The main focus at the State Capitol right now is the state budget. Recently the US Secretary of the Treasury, Jacob Lew astutely described the budget process in saying, “The budget is not just a collection of numbers, but an expression of our values and aspirations.” Every two years in Texas, our elected Legislature holds public hearings in Austin to listen to all of the agencies and interest groups that have some role in showing where Texas expresses its values and aspirations through its budget. If you have several days to study it, click here to see the basic budget documents and related presentations from the Legislative Budget Board: LBB.
It is a huge budget by most people’s standards, authorizing state spending for the next two years with a revenue estimate set by the Texas Comptroller of Public Accounts at $113 Billion in general funds. With additional federal funds and dedicated funds, the total is somewhere in the range of $205-210 Billion. Of course, while this number is big, remember that this budget will impact approximately 27 million people who call Texas home. When the Senate Finance Committee and House Appropriations Committee finish their hearings over the next couple of weeks, they will have listened to presentations about almost every dollar in that budget.
To complicate matters, most of the future revenue and expenditures are very difficult to predict over the course of the coming two years. If the economy continues to be strong, there could be less demand on Medicaid and there will be more sales tax revenue. If the economy goes south, it could be a double whammy by increasing demand for support services while reducing funding. Additionally, the state has an obligation to pay for part of education based on attendance, and estimating the number of children in public schools across this state has traditionally been difficult to correctly hit. These uncertainties explain why every two years the Legislature either is looking at a fairly substantive deficit or surplus. Fortunately this year, they are sitting on a nice sizeable surplus. Which brings us to the big question: when you have a budget surplus in Texas, what is the best way to budget?
In an effort to express Texas’ values and aspirations, there have been numerous recommendations on what to do this year. The discussions have included increasing funding for border security, provide for tax cuts, restoring funding to education from cuts made in 2011, appropriately funding health and human services in Texas, increasing funding for higher education, fixing several budget gimmicks used in previous sessions, and numerous others. At this point, it is tough to see how these competing interests will find common ground as there has only been listening and discussing things in general rather than in specifics. We will know more as the committees start making decisions on the different sections of the budget, and as that happens we will keep you informed. The Alliance is actively communicating with the members of these committees about the importance of health and human services funding, and we talk daily about the impact that these funds have in our region. We collaborate with the efforts of our statewide organizations as well as other Houston groups like One Voice and many other HCHA Members. Most importantly, this is not about just numbers as much as it is an expression of our values and aspirations: improving the health of our citizens and the systems that deliver health care to the sick and injured in our region.
For months in Austin and across Texas, several different advocacy groups and a few legislators have been calling for Medicaid Expansion utilizing the Affordable Care Act (ACA); additional voices support the effort but call for an alternative that achieves coverage expansion in a Texas specific manner. On the other side, conservative think tanks have been posting up stories and articles opposing any form of Medicaid or coverage expansion that embraces the ACA (short of some sort of undetermined block grant). The arguments move from policy to financial to philosophical to political and everything in between.
In the coming weeks and months, it is expected that the debate will include the challenges of renewing the 1115 waiver in Texas that has increased mental health services as well as improving numerous other points of needed access to health services. Unfortunately, it would seem that at the moment, the leaders of Texas would prefer discussing anything other than the fundamental components of this challenge.
What has been lost in this debate is the actual problem that has been a challenge to the healthcare systems in Texas (as well as the country) for decades: people who lack health coverage still get sick and hurt, and as a society we support delivering care to those in need regardless of the ability to pay. In fact, President Ronald Reagan signed the law that mandates care back in 1986 (via emergency facilities in hospitals), and the federal government has been holding hospitals accountable to that mandate ever since.
A direct payment for the cost of delivering this care was not included in that act or subsequent acts of Congress, so hospitals (and communities) have created cost-shifting mechanisms to cover this uncompensated care, including pursuing special funds from the federal government to help offset the costs. With the passage of the ACA in 2010, Congress and President Obama called for a change in this uncompensated system by significantly reducing the number of uninsured, but the implementation of that law has been a challenge from the start.
We are not going to begin defending or critiquing the ACA, but with this change in law, the challenge of paying for the care of people who lack health coverage is shifting. The tools and mechanisms that have held health care delivery systems together, including those in Houston, can’t address the current situation. As the Harris County Healthcare Alliance, we are working to encourage an open and collaborative conversation about the best way to move forward, but we must first gain consensus from the leaders that indeed this challenge is the one we are working to solve: finding the most effective and efficient way to provide healthcare to Texans who are sick or hurt and have no health insurance coverage. If we can encourage leaders to agree on the problem, we are at least 80% of the way to finding a solution that is palatable to all Texans.
The Alliance will be working to build a consensus to make the case that this needs to be the focus of the discussions as the Legislature continues its work. We will keep you posted on how you can help. Stay tuned!
The Texas Legislature officially convened on January 13th, but truth be told, the first few weeks of most legislative sessions are more pomp and circumstance with very little work being done, and 2015 has been much the same. Now that the inaugural parades and parties are over and most elected officials in Austin have hired staff, it’s time to get to work. Yesterday (February 4th) marked the de facto beginning of the 84th Regular Session of the Texas Legislature as Speaker Straus named the House Committee appointments. On the other side of the Capitol, Lt. Governor Patrick named the Senate Committee appointments two weeks ago, but the only committee with any official action so far has been the Senate Committee on Finance, which has held hearings on the various articles of the budget. As it relates to the Harris County Healthcare Alliance issues and concerns, let’s take a look at who will be our key players.
The Texas Senate is a mixed bag for health and human services funding and policy that impacts the Houston region. The Senate Committee on Finance is where all the major funding decisions occur, and it includes five members from our region (four Republicans and one Democrat out of 15 total members): Senators Huffman, Bettencourt, Kolkhorst, Taylor (Larry), and Whitmire. While we know and respect all of these Senators, Huffman, Taylor and Kolkhorst have shown a high level of interest and expertise related to health funding, and we are optimistic that we can work with all three of these Senators and their staff. The Senate Committee on Health and Human Services is not quite as receptive to the urban areas, especially Houston. Only Senator Kolkhorst (whose district includes Katy and points west) is on this committee from our region, and only two of the nine members come from urban areas (Uresti of San Antonio and Rodriguez of El Paso). When it comes to the policy issues before this committee, we will be networking strategically with others who have similar concerns from outside our region.
The Texas House committee assignments are full of surprises this year. While we knew that the Speaker had several open chairs to fill from elections and retirements that moved people to the Senate and out of office, there were a number of surprises and some will impact our health and human services champions. The House Committee on Appropriations (HAC) will be chaired by Rep. Otto from Dayton, in the upper northeast part of the Houston region, as well as our good friend from here in Houston, Vice Chair Rep. Turner (Sylvester). This 27 member committee has traditionally broken down into four subcommittees, but those have yet to be named. In addition to this strong leadership from the Houston area, our region will be well represented on the committee by Reps. Bell, Bonnen (Greg), Davis (Sarah), Miles, Miller (Rick), and Phelan. Of note relating to our issues before the HAC is the absence of State Rep. Zerwas, who had been the chair of the subcommittee on health and human services for the last several sessions. While he will not be on the HAC this year, Rep. Zerwas will be chairing the House Committee on Higher Education as well as serving on the House Committee on Public Health. Speaking of the 11 member Public Health Committee, it will be have a new chair in Rep. Myra Crownover from the Dallas region, and will include the following Houston members: Reps. Zerwas, Coleman, Davis (Sarah) and Miller (Rick). Stay tuned, now that we know the players and the roles they will be playing on the various committees, it’s time to roll up our sleeves and get to work…
Our new governor was sworn in Tuesday and the 84th regular session of the Texas Legislature officially started last week. With all the new faces in leadership in Texas, nobody is expecting much action the first several weeks; but like any good race, it will accelerate quickly toward the finish line 140 days later.
We are cautiously optimistic that several big health and human services budget and policy items could make progress this year with the new leadership, but fully realistic in our expectations that “Medicaid Expansion” as outlined in the ACA is a longshot. The most important activity of every Texas Legislative regular session is to pass a budget that will cover the next two fiscal years. Even with the falling price of a barrel of oil, most early expert prognosticators indicate that they should have adequate resources to properly fund existing services with perhaps some extra revenue left over (NOT a common occurrence in Texas). The big debate will be what to do with the expected “surplus” revenue. With several newly elected leaders already promising tax cuts and other voices calling for restoration of cuts that went into effect in 2011, it is likely a safe bet that there will a mix of the two to get a budget adopted in both houses and signed by the new governor.
Speaking of the new governor, Governor Abbott will be the center of attention on where (or if, in reality) he directs the Health and Human Services Commission (HHSC) to focus energies as it relates to negotiating with the federal government on strategies to cover the uninsured. The other big item of attention as it pertains to health and human services will be the Texas Sunset Commission report and resulting legislation relating to reforming the entire HHSC enterprise. Look for regular updates on this legislation as it gets rolling through the process.
And finally, speaking of legislation, there are lots of bills that have already been filed and many, many more to come. We will be tracking all sorts of interesting issues and activating our network when the situation calls for it. Buckle in, it is going to be a bumpy ride!