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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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.

Spotlight at the Capitol Squarely on the Budget

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.

New Faces of Leadership in 2015 House and Senate Committees

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. BellBonnen (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…

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!