Author: Will Humble

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

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

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

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

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

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

·       Repeal the ACA individual and employer mandates;

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

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

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

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

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

·       Double maximum contributions to health savings accounts.

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

Dear Senator McCain:

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

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

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

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

We thank you for your leadership and your statesmanship.

Sincerely, 

Will Humble, MPH

Executive Director, 

Arizona Public Health Association

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

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

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

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

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

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

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

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

• Eliminate federal subsidies to purchase individual market coverage;

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

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

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

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

During the 2015 Legislative Session, the Legislature passed and the Governor signed a bill requiring AHCCCS to annually submit an Amendment to their 1115 Demonstration Waiver asking permission to implement the following requirements for “able-bodied adult” Medicaid members:

• Limit lifetime AHCCCS coverage for all able-bodied adults to 5 years except for certain circumstances;
• Require all able-bodied adults to become employed or actively seeking employment or attend school or a job training program;
• Require most members to verify monthly any changes in family income; and
• Ban eligible persons from enrolling in AHCCCS for 1 year if a member knowingly fails to report a change in income.

The Obama Administration officials denied these waiver requests in 2016, but the landscape in that regard looks very different today.

AzPHA submitted our response letter on this year’s waiver application back in February.  Several hundred people and organizations turned also in comments regarding the waiver request.  More than 90% of the commenters expressed concerns about the various items in the waiver including the 5-year limitation on benefits, monthly income reporting and other proposed requirements.  Five percent of the commenters expressed support for the waiver request.

Here are links to the Individual Comments, Organization Comments, and Tribal Comments.

Arizona’s 2017 request to the federal government to tighten its Medicaid eligibility has been delayed by about 5 months, but all indications are that AHCCCS will submit the directed waiver to CMS in the near future.  Signals from CMS suggest that all or most of the request will be approved this time (see this letter this letter from Seema Verma of CMS & and Secretary Price to governors for details).

Stephanie Innes from the AZ Daily Star wrote a good article over the weekend diving into how Arizona is Moving Ahead With Proposal To Add AHCCCS Work Requirements.

Stay tuned- although there’s not much our members can do to influence the outcome at this point.

Obesity remains one of America’s most pervasive, expensive and deadly health problems.  Obesity increases the risk of developing high blood pressure, heart disease, type 2 diabetes, stroke, arthritis, liver disease, kidney disease, Alzheimer’s disease, gallbladder disease and mental health issues, as well as many types of cancer.  During pregnancy it increases the chances of complications, including diabetes, cesarean delivery and stillbirth.  Each year, obesity is associated with more than 100,000 premature deaths in the US (2,000 in Arizona).

These days more than one-third of U.S. adults are obese (29% in Arizona).  Back in 1990 only 10% of adults were obese.   Needless to say- a Big problem.

The causes of obesity are complicated but the bottom line is that most Americans don’t eat enough healthy food or get enough physical activity.  Communities designed for transportation by cars, jobs that require hours sitting behind a desk, and entertainment revolves around watching a screen all encourage a sedentary lifestyle. Processed food and sugar-sweetened beverages are heavily advertised, and often less expensive and more readily available than healthier alternatives.  In lots of places there aren’t grocery stores where people can buy affordable and nutritious food.

What can be done?

A new report from the Trust for America’s Health Trust for America’s Health does a really good job documenting the extent of the surveillance and public health problems posed by obesity- but more importantly- it provides a host of evidence based (and practical) state and local policies that are being implemented that are making a difference.  These tools provide states and communities with info so that they don’t need to reinvent the wheel.

State policies play a big role in improving access to healthy food and increasing physical activity.  THAH has developed a new feature that tracks the status of each state’s efforts on more than two dozen policies aimed at preventing obesity and supporting health.  

Here’s where you can view state policies to prevent obesity– excellent information that our members can use to advocate for the advancement of state laws and policies that can make a difference.

Over the past 15 years the number of prescription opioid painkillers has gone up by 400% yet the amount of pain or disability that Americans experience has remained unchanged.   From 2000 to 2014, more than 165,000 people in the US have died from overdoses related to prescription opioid use.

One critical component to turning the corner on this epidemic is to identify higher risk populations that rely heavily on opioids.  That info can give us important information which can be used to craft targeted interventions among high risk folks.  

There was a super interesting study published in the Journal of the American Board of Family Medicine last week that found more than half of all opioid prescriptions in the US are written for people with anxiety, depression, and other mood disorders.

People with mood disorders are at increased risk of abusing opioids, yet they received many more prescriptions than the general population, according to an analysis of data from 2011 and 2013.

The study, Prescription Opioid Use among Adults with Mental Health Disorders in the United States concluded that the 16% of Americans who have mental health disorders receive over half of all opioids prescribed in the United States.

The study found that 19% of the 38 million Americans with mood disorders use prescription opioids, compared to 5% percent of the general population — after controlling for physical health, level of pain, age, sex and race.

These findings are surely applicable to Arizona as well – and it provides really important information that we can surely use to augment the findings of the Arizona Department of Health Services’ report that was published this week outlining the results of their enhanced surveillance and recommended policy interventions.

This week the Arizona Department of Health Services released their ”Opioid Overdose Epidemic Response Report” in accordance with the public-health emergency declaration issued by the Governor in June.  The executive order required the agency to release a report with surveillance results and policy recommendations.

The Report is robust and has many practical and specific recommendations and planned policy and operational interventions that, if implemented, would clearly have a significant impact on the epidemic.  The full report is 92 pages long, but you can get a fairly-complete picture by reading the first 38 pages.

Intervention recommendations are included for various categories including: state opioid legislation; federal interventions; youth prevention; law enforcement; medical education curriculum; insurance parity; regulatory boards; correctional facilities; continuity of care; educating the public; and controlled substances prescription monitoring program (CSPMP) improvements.

There are literally dozens of recommendations, but I picked out a few of the more interesting ones below:

• Impose a 5-day limit on all first fills for opioid naïve patients for all payers;
• Require pharmacists to check the CSPMP prior to dispensing an opioid;
• Require different labeling and packaging for opioids (“red caps”);
• Require 3 hours of opioid-related CME for all professions that prescribe or dispense opioids;
• Establish an all payers claims database to establish better surveillance data;
• Eliminate dispensing of controlled substances by prescribers;
• Regulate pain management clinics to prohibit “pill mill” activities;
• Establish enforcement mechanisms for pill mills and illegal opioid dispensing;
• Enact a good Samaritan law to allow bystanders to call 911 for a potential opioid overdose;
• Allow Medicaid to pay for substance abuse treatment in correctional facilities;
• Remove the IMD exclusion to allow facilities to receive reimbursement for substance abuse treatment;
• Remove the pain satisfaction score completely from the CMS HCHAP (patient satisfaction) score; and
• Require federal health care facilities to maintain state licensure (e.g. VA, IHS). 

For the full picture including some results from the enhanced surveillance you should visit the Full Report which is quite impressive and a testament to the team effort that went into the development of the report.

Sheila Sjolander from ADHS will be kicking off our September 28 Fall Conference & Annual Meeting with the results of the Report.  About 150 folks are already registered, and if registration trends hold, this may be our most well-attended conference in quite some time- and a great networking opportunity to boot.  You can View our Agenda and Register on our AzPHA website.

Despite AHRQs groundbreaking work in analyzing data and making recommendations to clinicians and the health care system, guiding systems toward services and interventions that have a positive return on investment, and providing an evidence base for value-based reimbursement… the President’s budget envisions a large cut to AHRQ’s budget and mission.

The President’s budget proposes that AHRQ be merged with the National Institutes of Health and cutting that budget by 20%.  His proposed budget would cut $6 billion from the NIH the year of the proposed merger with AHRQ.

Back in July, the House Appropriations Committee released their fiscal year 2018 Labor, Health and Human Services, and Education funding bill, which includes a 10% reduction in AHRQ’s budget (to $300M) and also proposes merging most of AHRQ’s activities into NIH. The USPSTF uses the systematic evidence review to develop a recommendation and follows a rubric for assigning grades based on the magnitude of net benefit anticipated for the preventive service (that is, benefits minus harms) and the certainty of that estimate. When a decision to issue a recommendation for specific segments of the population is being made, the ability to clearly and easily identify the factors that define the specific population is important (for example, age, easily measured risk factors, or self-identified race/ethnicity). Although many features may distinguish a specific population under consideration, the final decision to issue a separate graded recommendation for that population is primarily based on whether a difference in magnitude of net benefit can be confidently identifiedThe USPSTF uses the systematic evidence review to develop a recommendation and follows a rubric for assigning grades based on the magnitude of net benefit anticipated for the preventive service (that is, benefits minus harms) and the certainty of that estimate. When a decision to issue a recommendation for specific segments of the population is being made, the ability to clearly and easily identify the factors that define the specific population is important (for example, age, easily measured risk factors, or self-identified race/ethnicity). Although many features may distinguish a specific population under consideration, the final decision to issue a separate graded recommendation for that population is primarily based on whether a difference in magnitude of net benefit can be confidently identified

Two weeks ago, the House Committee on Rules released a combined appropriations bill for Fiscal Year 2018.  That budget also has AHRQ on the chopping block, with a similar budget reduction as the Appropriations Committee & the President’s budget.

All in all, not good news for those of us that are interested in addressing patient safety, healthcare quality, and reducing costs.

A prevention model of health is weaving its way into the fabric of traditional models of care.  The Affordable Care Act is expanding the use of preventive services in the US health care delivery system.  Preventive health care services avert diseases and illnesses from happening in the first place rather than treating them after they happen.

The United States Preventive Services Task Force analyzes the evidence base and cost effectiveness of various preventive services.  They publish a running list of “Category A & B” preventive services that are evidence based best practices that have a positive return on investment.  Category A & B Preventive Health Services are covered at no cost to consumers in the Qualified Health Plans offered on the Marketplace. In addition, many employer-based and government-sponsored health plans include Category A & B Preventive Services in the health insurance plans they offer to their members.

The United States Preventive Services Task Force recommends more than 50 preventive health services for clinicians to use in their practice.  They include various screening tests, counseling, immunizations, and preventive medications for adults, adolescents, and kids.  Their most recent recommendation is to screen for obesity in kids 6 years and older and offer or refer them to comprehensive, behavioral interventions to promote improvements in weight status.

The Task Force operates within the Agency for Healthcare Research and Quality (AHRQ) and consists of a panel of experts representing public health, primary care, family medicine, and academia.  They update the list of recommended services by reviewing best practices research conducted across a wide range of disciplines.

The AHRQ & Team Force use a systematic evidence review to develop the recommendations and follow a rubric for assigning grades based on the magnitude of net benefit and costs anticipated for the preventive service (basically the return on investment).

The overarching mission of the AHRQ, including their administration of the Preventive Services Task Force, is to reduce healthcare costs by analyzing data and making recommendations to clinicians and the health care system and guiding systems toward services and interventions that have a positive return on investment.   In other words, they find ways of preventing bad health outcomes and examine the evidence to identify interventions and prevention services that have a positive ROI.

AHRQ’s research has become more important in recent years as value-based reimbursement arrangements tie payment to clinical quality.  Clearly, AHRQ is one of our country’s beacons of evidence based decision making.