Making Democracy Work




Health Means More than Healthcare or What Prevention Elements are Necessary for a complete Arizona Health Care Plan

Mary Ellen Cunningham MPA, RN Arizona League of Women Voters-Metro Phoenix June 2017

As Congress examines and modifies health care insurance, it is important to understand that the desired outcome of these strategies and policies is health for the Nation. According to the World Health Organization, health is `not just the absence of illness but mental, social and physical well being'.1 Optimal health requires preventive efforts, not solely acute care. The nation's public health agencies; national, statewide or local, work to prevent population level disease outbreaks including Zika or measles as well as supporting individual prevention efforts which could include obesity or unplanned teen pregnancies.

Congress has long funded public health prevention efforts. Many of these efforts were folded into the Prevention and Public Health Prevention Fund (PPHF), which later became a part of the Affordable Care Act. In Arizona, this funding is used to help support immunizations for children, infectious disease prevention and control programs and projects, Arizona's public health lab, childhood lead poisoning prevention and programs for prevention of chronic diseases, such as obesity, diabetes, heart disease and smoking.

The Affordable Care Act also recognized the importance of wellness by including the requirement that Essential Health Benefits are included in policies. By including these elements in every health plan, families or individuals would not have to make hard choices because of cost when they selected insurance plans, for instance having to elect to not include maternity care or behavioral health services. The essential benefits captured the services that families needed to be able to access care and at the same time stay solvent if and when they were faced with a life event like a pregnancy or an injury that required rehabilitative services. Many people do not consider, especially in their youth, that they will ever be faced with a catastrophic injury or illness.

States were given the freedom to select their package of required benefits. Arizona chose to use the state employee health plans as a model. The mandated Essential Health Benefits include (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices; (8) laboratory services; (9) preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care. 2

1 Preamble to the Constitution of WHO as adopted by the International Health Conference, New York, 19 2The Center for Consumer Information & Insurance Oversight, Information on Essential Health Benefits (EHB) Benchmark Plans. Retrieved from:

Beyond the risk of loss of the Essential Health Benefits, both of the newest health care proposals from the US House and Senate also completely eliminate the Prevention and Public Health Fund (PPHF). It is important to know that some of these funds date from the late 1980's. The nature of a block grant means states choose their own priorities based on the data and direct funding and programs towards those priorities.

It would be fair at this point to ask why is this important? Why should we care? That may be more clear after we look at some of the leading causes of death and disability in Arizona and where some of these essential health benefits and prevention efforts would make a difference. The following is a short description of some of the health statistics for Arizona including teen birth, infant mortality and the leading causes of death for major age groups.

According to Arizona Department of Health Services, Teenage Pregnancy Arizona Report 2015, Arizona's teen pregnancy rate decreased from 32.7 in 2005 to 15.9 in 2015, a decrease of 51.3 percent. The pregnancy rate for the youngest teen, from 15-17, decreased from 39 in 2005 to 14.1 in 2015, a decrease of 63.9 percent. That means a decrease of 4,790 to 1,887 pregnancies of teens between 15-17 years of age in that decade. 3 There are several factors attributed to the decrease in teen pregnancies from the downturn in the economy to the effects of prevention programs and the availability of Long Acting Reversible Contraceptives (LARC), accessible during a preventive health visit. 4

Access to reproductive health planning and in fact access to preventive health visits (Ambulatory services) afford care providers the opportunity to discuss a woman's reproductive plans and address any chronic health issues. 5 Discussing a woman's health before she becomes pregnant is referred to as preconception or interconception health. Almost half of all pregnancies in the United States are unplanned. When a woman becomes pregnant without planning she can start that pregnancy with undiagnosed or unmanaged diabetes or STDs for example. Unplanned pregnancies are at greater risk of delivering preterm or low birth weight babies. 6 Prevention funds in the ACA have also supported Teen Pregnancy Prevention programs in Arizona and nationally.

3 Teenage Pregnancy Arizona 2005-2015, Arizona Department of Health Services. Retrieved from:

4 Patten, E., Livingston, G. (2016, April 29). Why is the teen birth rate falling? . Retrieved from: falling/

5 Women's Preconception health. Retrieved from:

6 Dean,S. , Elizabeth Mary Mason, Christopher P Howson, Zohra S Lassi, Ayesha M Imam, and Zulfiqar A Bhutta. Reprod Health. 2013; 10(Suppl 1): S3. Published online 2013 Nov
15. doi: 10.1186/1742-4755-10-S1-S3PMCID: PMC3828587Born Too Soon: Care before and between pregnancy to prevent preterm births: from evidence to action. Retrieved

In 2015, Arizona's infant mortality rate was 5.6, a decrease of 9.9 percent from 6.2 in 2014.7 According to the Arizona Health Status and Vital Statistics 2015 Annual Report, the leading causes of death to Arizona's infants were congenital malformation and prematurity, followed by suffocation, often related to an unsafe sleep environment.8 Arizona's Safe Sleep program helped reduce the rate of unsafe sleep-related deaths ten percent from 82 deaths in 2014 to 74 deaths in 2015. 9 These efforts included a media campaign and the concerted efforts of physicians, nurses, home visitors and care providers to educate families about safe sleep practices.

Arizona's prematurity rate decreased from 10.8 in 2005 to 9.0 in 2015, below the Healthy People 2020 goal. 10 Maternity care allows pregnant women to access the services they need to support a healthy pregnancy, which increase the chances of a healthy baby. Time with a care provider also allows for education of critical newborn care including safe sleep practices. This education is also reiterated during newborn care visits.

The Arizona Health Status and Vital Statistics 2015 Annual Report tells us that the five leading causes of death for children from 1-14 from 2005-2015 were accidents or unintentional injuries including motor vehicle accidents and drowning, cancer, congenital malformations, homicide, and suicide. 11

The five causes of deaths among adolescents aged 15-19 over the same decade were unintentional injuries including motor vehicle accidents, intentional self harm also referred to as suicide, homicide, cancer and heart disease. 12


7Arizona Health Status and Vital Statistics 2015 Annual Report. Retrieved from:

8 ibid

9 Arizona Child Fatality Review Program Twenty Third Annual Report, November 15, 2016. Retrieved from: health/reports-fact-sheets/child-fatality-review-annual-reports/cfr-annual-report- 2016.pdf

10 Healthy People 2010 MICH-9.1 Reduce total preterm births Target 11.4 Retrieved from: health/objectives

11 Arizona Health Status and Vital Statistics 2015 Annual Report. Retrieved from:

12 Arizona Health Status and Vital Statistics 2015 Annual Report. Retrieved from:

In 2015, 768 children under 18 years of age died in Arizona. Arizona has had a Child Fatality Review program in existence for over 20 years. By statute, the death of every child from birth to age 18 is reviewed by multidisciplinary teams to identify trends in preventable child deaths. According to the Twenty Third Annual Report,13 almost 40 percent of these deaths were preventable. The leading causes of preventable deaths were prematurity, suffocation, generally related to unsafe sleep for infants, drownings, motor vehicle crashes and firearm injury. Early childhood home visiting programs, funded through the ACA, provide education and support to young families not only about early brain development but also about home safety including drowning prevention, automobile safety and gun safety. Again, when these trends are identified pediatricians and primary care providers also educate and reinforce messaging about what families can do to prevent avoidable child deaths.

The leading causes of death among our young adults, aged 20-44 included accidents, suicide, cancer, heart disease and assault or homicide. 14 For middle aged adults, aged 45- 64, the leading causes of death were cancer, heart disease, accidents, chronic liver disease and chronic lower respiratory disease.15 Finally, the leading causes of death for Arizona's elderly, aged 65 and older included heart disease, cancer, chronic lower respiratory diseases, Alzheimer's disease and cardiovascular disease. 16

The preponderance of these leading causes of death, except for accidents, homicide and suicide, can be considered chronic disease and can be manageable. Preventive and wellness services and chronic disease management and Prescription drugs are included in the Essential Health Benefits and the Prevention and Public Health Prevention Fund supports programs to address chronic diseases. Arguably Mental health services and addiction treatment, a part of the essential health benefits at risk, would affect the loss of life or injury due to accidents, ho Finally, in 2016, the death of 790 people in Arizona was a direct result of opioids. There has been a 74% increase in deaths attributed to opioids in Arizona since 2012. 17 According to the Substance Abuse and Mental Health Services Administration (SAMHSA), in

13 Arizona Child Fatality Review Program Twenty Third Annual Report, November 15, 2016. fact-sheets/child-fatality-review-annual-reports/cfr-annual-report-2016.pdf

14 Arizona Health Status and Vital Statistics 2015 Annual Report. Retrieved from: . 15 Arizona Health Status and Vital Statistics 2015 Annual Report. Retrieved from: 16Arizona Health Status and Vital Statistics 2015 Annual Report. Retrieved from: 17 2016 Arizona Opioid Report. Retrieved from: recommendations/prescribing-guidelines/arizona-opioid-report.pdf

2014, while 15.7 million adults reported having a major depressive episode within the past year, almost one third did not seek professional care. National Survey on Drug Use and Health (SNSDUH) data also shows that of the over 21 million people over age 21 who needed treatment for a drug or alcohol problem, only about 2.5 million people received this treatment. 18

The Institute of Medicine and National Research Council's 2009 report Preventing Mental, Emotional, and Behavioral Disorders Among Young People which is referred to in the web page tells us that for every $1 we spend on prevention of substance abuse and mental illness we could save $2 to $10 on treatment. 19 A poignant reminder from the report introduction reads: "As a society, we suffer from a collective health care myopia: we have not figured out how to balance rescue which is after-the fact treatment with the less dramatic but often far more cost-effective and socially desirable prevention of a problem." 20

After reviewing the causes of death and disability for Arizonians, it is clear that ensuring access to care, which includes the elements of the Essential Health Benefits and prevention funding can ensure more general wellness for our families; helping to reduce premature birth and death or disability from a treatable chronic disease. This will lead mental, social and physical well being for all Arizonans.

18 SAMHSA Behavioral Health Treatments and Services. Retrieved from:

19Prevention of Substance Abuse and Mental Illness. Retrieved from:

20 O'Connell, M.E., Thomas Boat, and Kenneth Werner, Editors. Preventing Mental, Emotional and Behavioral Disorders among Young People: Progress and Possibilities. Committee on the Prevention of Mental Disorders and Substance Abuse among Children, Youth, and Young Adults: Research Advances and Promising Interventions. National Research Council and Institute of Medicine. (2009). Retrieved from:


Overview - A Comparison of the ACA and the AHC



LWV- Position on Health Care
  • Ensure access to affordable, quality health care for all Americans, and
  • A basic level of care - includes disease prevention, primary care, prenatal and reproductive health, acute long-term care, mental health care and health promotion and education.
  • League's efforts include organizing community education projects, holding public forums and debates, creating and distributing resource materials and engaging members of Congress

LWV + Take Action 6/8/2017 - League's Take Action e-mail. Tell Legislators they must: ĜGuarantee that pre-existing conditions can't be used to deny coverage or raise rates ĜEnsure insurance rates and access do not discriminate against women ĜProvide coverage of preventive care, limit out of pocket costs and prohibit life- time insurance caps ĜEnsure that Medicaid recipients can continue to receive full health care services

Current Legislation: Three Prongs - Phases of Change
1. The American Health Care Act + The Reconciliation Bill passed by the House of Representatives v Budgetary provisions only: Revenue sources and effective dates of the replacement provision v Can Pass the Senate with only 50 votes. v Now in the Senate

2. Administrative changes + HHS Secretary Tom Price Roughly 1442 sections of the ACA could be targeted for repeal or revision

3. Passage of other legislation that doesn't qualify for reconciliation, i.e., no implications for the budget e.g., Health Insurance sold across state lines

Bottom line: More big changes to come

Biggest changes the ACA Made and Those that will Change again in the AHCA
1. Insurance Markets
2. Medicaid Expansion
3. Consumer Protections
4. Requirement for individuals to have insurance (Individual Mandate); and companies to offer to employees
5. Raised taxes related to high incomes, and players in the health industry, prescription drugs, medical devices, and health insurance companies
6. Reforms to Medicare

Insurance Markets + the Exchanges

  • Online markets, where people who didn't get insurance through work could shop for a health plan from a private insurer in their state.

  • Through the Exchanges, the ACA offered subsidies for Americans with lower incomes to help pay their premiums and deductibles

Premium subsidies to Individuals - ACA
  • ACA provided refundable, advanceable premium tax credits to eligible individuals with incomes between 100-400% Federal Poverty Level to purchase insurance through the exchanges
  • Credits were computed on a sliding scale so people pay no more than a required percentage of income for a plan for their age in their area
  • Credit amount decreases as income increases; amount increases as cost of the benchmark plan increases

Premium Subsidies to Individuals-AHCA For 2018-2019, modify premium tax credits as follows: ĜIncrease credit amounts for young adults with income above 150%FPL and decrease amounts for adults 50 and older earning above that income level ĜTax credits can be used to purchase plans sold outside of the exchange Starting in 2020, replace ACA income-based tax credits with flat tax credit adjusted for age. Credits are payable monthly; annual credit amounts for an individual are: $2,000 per individual up to age 29 $3,500 per individual age 50-59 $2500 per individual age 30-39 $4,000 per individual age 60 and older $3,000 per individual age 40-49

Cost Sharing subsidies - ACA These reduce deductibles, copays and Out of Pocket on a sliding scale. Under the ACA, the national average deductible and OOP limit under silver exchange plans in 2016 were: 100-150%FPL Annual Deductible: $221 Annual OOP Limit: $874 200-250%FPL " $2,491 " $4,850

Under the AHCA, cost sharing subsidies are repealed effective January 1, 2020.

Consumer protections under ACA ➢ Insurance companies prevented from denying coverage or charging a higher price for a pre-existing health problem ĜA ban on setting a lifetime limit on coverage ĜA requirement that insurers offer a minimum package of benefits ĜA guarantee that preventive health services be covered without a co-pay ĜA cap on insurance company profits ĜLimits on how much more insurers can charge older people than younger people ĜAdult children could stay on their parents' policies until age 26

Under the AHCA Private market rules include:

  • Prohibition on pre-existing condition exclusions
  • Requirement to extend dependent coverage to age 26
  • Age rating limit modified from a 3:1 ratio to a 5:1 ratio, unless states adopt different ratios, effective 2018
  • Insurers are required to impose 30% surcharge on premiums for those who experience a gap in coverage

Individual Mandate + ACA - AHCA Purpose: To ensure that enough healthy people entered insurance markets, the ACA included mandates to encourage broader coverage. (In 2016, the tax penalty for not having insurance was 2.5% of household adjusted gross income or $695 per adult.) Large employers that failed to offer affordable coverage, or individuals who failed to obtain insurance, could be charged a tax penalty. The Mandate is essentially repealed: Tax penalties for not having minimum essential coverage is eliminated effective January 1, 2016

Pre-existing conditions and AHCA State Waiver

  • About 27% of adult Americans under the age of 65 affected
  • States applying for waiver allow higher premiums for sicker people + if they had a gap in their coverage (over 63 days)
  • Waiver requires creation of a high risk pool

State Waiver + Essential Health Benefits

  • States can waive the requirement for insurers to cover essential health benefits and/or redefine them
  • Upshot: oHealthier people might get cheaper premiums with fewer benefits oEffect on out-of-pocket costs + difficult to predict

AHCA + Patient and State Stability Fund
  • $138 billion provided to states over 10 years
  • Can be used for various purposes, e.g., subsidizing premiums, providing coverage to people with pre-existing conditions, paying for mental health care, treatment for drug addiction
  • Additional $15 billion is allocated to the fund for Federal Invisible Risk Sharing Program (reinsurance) paid to health insurers

Medicaid Expansion - ACA Federal funding and eligibility were expanded significantly Federal funding for states to offer Medicaid coverage to anyone earning less than about $16,000 for a single person or $33,000 for a family of four (adj. gross incomes up to 138% FPL) Number of states opting for expansion: 37 Number of Americans covered by Medicaid in 2016: Over 70 million, or 1 in 5 people

ACA - Taxes to health industry & high earners The ACA raised taxes on several players in the health industry and on high-income earners ĜIncrease in Medicare payroll tax on wages for high-wage individuals (200K individual + 250K couple) by .9 percentage points) ĜThe 3.8% tax on unearned income for high-income taxpayers ĜTax on pharmaceutical manufacturers ĜTaxes on Insurance companies ĜExcise tax on sale of medical devices

ĜAHCA repeals all of them

AHCA - Medicaid

  • As of 2020: Converts federal Medicaid funding to a per capita cap based on 2016 expenditures, i.e., ends guarantee of federal support for Medicaid programs based on actual state spending
  • Provides a state option to elect Medicaid block grant instead of per capita cap
  • Creates state option to require work as a condition of eligibility for nondisabled, nonelderly, non pregnant Medicaid enrollees (provides 5% enhanced federal matching funds to implement work requirement
  • Repeal essential health benefits requirement
  • Effective upon date of passage, prohibit use of Medicaid funding for Planned Parenthood for 1 year

Impact on Medicaid
  • Medicaid provides coverage for 1 in 5 Americans
  • The cap on funding would disproportionately affect low-income children, adults, seniors, and people with disabilities
  • 1.9 million Arizonans covered by Medicaid (AHCCCS and CHIP)
  • 949,000 (14%) Arizonans receive Medicare
  • 17% of Medicare Enrollees in AZ also receive Medicaid

Impact and CBO Report--May 4, 2017
  • The federal deficit would be reduced by $119 billion - HOW?
  • Between 2017 and 2026, AHCA would reduce spending by $1,111 billion by cuts in Medicaid and cuts in Tax Credits for Americans seeking health insurance
  • Expenditures include $117 billion for Patient and State Stability Fund Grants
  • The deficit reduction is due to: Loss of revenue from Penalty payments from employers and uninsured people - $210 billion
  • And tax cuts for health industry and high earners reducing revenue by $664 billion
  • Bottom Line: Decrease in Medicaid spending - $834 billion; Revenue decrease due to tax cuts - $664 billion

Impact and CBO Report
  • In 2018, 14 million more people would be uninsured under AHCA than ACA due to projected higher premiums, and repeal of penalties associated with the individual mandate
  • In 2020, that number will rise to 19 million
  • In 2026, that number will rise to 23 million
  • Bottom Line: In 2026, an estimated 51 million people would be uninsured, compared with 28 million who would lack insurance that year under current law

AHCA effects on Medicare Program Repeal of the Medicare payroll surtax on high income earners results in: ĜReduction of revenue to the Medicare Hospital Insurance (Part A) trust fund by $117 billion between 2017 and 2026 (Joint Committee on Taxation) ĜWeakens Medicare's financial status by depleting the Part A trust fund three years sooner than under current law ĜProjected insolvency date moves up from 2028 to 2025

ACA -Terms to Know

  • Essential Health Benefits + basic set of 10 benefits required by ACA Outpatient care, emergency services hospitalization, maternity and newborn care, Mental health and substance use services, prescription drugs, rehab and habilitative services and devices; lab services, prevention and wellness, and chronic disease management; pediatric service, including oral and vision care. Community rating -requires health insurance providers to offer health insurance policies within a given territory at the same price to all persons, regardless of their health status. Age Rating + how much more insurance companies can charge older customers

Arizona Reform