Turn, Turn, Turn…

A couple of weeks ago, I chose the lyrics of The Clash to describe the current legislative session and this week The Byrds classic “Turn! Turn! Turn!” (recorded in 1962 and based on Chapter 3 of the book of Ecclesiastes) seems most fitting as the session comes to an end.

To everything, turn, turn, turn.
There is a season, turn, turn, turn.
And a time to every purpose under heaven.
A time to be born, a time to die.

Today marks the final day of the 140 days of the 84th Texas Legislative Session, otherwise known as Sine Die inside the Capitol. Now we have an opportunity to look back and see what this season meant for all of us in the Harris County Healthcare Alliance. We have been very busy working with the members of the Texas Legislature over the last two years to get to where we are. We have some good things coming and some areas where we did not make as much progress as we had hoped.

A time to be born, a time to die.
A time to plant, a time to reap.
A time to kill, a time to heal.
A time to laugh, a time to weep.

As we have discussed before in this blog, the only constitutionally mandated responsibility for the Texas Legislature is approving a budget for the next two years that funds all activities of the State of Texas. It is with this budget act that the values of the state are represented, and the 84th Legislature maintained the state’s commitment to funding education and health care while accounting for population growth as well as projected increases in the costs of those services. Unlike recent years, there were no cuts to any critical services. In fact, new money was appropriated to help Texans who need mental health services and new money was also appropriated for expanded pre-K. While we were ultimately unsuccessful in our efforts to expand Medicaid or a similar coverage model, we did not lose ground.

A time to build up, a time to break down.
A time to dance, a time to mourn.
A time to cast away stones.
A time to gather stones together.

Although it does not directly relate directly to HCHA priorities, this Legislature will probably be remembered as the one that produced a plan to gather stones and build roads and bridges to move our growing population in Texas. There will be a statewide ballot proposition to let Texans decide whether or not to increase funding for transportation. This process is instructive for those of us who care about health care in that we may need to take our issues directly to the voters of Texas if we expect to make significant progress in improving the access, quality and affordability of health care services. Specific to health and human services concerns, this Legislature did pass a series of reforms to the Health and Human Services Commission that, while not historic, should lead to some improvements relating to coordination between the agencies. We will work throughout the next several seasons on implementing this legislation and will continue to push for all those who need services in our communities.

A time of love, a time of hate.
A time of war, a time of peace.
A time you may embrace.
A time to refrain from embracing.

The 84th Legislature may be remembered for the proverbial train wreck that looked inevitable but never materialized. The cooler heads in both the House and Senate prevailed finding ways to work together (for the most part) and keep some of the worst legislation from passing. In January, there were several bills filed that could have changed the perception of Texas as a state filled with compassion and love to a state filled with bitterness and hate, but those bills made very little progress. Fortunately, our communities can still provide health care to immigrants, and the children of illegal immigrants still have the ability to become “dreamers” by attending college with in-state tuition in Texas.

There is a season, turn, turn, turn.
And a time to every purpose under heaven.
A time to gain, a time to lose.
A time to rend, a time to sew.
A time for love, a time for hate.
A time for peace, I swear it’s not too late.

Finally, please know it is not too late to impact the health and human services in our region and state. The next season starts tomorrow, which will lead to an election season, followed by another legislative season. Turn, turn, turn…

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And They’re Comin’ Round the Corner and into the Final Stretch…

The prospect of an elusive Triple Crown has grown in recent weeks after impressive runs from American Pharaoh in the Kentucky Derby and the Preakness Stakes, so I thought it was only fitting to compare the 2015 Texas Legislature to the world of horse racing. Plus today marks the final 14 days of the constitutionally mandated 140 day session, which means everyone is racing to get their bills passed before the deadline on June 1.

Prior to 1993, both the House and Senate basically allowed for all committee and floor activities up until the final day, which always made that last day a truly epic sprint to the finish line that often included all sorts of crazy amendments and bizarre negotiations (or horse trading). Starting in 1993, both the House and Senate developed rules to ensure rational processes that allowed for proper vetting of legislation, amendments and resolutions. Under these rules, there are several deadlines that bill and resolutions must meet in order to remain viable for consideration. For example, any House Bill that did not make it out of the House as of last Friday (May 15th) is considered dead. Saturday (May 23rd) will be the deadline for Senate Bills to be reported out of a House Committee. This process means that the bills still alive in the final days of session are actually read and understood (although that might be a bit of an optimistic assumption) before they are voted on by the Representatives and Senators. It also means that several bills that died at the hands of the deadline may see new life as amendments that could be added to related bills that are still moving.

Of course, the most important horse in this race (and the only bill that the Legislature is required to pass) is the budget for the next two years. While the last couple of weeks in the Capitol have been very difficult for the budget conference committee, there seems to be a growing sense of optimism that the negotiators have made progress and can finish the race without collapsing before they reach the finish line. The stumbling block that has tripped them up recently is the disagreement between the type of tax cuts they should pass, with the House favoring sales tax and franchise tax reductions and the Senate preferring property tax reductions.

For HCHA’s purposes, we expect the final version of this budget to be somewhat of a mixed bag. On the one hand, we do not believe there will be cuts to the important health and human services that have been cut too many times since 2009, and it actually includes some increases in the areas of mental health and women’s health; but on the other hand, there will be no coverage expansion or even a directive incorporated in the budget to pursue alternative methods to draw down earmarked federal dollars. Most of the advocates in the health and human services arena would have preferred that the additional revenue be spent on improving the lives of low-income Texans, but most of the participants in this Texas Legislature believe that tax cuts benefit more people than increasing state services.

As a side note, like horse racing, the audience/fans often engage in partying and silly behavior, with generally no noticeable effect on the actual race, but this year at the Capitol may have a bit of a different story. There have been a number of stories coming out of Austin the last couple of weeks about a conservative group that has been secretly filming legislators, both inside and outside of the Capitol. Those stories have fueled further rumors that the 800 hours of recordings include enough embarrassing material that several elected officials may choose to end their political careers after the videos are released. Reportedly, none of the recordings will be released before June 1, but will begin to be shared after that date. Somewhat of a “photo-finish,” but from a different point of view (sorry, I couldn’t help incorporating at least one ugly pun).

This Indecision’s Buggin’ Me…

This indecision’s buggin’ me (Indecisión me molesta)
If you don’t want me, set me free (Si no me quieres, librame)
Exactly whom I’m supposed to be (Dime! ¿Qué tengo ser?)
Don’t you know which clothes even fit me? (¿Sabes que ropa me quedar?)
Come on and let me know (Pero tienes que decir)
Should I cool it or should I blow? (¿Me debo ir o quedarme?)

“Should I Stay or Should I Go?”
The Clash

The 1981 hit “Should I Stay or Should I Go?” from the British punk rock band, The Clash, offers a fitting tribute to the 84th Texas Legislative Session: The lyrics of this song repeatedly beg for some sort of direction, even imploring in Spanish. Today’s missive is not specific to the HCHA agenda, but more of an observation on the entire legislative process this year that is impacting bills of all stripes.

Case in point is the disjointed committee process that has become the rule rather than the exception in both the House and Senate, i.e. leaving bills pending after a public hearing and discussion by the members of the committee. Traditionally, bills that had strong support were heard, discussed, and then voted on at the committee hearing, all on the same day. Bills that were not quite clear to the members or ones that were controversial where the sponsor wanted to continue to work on amendments were left pending for a week or two and then the Chair would bring the bill back up for a vote, usually with amendments from the interested parties to address specific concerns. This session, every bill has been left pending in every committee in both the House and Senate, sometimes for a few days, sometimes for weeks, and often when they are brought back up for a vote there are no amendments or substitutions.

The other interesting observation from the House, in particular, is the number of bills that have been brought up for a vote and then voted down. Again, traditionally, a Chair or the Speaker would ask the sponsor if they had enough votes to move the bill, and if the answer was no, the bill was simply left to die a quiet death. When House members have a hard time getting a “yes” or “no” when polling their bill (because the respondent’s answer is unclear or obtuse), they may mistakenly believe that there are enough votes to bring the bill up for passage. This miscommunication has occurred 29 times so far this session either in committee or on the floor of the House, often to the embarrassment of the author(s) and sponsor(s).

The last observation relating to the song title “Should I Stay or Should I Go?” has to do with the differences in bills passed from both the House and the Senate on virtually everything that is substantive. This observation is not unique to this Legislature, but what remains to be seen in the next couple of weeks is how they will come together on several pieces of legislation to address their differences. This process, when the House and Senate pass different versions of the same bill, is either solved quickly when one body concurs with the changes made by the other, or more slowly when they appoint a conference committee of 5 members from each body to work out the differences. It happens every session with the budget, and we expect numerous bills will be sent to conference committee in the coming weeks, but the question still remains as to whether or not these conference committees will be able to find enough common ground to fix the bills.

The logic behind parliamentary procedure creates a clear process for diverse groups to reach some sort of decision, and indecision slows and distracts progress. At some point, each committee, and even the full House and Senate, must hold a vote where the members choose to support or oppose a bill. Since the Texas Legislative session only lasts 140 days every other year, the indecision and delayed decision-making can literally kill numerous pieces of legislation, both good and bad. My prediction at this point in the session, thanks to the indecision, is that Governor Abbott and his staff will be significantly less busy in the first 20 days of June reviewing bills for either a signature or veto. There simply won’t be that many bills that make it to his desk this year.

Medicaid is Back in the News, What Does it all Mean???

There seems to be another burst of information about Medicaid in the news cycle, and unless you have been dealing with health care finance for numerous years, it seems pretty arcane and complicated. Kudos to Markian Hawryluk who did an outstanding job of taking this difficult subject and putting it into a reasonably condensed story: $4 billion health care for poor Texans at risk. The sad thing to me is that we don’t really hear much of a policy debate or even a funding debate or discussion going on in Austin; it is simply being rejected due to political bluster.

I will try to explain the steps that have led to the recent outburst of media attention, and like most things in health care, it is never simple. Let’s start with the fact that Texas has barely held together “systems” of caring for low-income Texans by reimbursing health care providers (mostly hospitals who care for people in the ERs) for uncompensated care through a convoluted mixture of local and state dollars matched by federal dollars. We have relied on these matching federal dollars to keep the safety-net health care providers operating since the 1980’s, as the state and local governments in Texas have not had the ability and/or will to meet the needs in the communities.

Interestingly enough, the last time the federal dollars were restricted (in the late 1990’s); we faced a crisis in emergency care that impacted everybody, not just the indigent. It took several years to build back the capacity to meet the increasing demands of a rapidly growing state population. One could argue that we barely have enough capacity to care for what we have on hand right now, let alone future growth. Please understand that these dollars are payments to providers for services to low-income Texans, but if the funds don’t continue in one form or another, all people living in Texas will be facing limited access to care.

Back to our Medicaid funding challenge: in 2010, Texas negotiated with the federal government to move one mechanism of supplemental funding (formerly known as UPL) to a program called an 1115 Waiver. When it was negotiated, the intent of both state and federal governments was for it to fund programs that would be sustainable after the five year timeline because the uninsured would be covered by components of the Affordable Care Act (ACA). This waiver will expire in the end of 2016, and renegotiating this waiver is what has caused all the recent uproar.

It should not be news to you that Texas has rejected any sort of engagement with the federal government on the pieces of the ACA, including covering low income people with a Medicaid expansion or some alternative coverage mechanism. So when the funding from the 1115 waiver ends in 2016 (due to the Supreme Court ruling that this was a state option and not a mandate), the sustainability of the safety-net will again be seriously challenged. Prior to last week, there seemed to be a level of confidence amongst leadership of the Texas Medicaid program in Austin that the federal government would renew or extend the existing waiver with enough funding to help the safety-net providers. Last week, the federal team that negotiates these waivers made it clear (first to Florida, and then Texas), that they would not provide funding for uncompensated care that is provided to patients who should be covered by Medicaid or an alternative coverage mechanism.

So, how did Texas leadership respond? Governor Abbott immediately supported Florida’s lawsuit against the federal government and released a statement that Texas would not expand Medicaid coverage in any way. Lt. Governor Patrick already explained his position by demanding flexibility. From what we can tell, there are no discussions about what really happens to the safety net health care providers or access to health care for Texans across this state, only political statements.

What can we, those of us not in elected leadership positions, do about this? First, we need to push our state leadership to find reasonable and rational pathways forward. While there isn’t any specific legislation to write in to support, you can still demand that they work toward a reasonable solution and stop the political pandering. We cannot accept political bluster; it is only the health care in Texas that is really at stake.

Bills and more bills being heard all over the Capitol, but not much really moving…

This has been the first week where several committees have held hearings that have lasted well after midnight. For example, the House Insurance committee was still discussing several health insurance related bills Thursday morning at 2:30am. But, while committees are meeting late into the night, very few bills have actually made it out of committee. There seems to be a developing pattern where bills are brought up for consideration, explained by their authors, testimony is taken, and then the bills are left pending without the chair of the committee calling for a vote. Traditionally, difficult or controversial bills were left pending so that the legislative staff and interested parties could work together to modify the bill and develop it into a committee substitute that would (hopefully) be an improvement on the original bill, but this year it is happening to almost every bill.

While chatting with several advocates about this, I did a little counting and found that the House Public Health Committee has only reported out 13 bills to the full House (last session it was 33 at this point), and the Senate Health and Human Services Committee has only reported out 39 bills (last session it was 146 by this point). Lest you think this is a healthrelated phenomenon, only 89 bills have been passed by either chamber and sent to the other for consideration (last session it was 797 by this point). Simply put, by the end of the second week in April in any of the legislative sessions in my memory (going back to 1993), there were lots of bills moving through the process. So, does this mean there is a flood of bills coming in the next couple of weeks or is it just a slow year? I would postulate that due to the nature of the limited issue-related discussions during the elections of 2014, we will simply see significantly fewer bills get to the Governor’s desk.

The easiest bills to track are sometimes the ones we like the most but are not moving, like Medicaid expansion and a contingency plan for the subsidized insurance purchased through the federal health insurance exchange (thanks for the effort to Reps. Garnet Coleman, Chris Turner, Sens. Rodney Ellis, Sylvia Garcia, and many others). One of the most important bills that is actually moving is SB 200, by Sen. Jane Nelson, relating to the continuation of the Health and Human Services Commission (the HHSC sunset bill); but even tracking this has been somewhat of an adventure this session. The reason for the challenge is that the authors chose to first pass SB 219, a non-substantive recodification bill, which simply updates and cleans up outdated language. SB 219 had to get passed by both chambers before the substantive bill, SB 200, could really get rolling. So, now we have a 96-page committee substitute to SB 200 that was adopted on Tuesday. While some of the deadlines in SB 200 relating to the reorganization were pushed to 2019, it is fundamentally still a streamlining effort for HHSC and a consolidation of administration that we anticipate will take years to make any impact at the local level.

One of the bills that has actually made it out of the Senate and relates to Alliance priorities is SB 760 by Senator Schwertner, which should enhance the adequacy of provider networks in managed care organizations that manage Medicaid populations in Texas. The House received SB 760 on April 8 and will likely send it to a committee on Friday, April 10 or early next week.

Another important bill is HB 2474 , by Reps. John Zerwas, J.D. Sheffield, et al, relating to improving the tracking of immunization exemption rates in children. Based on the recent measles outbreak at Disneyland, several public health advocates raised concerns that such an outbreak could occur in several Texas schools where immunization rates have become very low due to parents exercising their exemption rights. This bill seeks to improve transparency on immunization rates to help inform parents of children who may be vulnerable due to compromised immune systems.

These are just a few of the active issues right now in Austin, but as things continue to accelerate, we will do our best to keep you informed. If you have questions about specific bills you have read about or heard about from other sources, please feel free to shoot me a question via email at tschauer@cgagroup.com.

At the Halfway Point of the 84th Texas Legislature

With 10 weeks in the books and 10 weeks left to go, this week marks the halfway point for the Texas Legislature in 2015.  The cold weather of the winter is fading fast as bluebonnets bloom along the highways of our fine state, and inside the Capitol the pace of activities has definitely moved into high gear. So, how are things going for the priorities of the Harris County Healthcare Alliance? Let’s take a quick look at each point relating to our goal of improving access to healthcare through innovative funding and coverage initiatives:

  • Supporting efforts to provide health coverage to the over one million uninsured Harris County residents who could be eligible for coverage under federal law. It is seriously hard to believe that we have made so little progress on the issue of coverage expansion, especially considering that so many support this effort – our own Harris County Judge and several other urban and rural counties have endorsed the effort; the hospitals, physicians and health plans support it; the consumer groups, several religious organizations and all the disease groups are vocally supportive of it; and numerous business groups including the Texas Association of Business and the Greater Houston Partnership are on board. Unfortunately, the leadership in this state seems to be convinced (mostly by the TPPF, a conservative think tank) that any sort of expansion of coverage will give the appearance of handing President Obama a political victory, so they won’t even allow a legitimate public discussion of the issue. I wish I could be more positive, but it would seem that unless and until these leaders see the healthcare safety net collapsing, they just don’t seem interested.
  • Defend federal and state spending on Medicaid/CHIP for currently covered populations (including extending CHIP Reauthorization at the federal level). We actually have what appears to be good news on this front as the budget writers in both the Texas House and Senate are not looking to make any sort of cuts. It helps that the State of Texas has more cash on hand than at any time in my memory, but given the talk about tax cuts, we remain vigilant to ensure that existing programs are defended. Furthermore, there seems to be optimism in Congress that they can actually agree on extending the life of the CHIP program for another 2-4 years. How they work that extension into some sort of legislation is still anyone’s guess, but leadership from both parties and both chambers seem committed to helping kids and families who rely on CHIP coverage.
  • Encourage continuation of the Texas Medicaid 1115 Transformation and Quality Improvement Waiver. This issue is less about political courage and leadership at this point as it is about Texas bureaucrats negotiating with federal bureaucrats. The good news is that there seems to be bipartisan support for all the good work that has taken place across this state in the projects and programs that were initiated under the existing 1115 waiver. We are optimistic that we will be able to maintain at least some of that momentum going forward at the project and clinical levels. Unfortunately, the supportive funding that was included for uncompensated care in the original waiver will be difficult to renew at its current levels because the federal government had intended for the people below 100% of the federal poverty level to be covered by Medicaid. It would appear, based on the negotiations in other states, that they do not seem interested in continuing to subsidize hospital care for people who should have comprehensive (and already funded) Medicaid coverage.

Additionally, HCHA is working hard to promote and foster the development of sound healthcare policy; specifically, supporting the development of a comprehensive, coordinated system in Houston/Harris County that meets the healthcare needs of its residents. Here is a brief update on what the outlook is on those areas.

  • Supporting efforts to protect and improve the physical and behavioral health of adults, families and youth, including individuals and populations with special and/or chronic health-related needs. This Legislature has before it significant legislation relating to the entire enterprise of the Health and Human Services Commission that was developed by the Texas Sunset Commission over the last two years. The legislation was initially designed to complete the streamlining of the agencies started in 2003, but the contracting abnormalities discovered at the beginning of the year starting in the Office of the Inspector General seems to have dampened the aggressive timeline that Senator Nelson and Representative Price were targeting. Just last week, it was announced that the timelines for reorganization were being moved back a few years to ensure that the contract management pieces are cleaned up. While several consumer advocates still believe that this reorganization will put too much power into the hands of too few whom answer only to the Governor, there seems to be growing momentum for the streamlining effort. We will remain vigilant in this process to ensure that the actual needs of the people served by these programs are prioritized over bureaucratic wrangling.
  • Encouraging prevention programs and disease awareness through early screening, immunizations, clinic-based treatment and public health efforts. Thanks in part to the Ebola crisis last fall, there are several bills that look to help ensure our state is prepared for potential disease outbreaks, and even more bills have public health efforts. Stay tuned for next week’s blog where I will break down several efforts that HCHA is working to support.
  • Building awareness of the healthcare system sustainability and its impact on community health. We regularly reference the HCHA State of Health Report in our advocacy efforts and have talked with numerous legislators about the findings in this report. While this report is chocked full of useful data and trend information, it also includes policy recommendations to address the challenges with our region. We will continue to build awareness whenever we can relating to the excellent work that went into this report.

Medicaid Talks, Tax Cut Challenges, and Looming Lawsuits

Last week started with a very difficult press conference for health advocates. On Monday, March 2, Lt. Governor Dan Patrick and Sen. Charles Schwertner brought together the GOP caucus in the Senate to declare necessary reforms to the existing Medicaid system that must happen before progress on Medicaid expansion could ever be considered. While this may have sounded positive, the stipulations they set out included several “poison pills” that they knew the federal government would not likely approve. The only positive thing that several of us in the health care advocacy community noticed is that neither the Governor nor the Speaker was in attendance. Sometimes we have to look for small victories.

Budget discussions progressed last week with no decisions being made, but the Senate held two days of hearings on several tax cut proposals. These hearings culminated with the Senate leadership laying out a suggestion that tax cuts and debt reduction should not count against the spending cap. The House leadership did not seem to agree with the Senate on this issue immediately either, but it did lay out an interesting opportunity for legislators to consider ways that they could meet several obligations at once with the extra revenue they have this year without having to vote to break the spending cap.

Finally, much attention was on the US Supreme Court which heard the beginning arguments of the King vs. Burwell case. In summary, this critically important case could either reaffirm or discontinue the health insurance subsidies that have helped over a million Texans purchase health insurance this year under the ACA. Most importantly, it shined a light on the opportunities the Texas Legislature has to control its own destiny or be at the mercy of the court. A special thank you to State Representative Chris Turner  who has developed HBs 817 and 818 which would facilitate a state-based exchange and thereby protect the coverage subsidies that so many Texans need to maintain their coverage. We are not optimistic that either of these bills will make it to the Governor’s desk for signature, but it is good to know that there are members of the Legislature that see the challenge and are responding to it.

Now that the introductory committee hearings have all been completed and they are all comfortably staffed and operational, we are expecting substantive bills and decisions to come into focus. Considering we are eight weeks into a twenty week session, things will start to happen quickly.