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Rural Health Briefing Vol I, No. 3 October 27, 2000
An E-Health Newsletter published by the Arizona Critical Access Hospital (CAH) Program of the University of Arizona Rural Health Office
Table of Contents
1. Update: Critical Access Hospitals Program
a. BBRA II: Rural Assistance Report
b. AHA Comparison of Congressional Proposals
c. Border Hospital Relief Act
d. Technical Assistance and Service Center (TASC)
2. Arizona News
a. New Grants Awarded
b. Arizona Rural Development Council
c. Health Care Initiatives on the November Ballot
3. APHA Analysis of Health Care Reform Proposals
4. How to Contact Your Representatives
a. Congressional Delegation
b. State Legislators
5. Grant Opportunities
6. Conferences Relevant to Rural Health
7. Other Useful Information
a. HRSA Web-Site for Drug Pricing Program
b. NRHA Issue Papers Online
c. Border Health Website
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Editor’s Note: This online newsletter is a project of the Arizona Rural Hospital Flexibility Program, supported by the Federal Office of Rural Health Policy. The goal of the Flex Program is to improve the financial viability and stability of rural hospitals by creating a new designation for Critical Access Hospitals (CAHs). Designated CAHs are eligible for cost-based reimbursement for services provided to Medicare patients. For more information, please visit the project web site: http://www.rho.arizona.edu/cah/azruralflex.html
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1. Update: Critical Access Hospitals Program
a. BBRA II: Rural Assistance Report: The Capital Area Rural Health Roundtable, a project of The Center for Health Policy and Ethics at George Mason University in Fairfax,Virginia, at its September 6 Roundtable meeting, received reports from rural legislators Kent Conrad (D-ND) and Jim Nussle (R-IA) regarding Congressional proposals that have bipartisan support from House and Senate rural health coalitions.
Rural legislative priorities include:
(1) a full inflationary update for Medicare inpatient payments; and (noting sizable recent losses for rural hospitals), an additional market basket update plus 1.1 percent for them;
(2) rescinding of cuts to Medicaid DSH payments for FY 2001 and 2002;
(3) permanent authorization for the Medicare DSH program with better updates for rural hospitals and an equitable threshold for qualification; (4) improvements to the reimbursement formula for Sole Community Hospitals;
(4) Critical Access Hospitals – the inclusion of lab services in their reasonable-cost reimbursement status, and the option to bundle their payments for facility and professionals;
(5) funding the BBA-authorized program of grants for small rural hospitals to retool for Medicare prospective payment systems and a capital infrastructure loan program;
(6) permanent repeal of the 15% reduction in Medicare home health payments;
(7) a one-time update of 13.5% for PPS payments to skilled nursing facilities; also, improvement in operating cost surveys that provide the basis for reimbursements;
(8) cancellation of the rescheduled phase-outs for Medicaid cost-based payments to Rural Health Clinics and FQHCs;
(9) putting the new reimbursement formula for Medicare managed care into effect by removing the budget-neutral impediment to funding, raising the minimum per capita payment to $500 per beneficiary per month, and speeding the blend of national and local rates;
(10) expanding Medicare reimbursement for telemedicine to all rural areas (not just underserved areas, reimbursing for facility and technology charges, and broadening the range of practitioners who can present the patient.
Not included, but being considered by some individual legislators are reimbursement for rural EMS and adjustment of the wage index for rural health professionals.
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b. AHA Comparison of Congressional Proposals: The American Hospital Association’s website for Small and Rural Hospitals offers an October 5, 2000 comparison of congressional BBA relief proposals for rural hospitals in the House Ways & Means Health Subcommittee and the Senate Finance Committee (rural health titles only). A similar comparison of House and Senate proposals for provisions found in areas other than the rural titles is promised soon.
Provisions related specifically to CAHs include:
(1) Payments for lab services (House: Medicare beneficiaries would not be liable for any coinsurance, deductible, copayment or other cost sharing amount for lab services furnished as an outpatient CAH services; CAH reimbursed on reasonable cost basis for lab services; Senate: allows services to be paid on a cost basis).
(2) Payment of professional services (House: at the CAH’s choice, Medicare would pay for outpatient services based on reasonable costs or a facility fee based on reasonable costs plus 110% of the Medicare fee schedule for professional services; Senate: gives CAHs an option to obtain reimbursement at 120% of the physician fee schedule or a cost-based hospital outpatient service payment plus a fee schedule payment for professional services.
(3) Excluding psych and rehab DPU beds for eligibility as CAH (House: facility would not be designated a CAH if it had a DPU for rehab or psych; Senate: allows facilities choosing to seek CAH status to operate PPS-exempt psych and rehab DPUs without counting beds in these units to classify as CAHs.
(4) Exempting CAH swing-beds from SNF-PPS (House: exempts swing-beds in CAHs from SNF PPS and would pay them on reasonable cost basis; Senate: makes BBA of 97 exemption permanent for CAHs).
(5) Payment in CAHs for ER on-call physicians (House: compensation and related costs for on-call emergency room physicians who are not present on the premises, are not providing services, and are not on-call at any other provider or facility will be included in determining the allowable, reasonable cost of outpatient CAH services; Senate: no provision).
(6) Treatment of ambulance services furnished by certain CAHs (House: ambulance services provided by a CAH or owned or operated by a CAH would be paid reasonable cost if the CAH were the only provider or supplier of ambulance services within a 35-mile drive of the CAH; Senate: no provision).
Other rural health provisions include equitable treatment of rural DSH; refinement of MDH program; rebasing target amounts for SCHs; provider-based rural health clinic cap exemption; payment for certain physician assistant services; bonus payments to rural home health agencies; Medicare reimbursement for telehealth services; MedPAC study on low-volume, isolated rural health care providers; rural psychiatric care study; assistance for providers of ambulance services in rural areas; treatment of certain physician pathology services under Medicare; grant program for rural hospital transition to prospective payment.
The House Ways and Means Committee’s Subcommittee on Health Report includes an explanation of the proposed Medicare Refinement and Benefits Improvement Act of 2000; this document can be accessed via the subcommittee website: http://waysandmeans.house.gov/health.htm.
For continuing information, visit the Rural and Small Hospital website: http://www.aha.org/MemberServ/BBAreliefsidebyrural.html
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c. Border Hospital Relief Act:
The August 21, 2000 Health Care Supplement to Inside Tucson Business (Volume 10, Number 21, Page 3B) includes the following article by Tim Hull:
Border Hospitals Seek Relief for ER Costs: "A truck loaded with undocumented clients speeds north from the border. It overturns, throwing men and women and children onto the highway. The uninjured are detained by the Border Patrol, the injured sent to the emergency room.
As bad as this relatively common occurrence sounds, for many health care facilities in southern Arizona’s border region it gets even worse. The emergency room the injured are sent to is likely to be small, rural, and under-funded. Yet the responsibility to provide uncompensated care to the injured aliens often falls on such hospitals, a requirement that has grown this year alongside the ongoing border crisis.
The nearly 300 percent increase in incidents of undocumented alien emergency care this year at Bisbee’s Copper Queen Community Hospital is typical of what rural border hospitals are experiencing, prompting Rep. Kolbe, R-AZ . . . to introduce legislation calling for relief.
The Border Hospital Relief Act, HR 4973, would establish a $25 million grant program to reimburse border hospitals for emergency care provided to undocumented aliens. The bill makes a priority of those border hospitals with 100 or fewer inpatient beds.
‘Of course we have to provide quality care and we have to treat everybody,’ said May Kolbe, Director of Administrative Services at Copper Queen. ‘But if we are giving away compensation, it keeps us from doing some of the capital improvements like equipment and other things that affect the bottom line. We are trying hard to upgrade our facility and get new technology, and not being compensated certainly doesn’t help that.’
Both May Kolbe and Chris Cronberg, CEO of Northern Cochise Community Hospital in Willcox wrote letters to Kolbe last spring, encouraging the Congressman to act. Cronberg has seen his compensation hole grow by $60-$65,000 this year, and May Kolbe said Copper Queen is out more than $80,000 in the past 13 months.
‘For a small hospital like ours, that could be half of our bottom line,’ she said.
In Tucson, where undocumented aliens are often sent when they need more complex – and more expensive treatment – University Medical Center estimates that it will see $7.3 million in uncompensated costs for the care undocumented aliens, a 60 percent increase over 1999. According to Kolbe’s office, the statewide cost of providing emergency care for illegal aliens approaches $30 million per year.
In the bill, ‘a border hospital’ is defined as one located in an area contiguous with the U.S.-Mexico border or one in which ‘the number of cases in which the border hospital provides emergency medical care to qualifying undocumented aliens is significantly above the number of cases in which other border hospitals provide emergency health care to such cases.’ Under this definition, hospitals in Tucson and possibly Phoenix could qualify for the funds.
The qualifying hospital, according to the bill, would have to prove THT the care for which sought reimbursement was for an undocumented alien who was not eligible for any other medical assistance under another state plan. If this is proved, the border hospital would receive the compensation directly, by-passing the state’s general fund.’
‘It (the bill) is going to give money back to us for operations,’ said Cronberg. ‘We are a very small rural facility and a few dollars to us is a lot of money. It is hard for me to translate in my mind the fact there here is the federal government and they have money and yet they expect the patients who use this facility and the taxpayers who support it to pick up the cost of its job.’
A copy of the Border Hospital Relief Act (H.R. 4973) was referred to the House Commerce Committee’s subcommittee on August 31,2000. A copy of the bill is available online: http://thomas.loc.gov/cgi-bin/bdquery.
d. Technical Assistance and Service Center (TASC): TASC is the technical assistance agency for the national Rural Hospital Flexibility Program. A new website is available with detailed information about all aspects related to Critical Access Hospital designation. This site can be accessed via Resources for Critical Access Hospitals, technical assistance links at: http://www.rho.arizona.edu/cah/azruralflex.html
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2. Arizona News
a. New Grants Awarded:
(1) HRSA Pharmacy Services Grants to Community Health Centers: On September 15, the Health Resources and Services Administration announced the award of $1.6 million to expand clinical pharmacy services at seven health center networks in Arizona, Iowa, Massachusetts, Michigan, Mississippi, Utah, and Washington. Each grantee has established a partnership with at least one other local health center and a college of pharmacy. The health centers will use the grants to establish telepharmacy services allowing a chief pharmacist to communicate via video-teleconferencing equipment with remote, isolated dispensing sites; introduce disease management services for health center patients with diabetes and other chronic conditions; bring pharmacy students, residents, and faculty into the health center setting for rotations and consultation; link the health center with computerized health and drug information at the college of pharmacy; establish shared pharmacy information systems across the community; conduct outcomes research and evaluation into clinical, economic, and humanistic outcomes of comprehensive pharmacy services; and establish linkages, contracts, and training programs with community pharmacies.
El Rio Santa Cruz Neighborhood Health Center, Inc., in Tucson, received at $249,886 grant award.
(2) HRSA Grants to States to Enroll Rural Children in SCHIP and Medicaid Programs: On September 29, HRSA announced the award of 20 grants to State Offices of Rural Health to help them bring health insurance coverage to rural children by enrolling them in the State Children’s Health Insurance Progrram (SCHIP) and Medicaid.
The State Office of Rural Health (SORH) in Arizona received a grant for Nuestros Ninos (Our Children), an initiative begun by the Border Vision Fronteriza (BVF) Project through the Western Arizona Area Health Education Center (WAHEC). The project will seek to enroll 900 and re-certify 300 children into medical insurance programs; improve access to health services for 3,500 south county residents; train 20 community health worker’s for a community household census; and disseminate knowledge from lessons learned to BVF site directors and community health workers in New Mexico, California, and Texas.
In addition, the Arizona SORH received a $95,000 supplemental award for the BVF Project.
(3) Southern Arizona Border Health Careers Opportunity Program: The University of Arizona Rural Health Office recently received a five-year grant award of $2.5 million for a Southern Arizona Border Health Careers Opportunity Program (SAB-HCOP). The project is a multi-partner academic program designed to encourage socioeconomically disadvantaged middle and high school students in four Arizona-Mexico border counties – Cochise, Pima, Santa Cruz, and Yuma – to pursue health care careers.
To accomplish this goal, SAB-HCOP will create an "educational pipeline" linking high schools with community colleges and the university. School-based HCOP teams will provide students with educational programming, including: financial aid and learning-to-learn workshops; preparatory workshops for the SAT, GRE, and AIMS tests; cultural competency training; tutoring services for math, science, and writing; participation in the UA’s Med-Start and PREP summer enrichment programs and Minority Medical Education Program; and biology workshops conducted by UA medical students in the College of Medicine’s Commitment to Underserved People (CUP) program during university site visits. The program involves partnerships with more than 20 organizations in Arizona’s southern border region.
For further information, please contact Kevin Driesen or Carmen Garcia-Downing (520) 626-7946).
(4) Virtual Development Center: The University of Arizona has been named as one of the nation’s seven Development Centers within the Institute for Women and Technology (www.iwt.org). The purpose of the project is to recruit and retain women, particularly those from underrepresented groups, into careers as engineers, information technologists, and scientists. The UA DC has received equipment valued at $257,000 from Hewlett-Packard to help start the program. The equipment will include desktop computers, laptops, printers, scanners, and other computer hardware.
Each of the nation’s Virtual Development Centers brings together interdisciplinary students and faculty with women in their communities to generate new product ideas through Innovation Workshops. Students and faculty from several engineering and science departments work throughout the school year on projects that create product from the ideas generated at the workshops.
A workshop held October 23 focused on the use of communications and medical informatics technology in delivering health care to rural communities in Arizona. Medical informatics involves using software to deal with large volumes of medical data. One of the UA DC’s first projects will use software developed in the Electrical and Computer Engineering Department to link rural Hospitals to urban hospitals that have sophisticated radiology capabilities.
For further information, contact Ray Umashankar, (520) 621-8103; ray@u.arizona.edu.
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b. Arizona Rural Development Council: On October 13, the Arizona Department of Commerce hosted an organizational meeting of stakeholders for an Arizona Rural Development Council.
This is a project sponsored by the National Rural Development Partnership (NRDP) of the U.S. Department of Agriculture. The purpose of the NRDP is to strengthen rural America through collaborative partnerships, bringing together partners from local, state, tribal, and federal governments, as well as from the for-profit and non-profit private sector. The NRDP has three components: State Rural Development Councils (SRDC); a National Rural Development Council (NRDC); and The National Partnership Office. There are currently 37 State Rural Development Councils, with Arizona in the process of creating one.
Draft By-Laws of the new Arizona State Rural Development Council define the purpose of the Council: "The ARDC is a statewide network of organizations and individuals from a variety of perspectives aimed at improving the quality of life in rural areas. This network will include local, state, tribal, federal and private (for-profit, nonprofit, and community-based organizations). A key goal of the Council is to enhance cooperation and collaboration on rural issues across program and governmental boundaries. The ARDC is designed to be inclusive, cooperative, and broad-based." Membership is intended to be non-partisan and nondiscriminatory, with all interested parties invited to participate.
Participants in the October 13 meeting reviewed a list of organizations and agencies on board, and suggested additional individuals/
organizations to be invited to participate; reviewed the type of work their organizations contribute to rural Arizona, and resources each organization may contribute to the ARDC; brainstormed buzz words for an organizational mission statement; considered how the governing board should be constituted; and identified the top six common interests in rural Arizona that will constitute the governance issues for the Council: (1) Telecommunications; (2) Infrastructure; (3) Healthcare; (4) Economic Development; (5) Coordination; (6) Education.
If you are interested in learning more about the Arizona Rural Development Council, please contact Phyllis Murray, Assistant Director, Office of Housing and Community Development, Arizona Department of Commerce, 3800 North Central Ave., Suite 1500, Phoenix, AZ 85012; Phone: (602) 280-1300; Fax: (602) 280-1305.
For more information about the national program, see the project website: http://www.rurdeve.usda.gov/nrdp/what.html
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c. November Arizona Ballot Initiatives: Voters will make several decisions in the November 7 election that will impact health care in rural areas. An explanation of the differences between two initiatives, Proposition 200 (Healthy Children, Healthy Families) and Proposition 204 (Healthy Arizona II) follows. Background information about the two propositions was taken from the Ballot Propositions and Judicial Performance Review for the November 7, 2000 General Election, distributed to voters by the Secretary of State’s Office. Please note: Proposition 200 is much longer than Proposition 204, and that difference is reflected in the length of the analyses below. For an explanation of other voter initiatives on the November ballot, you can obtain a copy of the League of Women Voters’ Guide through the League’s toll-free citizen information number (602) 711-VOTE or email: lwvaz@aol.com.
Background: In 1998, the attorneys general of 46 states, including Arizona, agreed to settle a lawsuit they brought against the manufacturers of tobacco products. As a result, the tobacco manufacturers must pay each of those states a portion of the estimated $206 billion settlement (to be adjusted for inflation) each year over the next 25 years. Arizona’s share is estimated to total approximately $3.2 billion. The settlement agreement allows each state to determine how it will spend its share of the settlement.
Proposition 200 requires that all of the tobacco settlement monies be deposited in a newly-created Healthy Children, Healthy Families (HCHF) Fund. The proposition prohibits Arizona counties from suing tobacco companies to recover monies expended by the counties for indigent health care expenses from tobacco-related illnesses, and requires the counties to turn over any sums recovered from tobacco settlement monies to the Fund. The proposition also diverts 70% of existing tax revenues generated by the state’s tobacco tax from existing programs to the HCHF Fund. The proposition creates new administrative structures for programs authorized by the initiative.
Proposition 204 requires that tobacco settlement monies received by the State of Arizona be used to fund the health insurance and health programs authorized in the Healthy Arizona Initiative passed by 70% of the voters in the 1996. Any resident at or below 100% of the federal poverty level would be eligible for health insurance coverage through the state’s AHCCCS Program.
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(1) Proposition 200 (Healthy Children, Healthy Families)
What it Will Do: The State Treasurer is required to deposit any funds received from the tobacco settlement into the HCHF Fund, except for 2 cents of each dollar for an existing corrections fund to compensate for decreases in the corrections fund resulting from lower tobacco tax revenues resulting from the passage of Proposition 200; 23 cents of each dollar for an existing health education program; and 5 cents of each dollar for an existing Disease Control Research Fund.
Monies deposited in the HCHF Fund each year will be allocated among a variety of different accounts and subaccounts. (1) Prevention Account, 3.5 cents of each dollar, not to exceed $5 million in any fiscal year; (2) Smart Beginnings Prevention Account, 21 cents of each dollar, not to exceed $35 million in any fiscal year, with the first year limited to $1 million, the second year limited to $7 million; the third year limited to $14 million, the fourth year limited to $28 million; (3) Oversight and Enforcement Account, $350,000; (4) Auditor General Account, $350,000; (5) Health Care Coverage Account, all remaining funds.
Proposition 200 provides that any other act, statute, initiative, or referendum that seeks to authorize the expenditure of or seeks to appropriate any money from the Tobacco Settlement Fund will be in conflict and inconsistent with Proposition 200 and therefore void. This would have the effect of nullifying the passage of Proposition 204, as well as the provisions of the original Healthy Arizona Initiative passed by voters in 1996.
How The Money Will Be Spent: Monies deposited in each account must be used in the manner required by Proposition 200:
(1) Prevention Account, programs for prevention and early detection of cancer, cardiovascular and pulmonary disease and strokes.
(2) Smart Beginnings Prevention Account, to establish, expand, enhance, plan, oversee, and fund coordinated prevention and family support services for pregnant women and families whose youngest child is under six years of age, including parenting education, prenatal outreach, family mentoring and preschool. Funds from the existing Healthy Families and Health Start Programs may be transferred to the Smart Beginnings Prevention Account. Funds may be withdrawn from the Smart Beginnings Prevention Account to hire staff, consultants, administrative support, and to pay administrative expenses.
(3) Oversight and Enforcement Account, for the Attorney General’s Office to support expenses associated with lawsuits to enforce the provisions of Proposition 200.
(4) Auditor General Account, for the Auditor General’s Office to conduct annual program and fiscal audits.
(5) Health Care Coverage Account:
(A) State Medical Laboratory SubAccount, $15 million in the first two years for construction of a state medical laboratory; in the third year, any remaining funds revert to the HCHF Fund.
(B) Mental Health Facilities and Services SubAccount, $15 million in the first year, $30 million in the second and third years, for construction or renovation of mental health facilities and the provision of mental health services, any funds remaining at the end of the fourth year revert to the HCHF Fund.
(C) Behavioral Health SubAcount, 9 cents of each dollar, not to exceed $11,000,00 in any fiscal year, 75% to provide psycho tropic medications for persons with serious mental illnesses who are not eligible for services under Title XIX of the Social Security Act, 25% to be used for regional behavioral health authorities to provide crisis stabilization and residential treatment services to children with significant and serious psychiatric impairments that pose a threat to themselves, their families, or the community.
(D) Older Arizonans SubAccount, 3 cents of each dollar, not to exceed $3,500,000 in any fiscal year, 85% to provide care, including custodial and supportive services for older Arizonans suffering from chronic diseases including cancer, cardiovascular and pulmonary diseases, respiratory illnesses, strokes, Alzheimer’s disease and other diseases of aging, and who cannot otherwise secure such services privately or through programs under Title XVII of the Social Security Act, 15% to fund non-medical home and community-based care programs.
(E) Primary Care and Community Health Centers SubAccount, 9 cents of each dollar, not to exceed $11,000,000 in any fiscal year, to fund primary care and community health centers services.
(F) Annual Health SubAccount, 15 cents of each dollar, not to exceed $20,500,000 in any fiscal year to fund health care, including behavioral health care, for individuals who cannot otherwise afford or obtain such services or to provide funding for innovative health care programs.
(G) Children’s Health Insurance and Working Uninsured SubAccount, 34 cents of each dollar in the first two years, 50 cents each year thereafter, and any remaining funds in the other subaccounts, to pay the federally required state share of the Children’s Health Insurance Program, to pay the cost of organ transplants, to pay the cost of HIV/AIDS drug treatment (not to exceed $1,230,000 in any fiscal year), to pay administrative costs, not to exceed 4 percent of the total amount withdrawn from this SubAccount in any fiscal year, and to pay $1 million annually for outreach programs to inform eligible or potentially eligible persons about health insurance benefits available for them.
Who Will Be in Charge:
(1) State Treasurer receives funds, invests funds, and deposits funds in accounts;
(2) Department of Revenue administers corrections adjustment account; (3) Disease Control Research Commission administers Disease Control Research Fund;
(3) Department of Health Services administers Prevention SubAccount, taking into consideration impact each disease has on mortality rates in Arizona as determined by the Centers for Disease Control;
(4) Smart Beginnings Commission is established to administer the Smart Beginnings Prevention SubAccount. Governor appoints members of the Smart Beginnings Commission, including two members of the executive branch whose official responsibilities relate to promoting the healthy development of young children; two public members who represent entities with expertise in the healthy development of young children, one public member who is a parent with a young child. Governor appoints a full-time Executive Director for the Smart Beginnings Prevention Commission. The Commission will be exempt from state laws regarding competitive bids.
(5) State Legislature may appropriate funds from the State Medical Laboratory SubAccount for construction of facility.
(6) State Legislature may appropriate funds from the Mental Health Facilities and Services SubAccount for construction or renovation of facilities and providing services.
(7) Department of Health Services administers Behavioral Health SubAccount.
(8) "The Administration" administers the Older Arizonans’ SubAccount, with services provided by qualified persons or entities selected through competitive bids, except the Department of Economic Security will administer funding of non-medical home and community-based care programs.
(9) State Legislature may appropriate funds from the Primary Care and Community Health Centers SubAccount.
(10) Director of State Health Department administers Children’s Health Insurance and Working Uninsured SubAccount. Director has authority to adjust applicant income limits to lower than 100% of federal poverty level.
Financial Impact: Total estimated costs for the first year (2002): $184.2 million. In addition, Proposition 200 also requires that certain programs currently funded by tobacco tax revenue be picked up by the State’s General Fund, requiring $28 million in additional funds annually from the General Fund. In addition, some current tobacco tax programs would be cut unless the State covers their costs. If Proposition 200 passes, the provisions of the Healthy Arizona Initiative passed in 1996, increasing the income eligibility for AHCCCS coverage to 100% of the federal poverty level, will be voided.
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(2) Proposition 204 (Healthy Arizona II)
What It Will Do: Provides that Tobacco Settlement Funds shall be used to fund the provisions of the Healthy Arizona Initiative passed by voters in 1996. The provisions include raising the income eligibility for AHCCCS health care insurance coverage from 34% to 100% of the federal poverty level, and funding for six health programs: (1) $5 million for the Healthy Families Program; (2) $4 million for the Arizona Area Health Education Centers Program; (3) $ 3 million for Teenaged Pregnancy Prevention Programs; (4) $2 million for the Health Start Program; (5) $2 million for the Disease Control Research Fund; (6) $1 million for the Women, Infants, and Children Program. Provides that neither the Executive nor the Legislature may establish a cap on the number of eligible persons who may enroll in the system.
Provides that Tobacco Settlement Funds be supplemented, as necessary, by any other available resources, including legislative appropriations and federal monies. Provides that monies in the fund may not be used to supplant existing and future appropriations to AHCCCS for existing and future programs, do not revert to the state general fund, are exempt from the statutes governing lapsing of appropriations, and are continuously appropriated.
Provides that any provision of the measure not contrary to the provisions of a separate initiative and that receives a higher total vote in the election is valid.
Who Will Be In Charge:
(1) The people, by initiative, or the Legislature, by a simple majority vote, to increase the income eligibility for AHCCCS health insurance coverage from the 100% of federal poverty level authorized in 1996, to a more inclusive threshold.
(2) AHCCCS Program, for expanded AHCCCS coverage. Permits the Director of AHCCCS to use any remaining monies to fund expanded health insurance coverage, including through the Premium Sharing Program.
(3) Department of Economic Security, Healthy Families Program.
(4) Arizona Board of Regents, Arizona Area Health Education Centers Program.
(5) Arizona Department of Health Services, Teenaged Pregnancy Programs.
(6) Arizona Department of Health Services, Health Start Program.
(7) Arizona Department of Health Services, WIC Program.
(8) Disease Control Research Fund.
(9) Permits the Legislature, by a simple majority vote, to increase the income eligibility for AHCCCS health insurance coverage from the 100% of federal poverty level authorized in 1996, to a more inclusive threshold, and permits the Legislature to appropriate any monies that remain in the fund, but only for programs that benefit the health of the residents of the state.
How Will It Be Administered: Tobacco Settlement Funds received by the state must be distributed to the designated agencies for the designated purposes.
Financial Impact: Proposition 204 would fund health insurance for all uninsured residents with income at or below 100% of the federal poverty level. It is estimated this would add 130,000 of the state’s poorest residents to the AHCCCS program, compared to 40,000 who would be added to the AHCCCS program by Proposition 200.
For every dollar the state spends to provide health care to the indigent, Medicaid contributes $2. Medicaid was set up to serve families, the elderly, the disabled, and pregnant women of low income. Adding indigent childless adults would require approval (technically called a waiver) from the federal agency that administers Medicaid, the Health Care Financing Administration (HCFA). This waiver was rejected, after the original Healthy Arizona Initiative passed in 1996, because the state’s request for the waiver put a cap on the number of uninsured residents who could be covered of 100,000 people.
HCFA rejected the waiver on the grounds that Medicaid coverage must be available to anyone who qualifies. As a result, Arizona changed the language of its request for waiver to reflect these federal guidelines and resubmitted the request in August of this year. Assuming the waiver is granted, as it has been in Wisconsin, Vermont, and Hawaii, Arizona will received $2 in federal funding for every $1 of tobacco tax settlement funds spent for health insurance coverage for the poor.
In addition to expanded health insurance coverage, $17 million is allocated for specified health programs.
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3. APHA Analysis of Health Care Reform Proposals: The American Public Health Association’s Working Group on Universal Health Care has developed 14 principles for health care reform, and an analysis of the extent to which Presidential candidates’ health care proposals, Congressional proposals, and state proposals conform to those principles: http://www.apha.org/Legislative A synopsis of the analyses for the major presidential candidates’ proposals follow:
Democratic Party/Al Gore: Provides for incremental expansion of public programs to cover all children and some more adults. Strengths include expanded coverage; recognizing importance of prevention, outreach, safety net programs, patients’ rights, quality programs; expansion of programs through existing public sector programs, preserving potential for future improvements. Weaknesses include does not attempt to provide universal coverage; does not address need for comprehensive services; subsidies to low-income may make insurance more affordable for some individuals, but does not shift system to financing based on ability to pay; little attention to delivery system, none to workforce issues.
Republican Party/George Bush: Provides tax credits and tax incentives to individuals and small businesses to buy private insurance Strengths include additional funding for community health centers and some safety net programs; reference to generous program of benefits similar to Federal Employee Benefits Health Plan; recognition of patients’ rights. Weaknesses include no coherent program to expand coverage, access, affordability, or quality; subsidies of up to $2,000 per family to buy private health insurance are inadequate and unlikely to increase coverage; proposals do not address efficient organization of services and are antithetical to greater consumer control or greater role for accountable public administration of system.
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4. How to Contact Your Representatives
a. Arizona Congressional Delegation: Available through the Publication Technology Project at Arizona State University: http://aspin.asu.edu/~pctp/azdeleg.html. To get Congressional Handbook, http://www.congresshandbook.com. Links to Representatives are available at http://www.house.gov. Links to Senators are available at http://www.senate.gov.
Senate:
John McCain (R-AZ) DC Phone 202-224-2235; DC Fax 202-228-2862
State Offices: Phoenix 602-952-2410; Tucson 520-670-6334; Mesa 602-491-4300; Email: John_McCain@mccain.senate.gov
Jon Kyl (R-AZ) DC Phone 202-224-4521; DC Fax 202-224-2207
State Offices: Phoenix 602-840-1891; Tucson 520-575-8633; Email: info@kyl.senate.gov
House of Representatives:
Matt Salmon (R-1-AZ) DC Phone 202-225-2635; DC Fax 202-225-3405; Tempe 480-946-3600; Email: msalmon@mail.house.gov
Ed Pastor (D-2-AZ) DC Phone 202-225-4065; DC Fax 202-225-1655; Tucson 520-624-9986; Phoenix 602-256-0551; Yuma 520-726-2234; Email: edpastor@mail.house.gov
Bob Stump (R-3-AZ) DC Phone 202-225-4576; DC Fax 202-225-6328; Phoenix Phone: 602-379-6923.
John Shadegg (R-4-AZ) DC Phone 202-225-3361; DC Fax 202-225-3462; Phoenix 602-263-5300; Email: j.shadegg@mail.house.gov
Jim Kolbe (R-5-AZ) DC Phone 202-225-2542; DC Fax 202-225-0378; Tucson 520-881-3588; Sierra Vista 520-459-3115; Email: jim.kolbe@mail..house.gov
J.D. Hayworth (R-6-AZ) DC Phone 202-225-2190; DC Fax 202-225-3263; Mesa 602-926-4151; Flagstaff 520-556-8760.
b. Arizona State Legislators: Available through the Arizona Legislative Information System (ALIS): Call 1-800-352-8404 http://www.azleg.state.az.us/members/members.htm.
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5. Grant Opportunities
a. Current federal grant opportunities related to rural health are available at http://www.nal.usda.gov/ric/richs/grants.htm
b. Foundations: Current Funding Programs and Master List is available at http://www.nal.usda.gov/ric/richs/foundat.htm
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6. Conferences Relevant to Rural Health
NOVEMBER
* Rural Recruitment and Retention Network (RRRNet) Annual Membership and Conference, Albuquerque, New Mexico , November 2-3. Contact: (800) 787-2512; Email info@3rnet.org.
* 128th Annual Meeting of the American Public Health Association (APHA): Eliminating Health Disparities, Boston, Massachusetts, November 12-16. Contact: (202) 777-2478.
* Rural Mobility Solutions for the 21st Century: National TRB Rural Public and Intercity Bus Transportation Conference, Lake Tahoe, Nevada November 12-15. Contact: (202) 334-2966.
DECEMBER
* Health Workforce 2000: Building A Foundation for Health Care in the 21st Century, Washington DC, December 11-12. Contact: (301) 443-3148.
* Sixth Annual Rural Minority Health Conference, Involving Youth in the Future of Rural Minority Health, December 7-9. Contact: (816) 756-3140.
JANUARY
* Rural Workforce 2002 Conference: Connecting Partners for Healthy Rural Communities," Coeur d’Alene, Idaho, January 23-25. Contact: (541) 928-0241.
MARCH
* Growing Partnerships for Rural Special Education, San Diego, California, March 20-31. Contact: (785) 532-2737.
For others, see http://www.nal.usda.gov/ric/richs/conf.htm (rural health) and http://www.nal.usda.gov/ric/conf.html (rural general).
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7. Other Useful Information
a. HRSA Web Site for Drug Pricing Program: On October 2, HRSA launched a new web site for its Drug Pricing Program. Health care programs that are part of HRSA’s Prime Vendor Program can use this web site to determine if they are getting the best prices for drugs. Providers can now look up the discount prices for 207 of the most commonly prescribed drugs online, and can also use the site to compare the cost effectiveness of various drug regimens. Providers not signed up for the Drug Pricing Program can use the site to complete a drug cost assessment. See http://www.hrsa.gov/odpp.
The Drug Pricing Program is managed by HRSA’s Bureau of Primary Health Care, Office of Pharmacy Affairs. The program was established as part of the Veteran’s Health Care Act of 1992. Under this program, health care organizations that receive certain federal grants are eligible to purchase drugs for their patients at substantial discounts. Eligible providers include health centers, disproportionate share hospitals, and some HIV, STD, and TB grantees.
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b. NRHA Issue Papers Online: The National Rural Health Association’s Rural Health Policy Board regularly develops issue papers regarding issues impacting the nation’s rural health care delivery system.
Issues papers adopted between May, 1995 and May, 1999 are available online: http://www.nrharural.org/dc/a7.html.
These include:
(1) Access to Health Care for the Uninsured in Rural and Frontier America;
(2) Mental Health in Rural America;
(3) A National Agenda for Rural Minority Health;
(4) Rural Physician Recruitment and Retention;
(5) Facilitating the Use of National Surveys in Rural Health Research;
(6) A Vision for Health Reform Models for America’s Rural Communities;
(7) The Role of Telemedicine in Rural Health Care;
(8) Funding of Graduate Medical Education;
(9) HIV/AIDS in Rural America;
(10) Rural and Frontier Emergency Medical Services Toward the Year 200;
(11) Rural Health Clinics in Rural America;
(12) The Need for a National Limited-Service Hospital Program;
(13) Antitrust and Rural Health;
(14) Managed Care as a Delivery Model in Rural Areas;
(15) Essential Community Access Providers;
(16) The Impact of Entitlement Programs on Rural Health.
Copies are available through the NRHA Communications Department, One West Armour Blvd., Suite 203, Kansas City, Missouri 64111; Fax: (816) 756-3144; Email pubs@nrharural.org.
If you have ideas for future issue paper topics or would like to contribute information on papers being drafted, email the NRHA Government Affairs Office at: dc@nrharural.org.
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c. Border Health Website: The Pan American Health Organization (PAHO) has published a useful new document, "Mortality Profiles of the Sister Communities on the United States-Mexico Border – 1992-1994." This is an extensive statistical document for people conducting research on border health issues, as it examines in detail (including ICD-9 coding and other standard rubrics for representing health statistical mortality data for the 14 pairs of sister border communities. The document is available on the web: http://www.paho.org/English/SHA/mortprofiles-usmb.pdf.
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Please address comments, questions, requests, contributions, and suggestions to ahughes@u.arizona.edu. If you know of someone who would like to be added to our distribution list, or if you wish to be removed from the list, please contact atromble@rho.arizona.edu.
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