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.

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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.

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!