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).

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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.

Focusing on the Fundamental Challenge: Texans Lacking Health Insurance

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!

Texas Legislature in the Starting Blocks

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!