’ll likely have an enrollment freeze of the Kids Care program again this time next year.
The fact that AHCCCS included the $7.9M in state matching funds in the budget is encouraging, but the legislature would need to change the statute and appropriate the funds to prevent an enrollment freeze.
Kids Care is run by AHCCCS and currently covers about 30,500 kids with a set of benefits and reasonable premiums. It’s only available for kids in families that don’t qualify for regular Medicaid and who live in a family that makes under 200% of poverty.
Kids Care & ACA Advocacy
Election season is upon us and KidsCare and healthcare generally are key issues we want candidates for state office to weigh in on. The Children’s Action Alliance has a helpful election’s page up and running now! On it you can link to it to point the communities your organization serves to where they can contact candidates, see where candidates stand on issues, and register to vote. CAA is also launching a digital ads campaign around the key questions for candidates today.
Here’s a fact sheet from Families USA explaining what’s at stake for people with pre-existing conditions in Arizona. Currently, there is a lawsuit, Texas v Azar, making its way through the courts that challenges the ACA as unconstitutional.
Arizona Attorney General Mark Brnovich has signed Arizona on as a plaintiff state. If the lawsuit is successful, the protections for people with pre-existing conditions, along with other parts of the ACA, will be repealed.
We don’t know the timetable on a final court decision, but we do know that, if the lawsuit is successful, Arizona’s law is set up so that these protections will essentially be repealed simultaneously in state statute.
Leveraging State Policy to Reduce Maternal Mortality
Black women die from pregnancy-related causes at three to four times the rate of white women, even after controlling for social determinants. Women in rural areas also have higher maternal mortality rates than urban women. Here’s a super-interesting story that highlights some of the issues in an easy to read way.
Fortunately, there are public health policy leverage points that can make a difference: state health departments and Medicaid agencies.
Medicaid finances over half of all births each year in 25 states including Arizona. All states provide Medicaid coverage for women with incomes up to 133% of poverty during pregnancy and for 60 days after delivery. But the scope of services covered and coverage after delivery vary between states. As a result, some women lose coverage or Medicaid eligibility after that 60-day period (mostly in states without Medicaid expansion).
In states (like AZ, which expanded Medicaid), women have more opportunities to achieve better preconception health because they’re more likely to be able to access contraception and plan their pregnancies, receive primary care services to manage chronic conditions prior to and between pregnancies, and access prenatal and perinatal care once pregnant.
Evidence-based policy making is the key. 29 states including Arizona, have committees that review maternal deaths and make public policy recommendations. Back in 2011, Arizona passed, and Governor Brewer signed a bill that amended our child fatality review statutes by adding reviews of maternal deaths. This change charged our existing Child Fatality State Teams to review maternal deaths (called the Maternal Mortality Review Subcommittee) and make policy recommendations. The primary goal for the Team is to identify preventive factors and make recommendations for systems change.
One of the best parts of these review boards is that it is not just public health, but it's other agencies and community docs and corrections and academics all coming together to review these deaths. Here are some of the recommendations from the most recent report:
All pregnant women must have access to prenatal care;
Promote public awareness of the importance of healthy behaviors and women’s overall health prior to pregnancy;
Women should always wear proper restraints when riding in cars;
Encourage maternal care professionals, organizations, and health facilities to update their standards of practice and care to include all recommended guidelines for the prevention of medical complications;
Maternal health-care systems require strengthened, prepared, and educated communities to improve deliveries in health facilities, particularly in rural areas;
Increase and streamline access to behavioral health services statewide, including training and education for advanced practice nurses in behavioral health services.
Support and implement community suicide prevention and awareness programs, such as Mental Health First Aid;
Health care providers should screen frequently for perinatal depression and domestic violence;
Institute and follow recommended California Maternal Quality Care Collaborative guidelines (www.cmqcc.org) for the timely transfer and transport to a higher-level care facility for any complications using regional transport services; and
Educate providers on the availability of maternal postpartum resources such as home visiting programs.
Some states have gone further. For example, the South Carolina’s Medicaid agency formed the South Carolina Birth Outcomes Initiative to advance reductions in early elective deliveries; incentivize Screening Brief Intervention and Referral to Treatment; promote long-acting reversible contraception; and support vaginal births.
One outcome of the SC initiative was to reimburse for long-acting birth control (LARC) devices provided in a hospital setting.
Fortunately, Arizona has also included LARC reimbursement in a hospital setting post-partum. This is an important policy intervention because LARC provides women with a long-acting and reversible option, so they can better plan future pregnancies – improving opportunities for preconception health, which is a key to improving health outcomes.
FDA Steps It Up (A Little Bit)
Last week the FDA Commissioner called out the manufacturers of electronic cigarettes for their clear efforts to market to teenagers and put them on notice that additional regulations could be on the way. You probably heard about this in the media this week. When I went to the FDA ebsite to get the details, I discovered that the media had overstated FDA’s intervention commitments.
Apparently, the FDA is at least considering removing certain flavored e-cigarettes from the market and shortening the time to market review for most cigarettes now being sold. At a press conference last week, he acknowledged that his agency has failed to recognize the extent of the problem.
Here’s a direct quote from him:
"We didn't predict what I now believe is an epidemic of e-cigarette use among teenagers, and today we can see that this epidemic of addiction was emerging when we first announced our plan last summer. Hindsight, and the data now available to us, reveal these trends. And the impact is clearly apparent to the FDA."
The FDA issued more than 1,300 warning letters and civil money penalty complaints to retailers who illegally sold JUUL and other e-cigarette products to minors during a nationwide. Last week’s action also included a request to 5 e-cigarette manufacturers to put forward plans to immediately and substantially reverse these trends toward marketing to teens or face a potential decision “to reconsider extending the compliance dates for submission of premarket applications.”
Senate Passes Budget that Including Health Agencies
Yesterday the US Senate passed the FY19 Defense and Labor, Health and Human Services and Education appropriations bill. It would provide funding for health agencies for FFY19. The bill contains a continuing resolution through December 7, 2018 in case the House doesn't take action on the bill in short order. Here's a summary:
CDC: $7.9B which is an increase of $126 million from FY18. The bill creates a $50M infectious disease rapid response fund (but the funds only become available for use in the event of a public health emergency). The bill includes $10M to continue efforts to track children and families affected by the Zika virus and $5M to address infectious diseases related to the opioid crisis.
HRSA: $6.8B, a $107M increase from FY18. This funding includes a $26M increase for the Title V Maternal and Child Health block grant and a $12M increase for the Healthy Start program.
SAMHSA: $5.7B, which is a $584M increase from FY18. Sadly, the legislation maintains a prohibition on federal funds for the purchase of syringes or sterile needles but allows communities with rapid increases in cases of HIV and hepatitis to access federal funds for other stuff like substance use counseling and treatment referrals. The bill also includes $1.5B for the state opioid response grants.
The bill doesn't include the bad policy riders that were in previous versions that would have eliminated funding for important reproductive health services (Title X).
State Action to Stem Rising Prescription Drug Costs
By Association for State and Territorial Health Officials Staff
The high cost of prescription drugs is a persistent problem in the United States, with about 10 percent of overall health spending attributed to prescription drugs. In recent years, there has been increased interest among states to address the rising cost of prescription drugs. Just this year, 24 states passed 37 bills to stem rising drug costs. In total, state legislatures have introduced 160 bills targeting prescription drug costs in 2018.
States have pursued a wide range of strategies to tackle the high cost of prescription drugs, including policies that address drug price transparency, rate setting requirements to prevent price gouging, drug importation programs, generic drugs companies, and pharmacy benefit manager transparency.
Drug Price Transparency
Controlling healthcare costs is one of the three elements of the Triple Aim, along with improving population health and patient care experience. As a first step toward controlling costs, states are seeking more price transparency requirements from drug manufacturers. In 2018, six states passed legislation addressing drug price transparency. Many of these laws adopt more stringent transparency policies requiring drug manufacturers to justify price increases over certain thresholds. For example, Connecticut requires drug manufacturers to justify price increases for specific drugs if the price increases by 20 percent or more in a year or 50 percent over three years.
Price-Gouging and Rate Setting Requirements
Anti-price gouging and rate setting requirements use information collected from transparency laws to allow states to impose penalties for excessive drug price increases. Currently, Maryland is the only state with an anti-price gouging law. The policy allows the state Medicaid agency to notify the state’s office of the attorney general when an essential off-patent brand name drug or generic medication has an excessive price increase.
Maryland’s attorney general can then request justification from manufacturers for the price increase. If the rationale of the price increase is deemed unjustified by “the cost of producing the drug, or the cost of appropriate expansion of access to the drug to promote public health,” the state can impose civil penalties or use other mechanisms to penalize the manufacturer. However, a lawsuit has since been filed in federal court by drug manufacturers asserting violations of Constitutional law as it relates to interstate commerce. To date, twelve other anti-price gouging bills have been introduced in states, although none have been enacted.
Earlier this year, Vermont became the first state to pass a drug importation bill, allowing the state to import wholesale prescription drugs from Canada for use by all state residents. The law requires the designation of a state agency to become a licensed drug wholesaler, or to contract with a licensed drug wholesaler. Several steps remain before Vermont’s program can go into effect, including the state health department receiving federal approval from HHS by July 2019. In addition, although the Utah legislature failed to pass a bill that would have created a program for importing drugs from Canada, the legislature requested that the Utah Department of Health conduct a feasibility study associated with drug importation.
Recently, Maine passed a law requiring brand name manufacturers to make samples of drugs available to generic drug manufacturers, with the intention of promoting competition by increasing access of information for companies developing lower-cost generic drugs. The law states that, “In order for there to be competition in the prescription drug market, developers of generic drugs and biosimilar biological products must be able to obtain quantities of the reference listed drug or biological product with which the generic drug or biosimilar biological product is intended to compete.”
Pharmacy Benefit Managers
Several states have passed bills regarding pharmacy benefit managers (PBMs), which require increased transparency and disclosure of information on drug rebates and concessions. For example, Nevada passed a law in 2017 requiring PBMs to disclose the amount of rebates received from drugs used to treat diabetes. Connecticut’s drug price transparency law also requires PBMs to provide information on rebates and other price concessions received from drug companies. Mississippi passed a law preventing PBM gag clauses, which stop pharmacists from sharing information with patients on lower-cost drug options.
Other State Policies
In Montana, the legislature passed a bill establishing an interagency committee to study state drug pricing and spending trends, which will make recommendations to the state legislature on drug pricing policies in late 2018. In addition, New York implemented an annual cap on drug spending in its Medicaid program. Under the law, if spending projections extend beyond the cap, the state health department must identify the costliest drugs and attempt to negotiate additional rebates with manufacturers. This law also gives the state the authority to develop an independent panel that can penalize manufacturers through various mechanisms.
Emerging state legislation to address the rising cost of drug prices in demonstrates potential paths forward to address drug prices at the state level. The National Academy of State Health Policy (NASHP) has developed model legislation to address drug price transparency, drug importation, rate setting, and pharmacy benefit managers. The NASHP resource includes model legislation for states, bill text from states that have already passed legislation, and relevant briefing documents.
Congress is Back in Session: Important Bills in the Balance
Members of the U.S. House of Representatives return to Washington D.C. this week. They’ll be discussing important public health bills including the Labor-HHS-Education appropriations bill for fiscal year 2019 and the reauthorization of the Farm Bill.
Last month the Senate passed H.R. 6157 which is the combined Defense and Labor, Health and Human Services, Education and Related Agencies appropriations bill for FY19. This one is the eighth and ninth out of 12 spending bills to be passed by the Senate for FY19. The legislation includes increased NIH funding and boosted resources for opioid treatment, prevention, and recovery programs. Here’s a list of some of the adopted amendments:
Schumer-Collins amendment to increase funding for Lyme disease activities (3759).
Cortez-Masto-Ernst amendment to provide for conducting a study on the relationship between intimate partner violence and traumatic brain injury (3825).
Peters-Capito amendment to ensure youth are considered when the Substance Abuse and Mental Health Services Administration follows guidance on the medication-assisted treatment for prescription drug and opioid addiction program (3870).
Heitkamp amendment to provide funding for the SOAR (Stop, Observe, Ask, Respond) to Health and Wellness Program (3893).
Casey amendment to provide funding for the Secretary of Health and Human Services to establish the Advisory Council to Support Grandparents Raising Grandchildren (3875).
Schatz-Hirono amendment to assess the ongoing mental health impact to the children and families impacted by a volcanic eruption covered by a major disaster declared by the President in calendar year 2018 (3897).
Heller-Manchin amendment to provide additional funding for activities related to neonatal abstinence syndrome (3912).
Heitkamp-Murkowski amendment to improve obstetric care for women living in rural areas (3933).
Durbin-Grassley amendment to provide for the use of funds by the Secretary of Health and Human Services to issue regulations on direct-to-consumer advertising of prescription drugs and biological products (3964).
The House hasn’t adopted its FY19 Labor, Health and Human Services, and Education appropriations bill. It’s unclear how both chambers will resolve differences in funding levels between their bills. The House could work on its Labor, Health and Human Services, and Education bill or skip a floor vote and start negotiations with the Senate. The Farm Bill, which funds WIC & SNAP also hangs in the balance. Here's a summary of the Farm Bill (in less than 500 words) The current legislation is scheduled to expire Sept 30th.
Bottom line: with only a few legislative days before the end of FY18, it’s likely that a continuing resolution will keep the government funded into FY19.
The APHA has several tools that you can use to get the attention of your Representative or Senator. They’ve developed APHA’s Speak for Health advocacy resources, including state-specific fact sheets to help you be a better advocate. They also have tools to help you meet with your members of Congress or their staff or invite them to visit you and Email or call your members of Congress using the APHA action alert as a phone script or email message. It’s quick and easy.
More States following AZ’s Lead to Establish Overdose Fatality Review Teams
Overdose fatality reviews allow states to better understand the circumstances surrounding fatal drug overdoses so they can design better interventions. Review teams can uncover the individual and population factors and characteristics of potential overdose victims. Knowing the who, what, when, where, and how of fatal overdoses provides a better sense of the strategies and coordination needed to prevent future overdoses and results in the better allocation of overdose prevention resources and services.
Nine states including AZ have set up teams so far. The Network for Public Health Law provides a good overview of the states that have review teams. Here are some of the laws [OK (HB 2798), RI (S 2577 and H 7697), and VA (SB 399)], DE (HB 211) and our own (HB 2038). The laws establishing fatal overdose reviews often include the entity authorized to create and manage the review team or committee, the membership requirements for teams or committees, the scope of work of the teams or committees, confidentiality and liability protections, and data access authorizations.
FY 17-18 Opioid Emergency Response Report
The ADHS released their 2017 Arizona Opioid Emergency Response Report in July. The report confirms that there’s been real progress as a result of the policy interventions from a host of organizations in the public health and health care sectors, health insurance, EMS, and law enforcement sectors in the last few years… but that there’s clearly more work to do. More time will also be required for the existing interventions to mature and yield results.
The summary portion of the report is about 30 pages long- but the real meat of the report is in the Appendices. Many of you will be particularly interested in Appendix I and J at the very end of the report. Here are some of the findings:
There were 949 overdose deaths in the FY 17-18 timeframe which is a 20% increase from 2016 and a 109% increase since 2012.
Heroin was responsible for 51% of the growth in opioid deaths over the last 5 years.
The number of opioid prescriptions filled in AZ declined 40% last fiscal year.
The percent of patients receiving referrals to behavioral health or substance abuse treatment services after an overdose increased from 45% in June 2017 to 73% in May 2018.
Naloxone is becoming much more common in the community, among EMS and law enforcement.
Can the Arizona Medical Marijuana Fund pay for Drug Treatment?
On August 6, 2018, Attorney General Brnovich wrote an Opinion stating that state lawmakers (or presumably the ADHS) can use qualified medical marijuana patient card fees to operate programs to help get people off of other drugs. The Arizona Medical Marijuana Fund (administered by the ADHS) contains more than $44M right now (the fund consists of fees paid by patients for cards, other card fees like dispensary agent cards, and dispensary application fees).
Here’s a simple Q & A from the Opinion:
Q. Could the Legislature, through the budget process, direct the ADHS Director to appropriate some of the Fund monies to help people addicted to drugs?
A. Yes. The Legislature may direct the ADHS Director to spend Fund monies for programs to help people addicted to drugs if: (1) the appropriation is passed with a three-fourths vote of each legislative chamber; (2) the appropriation does not deplete the Fund and leave insufficient revenues to cover the immediate and future costs of the initiative; and (3) the appropriation furthers the purpose of the AMMA, i.e., it relates, in some way, to medical marijuana.
The AG Opinion states that:
“The Legislature may direct the ADHS Director to expend monies from the Fund for programs to help people addicted to drugs if: 1) the appropriation is passed with a three-fourths vote of each house; 2) the appropriation does not deplete the Fund and leave insufficient revenues to cover the immediate and future costs of the initiative; and 3) the appropriation furthers the purpose of the AMMA.
To that end, an appropriation for activities related to distinguishing between medical and nonmedical uses of marijuana, protecting patients and providers from criminal prosecution, or carrying out, implementing, or administering the AMMA would meet this criterion. If these requirements are met, it is not necessary to submit an appropriation request to Arizona’s voters.
Substance Abuse Prevention Needs Assessment
AHCCCS is conducting a Statewide Substance Abuse Prevention Needs Assessment to better understand what prevention activities are going on and what the prevention needs in our communities are and about the experiences of folks who work or volunteer in substance abuse prevention. If you fit the bill, it would be great if you could take 10 minutes to support this important effort by taking this Arizona Substance Use Prevention Workforce Survey.
Medicaid Program Scorecard Released by Feds
The Centers for Medicare & Medicaid Services released a new Medicaid program scorecard earlier this year. It includes some quality metrics along with federally reported measures in a Scorecard format.
The data that’s built into the state by state scorecard only uses information that states voluntarily submit. There are 3 main categories (state health system performance; state administrative accountability; and federal administrative accountability) and lots of subcategories.
The Scorecard includes a State Health System Performance Measures portion. Some of the subcategories that are reported in that category on a state by state basis are things like include hospitalization for mental illness, opioid use in high dosage, alcohol and other drug dependence treatment, and other chronic health conditions.
Opioid Public Health Emergency Executive Order Ends
In May, the Governor of Arizona officially ended the emergency public health declaration that was signed via an Executive Order about a year ago. Much has been accomplished over the last year including implementing legislation that improves prescribing practices and enhances emergency responses and increases access to treatment. Of course- the work will go on. The epidemic didn’t start overnight, and it surely won’t end overnight. You can read the official end of the emergency declaration here.
Legislative Session Webinar Posted
The UA has posted AZPHA's webinar from May that summarizes the legislative session from a public health perspective. The whole thing is about an hour long. You can check out the webinar on the UA Telemedicine Website. Here’s the PowerPoint.
Sonoran Prevention Works Scores Syringe Access Grant
Sonoran Prevention Works received a $125,000 grant in May from the Vitalyst Health Foundation to support advocacy and education for syringe access programs – a proven harm reduction strategy in response to the opioid crisis and rising hepatitis-C and HIV infection rates. They’ll be partnering with the University of Arizona College of Medicine Tucson and Creosote Partners to destigmatize syringe access programs and understand the comprehensive needs of people who inject drugs.
The Maricopa County Sheriff's Office will also work with Sonoran Prevention Works to implement a needle stick prevention program and to educate law enforcement on injection drug use. These partnerships will work to support policy change that treats substance use as a public health issue.
Snapshot of Public Health-related Bills in 2018
HB 2324 Voluntary Certification for Community Health Workers
HB 2088 Public Health Guidelines in Schools
HB 2235 Dental Therapy Licensure
SB 1245 SNAP- Fruits and Vegetables
HB2371 Statewide Food Truck Licensing
Public Health-related Bills Signed Into Law (2017)
HB 2038 Drug overdose review teams; records was passed and signed. Once it takes effect later this year, law enforcement agencies will now be required to provide unredacted reports to the chairperson of a local Drug Overdose Fatality Review Team on request.
HB 2228 Annual waiver, applicability was signed by the Governor. It’s good. It will direct AHCCCS to exempt tribes from their directed waiver request that asks for CMS permission to implement work requirements for some Medicaid members. The recently submitted Waiver request includes an exemption for American Indians, however, this would place the exemption into statute.
HB 2323 Schools; inhalers; contracted nurses was signed by the Governor. This bill adds contracted nurses to the list of people who are authorized to provide emergency inhaler medication in case of respiratory emergencies. Some charter and independent schools don’t employ nurses directly but engage them through contracts.
HB 2484 local food tax; equality, which will ban Arizona cities and counties from taxing sugary drinks as a public health intervention.
SB 1022 DHS; homemade food products ADHS will be required to establish an online registry of food preparers that are authorized to prepare "cottage food products" for commercial purposes. Registered food preparers would be required to renew the registration every three years.
SB 1083 Schools; recess periods was passed and signed! Beginning next school year K-3 will need to have at least 2 recess periods. Grades 4 and 5 will need to have 2 recess periods the year after that.
SB 1389 HIV; needs assessment; prevention was signed by the Governor last week. It requires the ADHS to establish and implement an HIV Action Program.
SB 1394 Abortion reporting was passed by the House and signed by the Governor. It will require the ADHS to collect and report additional data regarding abortions that are performed in AZ.
HB 2038 Drug overdose review teams; records
HB 2228 Annual waiver, applicability
HB 2484 local food tax; equality
SB 1022 ADHS; homemade food products
SB 1083 Schools; recess periods
SB 1389 HIV; needs assessment; prevention
SB 1394 Abortion reporting